1. A Senior Management Course for Health Managers in Kenya Unit 1.3: Key Principles of Health Care Delivery and their Application Health Systems Management 2nd edition July 2014 senior management course for health managers

2. Purpose This unit introduces participants to the principles underpinning provision of quality health care. It discusses how the principles affect service delivery, including their application: access, coverage, quality, safety, equity, effectiveness, efficiency, lifecycle approaches, rights based approaches/client centered approaches and sustainability. 2nd edition July 2014 senior management course for health managers

3. Objectives By the end of this unit, the participant should be able to: Describe the Kenya Essential Package for Health (KEPH); Explain the health care delivery principles, and their relationship to the health system; Apply the principles and concepts in health service delivery. 2nd edition July 2014 senior management course for health managers

4. Overview Description of the Kenya Essential Package for Health (KEPH) – levels and services. There are nine (9) principles of health care delivery categorised as: a) Affecting intermediate outcomes (4): – access, coverage, quality and safety. b) Affecting final outcomes (5): – equity, efficiency, effectiveness, client centeredness, sustainability. 2nd edition July 2014 senior management course for health managers

5. Overview (Cont’d) For each principle: Describe the principle; Outline how the principle relates to the building blocks; Interpret its application to Kenya Essential Package for Health. 2nd edition July 2014 senior management course for health managers

6. Session 1.2 Introduction to Principles of Health Care Delivery and KEPH 2nd edition July 2014 senior management course for health managers

7. The Nine Principles of Health Care Delivery Affecting intermediate outcomes: 1.Access; 2.Coverage; 3.Quality; 4.Safety. Affecting final outcomes: 5.Equity; 6.Efficiency; 7.Effectiveness; 8.Client Centredness; 9.Sustainability. 2nd edition July 2014 senior management course for health managers

8. Application of the Principles The focus is to help participants understand: –Who is responsible for individual health; –What should determine the level of basic health care; and –How health care costs can be contained. This requires a clear understanding of the scope of services that need to be delivered in the country. The service package/scope in Kenya is defined in the Kenya Essential Package for Health (KEPH). 2nd edition July 2014 senior management course for health managers

9. Restructured KEPH in KHSSIP III 2013- 2018 This represents the need for: Better integration of all health programmes into a single package that focuses its interventions towards the improvement of health across the life course and emphasises inter-connectedness of the various phases in human development; More accurate data and information for target setting, planning and monitoring performance, especially MDGs; 2nd edition July 2014 senior management course for health managers

10. Restructured KEPH in KHSSIP III 2013-2018 (Cont’d) Harmonisation and clear definition of KEPH interventions for each cohort; Incorporation of new strategic imperatives in the Kenya Health Policy Framework 2012- 2030 and Constitution of Kenya, 2010. 2nd edition July 2014 senior management course for health managers

11. Structure of Health Services In Kenya, health services are organised based on: 1.Type; 2.Cohorts (Target group ); 3.Tiers (Level) 2nd edition July 2014 senior management course for health managers

12. 1. Structure of Health Services by Type The KHSSIP III 2013–2018 defines the Kenya Essential Package for Health (KEPH) to comprise the following types of health services: Promotive; Preventive; Curative; and Rehabilitative. 2nd edition July 2014 senior management course for health managers

13. 2. Structure of Health Services by Cohorts (Target) KEPH revised cohorts represent the life-cycle approach to health service management. Each age group has special needs that relate to the development phase they are passing through. Services based on five (5) life cohorts and cross-cutting interventions, encompassing the expectations of persons in Kenya are: 2nd edition July 2014 senior management course for health managers

14. Structure of Health Services by Cohorts (Target) (Cont’d) – Pregnancy and the new born (up to 28 days); –Early childhood (29 days – 59 months); –Late childhood and youth (5 – 19 years); –Adulthood (20 – 59 years); –Elderly (60 years and over); –Cross cutting interventions (all cohorts). Specific interventions by cohort and tier are defined in the KHSSIP III. 2nd edition July 2014 senior management course for health managers

15. Structure of Health Services by Tiers (Levels) KEPH services are defined for each of the six (6) cohorts for the newly defined four (4) tiers of the Health System (KHSSP III 2013- 2018): – Tier 1: Community level; – Tier 2: Primary care level (Health Centres/Dispensaries); – Tier 3: County level /Sub county – Tier 4: National level. 2nd edition July 2014 senior management course for health managers

16. Part I: Principles Affecting the Intermediate Health Outcomes 2nd edition July 2014 senior management course for health managers

17. Principles Affecting Intermediate Outcomes These are: 1.Access; 2.Coverage; 3.Quality; 4.Safety. 2nd edition July 2014 senior management course for health managers

18. Session 1.2 PRINCIPLE 1: ACCESS 2nd edition July 2014 senior management course for health managers

19. Definition of Access to Health Services Is a measure of the ability of a person or community to receive health care services. Defines the capacity, and factors influencing entry into, or use of the health care system. Implies health care services unrestricted by geographic, economic, social, cultural, organisational, or linguistic barriers. A prerequisite to high utilisation of health services. 2nd edition July 2014 senior management course for health managers

20. Definition of Access to Health Services (Cont’d) Describes the link between the potential client and the health system. The access dimensions are: 1.Availability; 2.Accessibility; 3.Affordability; 4.Adequacy; and 5.Acceptability. 2nd edition July 2014 senior management course for health managers

21. 1. Availability Indicates how well the defined health services meet the needs of the clients / target population. Health care interventions address the needs of the clients. NB. At times, the provided interventions are not necessarily related to the needs. 2nd edition July 2014 senior management course for health managers

22. 2. Accessibility: Geographical Access Implies the location of supply of services is in line with the location of the clients. Geographical access is determined by distribution of facilities, public transport, referral systems, sufficient community health services and degree of collaborations with other services providers. The WHO recommends an average distance of five (5) kms to reach the nearest health facility. 2nd edition July 2014 senior management course for health managers

23. 2. Accessibility: Geographical Access (Cont’d) Geographic access is measured by modes of transportation, distance, travel time, and any other physical barriers that could keep the client from receiving care. Imbalanced distribution of health facilities is related to numbers and types of facilities and lack of defined norms and standards for infrastructure development. 2nd edition July 2014 senior management course for health managers

