unit 3_service delivery system and performance metrics_db

8/3/2019 Unit 3_Service Delivery System and Performance Metrics_DB

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Service Delivery System

Lecture 3: Reach and Impact


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Review

In units 1 and 2 we defined Health systems Agents, Units, Institutions Adaptation, Adjustment, Coherence Incentives, Contracts

We laid out 7 basic subsystems in healthPrimary health service delivery systemHealth workforceLeadership and governance to assure qualityHealth systems financing

Supplying medical products and technologiesHealth systems informationHouseholds

Today we focus on primary health service delivery


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Outline

Ingredients of the services system

Local Example from Vietnam

Reach vs. impact on the last mile Institutional norms of service delivery

system


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Part 1: Ingredients of Primary Care


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Ingredients

Primary servicedelivery made up of Health care service

providers

Facilities

Drugs and supplies

Governance

Maintaining eachingredient is the workof an entire additionalsubsystem

Agents

Units

Institutions


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Centrality of Health Services

Health ServicesDelivery

Households

GovernanceHealth Financing

Health Workforce Supplies


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Ingredients must be combined

Primary clinics take things that arentmedical care and make them into medicalcare

Drug on the shelf is not medical care untilyouve handed it to a patient who has thatdisease

A nurse is not medical care until she is sitting

with a patient putting a bandage on them The way this is coordinated requires

thought and management


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Design of Primary Health Care

Different levels of Facilities

Primary, Secondary, Tertiary

Public, Private, NGO

Different specialties

Variable quality


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Performance Metrics

What do we want to get out of the primaryhealth care delivery system?

World Health Report 2000

Stewardship Financial equity

Responsiveness to peoples non-medical

expectations (dignity and respect) Equity (Fair delivery to rich and poor; deliverywithout barriers)


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ExamplesCountry Example Metrics Affected

Philippines: decentralization of responsibility forprimary health care to local governments in 1993.Assets, staff and budgets transferred to local level.Health workers now report to local government,

not to MoH. Supervision by MoH has becomemore difficult. Stewardship

Financial equity

Dignity and Respect

Equity

Mali: independent health centres are not-for-profitcooperative establishments owned, financed andmanaged by community; recruit their own staff.Few financially independent in practice.

Croatia: previously centrally employed, salariedambulatory care physicians. Now they areindependent contractors.

From Table 3.2 Examples of organizational incentives for ambulatory care, World Health Report 2000


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From Matsuda 1997


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Utilization Patterns in Vietnam

World Bank 2000


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Vietnamese Health Expenditure

ITEM 2000 2002 2004 2006Total Expenditure on Health as % of GDP of which: 5.4 5.2 5.7 6.6

Government Exp on Health (% of Total Expend) 30.1 30 26.9 32.4

Private Expenditure on Health (% of Total Expend) 69.9 70 73.1 67.6

Government Exp on Health (% of Total Expend) 6.4 6.1 4.7 6.8

External Resources for Health as % of Govern. Expend 2.6 3.4 1.9 2.2

Out-of-Pocket Expenditure (% of Total Expend) 91 86.5 86.1 89.5

Social Security spending on Health % of Gov. Expend 19.7 19.6 28.7 38.8

Prepaid plans as % of Private Expenditure on Health 4.1 2.3 2.8 2.5

Per capita Total Expenditure on Health (US$) 21 22 31 46

Per capita Total Expenditure on Health at PPP ($) 132 147 188 264

Per capita Government Expenditure on Health (US$) 6 7 8 15

Per capita Government Expenditure on Health PPP ($) 40 44 51 86


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Part 2: Last Mile: Impact and Reach


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The Last Mile Problem

High capacity conduits

Centralized

Easily manipulated

Low capacity conduitsSpatially disbursed

Costly to access


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The Last Mile: Examples

Fiberoptic trunk lines

Arteries

Interstate highways

Tertiary hospitals

Copper wireCapillaries

Back roads

Rural drug sellers


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Concrete vs. Abstract Metaphors

Thinking about the last mile provokes mental

images of concrete resources and people inspace

Last mile problems transcend who and what Locus of control is critical

Last mile problems affect processes and institutionalperformance

Managing these problems requires going down lastmiles


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Last mile in health is not just aboutsupplies

Health care deliveryrequires hardware plus

software

Not just the drug, theindications, side effects,motivational counseling

Not just the diagnostic, the

interpretation and thedecision making


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Impact

Definition of Impactthe effect oftreatment on the treated

To achieve high impact

Be selective Apply best inputs in the best place

Farmer puts one bag of fertilizer on the best soil

Teen pregnancy prevention programs in a church

A more technical word for impact is

in-tensive margin


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Systems and Incentives

What are the political and organizationalfactors that determine degree ofcentralization?

