1. By Hatim Jaber MD MPH JBCM PhD 16 - 7-2017
Faculty of Medicine Public Health ( ) الصحة العامة Lecture 17 Health policy and management, Health priorities By
Hatim Jaber
MD MPH JBCM PhD

2. Health policy and management, Health priorities
The global health impact of mental health and mental diseases. Drug abuse and Addictive substances
Global overview of communicable diseases
Global overview Non- Communicable Diseases(NCDs)
The global health impact of Hepatitis, Tuberculosis and HIV/AIDS
The global health impact of Cardiovascular Diseases , Diabetes and Obesity
Health policy and management, Health priorities
Health policies and management within a global health perspective
Healthcare service delivery in developed and developing countries
Healthcare systems and financing
Quality of care and effectiveness in different health services systems
Violence and Injuries
Migration and Travelers' health

3. Presentation outline
Time
Introduction of concepts :General Concepts in Management Sciences
08:00 to 08:10
Health Systems and Policies Introduction to Health Systems
08:10 to 08:20
Health Systems and Policies Introduction to Health policies
08: 20 to 08:30
Making Public Health Policies
08:30 to 08:40
Health priorities
08:40 to 09:00
09:00 to 09:15

4. Definition of Administration
We can define sound administration as:
“ The process of achieving defined goals at a defined time through the guidance, leadership, and control of the efforts of a group of individuals and the efficient utilization of non-human resources bearing in mind adequacy, speed, and economy to the utmost possible level.”

5. Health Administration
Sound administration is essential for the success of any public health program whether on the national, intermediate or the local level.

6. Elements of Administration:
Planning
Organization
Staffing
Directing
Coordinating
Reporting
Budgeting
Supervising
Evaluation

7. Levels of Administration
Central
level
Ministry of health
Intermediate
level
directorates of health
e.g. health office,
Hospital, health
care unit
Local Level

9. Management Management is the operational part of administration.
It is defined as:
“ It is a set of interactive processes through which the utilization of resources results in the accomplishment of organization objectives.”
It is through “management” that the objectives of the health care organization are achieved by gathering and positioning of resources.
It is a “conversion mechanism”.

10. Definitions and concepts
MANAGEMENT is both a SCIENCE and ART
As a SCIENCE, management has basic rules and principles.
As an ART, successful managers learn through experience, they follow flexible, adaptive, innovative approaches to fulfill objectives.

11. Definitions
Management is getting things effectively done to achieve desired objectives through proper planning, efficient implementation and evaluation to identify the needs for re-planning.
Management is thus a dynamic process.

12. Effectiveness is the degree to which a stated objective is being achieved.
Efficiency is the optimized (balanced) use of resources (Human resources, equipment, supplies, money, space, time & information).

13. Definitions
Management is a decision making process
translating the policies into plans, implementing those plans,
and evaluate the plans and the interventions to re-plan to achieve better results

14. Good Management Highlights priorities
Adapts services to needs and to changing situations (dynamic)
Makes most of limited resources
Improves the standard and quality of services
Maintains high staff morale

15. PRINCIPLES OF MANAGEMENT
Management by objectives: Setting targets (goals and objectives)
Learning from experience
Teamwork
Proper use of resources
Putting priorities

16. Management Process I. Planning II. Implementation: III. Evaluation
Organizing
Staffing
Leading/Directing
Controlling /Monitoring
III. Evaluation

17. A systems view of management
Process
Outputs
Inputs
Conversion
mechanism
Human resources
Non-human resources
Objectives
achievement

18. Management Skills Technical skills Human skills Conceptual skills +
Political skills
Technical skills
Mainly firs level
Human / interpersonal skills
All levels
Conceptual skills
Mainly top level

20. Health Care Management
1. A Health Care System and its components (Macro level) 2. Levels of Health care, and the main approaches to health care provision, in addition to Resources, and Financing. 3. Introduction to Management in health care organizations (Micro level ). 4. The Four Functions of Management: Planning, Organizing, Leading and Controlling.

21. Health Policy Defined
Health policies are public policies or authoritative decisions that pertain to health or influence the pursuit of health
Health policies affect or influence groups or classes of individuals or organizations

22. Public vs. Private Policymaking
Public Policy
Policy that is established by the federal, state, and local levels of government
Private Policy
Policy that is established by private organizations
For example, MCOs and JCAHO

23. Forms of Health Policies
There are five main forms of health policies
Laws
Rules/Regulations
Operational Decisions
Judicial Decisions
Macro Policies

24. Macro Policies
Macro policies are broad and expansive and help shape a society’s pursuit of health in fundamental ways
Example
FDA regulation of pharmaceuticals

25. In general, allocative policies come in the form of subsidies Examples
Public health policies are grouped into two categories 1-Allocative 2-Regulatory
1-Allocative Policies
Designed to provide net benefits to some distinct group of class of individuals or organizations, at the expense of others(?), in order to ensure that public objectives are met
In general, allocative policies come in the form of subsidies
Examples
Medicare and Medicaid policies, Federal aid to medical schools