24. 2. Accessibility: Geographical Access (Cont’d) Reasons for poor transport services: Inadequate ambulances; Inadequate budgetary provisions; Poor preventive maintenance; lack of standard transport guidelines that are in line with the expected functions and workload. 2nd edition July 2014 senior management course for health managers

25. 3. Affordability: Financial Access Is concerned with how well the price of services fits the clients’ income, and ability to pay. Economic barriers to access include user fees, low household income, low prioritisation of health at household level and low allocation of resources by the state to the health sector. The Abuja declaration recommends governments to allocate 15% of expenditure budget to health. 2nd edition July 2014 senior management course for health managers

26. 3. Affordability: Financial Access (Cont’d) Health expenditure of at least USD34 per capita is considered fair investment, while a household expenditure on health care above 40% of total disposable income limits financial access. Measures to improve availability of affordable services: –introduction of National Social Health Insurance Fund; –reviewing the cost sharing strategy; –community pre-payment schemes and developing a criteria for allocation of public funds. Universal access to essential care package can be improved through stronger partnership among governments, pharmaceutical companies, civil society, and consumers. 2nd edition July 2014 senior management course for health managers

27. 4. Adequacy Concerned with how well the organisation of health care meets the expectations of the clients. Service organisations that hinder access include: – Services available at a time when the clients are not; – A service placed in a facility located where clients are not comfortable using. 2nd edition July 2014 senior management course for health managers

28. Application of Principle 1: ACCESS 2nd edition July 2014 senior management course for health managers

29. Measuring Access Concerned with increasing the proportion of those in need of services actually accessing the service. The vision of health system is to achieve universal coverage e.g. HIV/AIDS services for vulnerable groups. The expected scope of interventions to be provided is defined in the Kenya Essential Package for Health (KEPH). A district should have a medium term strategic approach to improve access and coverage. 2nd edition July 2014 senior management course for health managers

30. Measuring Access (Cont’d) The strategy is to ensure the full scope of KEPH for its level of care, to the full population within its area of responsibility. To define and measure these two elements, monitoring and assessment should be done. 2nd edition July 2014 senior management course for health managers

31. Planning for Improvements in Access, and Coverage at District/Zone Level This is a three-step process that aims to: 1.Define critical problem areas in access to, and coverage of the KEPH; 2.Identify the specific solutions to addressing these; and 3.Prioritise the solutions over the period of the strategic approach for the planning unit. 2nd edition July 2014 senior management course for health managers

32. Step 1: Identifying Critical Problem Areas Drawn from the situational description in the planning process. Depends on the presence or lack of health facilities, and the scope of services they provide. Health activities and care levels for specific population groups defined on the basis of the need for equity and efficiency in carrying out the activities. Norms and standards define populations requiring each facility type. District map should be drawn based on the needs that identify the catchment areas for the different levels of care. 2nd edition July 2014 senior management course for health managers

33. Step 1: Identifying Critical Problem Areas Illustrated 2nd edition July 2014 senior management course for health managers

34. Step 2: Identifying Solutions Norms and standards define the process for a district to identify areas where additional facilities will be needed. Catchment areas and the scope of services provided in each of the existing facilities need to be assessed. Possible scenarios in the district for improving access, and coverage are based on either of the following: –the ‘activity’ approach; –the ‘facility’ approach. 2nd edition July 2014 senior management course for health managers

35. Activity 1.2.2.1: Group Work (30 minutes) Table 3: Categorisations of catchment areas: In groups, participants categorise the catchment areas in their districts, according to the six situations described overleaf. The dummy table provided below can be used. From this assessment, the district information is then summarised in a table similar to the one below. 2nd edition July 2014 senior management course for health managers

36. Identification of Critical Problem Areas in a District/ County 2nd edition July 2014 senior management course for health managers

37. Troubleshooting If more than one facility is in a location: catchment areas are sub-divided by sub-location / by village. If facility is not a government facility: all facilities should be treated equally – FBO/NGO facility can be responsible for a given catchment area in the district. If some cohort services are being provided: only score service delivery as YES if ALL the services are being provided. If any expected service is not being provided, then the area scores a ‘no’. 2nd edition July 2014 senior management course for health managers

38. Step 3: Prioritising Solutions Mechanism to prioritise the catchment areas in terms of when to address their solutions is provided. A set of criteria for prioritising the areas selected require: A specific description of the criterion; A score (for instance from 1 to 3-1 being the least favourable and 3 the most favourable condition) is further used to appraise each criterion for each catchment area. 2nd edition July 2014 senior management course for health managers

39. Activity 1.2.2.2: Group Work (20 minutes) Participants fill, for each catchment area, the criteria and calculate the total score using the dummy table below. Copy to TLA UNIT 1.3.3 2nd edition July 2014 senior management course for health managers

40. Step 3: Prioritising Solutions (Cont’d ) Ranking of catchment areas for revitalisation 2nd edition July 2014 senior management course for health managers

41. Step 3: Prioritising Solutions (Cont’d) Ranking of catchment areas for establishment of facilities 2nd edition July 2014 senior management course for health managers

42. Session 1.2.3 PRINCIPAL 2: COVERAGE 2nd edition July 2014 senior management course for health managers

43. Introduction Concerned with improving the range of services and population able to benefit from the services. The actual services and their characterisation are defined in the access dimensions. Coverage is therefore a measure of level of utilisation of the available health services. The major focus of improvement in coverage is on extending the defined package of health services to more populations. Adequate coverage is thus attained when there is universal coverage by the service. Overall sector coverage monitoring indicators are shown in the table below. 2nd edition July 2014 senior management course for health managers

