1. Components of a health care delivery system B Subha Sri, MPS course, July 2010

2. Components of a functioning health care delivery system 1. Attitudes 2. Technical competence 3. Referral systems 4. Infrastructural requirements 5. Access 6. Organisation of services 7. Supplies and Equipment systems 8. Accountability mechanisms

3. Attitudes Client provider interaction Hierarchical Cultural appropriateness Response to gender / poverty issues Abuse Corruption

4. Attitudes Health care delivery systems can reinforce prevailing gender norms. Negative attitudes can infringe on the reproductive and sexual rights of the people. Negative attitudes affect quality of care – perceived quality of care can affect health seeking. Affects women much more than men. Eg. Adolescent girl asking for contraceptives

5. How can you bring about a change in attitude? “Attitude, like water, flows from top to below” - Role models Training to change attitudes Better working atmosphere Counsellors Performance appraisal – to probe into provider attitudes and gender biases Gender mainstreaming into medical / paramedical education

6. Technical competence Rational Evidence based Standard treatment protocols

7. Technical competence Technical incompetence leads to failure in providing appropriate care and unnecessary / inappropriate referral. Leads to low self esteem and low morale among the staff and puts them under stress. Inadequate services impact differentially and detrimentally on women and men.

8. How can you bring about a change in level of competence? Staff training Standard protocols and guidelines Based on problems, relevant to local context Continuous monitoring Multi skilled people who can stand in for each other Training to handle difficult situations with tact Training in inter personal skills Appropriate allocation of adequately trained staff – prime responsibility of managers

9. Referral systems- common issues Unnecessary / inappropriate referral Lack of ambulances Referral note Follow up of referred patients Reverse referral Lack of awareness about the time constraints and gender issues in the patient’s real life context

10. How can change happen in referral systems? Referral protocols needs to be worked out Referral system needs to be developed Development of systems should be based on practical and systematic thinking process – Accompanied transfers Staff at each level needs to be trained in using the protocols and monitored. Follow up and reverse referral

11. Infrastructural requirements Ensuring privacy Cleanliness Ancillary services Enabling environment to put into practice the training and skill up gradation Should look into all factors of operational difficulties and not leave the clients to make their own arrangements Health providers in helpless situations and at the receiving end

12. Access Distance Socio cultural barriers Costs Organisational barriers Perceived quality of care Staff related System's responsibility to provide for overcoming barriers

13. Organisation of health services Timing Waiting time Interdepartmental referrals – multiple queues Staffing patterns

14. How to improve organization of services? Flexibility Better organisation of services Training in managerial skills Quality of service indicators Integration of services to meet client needs Multiple services by trained providers under one roof Inform the people about the facilities and the services they deliver. Information about where and what each level of facility provides

15. Supplies and equipments In spite of all training lack of supplies will be a barrier to effective services Demoralise providers Lose interest in taking forward initiatives Investment in training is lost Ordering and supply mechanisms and sometimes simple transport is non functional Local purchase from untied funds

16. Accountability mechanisms To community To system Mechanisms Monitoring

17. Health care delivery system wheel

18. Functioning health care delivery system The generic components of the health care delivery system needs to be in place and working for any health service intervention to be effective. They are like spokes on a wheel – the health system wheel. The role of health managers is to think through each of the components and to make them function