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
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
Outline
• Ingredients of the services system
– Local Example from Vietnam
• Reach vs. impact on the “last mile”
• Institutional norms of service delivery
system
Part 1: Ingredients of Primary Care
Ingredients
• 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
Centrality of Health Services
Health Financing
Health Workforce
Governance
Health Services
Delivery
Households
Supplies
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
Design of Primary Health Care
• Different levels of Facilities
– Primary, Secondary, Tertiary
– Public, Private, NGO
• Different specialties
• Variable quality
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)
Examples
Country Example
Philippines: decentralization of responsibility for
primary 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 become
more difficult.
Mali: independent health centres are not-for-profit
cooperative establishments owned, financed and
managed by community; recruit their own staff.
Few financially independent in practice.
Metrics Affected
Stewardship
Financial equity
Dignity and Respect
Equity
Croatia: previously centrally employed, salaried
ambulatory care physicians. Now they are
independent contractors.
From ‘Table 3.2 Examples of organizational incentives for ambulatory care’, World Health Report 2000
From Matsuda 1997
Utilization Patterns in Vietnam
Vietnamese Health Expenditure
ITEM
2000
2002
2004
2006
Total 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
Part 2: Last Mile: Impact and Reach
The Last Mile Problem
•High capacity conduits
•Centralized
•Easily manipulated
•Low capacity conduits
•Spatially disbursed
•Costly to access
The Last Mile: Examples
•Fiberoptic trunk lines
•Arteries
•Interstate highways
•Tertiary hospitals
•Copper wire
•Capillaries
•Back roads
•Rural drug sellers
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
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
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
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
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
Fundamental Laws of Service Delivery
• Law 1) Population Benefit=Reach  Impact
• Law 2) In any budget, there is a tradeoff
between reach and impact
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
TB Model: Impact Matters
Population Benefit=Reach  Impact
TB as function of diagnostic quality
TB Burden
350
300
TB Burden
250
200
150
100
50
0
20
21
22
23
24
25
26
27
28
29
Proportion of Active TB Patients Diagnosed by Clinic
Average Diagnostic Delay 25 Weeks
Average Diagnostic Delay 8.3 Weeks
Average Diagnostic Delay 4.1 Weeks
Average Diagnostic Delay 5 Weeks
Impact
30
TB Model : Reach Matters
Population Benefit=Reach  Impact
TB Burden
TB Burden as a function of Diagnostic Delay
350
300
TB Burden
250
Proportion Diagnosed 20%
200
Proportion Diagnosed 26%
150
Proportion Diagnosed 30%
100
50
0
0
5
10
15
20
25
Average Diagnostic Delay in Weeks
High Reach
Low Reach
Dual Impact of Reach and Impact
Population Benefit=Reach  Impact
TB as a function of Reach and Impact
Impact
Percent Diagnosed At Presentation
120
High Burden
100
80
60
40
Low Burden
20
0
0
5
10
15
20
25
30
Mean Delay in Weeks Between Symptoms and Diagnosis
TB Burden 0.004
TB Burden 0.0045
TB Burden 0.0055
Reach
TB Burden 0.006
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
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
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
Part 3: Institutions that govern reach
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
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
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
Ecology of Medical Care-USA
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
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
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
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
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?
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
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
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
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
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?
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
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
Part 4: Institutions that govern impact
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”
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
Reach, Impact, and the Poor
• Different political
systems. None is
naturally oriented to the
poor
– Liberal Democratic
• USA
– Egalitarian-Authoritarian
• Cuba
– Traditional-Inegalitarian
• 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
• Brunei
– Authoritarian-Inegalitarian
• Sudan
– Populist
• Kenya
•Public health systems natural tendency is to serve power not need
Summary
• 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.
Exercise on Performance Metrics
• Methods for how to measure these
indicators
• Break into groups and decide on how to
make indicator meaningful for local use.