Transcript FLGP M 3 - behdasht.gov.ir

In the Name of God
Dr Kambiz Monazzam
Lorestan – Khoramabad May 2005
Review of Health
Sector Reform:
The Basics
May 18-21, 2005
Khoramabad - Lorestan
Dr Kambiz Monazzam
Reform: Definition
“sustained, purposeful and fundamental
change”
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“Sustained” in the sense that it is not a "one
shot" temporary effort that will not have
enduring impacts;
“Purposeful” in the sense of emerging from a
rational, planned and evidence-based process;
“Fundamental” in the sense of addressing
significant, strategic dimensions of health
systems .
Why do we Reform?
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Health problems/Health System
Problems
Who find the Problems...?!
Unhappy People
....!
?
What Starts The
Cycle of Reform?
Economic crisis
 Political change
 External pressure
 Unhappy interest groups
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Main Goals of
Health Sector Reform
Equity
 Efficiency
 Quality
 Sustainability
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Fiscal Impact
Satisfaction
Access
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What do we need
“ R ” or “ r ” ?
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It depends on
degree, severity &
complexity of our
problems
!?
Reform Cycle
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Is there any space for politics?
Define The Problem
Evaluate
Identify Causes
The Health Systems
Reform Cycle
Implement
Develop Options
Decide What to Do
Politics
Health
Sector
Reform
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Economics
Management
Health Sector Reform Context
Problem Definition
Evaluation
Diagnosis
The Simplified
Policy Cycle
Implementation
Policy Development
Political Decision
Problem Definition
P
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Evaluation
Diagnosis
The Political
Policy Cycle
Implementation
Political Decision
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Policy Development S
Economics & HSR
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If someone asked you to find one problem of
all human which is the most important to them,
What problem do you address?
Needs / wishes
they can’t reach
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If someone asked you to find one problem of all Governments
which is the most important to them,
What do you say?
People Needs
they can’t meet
Lack of
Enough
Money
Economics?
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Definition ?
Gifted shared 100,000 to
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How do you do with 100,000 $ ?
How do you divide 100,000 $
between 5 people?
between 1000 people?
between 1000,000 people?
Money
People is different
Individual desires &
preferences
 Social desires & preferences
 Individual behavior
 Importance of the issue
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Decision making
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How decision could be made?
Values
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Who Decide?
Organization
Management?
Plan to Reform / Change
Through: ?
 Five Control Knobs
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Financing
Payment (Incentive Structure)
Macro-Organization of Provision
Regulation
Persuasion (Behavior)
Reform Cycle
Define The Problem
P
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Evaluate
Identify
Causes
The Health Systems
Reform Cycle
Implement
Develop Options
Decide What to Do
E
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Define The Problem
What’s the problem?
Is there
any problem?
Current
P
Goals
Define The Problem
How many?
How much?
Real or
Opinion?
YES
Define The Problem
Goals
Functions the system performs
Intermediate Goals
EQUITY
Stewardship
(oversight)
Ultimate Goals
Responsiveness
(to non-medical
expectations)
ACCESS
Creating resources
(investment
and training)
Delivering
services
(Provision)
EFFICIENCY
Health
FISCAL
IMPACT
Financing
(collecting, pooling
and purchasing)
Fair Financial
Contribution
What Constitutes the
Health System?
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Care providers
Financial intermediaries
Input producers
Planners and regulators
Preventive service providers
Other actors producing
system outcomes
Characteristics of
Health Systems
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Complexity: multiple actors with
multiple connections
Conflict: different participants have
different objectives
Politics matters: decisions inevitably
reflect political process
Societal context matters: conditions
and options reflects culture, history and
social norms
Define The Problem
How Should We
Define Problems?
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The health system is a means.
Reformers need to think deeply
about the ends
Problems should be defined
based on poor performance
in terms of outcomes
Define The Problem
How Should We
Define Problems? Cont’
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Aspects of the system only need to
be changed if the changes
contribute to improving poor
performance
Defining the problem has to be
done carefully because it will
influence what solutions you choose
Define The Problem
How Do We Know
Which Aspects of
Performance Matter?
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Different groups will have different views
Political processes often produce an
uneasy compromise
Reformers can influence those processes
Reformers have to consider ethics and
values to know what performance
problems to focus on
Define The Problem
The Role Of Ethics
In Problem Definition
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Deciding what aspects of performance
matter is not just a technical question
Deciding what matters requires values
Exploring ethical theory allows us to clarify
both our assumptions and their implications
The problem definition influences all that
follows
Define The Problem
How do you find to
meet the goals?
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Which
Indicators?
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Equity
Efficiency
Quality
Sustainability
Fiscal Im
Satisfacti
Access
Review of Health
Sector Reform:
Diagnosis &
Option appraisal
May 18-21, 2005
Khoramabad - Lorestan
Dr Kambiz Monazzam
How many problems
do you have in the
health / system !?
Identify Causes
Identifying Causes:
The Diagnostic Journey
Identify Causes
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Start with performance
problems
Ask “why” five times
Go from causes, to
causes of causes, etc.
Work “backwards”
Be “evidence based”
Start with problems:
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Where they are?
Identify Causes
Who can find the problems?
people have different ideas!
Which Problem is more important
than the others?
Who can exactly define the
problem?
Experts, Managers, People, Data …
Which areas are important?
