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

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

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

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

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

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

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

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

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

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

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.

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.

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

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”

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

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

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

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

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

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

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