Getting Health Reform Right From Diagnosis to Health Sector Reform

1. Getting Health Reform RightFrom Diagnosis to Health Sector Reform Shahram Yazdani

2. Once health sector reformers have decided which performance problems to focus on—that is, once they have decided on their strategic priorities—they have to determine causes of the poor performance they are concerned with. • This is the process we call “diagnosis.” Then they have to decide what to do about the situation—the process we call “policy development.”

3. With respect to diagnosis, the fundamental strategy is, “Work backwards.” • Keep asking “why” until you have discovered the causes of the poor performance you want to improve. • The goal of this process, called a “diagnostic journey,” is to construct a “diagnostic tree” that links aspects of poor performance to those causal factors that might be changed or modified by policy interventions.

4. Simple guidelines • Process matters • Imitate but adapt • Use evidence • Use control knob framework

5. Identifying potentially effective changes in one or more control knobs is the end of the diagnostic task and the beginning of the policy development task. • Analysts first work backward to causes. Next, they have to look to policies to change those causes, and then work forward from causes to forecasts of improved health sector performance as a result of various policy changes.

6. The Genesis of Major Health Sector Reform Efforts • Process of health system diagnosis and policy development as if it focused on one specific performance problem at a time is likely to provoke piecemeal, programmatic initiatives; • But as we have noted before, countries often confront a number of inter-linked performance problems. • The diagnosis for each specific problem may well reveal that certain common features of the health care system are important causal factors. • To deal effectively with these multiple problems, multiple interventions may be required. This kind of analysis, then, is one path that can lead a country to major health sector reform efforts.

7. The Genesis of Major Health Sector Reform Efforts • There is also a matter of coherence here. Multiple programmatic efforts run the risk of being uncoordinated and even inconsistent. • Someone may urge decentralization of primary care to the provincial level, even as someone else urges carrying out a centralized national vaccination program. • Dealing with such conflicts in an integrated way may require a coordinated look at and a plan for the revision of the system as a whole.

8. The Genesis of Major Health Sector Reform Efforts • There is also the issue of the limited political and technical resources typically available to reformers. • Tackling a large number of performance problems in isolation from each other can place far too great a demand on those resources. • Focusing instead on certain common and more fundamental problems can, potentially, be a cost-effective use of limited reformist energies—assuming, of course, that such changes are possible.

9. The Genesis of Major Health Sector Reform Efforts • An integrated and extensive reform effort may have political value, in that it often appears more dramatic and attention-getting than a series of narrow programmatic initiatives. • By promising more to the population, broad reform can seem like an effective political strategy—especially when the population is dissatisfied with the current system

10. Developing a Health System Diagnostic Tree • There are likely to be several stages or series of causes • Each effect may well be produced by more than one cause • Each cause is likely to have multiple effects • Causes and effects may interact and reinforce each other in various ways • Not every cause will be manipulable by public policy • Change may well require acting on more than one cause at a time—i.e., changing more than one control knob.

11. Developing a Health System Diagnostic Tree • Health system diagnostic treeis similar to, but different from decision tree, which is used for analyzing decisions under uncertain circumstances. • At each branching point in a decision tree, one of a set of mutually exclusive events occurs. • In a health system diagnostic tree, however, an analyst represents various possible causes for a particular situation at each branching point, and it may well be the case that several of the causes are in fact operating at the same time. • Unlike the decision tree, there is no presumption that paths are mutually exclusive.

12. Developing a Health System Diagnostic Tree • As we have done this analysis, quite a number of the intermediary performance characteristics have made an appearance: various aspects of efficiency, access and quality have played a role in all the potentially causal chains.

14. Linking Diagnosis to the Control Knobs • Financing: If we do have a quantity of service problem, can we tap new or additional sources of funding to expand the budget for this service? Alternatively, can we alter how we spend existing funds to increase allocative efficiency? • Payment: If we discover we have a problem of motivation, whether at the level of the organization or the individual provider, can we change how we pay, or the rates we pay, to improve both the quantity and quality of services? • Organization: If we are not organized to facilitate economies of scale and coordination, if patients experience cultural barriers or have preferences for certain types of providers, what changes could we make in who offers various maternal health services to overcome these problems? If the issue is technical efficiency and/or clinical or service quality, can we change how providers are organized at the microlevel in ways that would increase their performance? • Regulation: Are there regulatory devices we can deploy to increase the quality and quantity of services or to increase their utilization? • Behavior: If there are important causes on the demand side, could we seek to influence mothers to increase their use of the services that are available?

15. The Process of Policy Development participation of stakeholders • First, participation by those affected allows policymakers to hear and take into account interest groups’ concerns • Second, participation can increase the acceptance of a plan, because it increases the psychological and philosophical legitimacy of the process that developed it • Third, participation can serve to educate interest groups about the concerns of, and pressures exerted on reformers by, other constituencies. • Fourth, participation educates the participants about the detailed content of the proposals that ultimately emerge

16. The Process of Policy Development generating policy alternatives • People in general have a difficult time thinking “outside the box” of their familiar concepts and paradigms. • “Imitate but adapt.” • Imitation can take various forms. • Ideas from health sector initiatives in other countries • Ideas developed in other policy areas that can be adapted to the health context. • General theoretical arguments can also provide a source of new ideas.

17. Screening Tests for Policy Interventions Implementability Political Feasibility Controllability

18. Finding and Using Evidence for Diagnosis and Therapy • Evidence-based health policy requires…evidence! • Yet many lower and middle-income countries lack adequate evidence. • Even when data and information are available, they are often not well utilized. • Most desirable kind of evidences are well-designed studies that produce reliable statistical results linking policy to performance. However, such studies are rare

19. Finding and Using Evidence for Diagnosis and Therapy • Advices for Health sector reformers • Know the literature: • Get advice • Rapid assessment • Support good research:

20. Summary Advices • Work backwards up the causal chain until you can identify potentially manipulable variables • Do not jump to quick conclusions • Be scientific, not judgmental • Use numbers