44. Coverage Sector Monitoring Indicators CohortResultSample index indicators 1 Cohort 1 – Pregnancy and newborn (up to 28 days) a Mothers are kept healthy during pregnancy % pregnant women attending four ANC visits % pregnant women receiving IPT 2x b Mothers are able to have normal deliveries % deliveries conducted by skilled health staff in facility % maternal deaths in planning unit audited % WRA receiving FP commodities c All newborns (up to 2 weeks) receive protection against immunisable conditions % neonatal deaths (up to 28 days) in planning unit % HIV + pregnant women receiving PMTCT % pregnant women receiving TT (2 doses) 2 & 3 Cohort 2& 3 – Early ;and late childhood and youth (29 days to 59 months) and (5 – 19 years) a Children receive protection against immunisable diseases % children fully immunised at 1 year of age % children receiving DPT/HepB/Hib 3 b Children are able to survive childhood illnesses % deaths amongst under 5’s in planning unit % under 5s new visits with weight / age above lower line (PR) % children receiving Vitamin A (1-2 doses) c Children are protected against exploitation and abuse % under 5 new visits with height / age above lower line (PR) % Community Units under planning unit providing health promotion services targeting exploitation and abuse of children d Healthy lifestyle is adopted amongst children % under 5 attending Growth Monitoring Clinic (New visits) % children de-wormed at least once / year 2nd edition July 2014 senior management course for health managers

45. Application of Principle 2: COVERAGE 2nd edition July 2014 senior management course for health managers

46. Activity 1.2.3.1: Group Work (30 minutes) Discuss the barriers to access and coverage in relation to KEPH service delivery in your district/county. How would you mitigate against these barriers? Copy to TLA UNIT 1.3.3 2nd edition July 2014 senior management course for health managers

47. Session 1.2.4 PRINCIPLE 3: QUALITY OF CARE AND QUALITY SERVICE DELIVERY 2nd edition July 2014 senior management course for health managers

48. Quality of Care and Service Delivery Quality is defined as conforming to the ‘requirements’, ‘fitness for use’ (Juran, 1988). The degree of quality is a measure of the extent to which the care provided is expected to achieve the most favorable balance between risks and benefits. Based on its characteristics, a service can be categorised into three, namely: 2nd edition July 2014 senior management course for health managers

49. Quality of Care and Service Delivery (Cont’d) 1.Structure: the personnel, equipment, buildings, record systems, finance, supplies and facilities 2.Process: all aspects of the performance of activities of care; and 3.Outcome: the end results of care/service. All three categories need to be considered to obtain a balance of quality. 2nd edition July 2014 senior management course for health managers

50. Quality of Care vs Quality of Service Delivery Quality of care is often confused with quality of service delivery. Quality of service delivery encompasses: –the traditional inputs into health services (human resources, medical products, and finances); –the process elements (i.e. the production process of services), such as the tools necessary for the resources to be effective and efficient (guidelines and instruments to ensure rational performance); and –the result elements which imply that the service product will be priority determined and regularly measured. 2nd edition July 2014 senior management course for health managers

51. Quality of Care vs Quality of Service Delivery (Cont’d) The technical quality of service delivery does not necessarily match with what people may perceive as ‘quality of service delivery’. People may demand for injections or lab tests even when it is ‘technically speaking’ not necessary. The responsibility of the service provider is to try to convince the client of the unnecessary, and possibly the damaging effects of this demand. Measurement of quality of service delivery should take into consideration all its dimensions, and ensure it is differentiated from quality of care. 2nd edition July 2014 senior management course for health managers

52. Elements of Quality of Care Refers to the characteristics of the system of health care that enable it to take care of the client, taking into account all their socio- economic and disease dimensions. The ‘system’ quality of care refers to health care as it is delivered in a functional ‘system’. These system qualities of care are: 1.Relevance and acceptability; 2.Continuity of care; 3.Integration of care; 4.Comprehensive/holistic approach and the involvement of individuals, households and communities. 2nd edition July 2014 senior management course for health managers

53. 1. Relevance and Acceptability To meet this requirement, health care must: Take account of the demand for care and respond to the real and priority needs of the population; Be responsive to the cultural and social realities of the communities; and Take into account user satisfaction elements in the health care delivery equation. 2nd edition July 2014 senior management course for health managers

54. 2. Continuity of Care This implies that when a person seeks assistance in a health system for any health problem, his/her need is taken care of from the start of the illness or the risk episode until it is resolved. This calls for the existence of a functional referral and counter-referral system to ensure referral services for a sick person or a person at risk who needs it. This includes the active follow-up of certain patients at risk because of the critical need to do so for the patient or for the community at large. 2nd edition July 2014 senior management course for health managers

55. 3. Integration of Care One health unit with one team in the community takes care of all health problems of this community through curative, rehabilitative, preventive and promotive activities. Every contact with individuals, households and communities is used to ensure this set of activities. This is different from using ‘every opportunity to do everything’. 2nd edition July 2014 senior management course for health managers

56. 4. Comprehensive/Holistic Approach The health problems of an individual are taken care of while considering all the dimensions of the individual and her/his environment (i.e. the household, community, and their social, cultural, economic and geographic characteristics). The health teams at community-based health units have to know the population in order to consider a permanent interaction and dialogue with individuals, households and community at large. 2nd edition July 2014 senior management course for health managers

57. Involvement of Individuals, Households and Communities Creates a sense of ownership of all that the people have undertaken relating to their health. This involvement includes: -individual participation in the health activities of the health unit; and -collective participation through management of the health facilities. 2nd edition July 2014 senior management course for health managers

58. Application of Principle 3: QUALITY OF CARE 2nd edition July 2014 senior management course for health managers

59. Activity 1.2.4.1 (45 minutes) Discuss what constitutes quality of care in your facility and how it is applied. COPY TO TLA UNIT 1.3.3 2nd edition July 2014 senior management course for health managers

60. Assessment of Quality and Quality Control Involves assessment of the difference between expected and actual performance to identify opportunities for improvement. The quality of health services depends on the effectiveness of service processes. 2nd edition July 2014 senior management course for health managers

61. Tools/Methodology of Measuring Quality These include: –Checklists e.g. the KQM master checklist and supervision checklists; –Client exit survey tools and suggestion boxes. These aim to measure the level of quality of current practice against a given standard from the technical perspective and the client perspective. 2nd edition July 2014 senior management course for health managers

62. Role of Committees in Quality Assurance Roles of various committees include: Assuring quality of health care delivery; Ensuring that finances available are utilised in the most cost effective way and that supplies meet standards required for delivery of care; The HMT has the overall supervisory role of assuring quality of care. 2nd edition July 2014 senior management course for health managers