26. Public health policies are grouped into two categories 1-Allocative 2-Regulatory
2-Regulatory Policies
Policies designed to influence the actions, behaviors, and decisions of others to ensure that public objectives are met
Five main categories of regulatory policies
Social regulations :Environmental protection, Childhood immunization requirements, No smoking
Quality controls on the provision of health services: FDA regulation of pharmaceuticals, New Pay for Performance (P4P) regulations
Market-entry decisions: Certificate of Need programs Physician credentialing (Hospital privileges)
Rate or price-setting controls on health service providers :The federal government’s control of the rates of reimbursement to hospitals that participate in the Medicare program
Market-preserving controls: Antitrust legislation

27. WHO Support
an increase in effective services to all people in need, including service delivery management and support
improved patient safety, efficacy of services and financial protection
increased efficiency and building of financial, human, institutional, and knowledge capacities
coordinated, participatory and accountable policy formulation and implementation.

28. Where is the problem?
Problems with health systems are not confined to poor countries.
Some rich countries have large populations without access to care because of inequitable arrangements for social protection.
Others are struggling with escalating costs because of inefficient use of resources.

29. Planning cycle 1- Analysis of health situation.
Involve collection ,assessment and interpretation of information to provide a clear picture of health situation eg. population structure , mortality , morbidity ,
Epidemiological and geographical distribution ,medical care facilities , hospital or PHC and man power to defined the problem
2- Establishment of objectives and goals.
Objective must be established at all level .
3- Assessment of resources.
Man power , money , material , skills , knowledge.
Planning cycle

30. 5- Write up of formulated plan.
4- Fixing priorities.
Once the problem, resources and objectives have been determined, the second most important step in planning is establishment of priorities according to many factors for example :
magnitude , resources, cost, time needed, mortality , morbidity, political and community interests and pressures .
5- Write up of formulated plan.
preparation of the detailed plan or plans . For each proposed health progamme , the resources (input) required are related to the results (output) expected.
6-Programming and implementation.
Once the health plan has been selected and a proved programming and implementation are begun

31. · Evaluation refers to the assessment of the final outcome of the plan
7- Monitoring
· Monitoring refers to the assessment of the day to day functioning of the
program
· Any suggestions for improvement should be implemented
8- Evaluation
· Evaluation refers to the assessment of the final outcome of the plan
· A good plan should have an in built evaluation system

32. Prioritization in Healthcare

33. Priority-setting is the act of deciding which health interventions to carry out, and can occur at several levels of granularity.

34. What is Priority Setting?
Process of assigning rank orders
Individual disease or health states and interventions or approaches
To mitigate specific health situations,
Based on their relative contribution to quality of life, and cost effectiveness of interventions.
Complex calculations are complex and Often fraught with controversies

35. Priority Setting — Concepts
Precedence, established by order of importance or urgency.
Establishment of the order of precedence
Rationing and Resource Allocation
Rationing - Taking care of existing demands when the supply of resources constrained
Resource allocation — Limited resources (time, money) invested systematically

36. Priority-setting can occur at the following levels
health budget level (i.e. deciding how much to spend on health overall)
overall strategy level (i.e. selective primary healthcare  versus primary healthcare versus more general health systems strengthening)
disease level (i.e. deciding which disease to alleviate)
intervention level within each disease (i.e. restricting to a specific disease and prioritizing among interventions for that disease)
drug level
research level (i.e. which health research to carry out)

37. In global health, priority-setting is a term used for the process and strategy of deciding which health interventions to carry out.
Priority-setting can be conducted at:
the disease level (i.e. deciding which disease to alleviate),
the overall strategy level (i.e. selective primary healthcare versus primary healthcare versus more general health systems strengthening),
research level (i.e. which health research to carry out

38. How to compare interventions
Various metrics have been used to compare interventions. These include:
Disability-adjusted life year per unit cost (used by e.g. Disease Control Priorities Project),
 quality-adjusted life year, and other forms of cost-effectiveness analysis
Reasons that the disease burden has persisted
Adequacy of funding

39. Who sets the priorities?
Priority-setting can be done by various actors. These include:
Governments: "In most countries, health spending by governments vastly outpaces international health aid, so governments set most health priorities."
Non-profits and companies that assist governments
If a country is using a Health in All Policy (HiAP) approach, then priority-setting is done by stakeholders who do not directly deal with health.
International organizations
Foundations
Private donors (including high-net-worth individuals and ultra-high-net-worth individuals): "A common outcome is a negotiated set of priorities that reflect some domestic needs and some technical, political, and economic considerations defined largely by the interests of donors."[6] In some highly aid-dependent countries, donors "have huge influence on health priorities".[8]
According to Devi Sridhar, professor of global health at the University of Edinburgh,“ the priorities of funding bodies largely dictate what health issues and diseases are studied"

41. Priority setting in healthcare= Overview
Rationing in healthcare
Economic approach to setting priorities
Equity & fair innings

