Transcript Global Health Master class on Health Systems analysis

Global Health Master class on
Health Systems in LICs
Barbara McPake, Institute for
International Health and Development,
Queen Margaret University, Edinburgh
and
Peter Annear, Nossal Institute for Global
Health, University of Melbourne
Structure of session
• What is the current context of health system
development in low income countries?
• A review of frameworks of analysis designed to
address health system problems and identify
ways forward
• Conclusions – comparative value of frameworks
• Case studies of these frameworks in action
– In Cambodia (Peter)
– In Uganda (Me)
• Conclusions – ways forward for health systems
Current context of health systems in
low-income countries
Changing global demographic and
disease situation
Millennium Development Goals (+)
Global Health Initiatives and their ‘health
system strengthening’ components
Universal coverage and other health
financing policies and debates
Health expenditure per capita: $PPP, 2008 (WHOSIS)
Health expenditure (as previous slide) compared to GDP per capita
(IMF, 2010; international $)
Human Resources for Health and
current initiatives
• Consensus in 2011 that health systems don’t
work and won’t cope with coming challenges
without
– significant investment
– new approaches
• Where will new investment come from?
• Where will new approaches come from?
Need for health system analysis
• Series of competing frameworks to shape that
analysis from international agencies
– Building blocks framework (WHO)
– Control knobs (WB flagship course)
– Marginal budgeting for bottlenecks (UNICEF +)
• And some from individual analysts such as
– Berman (2008)
– Kruk and Friedman (2008)
– McPake, Blaauw and Sheaff (2006)
www.qmu.ac.uk/iihd
A good health financing system raises adequate
funds in ways that ensure people can use
needed services, and are protected from
financial catastrophe or impoverishment
associated with having to pay for them. It
provides incentives for providers and users to
be efficient.
Revenue
generation
Access
Financial protection
Incentives for
efficiency
Control knobs framework
Financing
Payment
Organisation
Regulation
Behaviour
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Control
knob
Financing
Description
Payment
How are providers (hospitals, clinics, managers,
physicians, nurses etc.) paid?
SDO
Who delivers health care and in what settings? How
facilities organised? Where do people go for care; why?
Where does funding for the health system come from?
How are funds pooled? How allocated and spent?
Regulation How are different actors in the health system – insurers,
producers of inputs, providers and facilities regulated?
Politics
How can health system reformers mobilise the political
support needed to bring about positive change
Behaviour How does personal behaviour of providers and patients
influence both individual interaction with the health
system and individual health?
Marginal budgeting for bottlenecks
• 5 Steps:
1. Assessment of key indicators, trends in and
causes of maternal, newborn and child mortality
and morbidity and access to essential services
and the selection and packaging of interventions
to address causes
2. Identification of system-wide supply and
demand bottle-necks to adequate and effective
coverage of essential primary health care
services
3. Estimation of the expected impact on
survival rates for each of the interventions
4. Selection of the types, quantities and costs of
additional inputs
5. Analysis of the budgetary implications, the
identification of likely sources of funding and
the comparison of the marginal costs and
additional funding needs to the ‘fiscal space’
Bottleneck indicators
• Availability of drugs, vaccines, supplies and HRH
• Accessibility: presence of trained human
resources at community level; number of villages
reached at least 1/month by outreach; time taken
to reach a facility providing EMONc
• Utilisation: first attendances by service
• Adequate coverage: % target group receiving a
service
• Effective coverage: quality of care (skills of health
worker)
Coverage Bottlenecks for Skilled Attendance at Birth
(BDCS Districts - MP)
120%
100%
80%
Access Bottleneck
60%
40%
20%
0%
Availability delivery kits
& gloves
Access to ANM doing
deliveries
Deliveries by skilled
attendant
Skilled attendance+PNC ANM/MD with Life saving
and BW
skills
Dynamic responses model of the
health system
Dynamic responses:
How people (‘users’ and
‘providers’) react and
interact in response to
formal structures and rules
De facto system:
De jure system:
Organisational structures
Intended incentives
Management procedures
Training courses
Services as
experienced by (poor)
people
For example: access;
quality
www.qmu.ac.uk/iihd
Comparative value of different
frameworks
• Building blocks framework enables comprehensive
description of a health system: a check list of things
not to forget about
• Marginal budgeting for bottlenecks enables
identification of priority problems and micro
interventions
• Control knob framework enables identification of
possible macro interventions
• Dynamic responses framework enables analysis of
macro and micro interventions in implementation –
what affects their success and how to make more
successful
Case studies
The building blocks approach in
Cambodia
Why performance-based contracting
failed in Uganda: evaluating the
implementation, context and complexity
of health system interventions
Freddie Ssengooba , Barbara McPake and
Natasha Palmer
www.qmu.ac.uk/iihd
Background
• DRG of World Bank and Uganda MoH instituted a
randomised experiment to test performance
based payment for non-profit health providers in
5 districts of Uganda
• Implemented between (about) 2004-2006
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The DRG’s own evaluation is a ‘black
box’ type
‘Intervention’
‘Performance’
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Our evaluation focused on looking
inside all three boxes
‘Intervention’
What did it really
consist of?
