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 healthPrimary health service delivery systemHealth workforceLeadership and governance to assure qualityHealth systems financingSupplying medical products and technologiesHealth systems informationHouseholds

• 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 Services Delivery

Households

GovernanceHealth Financing

Health Workforce 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)

ExamplesCountry Example Metrics Affected

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. Stewardship

Financial equity

Dignity and Respect

Equity

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.

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

World Bank 2000

Vietnamese Health ExpenditureITEM 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 Burden

Impact

TB as function of diagnostic quality

0

50

100

150

200

250

300

350

20 21 22 23 24 25 26 27 28 29 30

Proportion of Active TB Patients Diagnosed by Clinic

TB

Bu

rden

Average Diagnostic Delay 25 Weeks Average Diagnostic Delay 8.3 Weeks

Average Diagnostic Delay 4.1 Weeks Average Diagnostic Delay 5 Weeks

TB Model : Reach Matters

Population Benefit=Reach Impact

TB Burden

High Reach Low Reach

TB Burden as a function of Diagnostic Delay

0

50

100

150

200

250

300

350

0 5 10 15 20 25

Average Diagnostic Delay in Weeks

TB

Bu

rden Proportion Diagnosed 20%

Proportion Diagnosed 26%

Proportion Diagnosed 30%

Dual Impact of Reach and Impact

Population Benefit=Reach Impact

Reach

Impact

TB as a function of Reach and Impact

0

20

40

60

80

100

120

0 5 10 15 20 25 30

Mean Delay in Weeks Between Symptoms and Diagnosis

Per

cen

t D

iag

no

sed

At

Pre

sen

tati

on

TB Burden 0.004 TB Burden 0.0045 TB Burden 0.0055 TB Burden 0.006

High Burden

Low Burden

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

• 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

•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.