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Service Delivery System. Lecture 3: Reach and Impact. 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 health Primary health service delivery system Health workforce

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Service delivery system l.jpg

Service Delivery System

Lecture 3: Reach and Impact

Review l.jpg

  • In units 1 and 2 we defined

    • Health systems

    • Agents, Units, Institutions

    • Adaptation, Adjustment, Coherence

    • Incentives, Contracts

  • We laid out 7 basic subsystems in health

    Primary health service delivery system

    Health workforce

    Leadership and governance to assure quality

    Health systems financing

    Supplying medical products and technologies

    Health systems information


  • Today we focus on primary health service delivery

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  • 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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Primary service delivery made up of

Health care service providers


Drugs and supplies


Maintaining each ingredient is the work of an entire additional subsystem





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Centrality of Health Services

Health Financing


Health Workforce


Health Services



Health Information

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Ingredients must be combined

  • Primary clinics take things that aren’t medical care and make them into medical care

    • Drug on the shelf is not medical care until you’ve handed it to a patient who has that disease

    • 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 primary health care delivery system?

  • World Health Report 2000

    • Stewardship

    • Financial equity

    • Responsiveness to people’s non-medical expectations (dignity and respect)

    • Equity (Fair delivery to rich and poor; delivery without barriers)

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

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The Last Mile Problem

  • High capacity conduits

    • Centralized

    • Easily manipulated

  • Low capacity conduits

    • Spatially disbursed

    • Costly to access

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The Last Mile: Examples

  • Fiberoptic trunk lines

  • Arteries

  • Interstate highways

  • Tertiary hospitals

  • Copper wire

  • Capillaries

  • 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 in space

  • Last mile problems transcend “who” and “what”

  • Locus of control is critical

    • Last mile problems affect processes and institutional performance

    • Managing these problems requires going down last miles

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Last mile in health is not just about supplies

  • Health care delivery requires “hardware” plus “software”

    • Not just the drug, the indications, side effects, motivational counseling

    • Not just the diagnostic, the interpretation and the decision making

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  • Definition of “Impact”—the effect of treatment 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 organizational factors that determine degree of centralization?

    • Incentives of decision-makers and agents

  • How does centralization affect the impact of primary services on the poor?

    • Incentives of decision-makers and agents

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  • Definition of “Reach”-The ability to bring more 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 tradeoff between reach and impact

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Example of Law 1

  • Example from TB

    • Reach is number of people who can access diagnostic 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


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TB Model : Reach Matters

Population Benefit=Reach  Impact

TB Burden

High Reach Low Reach

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Dual Impact of Reach and Impact

Population Benefit=Reach  Impact

High Burden


Low Burden


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Illustration of Law 2

  • Buying more TB reach means

    • Investing in training front line public and private workers to make the diagnosis

      • More clinics in more places that know how to diagnose

      • More diagnostic facilities

  • Buying more TB impact means

    • Investing in training public TB facilities to maintain good DOTS programs

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It is like fighting a battle

  • General has to defend a mile long line of defense (Reach)

  • Has different quality troops (Impact)

    • Cannon ($100)

    • Cavalry ($10)

    • Foot soldiers ($1)

  • Can’t afford cannon for every inch of the line

  • Shouldn’t use only foot soldiers

    • Deploy forces strategically

    • Achieve ideal mix

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Managing Primary Service Delivery

  • Each unit has a certain amount of effectiveness

    • Can improve the unit

    • Can build more low quality units

  • Who manages the big decision of where the troops go?

    • Market forces

    • Public policy

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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 and politics

    • Hospitals have economic gravity

      • Impact hundreds of health worker livelihoods

      • Supply chains and financing infrastructures are hard to change

    • Hospitals have political gravity

      • Civic pride

      • Sense of security for middle/upper class

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

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Incentives in Hospitals

  • For-profit hospitals

    • Owners maximize: Profit=Revenue-Cost

      • Bring in more revenue from more paying customers receiving high 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. tertiary is both a political question and a public health question

    • Political gravity of hospitals pulls them to centers 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 recurrent cost

      • (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 health workers at public facilities maintain private practices

    • 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 would otherwise 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 unless government pays wages that one can live on

    • Solved the main public problem of getting health workers 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 a health worker can earn in private practice

    • Health station utilization rates are low

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

    • Drive around and see private practices with busy waiting rooms

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Treating Private Market Pathology

  • Ask former health station workers for advice on incentives for dual practice

  • Improve finance at public health stations

    • Demand side strengthening with insurance

    • Supply side finance with contracting or budgeting

  • Improve non-financial incentives at public health stations

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NGOs/Private Not for Profits

  • NGOs mix features of government facilities and private 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 those they are serving

  • Service mix not always tied to government objectives

    • 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 sector NGOs well-intended activities interfere with the smooth performance of the primary service delivery 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 autonomy national priorities.

  • Some say “No”: NGOs inject new resources that would not otherwise be in health 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 NGO priorities: 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-wide approaches (SWAPs)

    • Ministry of Health convenes meetings to establish minstry’s priorities and invites input

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  • Best health impact from doing the right thing 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 imposes user fees on the poor, adherence with treatment can lower impact

  • Do health workers practice same level of quality in their private practices as public?

  • Governance systems have had difficulty governing the impact of workers who are entirely private

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Different political systems. None is naturally oriented to the poor

Liberal Democratic










Whether decentralizing serves the poor depends:

Which decision makers care about the poor?

Power is the currency of all political systems

Poor people don’t have power

Reach, Impact, and the Poor

  • Public health systems natural tendency is to serve power not need

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Summary the poor

  • Primary health care (PHC) delivery system takes ingredients (providers and supplies) makes services

  • 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 the poor

  • Methods for how to measure these indicators

  • Break into groups and decide on how to make indicator meaningful for local use.