District Health system Management:Wed. 30.09.09

BEHS III

Mangwi R. Ayiasi

Introduction

• How do you think the Museveni bush war was organised and won?

• How was the 1979 Uganda Liberation war executed?

• What strategies did both ‘liberation wars’ employ?

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Introduction...

• Have you ever been to hospital for any conditions?

• Have you ever attended to your relative or dear one at hospital?

• What was your experience while in Hospital-what did you like/dislike about the hospital, the people and the treatment?

• What would you like to see done in the health care setting?

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Think about this

• The trees versus the forest

• The disease in the person or... the person with the disease

• Individual or people or communities

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Introductions

• In Europe life-expectancy started to drop before antibiotics or vaccines

• Diseases have certain determinants: – Ecological– Social & Gender– ....

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Introductions: Thinking about the poor

• Less likely to seek care– Distance from health care

– Out-of-pocket expenditure & the poverty cycle!

• Susceptibility to ill health:– Access to clean water

– Safe housing & medical care

– Information

– Adequate nutrition6

Content:

• History & Evolution of the health system-Global, National

• & Definition (s) of the health system

• Goals and Principles of health systems

• Structure of the Health system

• The district Health System in Uganda

• Challenges of the health system

• Which ways to go in our health system

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HS=A Quasi-Military ApparatusJust like any army aiming to win a battle, behind

them:

• The frontline fighters must be adequately trained, informed, supplied, inspired and led

• Treat the population whom they are to protect well

• Teach the “civilians” how to protect themselves and their families against ill health

• And to fairly share the burden of the war

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The HS=A Quasi-Military Apparatus:• “Fighting” Malaria, HIV & TB

• Immunisation “Campaign”

• “Combating” Small Pox

• “Elimination” of Polio, Measles

• “Silver bullets” against Cancer

• Likewise health workers can be considered “Frontline” troops “defending” populations against disease

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History of Health systems:

• Throughout history health systems have existed

• People have always tried to keep healthy or attempt to treat disease

• Traditional/Modern methods continue to co-exist

• Traditional medicines still main source of care: the modern one not well understood, mistrust, expensive, ....

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History of modern health system Uganda..

• Initially by the colonial masters

• Located in the urban areas

• Specifically to serve the colonialists and a few of their workers and their families

• Health workers were initially the colonialists

• Later training of the indigenous to perform the ‘lowly’ work

• Wound dressers, medical assistants, assistant doctor BUT NOT Medical Officer!

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History...

• A few dispensaries and sub dispensaries

• Independence/post independence-maintained the hospital structures with dispensaries

• More emphasis on hospitals less attention to dispensaries-Sir Albert Cook Hospital

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History...

• Quarantine centres: Leprosy, SS,...

• Note that:

- Hospital maintenance is very costly

- But also most of our diseases burden could be

adequately managed at the health centres

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History...

• Globally, the realisation that disease killed more than the many wars: American civil war, Crimean & Boers wars

• Post WWI,II, Development of payment system-Bismarck, National health services and spread to Rest of Europe

• Importance to treat tropical diseases-following return from Africa

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History...

• Importance of the Political History of Uganda right from the 1900 agreement

• Wars, armed conflicts & rebellions

• Destruction, hunger etc

• Introduction of Parallel political and administrative structures-LC, RDC, CAO

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History-Reforms...

• Structural Adjustment Program-SAPs

- Introduction of User fees/Abolition

- own-sizing the public service

• Donor Funding-New Money- Aid alignment-Paris Declaration

• Decentralisation strategy

- Fiscal decentralisation strategy-FDS

- Local councils-I-V

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Changing landscapes-Today’s Health Systems

• Financing mechanisms-US-The Obama health reforms

• Africa-User fees, abolition, exemption; Asia equity funds in Cambodia, Community health Insurance; Social health insurance in Africa & Asia

• Social Health Insurance (SHI)

• Migration of health workers-Brain Drain

• Aid Alignment-Budget Support, Sector Support

• Global Health Initiatives (GHI)

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Health system-definition

• All actors,..

• institutions,...

• resources that undertake...

• health actions-with the primary intent...

• to improve health.