63. Roles of Regulatory Bodies in Assuring Quality The regulatory bodies include: –The Medical Practitioners and Dentists Board; –The Nursing Council of Kenya; –The Clinical Officers Council; –The Pharmacy and Poisons Board; –The Radiation Protection Board –Kenya Medical Laboratory Technicians & Technologists Board, etc. They are involved in: assuring quality of personnel, supplies and equipment; and providing the legal framework for implementing and enforcing quality. 2nd edition July 2014 senior management course for health managers

64. Clients Perspective of Quality Client satisfaction surveys assess the extent to which services are of the level of quality that the client expects. Recommendations from these surveys are then utilised to address the issues of quality of care. The surveys target populations using, or potentially using health services. 2nd edition July 2014 senior management course for health managers

65. Role Quantitative Research Methods in Assuring Quality Three methods of collecting data: –Observation visits; –exit interviews; and –face to face interviews. Quantitative research allows for gathering of information that is scientifically representative of the entire population under assessment. 2nd edition July 2014 senior management course for health managers

66. Systems Perspective of Quality A technical assessment by the health system. Different variables affecting quality of care are reviewed in an objective, or subjective manner by the immediate supervising level. Tools applied in the supervision process are from 3 sources: –HMIS unit; –Kenya Health Quality Assurance Model; –Hospital reform supervision tools. 2nd edition July 2014 senior management course for health managers

67. PRINCIPLE 4: PATIENT SAFETY 2nd edition July 2014 senior management course for health managers

68. Definition of Safety of Health Services Safety is a principle that aims to ensure the care provided does not become a cause of ill health. The WHO estimates that health care errors affect one in ten patients worldwide. Patient safety aims to limit or eliminate preventable adverse effects of care, whether or not these are evident or harmful to the patient. 2nd edition July 2014 senior management course for health managers

69. Areas Affecting Patient Safety There are three factors that can adversely affect patient safety: 1.Human errors; 2.Medical complexities; and 3.System failures. Measures aimed at adequate patient safety need to address these three (3) areas. 2nd edition July 2014 senior management course for health managers

70. 1. Human Factors They are attributed to ‘human error’ during the provision of health services. They are due to: –Variations in healthcare provider training and experience, fatigue, and burnout; –Diverse patients, unfamiliar settings, time pressures; –Failure to acknowledge the prevalence and seriousness of medical errors. 2nd edition July 2014 senior management course for health managers

71. 2. Medical Complexities These are attributed to a mismatch between the care providers, and the technology available. The technology being used may not be appropriate for the services being provided. They include: –complicated technologies; –powerful drugs; –intensive care; –prolonged hospital stay. 2nd edition July 2014 senior management course for health managers

72. 3. System Failures They are due to overall mismatching of investments in the system that leads to compromised patient safety. They include: –Poor communication or unclear lines of authority amongst the care providers; –Increased patient to health worker staffing ratios; –Disconnected and weak reporting and accountability systems - fragmented systems in which numerous handing-off of patients results in lack of coordination and errors; 2nd edition July 2014 senior management course for health managers

73. 3. System Failures (Cont’d) Drug names that look alike or sound alike; Poorly designed cost-cutting measures; Environment and design factors; for example, in emergency situations, care may be rendered in areas poorly suited for safe monitoring; and Infrastructure failures. 2nd edition July 2014 senior management course for health managers

74. Measuring Safety The science of measurement of patient safety is still in its infancy. The main focus is around hospital based services, where clients with hospital acquired ill health are followed up. In the public health field, cases of adverse effects following immunisation are followed up. Measurement of patient safety should cover the three areas affecting patient safety outlined above. 2nd edition July 2014 senior management course for health managers

75. Application of Principle 4: PATIENT SAFETY 2nd edition July 2014 senior management course for health managers

76. Introduction Addresses the principle of: safety of health services; Safety of patients; and input safety and solutions 2nd edition July 2014 senior management course for health managers

77. Patient Safety Solution Patient safety solution is any system designed or intervention that has demonstrated the ability to prevent or mitigate harm to patient arising from the processes of health care delivery. 2nd edition July 2014 senior management course for health managers

78. Areas of Patient Safety Solution Look alike-sound alike (LASA) medication names. Patient identification. Communication during patient hand-overs. Performance of correct procedure at correct body site. Control of concentrated electrolyte solutions. Assuring medication accuracy at transitions in care. Avoiding catheter and tubing mis-connections. Single use of injection devices. Improved hand hygiene to prevent health care - associated infection. 2nd edition July 2014 senior management course for health managers

79. Activity 1.2.5.1: (30 minutes) Propose actions that the County HMT’s medicines and therapeutics sub-committee will follow up on the relevant patient safety issues outlined above in your district. Use the template in the table below for compiling this. This will serve as the work plan for the therapeutics committee with regards to patient safety issues. Copy to TLA unit 1.3.3 2nd edition July 2014 senior management course for health managers

80. Recommendations on Patient Safety Patient safety solutionRelevant actions (from above) Activities of Therapeutics Committee for follow up Look-alike, sound-alike (LASA) medication names Patient identification Communication during patient handovers Performance of correct procedure at correct body site Control of concentrated electrolyte solutions Assuring medication accuracy at transitions in care Avoiding catheter and tubing misconnections Single use of injection devices Improved hand hygiene to prevent health care associated infection 2nd edition July 2014 senior management course for health managers

81. Part II: Principles Affecting the Final Health Outcomes 2nd edition July 2014 senior management course for health managers

82. Principles Affecting the Final Health Outcomes These are: 5.Equity 6.Efficiency 7.Effectiveness 8.Client centeredness 9.Sustainability 2nd edition July 2014 senior management course for health managers

83. Session 1.2.6 PRINCIPLE 5: EQUITY 2nd edition July 2014 senior management course for health managers

84. Equity in Health Care: Definition Refers to the absence of systematic disparities in health (or in the major social determinants of health) between social groups who have different levels of underlying social advantage/ disadvantage - i.e., different positions in a social hierarchy. Inequities in health systematically put groups of people who are already socially disadvantaged at further disadvantage with respect to their health. 2nd edition July 2014 senior management course for health managers

