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Service Delivery System

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Service Delivery System

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  1. Service Delivery System Lecture 3: Reach and Impact

  2. 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 Leadership and governance to assure quality Health systems financing Supplying medical products and technologies Health systems information Households • Today we focus on primary health service delivery

  3. Outline • Ingredients of the services system • Local Example from Vietnam • Reach vs. impact on the “last mile” • Institutional norms of service delivery system

  4. Part 1: Ingredients of Primary Care

  5. Primary service delivery made up of Health care service providers Facilities Drugs and supplies Governance Maintaining each ingredient is the work of an entire additional subsystem Agents Units Institutions Ingredients

  6. Centrality of Health Services Health Financing Governance Health Workforce Supplies Health Services Delivery Households Health Information

  7. 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

  8. Design of Primary Health Care • Different levels of Facilities • Primary, Secondary, Tertiary • Public, Private, NGO • Different specialties • Variable quality

  9. 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)

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

  11. From Matsuda 1997

  12. Utilization Patterns in Vietnam World Bank 2000

  13. Vietnamese Health Expenditure

  14. Part 2: Last Mile: Impact and Reach

  15. The Last Mile Problem • High capacity conduits • Centralized • Easily manipulated • Low capacity conduits • Spatially disbursed • Costly to access

  16. The Last Mile: Examples • Fiberoptic trunk lines • Arteries • Interstate highways • Tertiary hospitals • Copper wire • Capillaries • Back roads • Rural drug sellers

  17. 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

  18. 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

  19. Impact • 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

  20. 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

  21. Reach • 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

  22. Fundamental Laws of Service Delivery • Law 1) Population Benefit=Reach  Impact • Law 2) In any budget, there is a tradeoff between reach and impact

  23. 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

  24. TB Model: Impact Matters Population Benefit=Reach  Impact TB Burden Impact

  25. TB Model : Reach Matters Population Benefit=Reach  Impact TB Burden High Reach Low Reach

  26. Dual Impact of Reach and Impact Population Benefit=Reach  Impact High Burden Impact Low Burden Reach

  27. 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

  28. 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

  29. 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

  30. Part 3: Institutions that govern reach

  31. 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

  32. 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

  33. Hospitals • 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

  34. Ecology of Medical Care-USA

  35. 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

  36. 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

  37. 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

  38. 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

  39. 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?

  40. 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

  41. 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

  42. 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

  43. 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

  44. 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?

  45. 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

  46. 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

  47. Part 4: Institutions that govern impact

  48. Impact • 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”

  49. 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

  50. Different political systems. None is naturally oriented to the poor Liberal Democratic USA Egalitarian-Authoritarian Cuba Traditional-Inegalitarian Brunei Authoritarian-Inegalitarian Sudan Populist Kenya 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