• Broader than the health actions typically under the direct control of a health ministry

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Principles of the health system-PHC

• Equity, Universal access, Community Participation, Inter-sectoral Approaches

• Account for a broader Population Health issues

• Conditions for effective provision of services to the poor and excluded groups

• Provision of integrated care

• Continuous evaluation for improvement

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Health inequalities

• A child in Japan can not only expect to get reasonable access to health care throughout her life,...

• but also to receive medicines worth, on average, $550 per year (and more if necessary)

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Inequities of access in the Health System

• Inverse care:– Rich-Poor

– Urban-Rural/Urban rich-Urban Poor (slum)

– Educated-Less/not Educated

– Male female

– Adult-children

– Politically Powerful-Powerless

– Ethnicity

– Minority communities

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Goal of the health system

• The ultimate goal of the health system is to improve health-population,

• Reduce inequalities in population health

• Enhance the responsiveness of the health system-non health expectations: respect of persons, client orientation, inequalities within population

• Fairness in financial contributions-the poor paying less; the rich paying more

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Three Goals of the health system

Improve health as a primary objective

• What about the Education sector?

• Road sector....?

• Water department?

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Fairness in $ contributionFairness in financial contribution-Financial

Protection or economic sense “you get what you pay for!”

• Ill health is unpredictable, and costs are unpredictable

• Danger of exhausting all your savings/Assets to ill health

• Catastrophic health care expenditure

• Who should pay for health care and how should this payment be organised?

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Responsiveness

Responsiveness: Respect for:

• dignity, • autonomy & • confidentiality-

A Social Goal!

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A means to good health

A Health system has to be utilised...but this will happen only when it is:

• Accessible

• Affordable

• Acceptable

• Sustainable

• Of Good quality

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Health systems functions

• 1. Financing

• 2. Service provision

• 3. Resource generation

• 4. Stewardship

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1: Financing

• Revenue collection

• Pooling of finances

• Purchasing

• Consider the case of Uganda-how is the health system financed?

• What could be the better option for financing?

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2: Health Service provision

• Combined inputs to allow delivery of interventions

– Personal: individual, diagnostic, rehabilitative

– Non-personal: collective-health education, legislation or non-human-basic sanitation

• Formal and informal services

• Private or public service providers

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2. Service provision

• Work Force and Incentives: Economic, psychological, Social

• Essential Medicines-Supply chain management

• Intelligence/Information Gathering-HMIS, Surveillance

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Service Provision: The Agent & Principal

• Definitions – “The Principal” =the one who makes the request

– “The Agent”=the one requested

– “A Contract”=an offer by the principal to the agent to offer incentives to perform a task

– Who is the ‘Principal’ & ‘Agent’ in Uganda?

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3:Resource generation

• Workforce through-Educational institutions & Research centre

• Buildings and Equipments/Construction firms

• Technology: pharmaceuticals, equipment

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4: Stewardship

Careful and responsible management of something entrusted to ones care:

• Setting rules/Regulations

• Implementing the rules

• Monitoring the rules

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4: Stewardship...

• Assuring a level playing-ground among all actors

• Vision/Defining strategic directions for the health system

• Intelligence gathering/information sharing

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Health systems function & Objectives

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Nature of health systems

• Health systems are complex open systems– Contain a high number of interdependent and

interacting components – Interact also with elements from the environment

: highly context dependant– Results of these multiple interactions are to some

extent unpredictable36

Health systems performance!!

• HS are constantly concerned about performance and therefore efficiency!

• Resources are scarce-they have to be allocated efficiently and utilised efficiently

• Numerous competing priorities-emerging (e.g.) diseases, re-emerging diseases (e.g.)

• Strong demand from populations and governments

• Culminates in resources management

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Health systems performance

• IMPACT &

• REACH

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Health system performance

• Structure

• Process

• Output

• Outcome

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Health systems Performance...??

• How much of the goals can the health system attain with the given resources?

• How much can be demanded from the health system?

• How much has the health system achieved in terms of the goals?

• How do they carry out their functions

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The Last Mile Problem

•High capacity conduits

•Centralized•Easily manipulated

•Low capacity conduits

•Spatially disbursed•Costly to access

Health systems performances!!

