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Service Delivery System
Lecture 3: Reach and Impact
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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 financing
Supplying medical products and technologiesHealth systems informationHouseholds
Today we focus on primary health service delivery
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Outline
Ingredients of the services system
Local Example from Vietnam
Reach vs. impact on the last mile Institutional norms of service delivery
system
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Part 1: Ingredients of Primary Care
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Ingredients
Primary servicedelivery made up of Health care service
providers
Facilities
Drugs and supplies
Governance
Maintaining eachingredient is the workof an entire additionalsubsystem
Agents
Units
Institutions
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Centrality of Health Services
Health ServicesDelivery
Households
GovernanceHealth Financing
Health Workforce Supplies
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Ingredients must be combined
Primary clinics take things that arentmedical care and make them into medicalcare
Drug on the shelf is not medical care untilyouve handed it to a patient who has thatdisease
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
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Design of Primary Health Care
Different levels of Facilities
Primary, Secondary, Tertiary
Public, Private, NGO
Different specialties
Variable quality
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Performance Metrics
What do we want to get out of the primaryhealth care delivery system?
World Health Report 2000
Stewardship Financial equity
Responsiveness to peoples non-medical
expectations (dignity and respect) Equity (Fair delivery to rich and poor; deliverywithout barriers)
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ExamplesCountry Example Metrics Affected
Philippines: decentralization of responsibility forprimary 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 becomemore difficult. Stewardship
Financial equity
Dignity and Respect
Equity
Mali: independent health centres are not-for-profitcooperative establishments owned, financed andmanaged by community; recruit their own staff.Few financially independent in practice.
Croatia: previously centrally employed, salariedambulatory care physicians. Now they areindependent contractors.
From Table 3.2 Examples of organizational incentives for ambulatory care, World Health Report 2000
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From Matsuda 1997
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Utilization Patterns in Vietnam
World Bank 2000
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Vietnamese Health Expenditure
ITEM 2000 2002 2004 2006Total 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
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Part 2: Last Mile: Impact and Reach
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The Last Mile Problem
High capacity conduits
Centralized
Easily manipulated
Low capacity conduitsSpatially disbursed
Costly to access
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The Last Mile: Examples
Fiberoptic trunk lines
Arteries
Interstate highways
Tertiary hospitals
Copper wireCapillaries
Back roads
Rural drug sellers
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Concrete vs. Abstract Metaphors
Thinking about the last mile provokes mental
images of concrete resources and people inspace
Last mile problems transcend who and what Locus of control is critical
Last mile problems affect processes and institutionalperformance
Managing these problems requires going down lastmiles
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Last mile in health is not just aboutsupplies
Health care deliveryrequires hardware plus
software
Not just the drug, theindications, side effects,motivational counseling
Not just the diagnostic, the
interpretation and thedecision making
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Impact
Definition of Impactthe effect oftreatment 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
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Systems and Incentives
What are the political and organizationalfactors that determine degree ofcentralization?
Incentives of decision-makers and agents
How does centralization affect the impactof primary services on the poor?
Incentives of decision-makers and agents
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Reach
Definition of Reach-The ability to bringmore 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
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Fundamental Laws of Service Delivery
Law 1) Population Benefit=Reach Impact
Law 2) In any budget, there is a tradeoffbetween reach and impact
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Example of Law 1
Example from TB
Reach is number of people who can accessdiagnostic 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
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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
TBBurden
Average Diagnostic Delay 25 Weeks Average Diagnostic Delay 8.3 Weeks
Average Diagnostic Delay 4.1 Weeks Average Diagnostic Delay 5 Weeks
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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
Burden
Proportion Diagnosed 20%
Proportion Diagnosed 26%
Proportion Diagnosed 30%
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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
PercentDiagnosed
AtPresentatio
n
TB Burden 0.004 TB Burden 0.0045 TB Burden 0.0055 TB Burden 0.006
High Burden
Low Burden
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Illustration of Law 2
Buying more TB reach means
Investing in training front line public andprivate workers to make the diagnosis
More clinics in more places that know how todiagnose
More diagnostic facilities
Buying more TB impact means Investing in training public TB facilities tomaintain good DOTS programs
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It is like fighting a battle
General has to defend a mile long line ofdefense (Reach)
Has different quality troops (Impact)
Cannon ($100) Cavalry ($10)
Foot soldiers ($1)
Cant afford cannon for every inch of the line
Shouldnt use only foot soldiers Deploy forces strategically
Achieve ideal mix
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Managing Primary Service Delivery
Each unit has a certain amount ofeffectiveness
Can improve the unit
Can build more low quality units
Who manages the big decision of wherethe troops go?