Incentives of decision-makers and agents

How does centralization affect the impactof primary services on the poor?

Incentives of decision-makers and agents


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Reach

Definition of Reach-The ability to bringmore people into treatment

To achieve high reach

Do not be selective Apply inputs as broadly as possible

Farmer spreads one bag of fertilizer over 10 acres

Teen pregnancy prevention programs on the radio

A more technical word for reach is

ex-tensive margin


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Fundamental Laws of Service Delivery

Law 1) Population Benefit=Reach Impact

Law 2) In any budget, there is a tradeoffbetween reach and impact


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Example of Law 1

Example from TB

Reach is number of people who can accessdiagnostic testing for TB in less than 1 week

of 1st symptoms Impact is number of people who complete

100% of directly observed treatment (DOTS) if

diagnosed Reaching more people with better

treatment means less TB


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TB Model: Impact Matters

Population Benefit=Reach Impact

TB Burden

Impact

TB as function of diagnostic quality

0

50

100

150

200

250

300

350

20 21 22 23 24 25 26 27 28 29 30

Proportion of Active TB Patients Diagnosed by Clinic

TBBurden

Average Diagnostic Delay 25 Weeks Average Diagnostic Delay 8.3 Weeks

Average Diagnostic Delay 4.1 Weeks Average Diagnostic Delay 5 Weeks


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TB Model : Reach Matters


TB Burden

High Reach Low Reach

TB Burden as a function of Diagnostic Delay

0

50

100

150

200

250

300

350

0 5 10 15 20 25

Average Diagnostic Delay in Weeks

TB

Burden

Proportion Diagnosed 20%




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Dual Impact of Reach and Impact


Reach

Impact

TB as a function of Reach and Impact

0

20

40

60

80

100

120

0 5 10 15 20 25 30

Mean Delay in Weeks Between Symptoms and Diagnosis

PercentDiagnosed

AtPresentatio

n

TB Burden 0.004 TB Burden 0.0045 TB Burden 0.0055 TB Burden 0.006

High Burden

Low Burden


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Illustration of Law 2

Buying more TB reach means

Investing in training front line public andprivate workers to make the diagnosis

More clinics in more places that know how todiagnose

More diagnostic facilities

Buying more TB impact means Investing in training public TB facilities tomaintain good DOTS programs


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It is like fighting a battle

General has to defend a mile long line ofdefense (Reach)

Has different quality troops (Impact)

Cannon ($100) Cavalry ($10)

Foot soldiers ($1)

Cant afford cannon for every inch of the line

Shouldnt use only foot soldiers Deploy forces strategically

Achieve ideal mix


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Managing Primary Service Delivery

Each unit has a certain amount ofeffectiveness

Can improve the unit

Can build more low quality units

Who manages the big decision of wherethe troops go?

Market forces

Public policy


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Part 3: Institutions that govern reach


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Governments, Markets, NGOs affect Reach

Governments (MOH) Government decides location of workers located in space Command and control incentives

Service obligations Constructing, buying, new facilities

Political factors and population needs enter these decisions

Markets Primary service agents seeking revenue Looking for patients with ability and willingness to pay Assessing competition

NGOs

Organizations locate facilities and hire staff Population needs and organizational convenience enter decisions Impact capacity of governments and markets by hiring away their staff


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Government Institutions

Hierarchical levels of decision making Center, province, district

Decision-making can be centralized or

decentralized Budgets need to be allocated across

primary, secondary, and tertiary services National hospitals, provincial hospitals, health

stations

Costs escalate at hospitals


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Hospitals

Hospitals and politics

Hospitals have economic gravity Impact hundreds of health worker livelihoods

Supply chains and financing infrastructures are hard tochange

Hospitals have political gravity Civic pride

Sense of security for middle/upper class

Hospitals have limited preventive impact, limitedrelevance to 98% of clinical problems


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Ecology of Medical Care-USA


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Incentives in Hospitals

For-profit hospitals Owners maximize: Profit=Revenue-Cost

Bring in more revenue from more paying customers receivinghigh price services

Competition with other hospitals in urban areas Compete on quality and price

Minimize costs without sacrificing quality

Government hospitals Administrator maximizes: Job security

Minimize scandals

Satisfy supervisors

Satisfy local powerful elites


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Hospitals vs. Health Stations

