1. Health Systems and Actors Tom Merrick, World Bank

2. Topics for this session: n How health reform relates to other forces affecting reproductive health outcomes n Health systems and their performance n Types of health reform and how they are expected to improve performance n Actors in the health system: roles and functions

3. Government policies & actions Health sys- tem & other sectors Pathways to Reproductive Health Outcomes RH out- comes Outcomes Households/ Communities Household behaviors & risk factors Health service supply Health reforms Other parts of health system Supply in related sectors House- hold resources Community factors Actions in other sectors

4. What is a health system? n ‘All the organisations, institutions and resources that are devoted to producing health actions. n ‘A health action is defined as any effort, whether in personal health care, public health services, or through intersectoral initiatives, whose primary purpose is to improve health’(WHR 2000)

5. How do health systems differ? n Roles of public and private providers in finance and provision of services (some are mainly public, others private, some mixed-- one size does not fit all) n How care is paid for (taxes, insurance, payments by consumers): follow the money n Health systems are not static; recognize the forces of change and how systems respond.

6. Public health services Pharmacies State medical practices Ambulatory care clinics Polyclinics Public hospitals Compulsory income related contributions General taxes Central government Regional authorities Population and enterprises Patients Former GDR Source: OECD, 1994

7. Population Patients Health insurance funds Social insurance Private insurance Government (confederations, cantons, municipalities) Hospitals Ambulatory care Outpatient care Switzerland c1990

8. Forces that shape health systems—and change them n Social compacts—what health care and finance that different societies decide the state should provide n Culture/values underlying such compacts n Demographic and epidemiological conditions n Financial and political conditions n In many countries—health systems a legacy of colonialism & change is led by donors

9. What is health reform? n Health sector reform has been described as sustained purposeful change to improve the performance of the health sector. n It is motivated by the need to address fundamental deficiencies in health care systems that affect all health care services, including reproductive health services. n It is an inherently political process, and it is often implemented on a sector-wide level.

10. Why are countries taking on health reform? n Poor performance of existing health systems n Public expenditures skewed toward rich and neglect the poor, particularly women n Resources are scarce, demands increasing —forcing governments/donors to be strategic n Consumers unhappy about poor treatment n Donor fatigue, concerns about sustainability

11. What forces affect health system performance? n Governance capacity n Skills, competencies of managers and providers n Resources and incentives n Technical and organizational capacity n Degree of accountability to consumers n Context: financial, political, social, demographic and epidemiological

12. Health reform measures: n New approaches to finance: charging fees, social and private insurance schemes, sectoral funding n New payment mechanisms: performance- based contracting, capitation n Reorganization of functions: new roles for ministries, separation of finance and provision, enhanced stewardship n Decentralization, devolution: budgets, control shift from central to local government n Changes in legal & regulatory environment

13. Example: the Kirghiz Republic n Kirghiz health system a legacy of the Soviet system n Financed by public sector n Providers were public servants n Breakup of Soviet system created a financial crisis n Reform is bringing new ways of financing, new structures and roles, new ways of paying providers

14. Health reform in the Kirghiz Republic: pre-1997

15. How the Kirghiz health system will look after 2001

16. Health system actors—the people factor n Identify the policy perspectives of various actors, including donor agencies, governments and others involved in efforts to improve health system performance n Apply this knowledge to your own experience, creating an enabling environment for reproductive health policies.

17. Who are the actors in the health system? Who is in? Who is out? What are their roles? n By Level n By Function n By Interaction n Consuming n Planning n Financing n Delivering n Oversight and accountability

18. Health System Actors, Functions and Outcomes People Demand Financing Revenue Generation Risk Pooling Allocation & Purchasing Input Management Human ResourcesKnowledge PharmaceuticalsTechnology Consumables Capital Private Sector Actors For Profit Non-Profit Non-Formal Allopathic Indian Systems Health Status Financial Protection Oversight Policy SettingInformation, Disclosure & Advocacy Developing Partnerships Regulation & Standard Setting Monitoring & Evaluation Strategic Incentives The State Union Government State Governments Local Bodies Consumer Responsiveness Service Delivery Public Health Services Ambulatory Care Inpatient Care

19. How do the actors relate? n The “market” n Regulation and stewardship n Information flows n Contracts and agreements n The political process n Accountability

20. From your own experience, how have actors influenced RH outcomes? n Positively? Give Examples n Negatively? Give Examples

21. Political Mapping Tool – Abt Policy Toolkit

22. Policymaker mapping of players

23. Example of mapping

24. More next week on actors n Engaging stakeholders n Your action plans