1. In the Name of God Lorestan – Khoramabad May 2005 Dr Kambiz Monazzam

2. Review of Health Sector Reform: The Basics May 18-21, 2005 Khoramabad - Lorestan Dr Kambiz Monazzam

3. Reform : Definition “sustained, purposeful and fundamental change ” “ Sustained ” in the sense that it is not a "one shot" temporary effort that will not have enduring impacts; “ Sustained ” in the sense that it is not a "one shot" temporary effort that will not have enduring impacts; “ Purposeful ” in the sense of emerging from a rational, planned and evidence-based process; “ Purposeful ” in the sense of emerging from a rational, planned and evidence-based process; “ Fundamental ” in the sense of addressing significant, strategic dimensions of health systems. “ Fundamental ” in the sense of addressing significant, strategic dimensions of health systems.

4. Why do we Reform? Health problems/Health System Problems Health problems/Health System Problems Unhappy People Unhappy People....!....! ? Who find the Problems...?! Who find the Problems...?!

5. What Starts The Cycle of Reform? Economic crisis Political change External pressure Unhappy interest groups

6. Main Goals of Health Sector Reform Equity Equity Efficiency Efficiency Quality Quality Sustainability Sustainability Fiscal Impact Fiscal Impact Satisfaction Satisfaction Access Access

7. What do we need “ R ” or “ r ” ? It depends on degree, severity & complexity of our problems It depends on degree, severity & complexity of our problems !?

8. Reform Cycle Is there any space for politics? Is there any space for politics?

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

10. Health Sector Reform Context

11. Problem Definition Diagnosis Policy Development Implementation Evaluation Political Decision The Simplified Policy Cycle

12. Problem Definition Diagnosis Policy Development Implementation Evaluation Political Decision The Political Policy Cycle POLITICSPOLITICS ETHICSETHICS

13. Economics & HSR If someone asked you to find one problem of all human which is the most important to them, If someone asked you to find one problem of all human which is the most important to them, What problem do you address? What problem do you address?problem If someone asked you to find one problem of all Governments which is the most important to them, If someone asked you to find one problem of all Governments which is the most important to them, What do you say? What do you say? Needs / wishes they can’t reach People Needs they can’t meet Lack of Enough Money

14. Economics? Definition ? Definition ?

15. Gifted shared 100,000 to How do you do with 100,000 $ ? How do you do with 100,000 $ ? How do you divide 100,000 $ between 5 people? How do you divide 100,000 $ between 5 people? between 1000 people? between 1000 people? between 1000,000 people? between 1000,000 people? Money

16. People is different Individual desires & preferences Individual desires & preferences Social desires & preferences Social desires & preferences Individual behavior Individual behavior Importance of the issue Importance of the issue

17. Decision making How decision could be made? How decision could be made? Who Decide? Who Decide? Values Organization

18. Management? Plan to Reform / Change Through: ? F Five Control Knobs Financing Payment (Incentive Structure) Macro-Organization of Provision Regulation Persuasion (Behavior)

19. Reform Cycle

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

21. Define The Problem Current Goals P What’s the problem? Is there any problem?

22. Define The Problem How many? How much? Real or Opinion? YES

23. Define The Problem Goals Stewardship (oversight) Financing (collecting, pooling and purchasing) Creating resources (investment and training) Delivering services (Provision) Responsiveness (to non-medical expectations) Fair Financial Contribution Health Functions the system performs EQUITY EFFICIENCY QUALITY FISCAL IMPACT ACCESS Ultimate Goals Intermediate Goals

24. What Constitutes the Health System? Care providers Care providers Financial intermediaries Financial intermediaries Input producers Input producers Planners and regulators Planners and regulators Preventive service providers Preventive service providers Other actors producing system outcomes Other actors producing system outcomes

25. Characteristics of Health Systems Complexity: multiple actors with multiple connections Complexity: multiple actors with multiple connections Conflict: different participants have different objectives Conflict: different participants have different objectives Politics matters: decisions inevitably reflect political process Politics matters: decisions inevitably reflect political process Societal context matters: conditions and options reflects culture, history and social norms Societal context matters: conditions and options reflects culture, history and social norms

