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 is Action 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 Encourages Critical 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 Matter in 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
Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

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
Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

12. The Health Reform Cycle
IDENTIFY THE PROBLEM
MONOTOR AND DIAGNOSE THE
EVALUATE CAUSES
IMPLEMENT DEVELOP 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”
Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

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
Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

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
Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

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
Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

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
Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

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
Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

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
Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2