85. Equity in Health Care: Definition (Cont’d) Implies a fair opportunity to all to attain their full health potential, and that: –no one should be disadvantaged from achieving this potential.’ Concerned with creating equal opportunities for health down to the lowest level possible without bringing health differentials. 2nd edition July 2014 senior management course for health managers

86. Dimensions of Equity The dimensions of equity are in two different forms: 1.The way investments are made to ensure equity: –equal utilisation for equal need, for equal quality of care for all, or equitable end state distributions; 2.The end state distribution being sought by equity: –allocate the same amount of resources to people in similar situations (horizontal equity), but –different amounts of resources to people in different situations, according to their difference in need (vertical equity). 2nd edition July 2014 senior management course for health managers

87. How Equity is Determined There is no single agreed method for distributing a health care good. Health care “goods” are different e.g.: –health insurance; –health care services; –health outcomes. The nature of a good affects its equitable distribution: –the physical nature of the good; –the degree to which a good has customised vs. generalised value across members of the community; –prevailing cultural beliefs about the good and its appropriate means of distribution. 2nd edition July 2014 senior management course for health managers

88. What Affects Equity? Analysis of equity focuses on three basic critical issues: 1.Identifying the appropriate policy focus; 2.Defining characteristics of potential recipients. 3.Defining the goods to be distributed and their characteristics. 2nd edition July 2014 senior management course for health managers

89. Identifying Appropriate Policy Focus Policy focus on equity is concerned with: –how to allocate (i.e., equitable processes); and –the acceptability of the resulting allocations (i.e., equitable end-states). Equity objectives can be defined in terms of fair processes, fair end-states, or both. Two policy focuses for ensuring fair resource allocation include: –focus on developing fair processes for distributing goods; and –focus on specifying fair end-states in the final distribution of goods. Health policy analysts can be concerned with either or both issues. 2nd edition July 2014 senior management course for health managers

90. Characteristics of Potential Recipients that might Justify their Claims to Particular Health Goods Recipients may be grouped either as individuals, populations or groups. Need is the discriminating characteristic most frequently used to define equitable distribution of health care: –often understood in terms of an individual's or population's ability to benefit from health care; –as the needs can be enormous, policy makers allocating limited resources must decide whose needs will be met, and whose will not. 2nd edition July 2014 senior management course for health managers

91. Characteristics of Potential Recipients that might Justify their Claims to Particular Health Goods (Cont’d) A need may be conceived differently depending on the “good” to be distributed. If the “good” is: –financial subsidisation of services, then neediness may be defined in part by degree of poverty; –fair distribution of health services, then the population will be divided by degree of health care need, but such information is seldom directly available. Analyses of equity commonly compare distributions of goods between wealthy vs. poor, old vs. young, one ethnic group vs. another, urban vs. rural, etc. 2nd edition July 2014 senior management course for health managers

92. Application of Principle 5: EQUITY 2nd edition July 2014 senior management course for health managers

93. Importance and Determinants Equity ensures that all inhabitants of a given region/area not only have equal access to health services, but also use them equally for equal need. Important determinants are geographical, demographic (age and gender), socio-cultural features, and economic. 2nd edition July 2014 senior management course for health managers

94. Assessment of Equity To ensure an adequate health stock, analysis and planning of interventions is done at 3 levels of care. The first level is the direct causes of ill health and/or death: -These are the actual disease conditions that impact on the health of the individual. The second level relates to underlying factors that exist to allow the direct causes to express themselves. –They are individual, household, or community based factors. 2nd edition July 2014 senior management course for health managers

95. Assessment of Equity (Cont’d) The third level relates to the basic, socio-cultural issues that influence the uptake and use of services targeting the direct or underlying causes: -These factors relate to poverty and underdevelopment. Other dimensions include powerlessness, exclusion, lack of opportunity, discrimination, marginalisation, deprivation of basic services and infrastructure. Distal factors include social conflict, especially wars and political instability. 2nd edition July 2014 senior management course for health managers

96. Determinants of Level and Distribution of Health SOCIO-CULTURAL ISSUES Poverty Literacy Urbanisation Security Exclusion Powerless UNDERLYING FACTORS Health Services Nutrition Personal Factors Safe water Sanitation DIRECT CAUSES OF MORBIDITY/MORTALITY Communicable conditions Non-communicable conditions Injuries / violence HEALTH STOCK Level of distribution Primarily influence level of health Primarily influence distribution of health 2nd edition July 2014 senior management course for health managers

97. Conceptual Framework Equity planning and assessment is based on reviewing the impact the different social determinants are having on the service coverage attained. For different coverage indicators, assessment is done comparing achievement of districts distinguished by different social determinants: –Level of education - analysis of literacy level differences; 2nd edition July 2014 senior management course for health managers

98. Conceptual Framework (Cont’d) Social determinants cont’d: –Level of empowerment of vulnerable groups - analysis of gender development index differences; –Physical access to services - analysis of urban/non urban differences, and the arid/non arid disaggregation (access is generally low in the more arid areas of the country); –Level of poverty (in all its dimensions) - analysis of level of Human Poverty Index. 2nd edition July 2014 senior management course for health managers

99. Activity 1.2.6.1 (45 minutes) In your county or planning unit, review information on different equity variables, highlighting the variables most likely to affect achievement of health outcomes. Copy to TLA Unit 1.3.3 2nd edition July 2014 senior management course for health managers

100. Session 1.2.7(a) PRINCIPLE 6: EFFICIENCY 2nd edition July 2014 senior management course for health managers

101. Introduction Efficiency ensures that the least amount is spent to generate the desired health outputs or that maximum amount of health outputs is generated with available funds. It ensures that the health system is producing health services in the quantities and qualities that society wants (allocative efficiency), and that it produces them at the lowest cost possible (technical efficiency). 2nd edition July 2014 senior management course for health managers

102. Introduction (Cont’d) Efficiency is therefore a measure of: Whether what we are spending money on is correct (allocative efficiency); Whether we are producing it correctly (technical efficiency). 2nd edition July 2014 senior management course for health managers