Market forces
Public policy
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Part 3: Institutions that govern reach
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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
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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
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Hospitals
Hospitals and politics
Hospitals have economic gravity Impact hundreds of health worker livelihoods
Supply chains and financing infrastructures are hard tochange
Hospitals have political gravity Civic pride
Sense of security for middle/upper class
Hospitals have limited preventive impact, limitedrelevance to 98% of clinical problems
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Ecology of Medical Care-USA
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Incentives in Hospitals
For-profit hospitals Owners maximize: Profit=Revenue-Cost
Bring in more revenue from more paying customers receivinghigh 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
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Hospitals vs. Health Stations
The balance between primary vs. tertiaryis both a political question and a publichealth question
Political gravity of hospitals pulls them tocenters of political power
Gravity of hospitals pulls public funds towards
them
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Health Station Incentives
Health stations often suffer resource limits Low salaries
Supply shortages
Incentives of health planners Good distribution of health stations at lowest recurrentcost
(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
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Syndrome 1: Private Market
Definition: Private marketosis is when healthworkers at public facilities maintain privatepractices 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 wouldotherwise not be in this remote location
Still has to pay
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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 unlessgovernment pays wages that one can live on
Solved the main public problem of getting healthworkers to remote areas
Patients pay for what they get
What do you think?
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Diagnosing pathological private market
Symptoms:
Health station salaries are well below what ahealth worker can earn in private practice
Health station utilization rates are low
Household surveys report high proportion ofout of pocket payments even in remote areas
Drive around and see private practices withbusy waiting rooms
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Treating Private Market Pathology
Ask former health station workers foradvice on incentives for dual practice
Improve finance at public health stations
Demand side strengthening with insurance
Supply side finance with contracting orbudgeting
Improve non-financial incentives at publichealth stations
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NGOs/Private Not for Profits
NGOs mix features of government facilities andprivate 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 thosethey are serving
Service mix not always tied to governmentobjectives Donors pick darling diseases, darling locations
Use facilities for vertical programs
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Syndrome 2: NGO-overload
Definition: NGO-overload is when health sectorNGOs well-intended activities interfere with thesmooth performance of the primary servicedelivery 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
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Is NGO-overload bad?
Some say Yes: Primary health systems
structure should reflect national autonomynational priorities.
Some say No: NGOs inject new
resources that would not otherwise be inhealth system, in return why not give them
a voice in the system What do you think?
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Diagnosing NGO-overload
Salaries for health workers are rising
Prices of primary health goods are falling
Budgets full of line items around NGOpriorities: HIV/AIDS, TB, Family planning,vaccines
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Treating NGO-overload
Dis-engagement
Some countries just say no
Engagement
Some countries adopt sector-wideapproaches (SWAPs)
Ministry of Health convenes meetings to
establish minstrys priorities and invites input
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Part 4: Institutions that govern impact
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Impact
Best health impact from doing the rightthing 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
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Private Markets and Impact
To the extent that private market imposesuser fees on the poor, adherence withtreatment can lower impact
Do health workers practice same level ofquality in their private practices as public?
Governance systems have had difficulty
governing the impact of workers who areentirely private
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Reach, Impact, and the Poor
Different politicalsystems. None isnaturally oriented to thepoor Liberal Democratic
USA Egalitarian-Authoritarian
Cuba
Traditional-Inegalitarian Brunei
Authoritarian-Inegalitarian Sudan
Populist Kenya
Whether decentralizingserves the poor depends: Which decision makers
care about the poor?
Power is the currency of
all political systems Poor people dont have
power
Public health systems natural tendency is to serve power not need
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Summary
Primary health care (PHC) delivery system takesingredients (providers and supplies) makesservices
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.
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Exercise on Performance Metrics
Methods for how to measure theseindicators
Break into groups and decide on how to
make indicator meaningful for local use.