Int roduction to the Flagship Framework

1. Introduction to the Flagship Framework Marc J. Roberts Professor of Political Economy and Health Policy Harvard School of Public Health Africa Flagship Kigali, June 21, 2010

2. The Flagship Framework isAction Oriented • It offers a way to think about health systems designed to support reform efforts • So two of the key components are: • The things policy makers can change—the “Control Knobs” • The results policy makers are seeking to achieve— the “Ultimate Outcomes” of health status, citizen satisfaction and risk protection

3. The Flagship Framework Calls Attention to the Role of Values • All reformers do not agree on goals and priorities • Deciding what goals to pursue is not a purely technical matter • Instead it is also a matter of ethics and politics • The flagship framework therefore: • Considers various ethical and philosophical views • Explores how politics works, and how it can be used by reformers to achieve their goals

4. The Flagship Framework EncouragesCritical Thinking • It begins by asking “What is the problem?”—that is, what is it about the performance of the health system that needs improvement • It proceeds to an explicit diagnostic analysis– designed to clarify the causes of the identified problem • It fosters the use of evidence in choosing and designing solutions

5. The Flagship Framework Fosters Conceptual Clarity • The framework calls attention to the need to define key terms • It clarifies that some system characteristics are intermediate goals– not ends-in-themselves but important causes of ultimate performance • Efficiency • Quality • Access

6. The Flagship Framework Respects Variations Among Countries • The framework assumes that variations in economic, social and political factors will influence a policy’s impact • International experience must be joined with local knowledge to design effective interventions • Thus all advice should be “conditional” on local circumstances

7. The Flagship Framework Presumes That Details Matterin Policy Design • The “within policy” variation in impact, as a result of the details of policy design, can be greater that the “among policy” variation • Thus choosing a broad reform approach is not enough—”The Devil is in the Details” • Some examples: • The impact of a pay for performance scheme will depend on how performance is measured • The risk protection provided by an insurance scheme will depend on the design of the benefit package

8. The Flagship Framework Recognizes the Importance of Implementation • Much of the “within policy” variation in impact comes from variations in implementation • Such variations are due to variations in: • Agency leadership -- Available resources • Technical expertise -- Institutional design • Political support -- Stakeholder response • Reformers thus must consider implementation issues in a program’s design, and be prepared to monitor and manage its implementation

9. The Flagship Framework Emphasizes the Need for Evaluation • Evaluation may influence program design—experimental or demonstration strategies • Evaluation has to be a considered before implementation if appropriate data are to be collected • Issues of data cost, quality and reliability need to be considered • Program managers may need different (and more rapidly available) data than long-term evaluations provide

10. Why Think Systematically About Health Systems Reform? • Clear thinking is more likely to produce good results • Avoid unintended results • Anticipate likely problems • Clarify goals and priorities • Facilitate accountability and transparency

11. Successful Reform Is Difficult • The health system is complicated and poorly understood • The consequences of policies are difficult to predict • Doing better on one goal may mean doing worse on another • Those who benefit from the system are powerful and resist change. • Countries are limited by their economic and administrative capacity

12. The Health Reform Cycle IDENTIFY THE PROBLEM MONOTOR AND DIAGNOSE THE EVALUATE CAUSES IMPLEMENTDEVELOP A PLAN GET POLITICAL APPROVAL

13. Understanding the Health Reform Cycle • The cycle is a description of what would/should happen in an ideal world • Actual reform processes often begin with the solution rather than the problem • Systematic analysis is often not done • International consultants and agencies have their favorite recommendations “To a man with a hammer everything looks like a nail”

14. The Diagnostic Journey: Identifying the Causes of Problems • Start with performance problems –that is undesirable outcomes • Ask “why” five times • Work “backwards”-- from causes, to causes of causes, and so on… • Be “evidence based”

15. The Role Of Ethics In Problem Definition • Deciding what aspects of performance matter is not just a technical question, it requires values • Reforms always incorporate value judgments—whether implicitly or explicitly • Public discussion about ethical principles may or may not be desirable from a political perspective

16. Developing Reform Strategies • Strategies should be based on an explicit analysis of what can be changed and how performance is likely to 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 of the plan • Influences the quality of the plan

17. The Health System“Control Knobs” • Financing—where the money comes from • Payment– how doctors, hospitals and other providers are compensated • Organization—both the macro aspects of who does what and the micro aspects of internal managerial structures • Regulation—coercive requirements imposed by the state • Persuasion—efforts to influence both providers and consumers

18. Reaching A Political Decision • Health sector reform is unavoidably political throughout the reform cycle • Doing better requires political skill, not just political will • Stakeholder analysis is a starting point • Successful reformers move from “mapping” political force to develop strategies to affect political outcomes

19. For Obvious Reasons Many Reform Efforts are not Effectively Implemented • Ministers and their staffs lack administrative experience and managerial sophistication • Leaders turn over quickly • Implementation – and its time and costs -- are not considered in program design • Entrenched interests resist • Political attention turns elsewhere

20. Why Does the Cycle Often Begin Again? • Poor design or flawed implementation leads to unsatisfactory results • Even successful reforms often create new problems • Actors defend their interests in unanticipated ways • Social, economic or political conditions change

21. 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