103. Application of Allocative Efficiency Public Expenditure Review process: ₋Annual assessment of planned, and actual expenditures; ₋Assumes planned expenditures were allocatively correct, and so ensures actual expenditures were as planned. Annual Work Plan reviews(AWP): ₋Assessment of expenditures across key building block areas in the sector; ₋AWP analysis compares investments, across these building blocks. 2nd edition July 2014 senior management course for health managers

104. Application of Technical Efficiency Efficiency is measured against different decision making units (DMUs). DMUs represent a unit of management that has some level of authority and/or capacity to affect efficiency levels. There are two methods of assessing technical efficiency: 1.Ration Analysis; 2.Frontier Analysis. 2nd edition July 2014 senior management course for health managers

105. 1. Ratio Analysis Involves piecemeal analysis of key measures of performance, e.g.: – Average cost per inpatient day; – Bed occupancy rate; – Average length of stay (ALOS) per inpatient admission. Currently applied in AWP reviews, to compare efficiency of different DMUs. 2nd edition July 2014 senior management course for health managers

106. 1. Ratio Analysis (Cont’d). Comparison of DMUs is done graphically using the following: ₋Average Length of Stay (ALOS); ₋Bed Occupancy Rate (BOR); ₋Bed Turnover Ratio (BTR). DMUs’ values for BOR and BTR ratios are plotted on a graph, with one on x axis, and the other y axis. Once all hospital values are mapped, 4 quadrants/zones are described, with the 50% value on each axis as the cut off point. 2nd edition July 2014 senior management course for health managers

107. DMU Mapping and Interpretation of Ratio Analysis using BTR and BOR Zone II (high BTR, low OCC)  Excess bed capacity  Unnecessary hospitalisation  Many patients admitted for observation  Predominance of normal deliveries Zone III (high BTR, high OCC)  Good quantitative performance  Small proportion of unused beds Zone I (low BTR, low OCC)  Excess bed supply  Less need for hospitalisation  Low demand/utilisation Zone IV (low BTR, high OCC)  Large proportion of severe cases  Predominance of chronic cases  Unnecessarily long stays Bed turnover (patients/bed) Occupancy rate (%) 2nd edition July 2014 senior management course for health managers

108. Interpretation Based on Ratio Analysis Method is easy and based on a single input and single output situation. Outputs are interpreted according to the zone in which the DMUs lie. Planning units (hospitals) in zone III are the most efficient hospitals: – Highest BTR, and high occupancy. DMUs in zone I, II and IV are inefficient according to this method. 2nd edition July 2014 senior management course for health managers

109. Possible Reasons for Inefficiencies Causes of inefficienciesPossible reasons for inefficiencies Failing to minimise the physical inputs used Excessive hospital length of stay Poor scheduling of diagnostics and procedures Prescribing interventions or diagnostic tests of no therapeutic value or relevance Over-prescription of drugs Wastage of stocks Over-staffing Failing to use the cheapest possible combination Inappropriate use of more expensive staff relative to less expensive staff Use of branded drugs when generics are available. Failure to secure lowest cost supply Using paramedic-staffed emergency ambulances to transport patients home from hospital Operating at the wrong point on the short-run average cost curve Implementing budget cuts that protect salaries at the expense of other expenditure items Not filling vacant posts Limited local demand (e.g. demand for hospitalization) Inadequate drug supply Operating at the wrong point on the long-run average cost curve Planning to provide full pathology laboratory facilities at every hospital when lab services usually demonstrate economies of scale and should therefore be concentrated centrally Planning to build a 1,500-bed teaching hospital when diseconomies of scale are know to operate in hospitals over 600 beds. 2nd edition July 2014 senior management course for health managers

110. Key Weakness of Ratio Analysis Approach Simplifies performance to a few ratios; performance in health is a function of many more variables. Method cannot provide decisive evidence of the level of efficiency at which a given hospital is operating. Some hospitals may appear inefficient due to patient characteristics, e.g. psychiatric hospitals will have low turnover, and high occupancy due to nature of their patients, not inefficiencies. 2nd edition July 2014 senior management course for health managers

111. 2. Frontier Analysis A statistical approach based on mathematical programming. Addresses weaknesses of the ratio analysis. Applied in determining overall sector performance. Allows use of multiple inputs and multiple outputs to be analysed to generate a similar scenario. Information on a series of inputs, and outputs is used to generate an expected level of efficiency (efficiency frontier) for DMUs being assessed. 2nd edition July 2014 senior management course for health managers

112. 2. Frontier Analysis (Cont’d) Each DMU is compared against this frontier. Frontier is the “production function” – a mapping of different levels of inputs for which outputs are efficient. Assuming we determine efficiency in use of two inputs (No. of nurses and number of facility beds) compared against a single measure of output. A number of DMUs with a similar achievement of the output, but employing different sets of the two inputs are used. 2nd edition July 2014 senior management course for health managers

113. 2. Frontier Analysis (Cont’d) The different facilities are plotted on a graph as shown in the figure. Facilities A, E, G, and H are all efficient (least inputs of either nurses, or beds), and so form the frontier of efficiency. Other facilities are compared against the resulting frontier. DMUs e.g. “C” are deemed inefficient. Measure of inefficiency is based on distance from the frontier. 2nd edition July 2014 senior management course for health managers

114. Illustration: Generation of an efficiency ‘frontier’ for 2 inputs – nurses & beds 2nd edition July 2014 senior management course for health managers

115. Advantages of Frontier Analysis Allows use of many inputs, and outputs – which is more realistic in the health sector. Programme generates analysis; only input from you is to enter the data. Allows many efficiency targets to be sought (different combinations of nurses and beds are efficient, as long as they lie along the frontier). 2nd edition July 2014 senior management course for health managers

116. Activity 1.2.7.1- 45 minutes Using the information in the table (Technical Learning Aid), carry out a ratio analysis to determine the efficiency of the different hospitals. Present the outputs in a table, showing which hospitals are in zone I, zone II, zone III and zone IV of the efficiency scoring. Provide solutions for focus, for each group of hospitals. Note: A table showing a list of hospitals is provided separately (Copy to TLA) 2nd edition July 2014 senior management course for health managers

