In the Name of God

1. In the Name of God Health Sector Reform Why, What, How ? THE BASICS Equity, Quality, Ethics Efficiency Politics Family Physician Referral System Control Knob behavior Health Dr Kambiz Monazzam Lorestan – Khoramabad May 2005

2. Review of Health Sector Reform: The Basics May 18-21, 2005 Khoramabad - Lorestan Dr Kambiz Monazzam

3. Reform: Definition “sustained, purposeful and fundamental change” • “Sustained” in the sense that it is not a "one shot" temporary effort that will not have enduring impacts; • “Purposeful” in the sense of emerging from a rational, planned and evidence-based process; • “Fundamental” in the sense of addressing significant, strategic dimensions of health systems .

4. Why do we Reform? Health problems/Health System Problems Who find the Problems...?! Unhappy People ....! ?

5. What Starts The Cycle of Reform? • Economic crisis • Political change • External pressure • Unhappy interest groups

6. Main Goals of Health Sector Reform • Equity • Efficiency • Quality • Sustainability • Fiscal Impact • Satisfaction • Access

7. What do we need “ R ” or “ r ” ? • It depends on degree, severity & complexity of our problems !?

8. Reform Cycle • Is there any space for politics?

9. Define The Problem Evaluate Identify Causes The Health Systems Reform Cycle Implement Develop Options Decide What to Do

11. Problem Definition Evaluation Diagnosis The Simplified Policy Cycle Implementation Policy Development Political Decision

12. Problem Definition P O L I T I C S Evaluation E T H I C S Diagnosis The Political Policy Cycle Implementation Policy Development Political Decision

13. Economics & HSR • If someone asked you to find one problem of all humanwhich is the most important to them, • What problem do you address? • If someone asked you to find one problem of all Governments which is the most important to them, • What do you say? Needs / wishes they can’t reach Lack of Enough Money People Needs they can’t meet

14. Economics? • Definition ?

15. Gifted shared 100,000 to • How do you do with 100,000 $ ? • How do you divide 100,000 $ between 5 people? • between 1000 people? • between 1000,000 people? Money

16. People is different • Individual desires & preferences • Social desires & preferences • Individual behavior • Importance of the issue

17. Decision making • How decision could be made? • Who Decide? Values Organization

18. Management? • Plan to Reform / Change Through: ? • Five Control Knobs • Financing • Payment (Incentive Structure) • Macro-Organization of Provision • Regulation • Persuasion (Behavior)

19. Reform Cycle

20. Define The Problem P O L I T I C S Evaluate Identify Causes E T H I C S The Health Systems Reform Cycle Implement Develop Options Decide What to Do

21. Define The Problem What’s the problem? Is there any problem? P Goals Current

22. Define The Problem How many? How much? Real or Opinion? YES

23. Goals Define The Problem Intermediate Goals Ultimate Goals Functions the system performs Responsiveness (to non-medical expectations) EQUITY Stewardship (oversight) ACCESS EFFICIENCY Creating resources (investment and training) Delivering services (Provision) Health FISCAL IMPACT Financing (collecting, pooling and purchasing) Fair Financial Contribution QUALITY

24. What Constitutes the Health System? • Care providers • Financial intermediaries • Input producers • Planners and regulators • Preventive service providers • Other actors producing system outcomes

25. Characteristics of Health Systems • Complexity: multiple actors with multiple connections • Conflict: different participants have different objectives • Politics matters: decisions inevitably reflect political process • Societal context matters: conditions and options reflects culture, history and social norms

26. Define The Problem How Should WeDefine Problems? • The health system is a means. Reformers need to think deeply about the ends • Problems should be defined based on poor performance in terms of outcomes

27. Define The Problem How Should WeDefine Problems? Cont’ • Aspects of the system only need to be changed if the changes contribute to improving poor performance • Defining the problem has to be done carefully because it will influence what solutions you choose

28. Define The Problem How Do We Know Which Aspects of Performance Matter? • Different groups will have different views • Political processes often produce an uneasy compromise • Reformers can influence those processes • Reformers have to consider ethics and values to know what performance problems to focus on

29. Define The Problem The Role Of Ethics In Problem Definition • Deciding what aspects of performance matter is not just a technical question • Deciding what matters requires values • Exploring ethical theory allows us to clarify both our assumptions and their implications • The problem definition influences all that follows

30. Define The Problem How do you find to meet the goals? • Which Indicators? • Equity • Efficiency • Quality • Sustainability • Fiscal Impact • Satisfaction • Access

31. Review of Health Sector Reform: Diagnosis & Option appraisal May 18-21, 2005 Khoramabad - Lorestan Dr Kambiz Monazzam

32. Identify Causes How many problems do you have in the health / system !?

33. Identifying Causes: The Diagnostic Journey Identify Causes • Start with performance problems • Ask “why” five times • Go from causes, to causes of causes, etc. • Work “backwards” • Be “evidence based”

34. Start with problems: • Where they are? • Who can find the problems? people have different ideas! • Which Problem is more important than the others? • Who can exactly define the problem? • Experts, Managers, People, Data … • Which areas are important? Identify Causes

35. Start with problems: • Find • Research • Situation analysis • Expert’s view • List & Classify • Affinity diagram • Logical cause & effect Diagram • Problem Tree Identify Causes Time Money Expertise

36. Problem identification – (What) What exactly is the problem? Who or what is most affected by this problem? How serious/important is the problem? What supportive data/facts do you have to demonstrate this severity or importance? Is this problem manageable in scope? Is this problem more important and devastating than any other problems? Is this problem more influential/crucial to the current situation than any others? Can you afford to ignore this problem for the time being? … Identify Causes

37. Problem analysis - (why) Problem analysis is to understand why there is a problem or what are the factors that contribute to the problem and the interrelationship between these factors. Identify Causes

38. Tools / Techniques: Identify Causes Problem Tree Fishbone Diagram Force Field Analysis SWOT or SWOC Analysis The 7s Model Problem Web.

39. Finding Root Causes: • Problems have a cause & effect relationship or other inter relationship between them. • At last: In health you reach a specific tree, which have multiple roots • Go backward, find evidence • Red line Identify Causes

40. Logical vs. political way of thinking to solve problems Identify Causes • Logical: • Political: Problem Tree Fishbone Diagram Force Field Analysis Decision Space …….

41. Tools for Political Analysis How do people think about political processes for policy change and implementation? • When decisions are made: Policy process sequences • How decisions are made: Decision-making models • Who makes decisions: Stakeholder analysis • Boundaries: Governance rules and Broader Contexts Identify Causes

42. Policy Process Sequence Signaling Evaluation & Feedback Consultation and Formulation Implementation Aggregation Ratification

43. Political Side Ethical Side The Health Systems Reform Cycle

44. Developing Options • Build on a sound model of a) what drives health system performance b) what can be changed Develop Options

45. Developing Options • “Imitate but adapt” - learn from others but consider local conditions Develop Options

46. Developing Options • “Process matters” – how you go about this task will influence the political acceptability and the quality of the plan Develop Options

47. Reaching A Political Decision • Health sector reform is unavoidably political Doing better requires : political skill, not just political will Decide What to Do

48. Reaching A Political Decision • Stakeholder analysis as a starting point From “mapping” to strategy Decide What to Do

49. Review of Health Sector Reform: Treatment May 18-21, 2005 Khoramabad - Lorestan Dr Kambiz Monazzam

50. Implementation Good ideas are not worth muchIfThey can not be implemented Implement