Technical Meeting for the Development of a Framework for
Universal Access to Prevention, Care, Treatment and Support
in the Health Sector
WHO Executive Board Room
Geneva, 18-20 October 2005
CONCEPT OF
UNIVERSAL ACCESS
Dr Michel Thieren (WHO/EIP/MHI)
Objectives of the session
•
What are the lessons learnt from the conceptual debate
and where does this debate currently stand?
•
•
What does "universal" mean?
What does "access" mean?
•
What determines and influences "universal access" and
how to build a measurable framework upon them?
•
What are the possible applications for universal access
to HIV/AIDS prevention, treatment and care?
1
Objectives of the session
• What are the lessons learnt from the conceptual
debate and where does this debate currently stand?
• What does "universal" mean?
• What does "access" mean?
• What determines and influences "universal access" and
how to build a measurable framework upon them?
• What are the possible applications for universal access
to HIV/AIDS prevention, treatment and care?
Building up on the "coverage"
debate
• Models or frameworks to explain / communicate
but also to measure the concept of coverage
– Piot - Fransen Model for STI
– Tanahashi Model for Health Services
– Phillips & Morisson Model of Access to Health Care
• Model or framework to track progress and
measure achievement on coverage
– Health System Effective coverage
– Service Availability Mapping
Piot – Fransen Model for STI
Source: C.P. Hudson. Bulletin of the World Health Organization, 2001, 79 (1)
Tanahashi: Health Service Coverage Diagram
Goal of service achievement
Effectiveness Coverage
Contact Coverage
Acceptability Coverage
Accessibility (geo. & fin.) Coverage
Availability Coverage
Target Population
Source: Tanahashi T. Bulletin of the World Health Organization, 1978, 56 (2)
A Model of Access to Health Care
Effective Coverage Model
New definition of coverage
The probability of receiving a necessary
health intervention conditional on the
presence of a health care need
Cj 
C d
d
ij
ij
i
ij
i
New definition of effective coverage
The magnitude of the realised health gain from the
intervention relative to the potential health gain possible with
the optimal performance of the providers for a given health
system
n
EC j 
 HG
i 1
n
 ( HG
i 1
ij
ij
C ij d ij
Pjk  Popt , R jk  1, Yij  1, k  1...)d ij
Service Availability Mapping
100%
7
Percent of districts
21
22
24
70
Two or more
One facility
No facility
72
54
10
20
0%
ART
PMTCT
Testing &
counseling
Lessons learned
• Low level of agreement internationally
• Some models are more complex than others
• Some are more convincing to convey a comprehensive
message on access and coverage, others are more
useful to monitor progresses on access and coverage
• The concepts are defined but there is broad space for
flexibility
• It is not useful to push the conceptual debate further
• It is more important to focus on how to take the various
concepts on board, agree on what they means for
HIV/AIDS prevention, treatment and care and develop
the framework accordingly
2
Objectives of the session
• What are the lessons learnt from the conceptual debate
and where does this debate currently stand?
• What does "universal" mean?
• What does "access" mean?
• What determines and influences "universal access" and
how to build a measurable framework upon them?
•
What are the possible applications for universal access
to HIV/AIDS prevention, treatment and care?
The concepts (1)
• Health supply terms
– Availability
– Affordability
• Health demand terms
– Utilisation
– Acceptability
Access =
Coverage =
how much a population can
reach health services
the share of a population eligible
(beneficiaries) for a set of interventions
Concepts (2)
• Universal
– Qualitatively, it gives a sense of equality, indivisibility
– Quantitatively it can be "all" or "enough for everyone to get
a chance"
• Target
– Can be an outcome, prevention, or treatment target
– Scopes of target (global, country)
– Targeted entity: % of population, population group, group
at risk, a group in need, districts, facilities …
(measurability!!!!)
• Scaling-up
– Expand geographically
– diversify
• Intervention vs. services
Key points on the concepts (1):
• Use the term universal "access" instead or universal
"coverage"
•
• Avoid benchmarking "universal" in absolute terms
• Use of the term "coverage" associated with outcome
(intervention) indicators
• The term "universal access" can be completed by its
target expressed in "universal access at 80% of
coverage" for a specific intervention
Key points on the concepts (2):
• Measuring "access" may actually measure just one or a
few domains of access (like availability, affordability
and/or acceptability), but rarely all of them
• Define country targets in national context instead of
focusing on global targets
• Define target taking into account the measurability of
the targeted entity (e.g. district or population)
• Overall, the concepts of access, coverage and
associated terms are not standardized across programs,
so there is room for flexibility.
3
Objectives of the session
• What are the lessons learnt from the conceptual debate
and where does this debate currently stand?
• What does "universal" mean?
• What does "access" mean?
• What determines and influences "universal access"
and how to build a measurable framework upon them?
• What are the possible applications for universal access to
HIV/AIDS prevention, treatment and care?
What determines effective coverage?
• Price of intervention j offered by provider k – Bjk
• Disposable income of individual i - Ii
• Geographic location of a provider k offering intervention j in
relation to individual i - Qijk
• Cultural and social acceptability of intervention j offered by provider
k to individual i - Zjik
• Availability of necessary technology to provider k for delivering
intervention j - Rjk
• Expected health gain from intervention - HGij
• Performance of provider k in relation to intervention j - Pjk
• Adherence of individual i to intervention j - Yij
EC ijk  f B jk , I i , Qijk , Z jik , R j , HG ij , Pjk , Yij 
DATA COLLECTION &
MEASUREMENT !!!