117. Session 1.2.7(b) PRINCIPLE 7: EFFECTIVENESS 2nd edition July 2014 senior management course for health managers

118. Introduction Measures how well an intervention restores the individual to as near his prior healthy state as possible. Measured by comparing the situation before, and after the intervention. Actual outcome of the interventions (health state) usually difficult to ascertain, so intermediate outcomes are usually used; – such as, malaria cases averted, TB treatment completion rates, children vaccinated, etc. 2nd edition July 2014 senior management course for health managers

119. Measuring Effectiveness using the Health Index Set of different effectiveness indicators to know impact on a given sector result / goal: – Designed based on KEPH results; – 30 indicators used across the different cohorts and result areas; – Fixed number of indicators per cohort, and result area; – Each indicator contributes same weight to overall index, to limit ‘fixing’ of the index (focus on high- weighted indicators); 2nd edition July 2014 senior management course for health managers

120. Measuring Effectiveness using the Health Index (Cont’d) ₋No information captured as zero value for the indicator; ₋All indicators converted to percentage, with values from zero to 100%; ₋All indicators interpreted similarly, with 0% being poor performance, and 100% good; ₋Indicators where less achievement is desired, such as mortality indicators, are reversed. 2nd edition July 2014 senior management course for health managers

121. Measuring Effectiveness using the Health Index (Cont’d) The index value is the average value derived, from the data. Expected comparisons include: ₋Overall effectiveness of services at different points in time; ₋Effectiveness of services in different cohorts of care; ₋Effectiveness of services by Medical Services and Public Health and Sanitation; ₋Different levels of care (counties, districts) against each other; ₋Different ownership of services (government, FBO/NGO, private services). 2nd edition July 2014 senior management course for health managers

122. Activity 1.2.7.2: 45 minutes Using the information in the table, carry out an assessment of the effectiveness in health care delivery in different districts. Which district is deemed most effective overall, and for each cohort of services? For each district, where should their efforts be made to improve effectiveness? Copy to TLA unit 1.3.3 2nd edition July 2014 senior management course for health managers

123. Session 1.2.8 PRINCIPLE 8: CLIENT CENTREDNESS (RIGHTS-BASED APPROACH & ETHICS) 2nd edition July 2014 senior management course for health managers

124. Human Rights-Based Approach Human rights are indivisible, universal and interdependent. Claim-holders have a right and are entitled to claim that right from those that have the duty to implement it (duty-bearers). Human rights imply corresponding duties and obligations. –Implies that the claim-holders should hold the duty- bearers accountable for the realisation of the right – in this case, access to health care. 2nd edition July 2014 senior management course for health managers

125. Human Rights-Based Approach (Cont’d) Important international human rights instruments with implication on health include: The Convention on the Rights of the Child (CRC); The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW); The Programme of Action of the International Conference on Population and Development; and The International Covenant on Economic, Social and Cultural Rights (ICESCR). 2nd edition July 2014 senior management course for health managers

126. Human Rights-Based Approach (Cont’d) Ministries of health and their staff working at all levels need to be well prepared in the adoption and implementation of the human rights approach to health services delivery. The Legislative and institutional frameworks should be geared towards safeguarding and promoting rights to health care. 2nd edition July 2014 senior management course for health managers

127. Human Rights-Based Approach (Cont’d) Human resources and other resources and policies should aim to ensure that “every health facility and its staff are committed to providing high quality health care services to all patients or clients with dignity, professionalism and within the shortest time possible”. 2nd edition July 2014 senior management course for health managers

128. Ethics in Health Ethics- based approach aims to apply moral values and judgments as they relate to health care. These are monitored and managed through the various councils. Seeks to ensure that the aim of health care is “to do good to others, and have them, and society, benefit from this”, and not “to do good, and benefit from it". It is based on values of: 1.Autonomy; 2.Beneficence (doing good); 3.Non-Malefficence (doing no harm); 4.Double effect. 2nd edition July 2014 senior management course for health managers

129. 1. Autonomy During a patient’s illness, the level of autonomy is an indicator of both personal well-being, and the well-being of the professional. Ethics tries to find a beneficial balance between the activities of the individual and its effects on a collective. By considering autonomy as a parameter for assessing (self) health care, the medical and ethical perspective both benefit from the implied reference to health. 2nd edition July 2014 senior management course for health managers

130. 2. Beneficence (doing good): Healing should be the sole purpose of medicine; any actions beyond this are not considered part of the process of care. 2nd edition July 2014 senior management course for health managers

131. 3. Non-Maleficence (doing no harm) Implies maintenance of patient safety even when providing treatments that carry some risk of harm. In desperate situations where the outcome without treatment will be grave, risky treatments that stand a high chance of harming the patient will be justified, as the risk of not treating is also very likely to do harm. So, the principle of non-maleficence is not absolute; it must be balanced against the principle of beneficence (doing well). "Non-maleficence" is also defined by its cultural context, as each has its own cultural collective definitions of 'good' and 'evil'. 2nd edition July 2014 senior management course for health managers

132. 4. Double Effect Some interventions can create a positive outcome while foreseeable, but unintentionally, doing harm. The combination of these two circumstances is known as the "double effect". An example is the use of morphine in the dying patient, which eases pain, while ‘arguably’ suppressing the respiratory drive, potentially accelerating death. 2nd edition July 2014 senior management course for health managers

133. Application of Principle 8: CLIENT CENTREDNESS (RIGHTS-BASED APPROACH & ETHICS) 2nd edition July 2014 senior management course for health managers

134. Application of Rights-Based Approach This approach implies fairness in the way we distribute and use available health resources. Equity is a rights based principle as it ensures that health resources are shared fairly. Equity is looked at in all its dimensions, including geographical, gender, age, vulnerability and others. The supply-side measures should be complemented by strengthening the demand-side of the provision of care. 2nd edition July 2014 senior management course for health managers

135. Application of Rights-Based Approach (Cont’d) Steps to promote rights based approach: Standards, protocols and guidelines need to be developed and used to: ₋ Strengthen patients’ rights; ₋ Revitalise and strengthen the relationships between the Ministries of Health and the various professional bodies to ensure ethical practice. 2nd edition July 2014 senior management course for health managers

136. Application of Rights-Based Approach (Cont’d) Steps to ensure protection of clients rights: Annual review of citizens health charter; Posting treatment fees and exemption schemes in clear view in all health facilities; Ensuring that proper complaints procedures are in place and known to the public. 2nd edition July 2014 senior management course for health managers

