Health Systems and the Cycle of Health System Reform

Prof. Peter Berman

The World Bank

2

What Is A Health System?“…all the activities whose primary purpose is to

promote, restore, or maintain health” WHO, 2000

• Health System…or Health Care System?• Activities? Or people, institutions who carry out

these activities?, E.g.

• Treatment providers – individuals and institutions• Preventive service providers• Financial intermediaries• Input producers• Planners, administrators, and regulators• Other actors producing system outcomes

3

Some Important Characteristics of Health Systems

• Complexity: Many products, many actors, complex connections

• Conflict: Different participants have different objectives…not always “positive sum”

• Embedded in Social Context: Technology conditioned by culture, history, and social norms

• Political: Current condition reflects power in society; change incurs political process

4

What Do We Mean by “Health System Reform”?

• Not everything that changes, or causes change, is a health system reform

• Purposeful efforts to change the system to improve its performance

• “little r” reforms; Small changes to one or a few features of the system

• “Big R” reforms; Large changes to more than one feature of the system

5

Why Is Successful Reform Difficult?

• The consequences of actions are difficult to predict

• Health systems have multiple goals. Doing better on one goal dimension may mean doing worse on another. The choices are truly difficult.

• Those who benefit from the system are powerful and resist change. Those who benefit from change are often less powerful

• Countries are limited by their economic and administrative capacity

6

Why Think Systematically About Health Systems Reform?

• Clear thinking is better than muddled thinking

• Avoid unintended results

• Anticipate likely problems

• Clarify goals and priorities

• Facilitate accountability and transparency

7

What Starts The Cycle of Reform?

• Fiscal and economic change -- crisis and/or opportunity

• Political change -- crisis and/or opportunity

• External pressure

• Unhappy interest groups

• Inspired leadership…usually NOT rational analysis

8

Define The Problem

Evaluate Identify Causes

Implement Develop Options

Decide What to Do

The Health SystemsReform Cycle

9

Problem Definition

Political Decision

ETHICS

POLITICS

Implementation

Policy Development

Diagnosis

Evaluation

10

Key elements of our approach

• Understand the ethical basis of values we bring to reform

• Consider politics throughout• Define problems in terms of health system

outcomes• Develop an evidence-based causal analysis for

health system performance• Build reform strategies based on determinants of

system performance that can be changed by policy• Implementation matters

11

What Do We Mean By “Problems” in “Problem Definition”?

• The health system is a means. Reformers need to be clear about the ends.

• Problems should be defined based on poor performance in terms of outcomes.

• Focus on changing things that contribute to improving poor performance.

• Defining the problem is a critical step often ignored or assumed.

12

Which Problems Matter?

• Systems reform means a strategic view of problems. Still, how wide to cast the net?

• Problems (outcomes) affect people and groups of people. Whose burden matters?

• Politics usually sorts this out…but political processes may be suspect or inadequate.

• Smart reformers try to influence problem definition.

13

The Role Of Ethics In Problem Definition

• Deciding what aspects of performance matter is not just a technical question, it requires values

• Reformers always incorporate value judgments in problem definition – but often cannot or will not be explicit about them

• Explicit consideration of ethical theory leads to clearer thinking about problem definition

• Public discussion about ethical principles may or may not be desirable from a political perspective

14

The Diagnostic Journey: Identifying the Causes of Problems

• Start with performance problems as outcomes

• Ask “why” five times

• Work “backwards”-- from causes, to causes of causes, and so on…

• Be “evidence based”

15

Developing Strategies and Options

• Strategies should be based on: – An explicit model of what causes health system performance to

be the way it is– What can be changed and how performance should change as a

result

• Imitate but adapt – learn from others but consider local conditions

• The process of strategy develop may matter as much as the content – Influences the political acceptability– Influences the quality of the plan

16

Reaching A Political Decision• Health sector reform is unavoidably political

• Politics matters throughout

• Doing better requires political skill, not just political will

• Stakeholder analysis is a starting point

• Successful reformers move from “mapping” politics to strategies to affect politics

17

Many Health Sector Reform Efforts Have Failed at The Stage of Implementation

• Ministers often lack administrative experience and their staff may lack the right kinds of experience

• Leaders turn over quickly

• Implementation – and its time and costs -- are not considered in program design. Politics demands quick results.

• Entrenched interests resist – reform is rarely easy

• Encountering opposition, political attention may turn elsewhere

18

Keys To A Successful Evaluation

• Evaluation doesn’t always mean a large, independent study. Less formal results tracking also useful

• Design an evaluation strategy early, before implementation begins

• Evaluate process and outputs as well as outcomes

• Collect baseline data

• Build in “redundancy” in evaluation design

• Create incentives for good evaluation

19

Why Does the Cycle Often Begin Again?

• Poor design or execution leads to unsatisfactory results

• Even successful reforms often create new problems

• Actors defend their interests in unanticipated ways

• Social, economic or political conditions change

• Health and health systems change

20

Health System Reform Requires Skills

• Many needed skills can be taught

• Skills are developed by practice

• Rules can help, but specific situations require judgment

• Learning requires effort and active participation

21

Problem Definition

Political Decision

ETHICS

POLITICS

Implementation

Policy Development

Diagnosis

Evaluation