SAM administration process
Interviewer :
Date :
Respondent :
District population :
The code numbers on this list are needed to fill out the questionnaire.
New health facilities can be added at the end of the list
NAME
CODE LAT
LONG
SUB-COUNTY COMMENT
TYPE
Questionnaire
programmed in
Palm Pilot
Enter data in
PDA and upload
them in PC
Liver
functions
7
CD4+ cell
count
7
83
Blood count
96
Hemoglobin
0
20
40
60
80
100
Analysis of data
and production of
district mapping
Building the framework
• Over-inclusive path
– WHO 2000-2003: the
concept of effective
coverage and its
measurement problems
• Simplified path
– WHO 2005: the Service
Availability Mapping Program
focusing on availability only
(is this enough?)
• Limit to what matters most
– Availability
– Affordability
– Acceptability
 measured through SAM
 equated to "free of charge" (SAM)
 population and/or facility based surveys
Key points: building a framework on
Universal Access (1)
• Set the objective of the framework:
– Communication: a comprehensive framework displaying all
the determinants of access and their inter-relationship is
required.
– Monitoring and evaluation: the framework should be
limited to measurable determinants.
• Consider a simplified (not simple!) approach to building
a framework for universal access
• Focus on "availability" of core interventions in the area
of prevention, treatment and care, at least at district level
(SAM concept)
Key points: building a framework on
Universal Access (2)
• Define the steps to be taken if additional factors are to
be included:
– "acceptability": could be measured for just a few
countries using population or facility based surveys;
– "affordability" could be measured through household
surveys for a few countries or equated to the
implementation of free services policies at districts level
• Promote academic debate and undertake research on
how to extract measures from geographical information
(i.e. computation of SAM generated availability data)
4
Objectives of the session
• What are the lessons learnt from the conceptual debate
and where does this debate currently stand?
• What does "universal" mean?
• What does "access" mean?
• What determines and influences "universal access" and
how to build a measurable framework upon them?
• What are the possible applications for universal
access to HIV/AIDS prevention, treatment and care?
Universal access in the context of HIV/AIDS
treatment, prevention and care interventions
1. Universal access for treatment is treatment that is
reachable, affordable and acceptable to all those in need
2. Universal access for prevention is along the same lines as
for treatment: key prevention services should be reachable,
affordable and acceptable to all those who need it: "all districts
should have VCT, PMTCT, condoms, sex & AIDS education
(general public, schools)", target population programs, which could
be specified and could be measured
3. A core package of HIV/AIDS treatment, prevention and care
interventions is defined, each one occurring in one of the four loci:
hospital, health centre, community, home
4. The framework for universal access is target driven
Key points: building a universal access
framework for HIV/AIDS (1)
• Build a framework for HIV/AIDS prevention, treatment
and care using a core set of interventions covering the
four primary loci of delivery: hospital, health centre,
community, home
• Define country targets in terms of availability for these
interventions at district level
• Borrow preventive targets from the MDG and UNGASS
Key points: building a universal access
framework for HIV/AIDS (2)
• Propose "universal access at least 80% coverage" for
a given intervention
• Or propose even further, "all districts should have at
least 80% coverage, all sub (risk) populations at
least 80% coverage"
• "Coverage" should be used primarily for "intervention"
targeting; the number of targets should nonetheless be
limited to avoid burdening measurement
WORKING GROUPS
1. WG1: Concepts and definitions
2. WG2: Determinants of universal access and
their measurement issues
3. WG3: Country and global targets for
universal access and their measurement
issues
WG 1: Concepts and definitions
In reference to the background paper, the glossary of terms and the
presentation on the concepts of universal access, coverage and
other associated terms:
• Propose a set of terms that suits the context of
universal access for HIV/AIDS treatment, prevention
and care
• Propose definitions of these terms in the context of
HIV/AIDS treatment, prevention and care
WG 2: Determinants of access
In reference to the background paper, the glossary of terms and the
presentation on the concepts of universal access, coverage and their
associated terms:
• Propose a set of determinants that suits the context of
HIV/AIDS treatment, prevention and care
• List the measurement issues associated with these
determinants
• Propose a measurement and data collection strategy
for each of these determinants
WG 3: Principles for Setting Targets
In reference to the background paper, the glossary of terms and the presentation on the
concepts of universal access, coverage and their associated terms:
• Propose a set of principles that should guide the
selection of targets that suits the context of HIV/AIDS
treatment, prevention and care
• Propose two global targets for treatment and
prevention and examples for formulating them at
country level
• List the measurement issues associated with these
targets
• Propose a measurement and data collection strategy
for each of these targets
WG 4: Principles for Prevention
Targets
In reference to the background paper, the glossary of terms and the
presentation on the concepts of universal access, coverage and their
associated terms:
• Propose a set of principles that should guide the
selection of targets that suits the context of HIV/AIDS
treatment, prevention and care
• Propose two global targets for treatment and propose
examples for formulating them at country level
• List the measurement issues associated with these
targets
• Propose a measurement and data collection strategy
for each of these targets