137. Application of Ethics Approach to Service Delivery Health managers must model and promote an understanding of ethical and legal issues relating to the use of technology. New protocols and safeguards to ensure their appropriate and effective use are required. There is need to adapt to changes relating to intellectual property rights, fair use, and acceptable use of digital materials and technology. 2nd edition July 2014 senior management course for health managers

138. Activity 1.2.8.1 (10 minutes) Brainstorm in Plenary: Which steps have been taken in your facility to improve protection and promotion of clients’ rights? Is patients’ charter clearly displayed and attention of clients drawn to it? Share experiences with the application and use of the patients’ charter. Copy TLA unit 1.3.3 2nd edition July 2014 senior management course for health managers

139. Session 1.2.9 PRINCIPLE 9: SUSTAINABILITY 2nd edition July 2014 senior management course for health managers

140. Introduction The system or service can be maintained at a steady state without exhausting the resources available to support it. Involves concepts such as long-term cost- effectiveness, maintenance of quality, equity of resource allocation and so on. 2nd edition July 2014 senior management course for health managers

141. Introduction (Cont’d) Sustainability requires designing and implementing a model of health financing that is affordable, ensures cost containment, special consideration for special groups, focusing on: local responsibility and viability (sustainability of systems); the generation and/or preservation of demand for health services; and the willingness to practice healthy behaviors (sustainability of demand). 2nd edition July 2014 senior management course for health managers

142. Systems Sustainability Components Has three components: 1.Financial Sustainability: having enough reliable funding to maintain planned health services. Looks at resource mobilisation and efficient allocation and use of resources; 2.Institutional Capacity: presence of systems likely to be used irrespective of staffing challenges. Systems are for planning and management, human resources, information, and logistics; 3.Enabling Environment: environment needed to sustain the achievements. Looks at policy and planning process, coordination and partnership, as well as community empowerment. 2nd edition July 2014 senior management course for health managers

143. Financial Sustainability Requires affordable levels of financial contributions from all partners to support a comprehensive financing and delivery system. This includes: –Issues of cost, choice and quality for individual, home and community care and support, as well as more aggregated models of delivery; –Consider new financing solutions while maintaining protections for people with very low incomes; –Requires cost containment, taking into consideration ethics governing each situation 2nd edition July 2014 senior management course for health managers

144. Financial Sustainability (Cont’d) Provider incentives should be aligned so that all stakeholders are pulling together towards affordable, sustainable, quality health care for all people. Realignment should ensure that health care providers and payers are not encouraged to provide certain types of care primarily because of the financial reimbursements or consequences associated with that care. –Emphasis on prevention, early intervention and chronic disease management will be cost-effective in the long term. Individual incentives should be aligned to encourage positive participation in their health management. 2nd edition July 2014 senior management course for health managers

145. Application of Principle 9: SUSTAINABILITY 2nd edition July 2014 senior management course for health managers

146. Indicators to Measure System Sustainability Sustainability area VariablesIndicators Financial sustainability Resource mobilisation % total health expenditure financed by donors % total health expenditure financed from private sources % facility budget programmed / managed at facility Efficient allocation of resources % budget allocated for preventive services Personnel expenditure compared to expenditure of commodities / supplies Operations expenditure as % of total recurrent expenditure Enabling environment Policy and planning Presence of a clear policy and strategy development system and process Presence of specific strategies and programme goals to actualise the strategic approach (detailed investment plan for programme areas) Coordination and partnership Existence of a functional coordination mechanism that includes all the health actors Community involvement Existence of functional community units that are working through the facility Presence of health sector representation (CHWs/facility HWs) in community discussion forums 2nd edition July 2014 senior management course for health managers

147. Indicators to Measure System Sustainability Sustainability area VariablesIndicators Institutional capacity Programme management Presence of a comprehensive strategic / investment plan Presence and use of a clear system for preparing yearly operational plans Presence of a functional mechanism for incorporating needs of clients into activities of the institution Presence of a manager whose job description includes responsibility for assessing clients. needs and desires, for developing the strategic and operational plan, for revising the plan, and for assessing the operational feasibility of the plan Human resources Presence of detailed, accurate, up-to-date job descriptions Presence of a system for regular staff performance assessment Presence of a system for the regular assessment of staff training needs Presence of a manager whose job description includes reviewing and revising job descriptions, personnel rules and regulations, and assessing job performance, training needs, and training outcomes 2nd edition July 2014 senior management course for health managers

148. Indicators to Measure System Sustainability Sustainability areaVariablesIndicators Institutional capacityInformation systems Analysed income/revenue data and cash flow analysis for specific service cost categories that is discussed in top management Presence of a manager whose job description includes reviewing financial data, analysing unit costs, making financial projections and tracking expenditures against budgets Use of information on clients and services in regular (monthly) management meetings and decisions Presence of a manager whose job description includes managing the programmatic information system and using information on clients and services for management and policy purposes Logistics systems Periodic (quarterly) review of logistical needs and resources of the institution (vehicles, computers, etc.) Presence of a system for tracking commodities and forecasting needs, including a periodic inventory and regular reporting of receipt and distribution of commodities Presence of a manager whose job description includes periodic review of resource needs and tracking of commodities 2nd edition July 2014 senior management course for health managers

149. Demand Sustainability Focuses on sustaining a sufficient level of demand to maintain uptake of health services and outcomes at acceptable levels. Measuring sustainability of demand should focus on how well demand is sustained as local resources replace donor support. Has two main components i.e. ability to pay and attitude. Specific indicators to show extent of demand sustainability are shown in the table overleaf. 2nd edition July 2014 senior management course for health managers

150. Demand Indicators to Measure Demand Sustainability 2nd edition July 2014 senior management course for health managers

151. Activity 1.2.9.1 (40 minutes) Assess your county or institution against the indicators of demand sustainability that are applicable to you. Discuss emerging trends and agree on possible actions to improve sustainability in your institution / county. Copy to TLA unit 1.3.3 2nd edition July 2014 senior management course for health managers

152. END 2nd edition July 2014 senior management course for health managers