Global Health Master class on Health Systems in LICs

1. Global Health Master class on Health Systems in LICs Barbara McPake, Institute for International Health and Development, Queen Margaret University, Edinburgh and Peter Annear, Nossal Institute for Global Health, University of Melbourne

2. Structure of session • What is the current context of health system development in low income countries? • A review of frameworks of analysis designed to address health system problems and identify ways forward • Conclusions – comparative value of frameworks • Case studies of these frameworks in action • In Cambodia (Peter) • In Uganda (Me) • Conclusions – ways forward for health systems

3. Current context of health systems in low-income countries

4. Changing global demographic and disease situation

5. Millennium Development Goals (+)

6. Global Health Initiatives and their ‘health system strengthening’ components

8. Universal coverage and other health financing policies and debates

9. Health expenditure per capita: $PPP, 2008 (WHOSIS)

10. Health expenditure (as previous slide) compared to GDP per capita (IMF, 2010; international $)

11. Human Resources for Health and current initiatives

12. Consensus in 2011 that health systems don’t work and won’t cope with coming challenges without • significant investment • new approaches • Where will new investment come from? • Where will new approaches come from?

13. Need for health system analysis • Series of competing frameworks to shape that analysis from international agencies • Building blocks framework (WHO) • Control knobs (WB flagship course) • Marginal budgeting for bottlenecks (UNICEF +) • And some from individual analysts such as • Berman (2008) • Kruk and Friedman (2008) • McPake, Blaauw and Sheaff (2006)

14. www.qmu.ac.uk/iihd

15. A good health financing system raises adequate funds in ways that ensure people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for them. It provides incentives for providers and users to be efficient. Revenue generation Access Financial protection Incentives for efficiency

16. Control knobs framework Financing Payment Organisation Regulation Behaviour www.qmu.ac.uk/iihd

18. Marginal budgeting for bottlenecks • 5 Steps: • Assessment of key indicators, trends in and causes of maternal, newborn and child mortality and morbidity and access to essential services and the selection and packaging of interventions to address causes • Identification of system-wide supply and demand bottle-necks to adequate and effective coverage of essential primary health care services

19. Estimation of the expected impact on survival rates for each of the interventions • Selection of the types, quantities and costs of additional inputs • Analysis of the budgetary implications, the identification of likely sources of funding and the comparison of the marginal costs and additional funding needs to the ‘fiscal space’

20. Bottleneck indicators • Availability of drugs, vaccines, supplies and HRH • Accessibility: presence of trained human resources at community level; number of villages reached at least 1/month by outreach; time taken to reach a facility providing EMONc • Utilisation: first attendances by service • Adequate coverage: % target group receiving a service • Effective coverage: quality of care (skills of health worker)

22. Dynamic responses: How people (‘users’ and ‘providers’) react and interact in response to formal structures and rules De facto system: Services as experienced by (poor) people For example: access; quality De jure system: Organisational structures Intended incentives Management procedures Training courses Dynamic responses model of the health system www.qmu.ac.uk/iihd

23. Comparative value of different frameworks • Building blocks framework enables comprehensive description of a health system: a check list of things not to forget about • Marginal budgeting for bottlenecks enables identification of priority problems and micro interventions • Control knob framework enables identification of possible macro interventions • Dynamic responses framework enables analysis of macro and micro interventions in implementation – what affects their success and how to make more successful

24. Case studies

25. The building blocks approach in Cambodia

26. Why performance-based contracting failed in Uganda: evaluating the implementation, context and complexity of health system interventions Freddie Ssengooba , Barbara McPake and Natasha Palmer www.qmu.ac.uk/iihd

27. Background • DRG of World Bank and Uganda MoH instituted a randomised experiment to test performance based payment for non-profit health providers in 5 districts of Uganda • Implemented between (about) 2004-2006 www.qmu.ac.uk/iihd

28. The DRG’s own evaluation is a ‘black box’ type ‘Intervention’ ‘Performance’ www.qmu.ac.uk/iihd

29. Our evaluation focused on looking inside all three boxes ‘Intervention’ What did it really consist of? Design features Implementation features Who came into contact with the intervention? How did they react? How did they influence others? What chains of effects were initiated and how was hospital performance affected? ‘Performance’ What has been measured? What has not? www.qmu.ac.uk/iihd

30. The DRG design in more detail • Randomised trial • ‘Control group’ – continued with pre-existing arrangements (received government grants and used them according to guidelines) • ‘Autonomy group’ allowed to allocate government grants without restrictions of guidelines • ‘Bonus group’ received grant as before; allowed to allocate grants with autonomy; received bonus if they achieved or exceeded targets www.qmu.ac.uk/iihd