Design features
Implementation
features
Who came into contact with the
intervention?
How did they react?
How did they influence others?
What chains of effects were
initiated and how was hospital
performance affected?
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‘Performance’
What has been
measured? What has
not?
The DRG design in more detail
• Randomised trial
• ‘Control group’ – continued with pre-existing
arrangements (received government grants and used
them according to guidelines)
• ‘Autonomy group’ allowed to allocate government
grants without restrictions of guidelines
• ‘Bonus group’ received grant as before; allowed to
allocate grants with autonomy; received bonus if
they achieved or exceeded targets
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DRG Conclusion:
• ‘..assignment to the performance-based bonus
scheme has not had a systematic or discernible
impact on the production of health care services
provided by PNFP facilities. … it appears that facility
autonomy in financial decision-making has a positive
impact on health care production. Those facilities
that were granted the freedom to spend their MoH
base grant .. increased their output relative to other
facilities in the sample’
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Opening up the first box: what is the
detail of the programme design?
• National workshop July 2003. Major stakeholders
invited to 2 day meeting. Pilot explained; pilot
districts selected, randomisation undertaken
• Baseline survey of outputs by PIT
• Selection of survey targets undertaken by
participating facility managers at one day meeting;
further orientation for managers
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• Signing of performance contracts
• Support and mentoring of HMTs (by PIT)
• 6 monthly performance surveillance: check
records; measure output volumes for selected
targets
• Feedback on performance relative to selected
targets
• Bonus award
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What was really implemented?
• Funding shortfall. MoH did not provide counterpart
funding as DRG expected
• Initial activities were undertaken, then long gap
while funds for follow up sought
• Follow-up (partial) funder changed the design – no
support for control group, reduced scope of feedback
meetings
• Support and mentoring lost to funding shortfalls and
priority for measurement activities
• Measurements rescheduled to save money – no time
to respond to last period performance review
• Further ad-hoc changes to design by the PIT
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Opening up the second box: how did
participants in the programme react?
• Implementers cut corners for the sake of time and cost
savings
– Selecting service targets: No opportunity for prior planning
with full facility management team; 2-3 members of the
hospital management team including a member of the
Board of Governors given a few hours in the one day
meeting to make this choice
• Implementers changed the rules and refused to allow
managers to change the targets for the second year
Implications
• Lack of strategic choice in selecting targets
• Lack of communication of programme to
other members of staff in hospitals
www.qmu.ac.uk/iihd
• ‘we selected .. I think OPD (looks up the file and
reads from it) ooh no! … yeah I wish we had selected
OPD. We selected maternal deliveries, immunization
and malaria treatment …’
• malaria, there is this home based management of
fevers (new program) that we did not factor in at the
start of PBC. We thought the malaria will always be
there but it was not to be. So I really don’t know how
we can treat 10% more malaria at this hospital’
Lack of communications within
hospitals
• Delays after inception of the programme in
appointing coordinator and releasing funds
• Lack of institutional memory within hospitals
by time programme really started
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• When bonuses were announced, different
approaches were taken to deciding on their
use
– Staff appreciated parties from which all
shared in the hospital’s success
– They accepted hospital improvements as a
good use of funds, where they were
consulted
– They disliked any attempt to reward
individuals according to their contributions
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Opening up the third box: What
performance was really measured?
• Primary registers instead of HMIS reports were used
for performance verification – attributed to the fear
that the aggregated HMIS reports were vulnerable to
manipulation (deviation from contract)
• Major workload implications for the PIT
• PIT concurrently tasked to collect additional data to
measure impact of the intervention: household
surveys, survey of organisational capacity; client exit
polls; count other service outputs to assess change
of case mix
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Implications
• Contract relevant performance verification
measurement crowded out by additional data
collection
• Reliability of measured output volumes
compromised. PIT team were not familiar with
clinical shorthand and recording practices in clinical
registers
DRG insight into why their intervention
didn’t work
• ‘Why has the performance bonus not worked? One
can imagine a number of possible explanations. First,
perhaps the performance bonuses were not large
enough. … Second, the performance bonus was paid
to the facility and not to the individual providers
directly. … Third, it is possible that the performancebased contract was too difficult to manage. …
Finally, it is possible that the experiment has not had
long enough to take effect.’ [10 page 31].
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Conclusions on Uganda
• Opening up the boxes gives information
needed for developing and managing the
intervention
• Multiple open box evaluations allow
understanding of how different types of
interventions relate to contexts
• Over multiple evaluations common patterns
that identify more and less promising types of
interventions emerge
Ways forward for health systems
• Challenge of ageing, NCDs and the financing gap – LICs
will not have health systems that look like those in HICs
in foreseeable future
• Universal access and comprehensiveness of health
system response are not compatible
• Prevention will have to be much more successful than
in HICs
• However much higher levels of health financing will be
required in the lowest income countries…
• … after which there is scope to apply various
frameworks of analysis to maximise desired health
system outcomes – which are common across the
frameworks
• Frameworks have distinctive contributions to make