Health Systems and Actors

Tom Merrick, World Bank

Topics for this session: How health reform relates to other forces

affecting reproductive health outcomes Health systems and their performance Types of health reform and how they are

expected to improve performance Actors in the health system: roles and

functions

Government policies &

actions

Health sys-tem & other

sectors

Pathways to Reproductive Health Outcomes

RH out-

comes

Outcomes Households/ Communities

Household behaviors

& risk factors

Health service supply Health

reforms

Other parts of health system

Supply in related

sectors

House-hold

resources

Community factors

Actions in other sectors

What is a health system?

‘All the organisations, institutions and resources that are devoted to producing health actions.

‘A health action is defined as any effort, whether in personal health care, public health services, or through intersectoral initiatives, whose primary purpose is to improve health’ (WHR 2000)

How do health systems differ?

Roles of public and private providers in finance and provision of services (some are mainly public, others private, some mixed--one size does not fit all)

How care is paid for (taxes, insurance, payments by consumers): follow the money

Health systems are not static; recognize the forces of change and how systems respond.

Public health services

Pharmacies

State medical practices

Ambulatory care clinics

Polyclinics

Public hospitals

Compulsory income related contributions

General taxes

Central government

Regional authorities

Population and enterprises

Patients

Former GDRSource: OECD, 1994

Population

Patients

Health insurance funds

Social insurance

Private insurance

Government (confederations, cantons, municipalities)

Hospitals

Ambulatory care

Outpatient care

Switzerland c1990

Forces that shape health systems—and change them

Social compacts—what health care and finance that different societies decide the state should provide

Culture/values underlying such compacts Demographic and epidemiological conditions Financial and political conditions In many countries—health systems a legacy

of colonialism & change is led by donors

What is health reform? Health sector reform has been described

as sustained purposeful change to improve the performance of the health sector.

It is motivated by the need to address fundamental deficiencies in health care systems that affect all health care services, including reproductive health services.

It is an inherently political process, and it is often implemented on a sector-wide level.

Why are countries taking on health reform?

Poor performance of existing health systems Public expenditures skewed toward rich and

neglect the poor, particularly women Resources are scarce, demands increasing

—forcing governments/donors to be strategic Consumers unhappy about poor treatment Donor fatigue, concerns about sustainability

What forces affect health system performance? Governance capacity Skills, competencies of managers and

providers Resources and incentives Technical and organizational capacity Degree of accountability to consumers Context: financial, political, social,

demographic and epidemiological

Health reform measures: New approaches to finance: charging fees,

social and private insurance schemes, sectoral funding

New payment mechanisms: performance-based contracting, capitation

Reorganization of functions: new roles for ministries, separation of finance and provision, enhanced stewardship

Decentralization, devolution: budgets, control shift from central to local government

Changes in legal & regulatory environment

Example: the Kirghiz Republic Kirghiz health system a legacy of the

Soviet system Financed by public sector Providers were public servants Breakup of Soviet system created a

financial crisis Reform is bringing new ways of

financing, new structures and roles, new ways of paying providers

Collection &Sources of Funds

Pooling & PurchasingIntermediaries Service Providers

Taxes toRepublicanbudget

Taxes toLocalbudgets

Ministry ofHealth

Oblast HealthDepartments

Central RayonHospitals

Individualcitizens

Infrastructure andutilization norms

Republican MOHinstitutes andnational centersNorm-based line

item budgets

Hospitals of otherMinistries

OtherRepublicanMinistries

Oblast general &specialist hospitals &polyclinics

Central Rayonhospitals, generalpolyclinics & ruralprimary care

Private providers

Infrastructure andutilization norms

Norm-based lineitem budgets

Formal and informal costsharing for all services

Direct out-of-pocket payment

Health reform in the Kirghiz Republic: pre-1997

How the Kirghiz health system will look after 2001

Taxes toRepublicanbudget

All citizens(universalcoverage)

Inpatient carecontracted fromindependent hospitals

Case-basedreimbursement

Primary care contractedfrom independentFamily Group Practices

Non-contractedservices

Capitation steeredby enrollment

Formal cost sharing forspecific services or settings

Direct out-of-pocket payment

Single MOHHealth Fund(MHIF)organized atlevel of Bishkekcity and eachoblast

Employercontributions

SocialFund

payrolltax

transfers

Taxes toLocal budgets

Contracted outpatientspecialty and diagnosticservices

Budget orreimbursementby fee schedule

Contracted privatepharmacies

reimbursementby fee schedule

budget allocationor global cap

Collection &Sources of Funds

Pooling & PurchasingIntermediaries Service Providers

Needs-weightedcategorical grant tooblast Funds

Allocation to local(oblast) Fund

Allocation to (pooled)Bishkek City Fund

Health system actors—the people factor Identify the policy perspectives of various

actors, including donor agencies, governments and others involved in efforts to improve health system performance

Apply this knowledge to your own experience, creating an enabling environment for reproductive health policies.

Who are the actors in the health system? Who is in? Who is out? What are their roles?

By Level By Function By Interaction

Consuming Planning Financing Delivering Oversight and

accountability

Health System Actors, Functions and Outcomes

People

Demand

FinancingRevenue Generation

Risk PoolingAllocation & Purchasing

Input ManagementHuman ResourcesKnowledgePharmaceuticals TechnologyConsumables Capital

Private Sector ActorsFor ProfitNon-Profit

Non-Formal Allopathic

Indian Systems

Health Status

Financial Protection

OversightPolicy Setting Information, Disclosure & Advocacy Developing Partnerships Regulation & Standard SettingMonitoring & Evaluation Strategic Incentives

The StateUnion GovernmentState Governments

Local Bodies

Consumer Responsiveness

Service DeliveryPublic Health Services

Ambulatory CareInpatient Care

How do the actors relate?

The “market” Regulation and stewardship Information flows Contracts and agreements The political process Accountability

From your own experience, how have actors influenced RH outcomes?

Positively? Give Examples

Negatively? Give Examples

Political Mapping Tool – Abt Policy Toolkit

Policymaker mapping of players

Example of mapping

More next week on actors

Engaging stakeholders

Your action plans