31. DRG Conclusion: • ‘..assignment to the performance-based bonus scheme has not had a systematic or discernible impact on the production of health care services provided by PNFP facilities. … it appears that facility autonomy in financial decision-making has a positive impact on health care production. Those facilities that were granted the freedom to spend their MoH base grant .. increased their output relative to other facilities in the sample’ www.qmu.ac.uk/iihd

32. Opening up the first box: what is the detail of the programme design? • National workshop July 2003. Major stakeholders invited to 2 day meeting. Pilot explained; pilot districts selected, randomisation undertaken • Baseline survey of outputs by PIT • Selection of survey targets undertaken by participating facility managers at one day meeting; further orientation for managers www.qmu.ac.uk/iihd

33. Signing of performance contracts • Support and mentoring of HMTs (by PIT) • 6 monthly performance surveillance: check records; measure output volumes for selected targets • Feedback on performance relative to selected targets • Bonus award www.qmu.ac.uk/iihd

34. What was really implemented? • Funding shortfall. MoH did not provide counterpart funding as DRG expected • Initial activities were undertaken, then long gap while funds for follow up sought • Follow-up (partial) funder changed the design – no support for control group, reduced scope of feedback meetings • Support and mentoring lost to funding shortfalls and priority for measurement activities • Measurements rescheduled to save money – no time to respond to last period performance review • Further ad-hoc changes to design by the PIT www.qmu.ac.uk/iihd

35. Opening up the second box: how did participants in the programme react? • Implementers cut corners for the sake of time and cost savings • Selecting service targets: No opportunity for prior planning with full facility management team; 2-3 members of the hospital management team including a member of the Board of Governors given a few hours in the one day meeting to make this choice • Implementers changed the rules and refused to allow managers to change the targets for the second year

36. Implications • Lack of strategic choice in selecting targets • Lack of communication of programme to other members of staff in hospitals www.qmu.ac.uk/iihd

37. ‘we selected .. I think OPD (looks up the file and reads from it) ooh no! … yeah I wish we had selected OPD. We selected maternal deliveries, immunization and malaria treatment …’ • malaria, there is this home based management of fevers (new program) that we did not factor in at the start of PBC. We thought the malaria will always be there but it was not to be. So I really don’t know how we can treat 10% more malaria at this hospital’

38. Lack of communications within hospitals • Delays after inception of the programme in appointing coordinator and releasing funds • Lack of institutional memory within hospitals by time programme really started www.qmu.ac.uk/iihd

39. When bonuses were announced, different approaches were taken to deciding on their use • Staff appreciated parties from which all shared in the hospital’s success • They accepted hospital improvements as a good use of funds, where they were consulted • They disliked any attempt to reward individuals according to their contributions www.qmu.ac.uk/iihd

40. Opening up the third box: What performance was really measured? • Primary registers instead of HMIS reports were used for performance verification – attributed to the fear that the aggregated HMIS reports were vulnerable to manipulation (deviation from contract) • Major workload implications for the PIT • PIT concurrently tasked to collect additional data to measure impact of the intervention: household surveys, survey of organisational capacity; client exit polls; count other service outputs to assess change of case mix www.qmu.ac.uk/iihd

41. Implications • Contract relevant performance verification measurement crowded out by additional data collection • Reliability of measured output volumes compromised. PIT team were not familiar with clinical shorthand and recording practices in clinical registers

42. DRG insight into why their intervention didn’t work • ‘Why has the performance bonus not worked? One can imagine a number of possible explanations. First, perhaps the performance bonuses were not large enough. … Second, the performance bonus was paid to the facility and not to the individual providers directly. … Third, it is possible that the performance-based contract was too difficult to manage. … Finally, it is possible that the experiment has not had long enough to take effect.’ [10 page 31]. www.qmu.ac.uk/iihd

43. Conclusions on Uganda • Opening up the boxes gives information needed for developing and managing the intervention • Multiple open box evaluations allow understanding of how different types of interventions relate to contexts • Over multiple evaluations common patterns that identify more and less promising types of interventions emerge

44. Ways forward for health systems • Challenge of ageing, NCDs and the financing gap – LICs will not have health systems that look like those in HICs in foreseeable future • Universal access and comprehensiveness of health system response are not compatible • Prevention will have to be much more successful than in HICs • However much higher levels of health financing will be required in the lowest income countries… • … after which there is scope to apply various frameworks of analysis to maximise desired health system outcomes – which are common across the frameworks • Frameworks have distinctive contributions to make