Start with problems:
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Find
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Research
Situation analysis
Expert’s view
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Time
Money
Expertise
List & Classify
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Affinity diagram
Logical cause & effect Diagram
Problem Tree
Identify Causes
Problem identification – (What)
What exactly is the problem?
Who or what is most affected by this
problem?
How serious/important is the problem?
What supportive data/facts do you have to
demonstrate this severity or importance?
Is this problem manageable in scope?
Is this problem more important and
devastating than any other problems?
Is this problem more influential/crucial to
the current situation than any others?
Can you afford to ignore this problem for
the time being?
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Identify Causes
Problem analysis - (why)
Problem analysis is to
understand why there
is a problem or what
are the factors that
contribute to the
problem and the
interrelationship
between these factors.
Identify Causes
Tools / Techniques:
Problem Tree
Fishbone Diagram
Force Field Analysis
SWOT or SWOC
Analysis
The 7s Model
Problem Web.
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Identify Causes
Finding Root Causes:
•Problems have a cause &
effect relationship or other
inter relationship between
them.
•At last: In health you reach
a specific tree, which have
multiple roots
•Go backward, find evidence
•Red line
Identify Causes
Logical vs. political
way of thinking to
solve problems
•Logical:
Problem Tree
Fishbone
Diagram
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•Political:
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Force Field
Analysis
Decision Space
…….
Identify Causes
Tools for Political Analysis
How do people think about
political processes for policy
change and implementation?
• When decisions are made:
Policy process sequences
• How decisions are made:
Decision-making models
• Who makes decisions:
Stakeholder analysis
• Boundaries: Governance rules
and Broader Contexts
Identify Causes
Policy Process Sequence
Signaling
Evaluation & Feedback
Implementation
Consultation and Formulation
Aggregation
Ratification
Political
Side
The Health Systems
Reform Cycle
Ethical
Side
Developing Options
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Build on a sound model
of
a) what drives health
system performance
b) what can be changed
Develop Options
Developing Options
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“Imitate but
adapt”
- learn from others but consider
local conditions
Develop Options
Developing Options
“Process matters”
– how you go about this task
will influence the political
acceptability and the quality
of the plan
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Develop Options
Reaching A Political Decision
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Health sector reform
is unavoidably
political
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Decide What to Do
Doing better
requires :
political skill,
not just
political will
Reaching A Political Decision
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Stakeholder analysis
as a starting point
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Decide What to Do
From “mapping”
to strategy
Review of Health
Sector Reform:
Treatment
May 18-21, 2005
Khoramabad - Lorestan
Dr Kambiz Monazzam
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Implementation
Good ideas are
not worth much
Implement
If
They can not be
implemented
Resistance to change is
almost always present
The old adage,
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Implement
“Better the devil
you know than the
devil you don’t,”
embodies this idea.
Resistance to change is
almost always present
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Psychological
New procedures
and structures are
strange and
unfamiliar.
 For many, the mere
fact of newness
creates anxiety and
resistance
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Implement
Resistance to change is
almost always present
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Implement
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change can bring costs
to specific groups and
individuals.
New procedures and
arrangements take time
and effort to learn.
Existing hierarchies can
be upset.
Resistance to change is
almost always present
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Implement
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Those who benefited
from the old system can
lose greatly.
those most successful
under the old system
have the most to lose;
hence, the currently
powerful are often the
most opposed to
reform.
Resistance to change is
almost always present
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Thinking Behavior
Difficulty we all have in
giving up familiar ways of
thinking
 Past, can have a strong
hold over us
Established patterns are
potent & fixed, If one want
to do differently, feels
extreme pressure
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Implement
Many Health Sector Reform Efforts Have
Failed at The Stage of Implementation
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Implement
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Ministers often lack
administrative experience
Leaders turn over quickly
Implementation is not
considered in program
design
Entrenched interests
resist
Political attention turns
elsewhere
Reaching A Political Decision
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Implement
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Decide What to Do
Health sector reform
is unavoidably
political
Doing better requires
political skill, not
just political will
Stakeholder analysis
as a starting point
From “mapping” to
strategy
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sophisticated leadership
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Monitoring
Implement
appropriate reporting
system
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Evaluation Plan
Evaluate
how well it has achieved?
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Before designing and conducting an
evaluation, the evaluator needs to be
clear on the issues such as:
Why evaluation is needed;
To whom the evaluation results will be
required and useful;
What data is needed and where and how
to collect it;
What comparative exercise should be
made.
Evaluate
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Keys To A
Successful
Evaluation
Design an evaluation strategy
in advance
Anticipate likely problems
Collect data before you begin
Create incentives for good
evaluation
Evaluate
Keys To A
Successful
Evaluation
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Before-and-after comparison
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Control group
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Similar neighboring country
Evaluate
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Collect baseline data
 Data is not free
 Data cost on people
 Time consuming
 Over-collection
Define The Problem
P
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L
I
T
I
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S
Evaluate
Identify
Causes
The Health Systems
Reform Cycle
Implement
Develop Options
Decide What to Do
E
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H
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C
S
The last point:
Five Core Elements:
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Importance of ethical theory
Explicitly identified health system
performance objectives
Systematic approach to health
system diagnosis
Use of the health system control
knobs
Political analysis
The
that moves the mountain
Political linkage
Social
movement
Knowledge
generation