1. Health Systems and the Cycle of Health System Reform
Prof. Peter Berman
The World Bank
Flagship Course: Washington DC, October 16, 2006, Session 3

2. What Is A Health System?
“…all the activities whose primary purpose is to promote, restore, or maintain health” WHO, 2000
Health System…or Health Care System?
Activities? Or people, institutions who carry out these activities?, E.g.
Treatment providers – individuals and institutions
Preventive service providers
Financial intermediaries
Input producers
Planners, administrators, and regulators
Other actors producing system outcomes
Flagship Course: Washington DC, October 16, 2006, Session 3

3. Some Important Characteristics of Health Systems
Complexity: Many products, many actors, complex connections
Conflict: Different participants have different objectives…not always “positive sum”
Embedded in Social Context: Technology conditioned by culture, history, and social norms
Political: Current condition reflects power in society; change incurs political process

4. What Do We Mean by “Health System Reform”?
Not everything that changes, or causes change, is a health system reform
Purposeful efforts to change the system to improve its performance
“little r” reforms; Small changes to one or a few features of the system
“Big R” reforms; Large changes to more than one feature of the system

5. Why Is Successful Reform Difficult?
The consequences of actions are difficult to predict
Health systems have multiple goals. Doing better on one goal dimension may mean doing worse on another. The choices are truly difficult.
Those who benefit from the system are powerful and resist change. Those who benefit from change are often less powerful
Countries are limited by their economic and administrative capacity

6. Why Think Systematically About Health Systems Reform?
Clear thinking is better than muddled thinking
Avoid unintended results
Anticipate likely problems
Clarify goals and priorities
Facilitate accountability and transparency

7. What Starts The Cycle of Reform?
Fiscal and economic change -- crisis and/or opportunity
Political change -- crisis and/or opportunity
External pressure
Unhappy interest groups
Inspired leadership…usually NOT rational analysis

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

9. Evaluation Problem Definition Implementation Diagnosis
ETHICS
Evaluation
POLITICS
Problem Definition
Implementation
Diagnosis
Political Decision
Policy Development

10. Key elements of our approach
Understand the ethical basis of values we bring to reform
Consider politics throughout
Define problems in terms of health system outcomes
Develop an evidence-based causal analysis for health system performance
Build reform strategies based on determinants of system performance that can be changed by policy
Implementation matters

11. What Do We Mean By “Problems” in “Problem Definition”?
The health system is a means. Reformers need to be clear about the ends.
Problems should be defined based on poor performance in terms of outcomes.
Focus on changing things that contribute to improving poor performance.
Defining the problem is a critical step often ignored or assumed.

12. Which Problems Matter?
Systems reform means a strategic view of problems. Still, how wide to cast the net?
Problems (outcomes) affect people and groups of people. Whose burden matters?
Politics usually sorts this out…but political processes may be suspect or inadequate.
Smart reformers try to influence problem definition.

13. The Role Of Ethics In Problem Definition
Deciding what aspects of performance matter is not just a technical question, it requires values
Reformers always incorporate value judgments in problem definition – but often cannot or will not be explicit about them
Explicit consideration of ethical theory leads to clearer thinking about problem definition
Public discussion about ethical principles may or may not be desirable from a political perspective

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

15. Developing Strategies and Options
Strategies should be based on:
An explicit model of what causes health system performance to be the way it is
What can be changed and how performance should 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
Influences the quality of the plan

16. Reaching A Political Decision
Health sector reform is unavoidably political
Politics matters throughout
Doing better requires political skill, not just political will
Stakeholder analysis is a starting point
Successful reformers move from “mapping” politics to strategies to affect politics

17. Many Health Sector Reform Efforts Have Failed at The Stage of Implementation
Ministers often lack administrative experience and their staff may lack the right kinds of experience
Leaders turn over quickly
Implementation – and its time and costs -- are not considered in program design. Politics demands quick results.
Entrenched interests resist – reform is rarely easy
Encountering opposition, political attention may turn elsewhere

18. Keys To A Successful Evaluation
Evaluation doesn’t always mean a large, independent study. Less formal results tracking also useful
Design an evaluation strategy early, before implementation begins
Evaluate process and outputs as well as outcomes
Collect baseline data
Build in “redundancy” in evaluation design
Create incentives for good evaluation

19. Why Does the Cycle Often Begin Again?
Poor design or execution leads to unsatisfactory results
Even successful reforms often create new problems
Actors defend their interests in unanticipated ways
Social, economic or political conditions change
Health and health systems change

20. 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

21. Evaluation Problem Definition Implementation Diagnosis
ETHICS
Evaluation
POLITICS
Problem Definition
Implementation
Diagnosis
Political Decision
Policy Development