• How can health systems be:- Fair- More inclusive- More Equitable

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Health Systems Performance!

• We still witness - A mother die from complications of labour- A child still missing immunisation- Children being disabled by polio- People dying from preventable RTA- Impoverishment from high cost of

healthcare- ...

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Health systems performance

• Globally, there is improvement in population health

• But, some countries are completely left behind– “The Bottom Billion!”– Also inequalities within countries

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Health systems Performances...

1. The overall level of health

2. Distribution of health in the population

3. Overall level of responsiveness

4. The distribution of responsiveness

5. The distribution of financial contribution

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Efficiency as an absolute measure

• For example: Life expectancy of Sweden: Uganda almost twice because Sweden spends about 35 times more than Uganda

• But Pakistan: Uganda-Pakistan has 25 years higher life expectancy yet they spend just about the same amount per capita for health

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Current challenges in the health systems

• Unstable and changing systems-Reforms-Shifting roles between the centre and the

district & sub districts- Conflicting roles-management & curative

services• Increasing importance of the private sector-less

regulation– Financing-commercialisation

• Globalisation-Migration of the workforce– Inequity in workforce distribution

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A booming private sector-at the expense of the pubic sector-’Marketosis!’

• Unregulated private sector-informal privatisation

• From informal payment systems to cost recovery

• “Services here are free, but please go and buy these medicines”

• Moonlighting among public workers48

...A booming private sector

• Those who cannot afford are excluded• Those who can afford may not necessarily get

the care they need• Asymmetry of information• Supplier induced demand• Most often too much of what is not needed

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...A booming private health sector

• The quest for treatment• Through a succession of ineffective therapies– Consider someone with a chronic disease

• Consumption of savings and other assets• Eventually poverty-two pathways– 1. through death or inability– 2. Excessive expenditure sale of assets etc

• Iatrogenic poverty! Recall iatrogenic diseases

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Health systems challenges-Decentralisation:

• Shifting roles• Personnel: Recruitment-deployment-retention• Revenue mobilisation• Inter-sectoral collaboration• Financial management• Supply chain management• Global Health Initiative (GHI)

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Health systems challenges-the workforce motivations-Active & Reactive-Make choices:

• Recruitment-deployment-retention-attrition• Housing for workers• Health workers salaries• Training for health workers-Per diems• Recreation centres• Electricity and water• Migration

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Challenges in the Health systems-support systems

• Health management Information Systems (HMIS)-timeliness, completeness-utilisation

• Supply chain management-Essential medicines-selection, procurement, storage, distribution and use

• Frequent stock-outs53

Challenges in the health systems-absence of research

• Bizarre concept of research at the sub national and sub district level!

• Yet managers must make decisions-evidence-based decision

• In the absence of information-erratic decisions are made

• Basic principals of Action research...54

Challenges of the health system-New Money (GHI), Bilateral Org. & NGOs

• GFTAM, GAVI, PEPFER, PREFA, ...• TASO, JCRC, ...• Vertical Programs• Ultimately-a fragmented system,• Duplication of services and activities-accounting,

supervision-increased transaction costs• Competition among programs• Poaching of workers

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Challenges with New moneys

• Service delivery is only for programs with money-’Darling Diseases!’ in ‘Darling locations!’

• People then become mere program targets

• Instead of looking at the people with the disease, programs look at the disease in people

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Challenges to the systemGlobalisation

Urbanisation

Government/MOH responses– Inadequate response

– Too much response and

– In the wrong direction

– Single/individual disease targets-instead of a systems approach

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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

The disconnect between service delivery and Incentives in our system:

• Principal does not (or cannot) specify the nature of the request in sufficient detail

• Principal does not (or cannot) monitor the agent’s performance

• The incentive offered is not something that motivates the agent

• Cultural and legal environment inhibits enforcement of the contract

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2. The disconnect in service provision

• Bad contracts lead to unintended consequences

– Agent does not do exactly what principal wants

– Principal wastes incentives

– Agent wastes effort

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Commonest diseases

• Mis-directed care:

• Most (70%) conditions can be adequately managed by very cheap and cost-effective methods:

-IRS-LLIN-Sanitation-waste disposal, clean water

-Immunisation-....