The balance between primary vs. tertiaryis both a political question and a publichealth question

Political gravity of hospitals pulls them tocenters of political power

Gravity of hospitals pulls public funds towards

them


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Health Station Incentives

Health stations often suffer resource limits Low salaries

Supply shortages

Incentives of health planners Good distribution of health stations at lowest recurrentcost

(Fixed cost: cost of building a station)

(Recurrent cost: cost of salaries and supplies)

Incentives of primary health workers Maximize Income and be somewhat concerned with

patient health


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Syndrome 1: Private Market

Definition: Private marketosis is when healthworkers at public facilities maintain privatepractices Natural outcome of the incentives in the system

Everyone is partly happy Public administrator gets a remote health station

staffed from 10AM till 4PM

Health worker gets supplementary income

Patient gets access to a health worker who wouldotherwise not be in this remote location

Still has to pay


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Is private marketosis bad?

Some say Yes Goal of totally free care at minimal government cost

is not realized Poor face lack of financial protection

Push to make dual practice illegal Some say No

Unrealistic to expect totally free care unlessgovernment pays wages that one can live on

Solved the main public problem of getting healthworkers to remote areas

Patients pay for what they get

What do you think?


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Diagnosing pathological private market

Symptoms:

Health station salaries are well below what ahealth worker can earn in private practice

Health station utilization rates are low

Household surveys report high proportion ofout of pocket payments even in remote areas

Drive around and see private practices withbusy waiting rooms


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Treating Private Market Pathology

Ask former health station workers foradvice on incentives for dual practice

Improve finance at public health stations

Demand side strengthening with insurance

Supply side finance with contracting orbudgeting

Improve non-financial incentives at publichealth stations


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NGOs/Private Not for Profits

NGOs mix features of government facilities andprivate facilities Uses salaried workers

Can do private things like charge user fees

Can use reputation to pull in more demand

Deployment based on interest of the NGO and thosethey are serving

Service mix not always tied to governmentobjectives Donors pick darling diseases, darling locations

Use facilities for vertical programs


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Syndrome 2: NGO-overload

Definition: NGO-overload is when health sectorNGOs well-intended activities interfere with thesmooth performance of the primary servicedelivery system

Examples Poaching talented health workers from other sectors Undermining referral patterns in public/private sector Reorienting health system priorities to suit the

interests of donors over the interests of community Keeping private sector from delivering solutions

Free condoms, bed nets, ARVs, stops private entrepreneurs Subsidies for free items can be unstable subject to donors


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Is NGO-overload bad?

Some say Yes: Primary health systems

structure should reflect national autonomynational priorities.

Some say No: NGOs inject new

resources that would not otherwise be inhealth system, in return why not give them

a voice in the system What do you think?


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Diagnosing NGO-overload

Salaries for health workers are rising

Prices of primary health goods are falling

Budgets full of line items around NGOpriorities: HIV/AIDS, TB, Family planning,vaccines


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Treating NGO-overload

Dis-engagement

Some countries just say no

Engagement

Some countries adopt sector-wideapproaches (SWAPs)

Ministry of Health convenes meetings to

establish minstrys priorities and invites input


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Part 4: Institutions that govern impact


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Impact

Best health impact from doing the rightthing at the right time

Requires good health workforce

Good governance

Good supply system

Covered in later units of the workshop

Choices on reach spill over to choices on

impact


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Private Markets and Impact

To the extent that private market imposesuser fees on the poor, adherence withtreatment can lower impact

Do health workers practice same level ofquality in their private practices as public?

Governance systems have had difficulty

governing the impact of workers who areentirely private


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Reach, Impact, and the Poor

Different politicalsystems. None isnaturally oriented to thepoor Liberal Democratic

USA Egalitarian-Authoritarian

Cuba

Traditional-Inegalitarian Brunei

Authoritarian-Inegalitarian Sudan

Populist Kenya

Whether decentralizingserves the poor depends: Which decision makers

care about the poor?

Power is the currency of

all political systems Poor people dont have

power

Public health systems natural tendency is to serve power not need


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Summary

Primary health care (PHC) delivery system takesingredients (providers and supplies) makesservices

Reach and Impact suffer from last mile problems They need to occur on last mile

They are easiest to do on first mile

Institutions in PHC prey to 2 syndromes

Private market pathology and NGO-overload Performance metrics can help diagnose

Understanding incentives helps treat.


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Exercise on Performance Metrics

Methods for how to measure theseindicators

Break into groups and decide on how to

make indicator meaningful for local use.

unit 3_service delivery system and performance metrics_db

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