42. Seven forms of rationing
By Denial:
Patients denied care they need, for example, deemed unsuitable or not urgent enough
By Selection:
Patients selected because of characteristics, for example, most likely to benefit from treatment
By Deflection:
Patients encouraged or turned towards another service, for example, private care
By Deterrence:
Patients deterred from seeking care, for example, barriers or costs put in place or not removed.
By Delay:
Needs not met immediately, for example, wait for appointments or waiting-lists.
By Dilution:
Services given to all but amount given reduced, for example, general practitioner consultants.
By Termination:
System no longer treats certain patients, for example, cessation of cancer treatment

43. Nature of Prioritization
Core Issues are Political and Ethical
How Resources, Rights, and Responsibilities are distributed.
Political considerations underpin why implement validated technical interventions are difficult

44. Alternatives to Prioritization
Add More Resources
Take out Services

45. Why Prioritize When Adding Resources Might Work?
Assure donors to maintain or increase the flow of funds
Prioritization can itself increase resources
Prioritization is needed if we are to know that prioritization is insufficient
Most important when there is little money
Risk of Spending Too Much on Tertiary Care: Poor Spending Pattern
Unfunded Primary Care —> Lethal in the poorest countries

46. Challenges of Prioritization
Resources are limited
Impossible to provide everyone with every effective intervention
Limited resources and unlimited demands
Justice and efficiency
Lack of Consensus
Little interaction about priority setting among decision makers

47. Points Multiplicity of priorities and
Lack of institutional mechanisms to rationalize services and spending often results in
Poor overall system performance,
Low coverage for highly cost-effective health technologies

48. Controversies of Prioritization
Process Affects Who, What, “How Much”, “When”, and at “What Cost”
Donors want to see their investments incorporated into public budgets
No simple or purely technical answers
Uncertainties around which values should guide decisions about Prioritization

49. Adjudication in the Context of Prioritization Exercises
Every Disease Condition is a Priority
Governments Cannot set policies in vacuum.
Between many relevant values and that
People (and disciplines) disagree which values should dominate
There is no agreed upon normative approach

50. How to Conduct Priority Setting Exercises
Collect information on the costs and benefits of all the interventions to be considered —> creating a common currency for measuring and comparing the benefits
Use models and assessments, such as the burden of disease and cost-effectiveness, to create a package of services

51. Factors Considered for Priority Setting Exercises
Burden of Disease
Cost effectiveness of Interventions
Equity
Existing Capacity to Deliver
Risk Pooling :Some health conditions are rare and too costly for most uninsured individuals to pay out-of-pocket

52. Approaches to Priority Setting
Using Formulae or Models
Using Guidelines or Technology Assessments
Utilize Explicit Criteria (NZ early 90s, UK, Holland, Oregon)
Include community needs, community preferences, economic evaluations of cost-effectiveness, public health considerations
Basic package of services is provided or financed based on an agreed criteria list
Social preferences can influence how the different benefits are combined and valued

53. Best Practices Use recent data Analysis should be country specific
Be based on a well functioning and representative set of information systems
Rank Order by Burden and by population subgroup in order to provide useful advocacy information for the different groups
Build Flexibility in Budget
Build Linkages across services
Ensure Sufficient time and resources to deliver the interventions

54. Dilemma Imagine you have only $1000 to spare to pay for treatment
Who will get treatment?
$1000 to Spend
Child with appendicitis needs an urgent surgery, overall cost $1000 out of your pocket
You need to get a root canal treatment done for a cavity in your tooth
Cosmetic surgery (skin grafting) to cover an old burn scar

55. Parent with Three Children
You see a parent. He has diabetes for which he takes medicines, on a diet, and exercise.
He works at an office (junior management) and is the sole earning member of the family. They have three children: one suffers from Chronic Asthma and needs regular medication,
the second has a congenital heart disease and will need surgery soon, and
the third just got diagnosed with tonsillitis and the doctor wants him operated urgently.
What will be your advice to the parent to manage this?

56. Clinic Director
X has set up a clinic around Irbid (an upscale yet recent immigrant dense neighbour hood). The population that the clinic serves is aging (60% above 65 years and 40% are young families (35 years average age with two kids).
X wants to set up a suite of services to offer to this community but has resource limitations.
What mix of services you will advise him?

57. Range of Services
Y is a consultant and wants to work in areas of public health and preventive health services at a rural township where a large farming community exists.
The average age of the population is about 55 years, most are locally based farmers, or work in sheep shearing sheds, or have work with farming machineries.
With Limited Budget, what kind of services would you advise Y to plan for?

58. How to Play God
Z is a venture capitalist and just got an offer from the Bill and Melinda Gates foundation that he has 5 million dollars to spend but has to pick ONLY two disease control/prevention/public health issues in Mafraq . Z comes to you for advice.
What will you advise Z?

59. Conclusions and Comments
Priority Setting As Balance Between Resources and Demands
Necessary for Best Allocation of Resources
Frameworks Provide Good Structures to Achieve Prioritization
Discussions and Comments?