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??• Why then should we spend a lot of money and

other resources in the provision of health care?

• Resource mobilisation, resource allocation and resource utilisation-efficiency!

• Every day managers are pre-occupied by: How best can I deploy my resources in order to reap the optimum benefits?

• Consider your individual budget/resource management

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Structure of the district health system

MOH

DDHS

Hospital

H/C III

H/C II

H/C I

LC IV

LC III

LC II

LC I

Health sub district

County

Sub county

Parish

Village

Health sub district

LC VDistrict

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District Health systems management-the Health Sub District-HSD

• The HSD-‘operational unit’ of the health care system in Uganda

• Constituted by a Hospital/HCIV as the HQtrs.• Responsible for

- Supervision- Management and leadership

• Satellite Health facilities within a geographical area- Responsible for service provision- Surveillance- Routine data collection, analysis, interpretation

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District Administrative Structure

• District-Local Council V-Chief Administrative Officer-CAO

• County-Local Council IV-Assistant CAO

• Sub County-Local Council III-Sub County Chief

• Parish-Local Council II-Parish Chiefs

• Village-Local Council I-?65

Organising a district health system

• Using our own experiences with the health system in Uganda, lets discuss Responsiveness the way we see it

• Fair Financial contribution-how is it working in Uganda?

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Structure of the district health system• District-District Health Office-DHO

• District-General Hospitals-Medical Superintendent

• County-Health Sub Districts-HSD Head of HSD

• Sub County-Health centre III-In charge

• Parish-Health Centre II-In charge

• Village-Health Centre I-VHT

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Health systems-Decentralisation as an opportunity

• Autonomy

• Innovations

• Space for decision making-note that, most decisions are politically motivated

• Short lead time-from decision to implementation

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The way to go-Management

• Management and leadership at the sub national and sub district level

• Relevant management Competences at these levels-skills, knowledge & behaviours

• Direction-team building

• Integration of services-easier said than done!69

Way to go-management of district health system-supervision

• Team building

• Supervision structures

• Feedback mechanisms at the different levels of care

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The way to go-Management of district health systems-Action Research

• Starts with a problem

• Analysis of the problem-magnitude, importance, causes of the problem, possible solutions (Hypothesis)

• Testing of the solution(s)

• Evaluation of the actions

• A cyclical process

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Way to go-management of the district system-investing in the workforce:

• Delegation-Hands off-eyes-on!

• Giving more challenging tasks

• An asset for health system strengthening • Responsibility and creativity contributes to better

adapted solutions

• If adequately supported, participation (in the sense of empowerment, not utilitarian) is likely to contribute to sustainable and responsive services

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Organisation of care

• People centred care: expectations, respect and dignity

• Professionalism-competence in required skills

• Participation-to have a say in how HS should be organised

• Continuity of care73

Conclusion-Keep in Mind! REACH-IMPACT-the POOR

• Power

• Politics &

• Resource distribution

• The poor have no POWER....

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Conclusions-

• REACH and IMPACT suffer from...

• Last Mile Challenges

• That is where the household is involved

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Conclusion

• Health systems management-an up-hill task for most low and middle-income countries

• They are under stress from numerous factors-LICUS

• We need managers at the district and sub district levels-who can champion the leadership

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Summary for District HS Management...

• Health systems are complex by nature

–With multiple interactions

–Multiple interdependence

• A sum total of parallel interventions may not necessarily improve health systems

• A holistic approach is proposed involving management & leadership at the helm

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Conclusion-District health systems management

• With management competences-knowledge, skills & behaviours

• Keep in focus goals of the health system good health, fair financial contribution & responsiveness

• Efficient allocation and utilisation of scarce resource...

• Priority setting...

• Integrating services as much as possible

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Bibliography

• WHO-World health report 2000• WHO-Commission on Microeconomics and health 2001• WHO-World health report 2003• WHO-World health report 2008• WHO-World statistic 2008• Meessen et al (2003) Iatrogenic poverty. Tropical medicine and

international health (8) 7: pp 581-584

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