26. Define The Problem How Should We Define Problems? The health system is a means. Reformers need to think deeply about the ends The health system is a means. Reformers need to think deeply about the ends Problems should be defined based on poor performance in terms of outcomes Problems should be defined based on poor performance in terms of outcomes

27. Define The Problem How Should We Define Problems? Cont’ Aspects of the system only need to be changed if the changes contribute to improving poor performance Aspects of the system only need to be changed if the changes contribute to improving poor performance Defining the problem has to be done carefully because it will influence what solutions you choose Defining the problem has to be done carefully because it will influence what solutions you choose

28. Define The Problem How Do We Know Which Aspects of Performance Matter? Different groups will have different views Different groups will have different views Political processes often produce an uneasy compromise Political processes often produce an uneasy compromise Reformers can influence those processes Reformers can influence those processes Reformers have to consider ethics and values to know what performance problems to focus on Reformers have to consider ethics and values to know what performance problems to focus on

29. Define The Problem The Role Of Ethics In Problem Definition Deciding what aspects of performance matter is not just a technical question Deciding what aspects of performance matter is not just a technical question Deciding what matters requires values Deciding what matters requires values Exploring ethical theory allows us to clarify both our assumptions and their implications Exploring ethical theory allows us to clarify both our assumptions and their implications The problem definition influences all that follows The problem definition influences all that follows

30. Define The Problem How do you find to meet the goals? Which Indicators? Which Indicators? Equity Equity Efficiency Efficiency Quality Quality Sustainability Sustainability Fiscal Impact Fiscal Impact Satisfaction Satisfaction Access Access

31. Review of Health Sector Reform: Diagnosis & Option appraisal May 18-21, 2005 Khoramabad - Lorestan Dr Kambiz Monazzam

32. Identify Causes How many problems do you have in the health / system !?

33. Identify Causes Identifying Causes: The Diagnostic Journey Start with performance problems Start with performance problems Ask “why” five times Ask “why” five times Go from causes, to causes of causes, etc. Go from causes, to causes of causes, etc. Work “backwards” Work “backwards” Be “evidence based” Be “evidence based”

34. Identify Causes Start with problems: Where they are? Where they are? Who can find the problems? people have different ideas! Who can find the problems? people have different ideas! Which Problem is more important than the others? Which Problem is more important than the others? Who can exactly define the problem? Who can exactly define the problem? Experts, Managers, People, Data … Experts, Managers, People, Data … Which areas are important? Which areas are important?

35. Identify Causes Start with problems: Find Find Research Research Situation analysis Situation analysis Expert’s view Expert’s view List & Classify List & Classify Affinity diagram Affinity diagram Logical cause & effect Diagram Logical cause & effect Diagram Problem Tree Time Money Expertise

36. Identify Causes Problem identification – (What) What exactly is the problem? Who or what is most affected by this problem? How serious/important is the problem? What supportive data/facts do you have to demonstrate this severity or importance? Is this problem manageable in scope? Is this problem more important and devastating than any other problems? Is this problem more influential/crucial to the current situation than any others? Can you afford to ignore this problem for the time being? …

37. Identify Causes Problem analysis - (why) Problem analysis is to understand why there is a problem or what are the factors that contribute to the problem and the interrelationship between these factors.

38. Identify Causes Problem Tree Fishbone Diagram Force Field Analysis SWOT or SWOC Analysis The 7s Model Problem Web. Tools / Techniques:

39. Identify Causes Finding Root Causes: Problems have a cause & effect relationship or other inter relationship between them. At last: In health you reach a specific tree, which have multiple roots Go backward, find evidence Red line

40. Identify Causes Logical vs. political way of thinking to solve problems Logical:Logical: Political:Political: Problem Tree Fishbone Diagram Force Field Analysis Decision Space …….

41. Identify Causes How do people think about political processes for policy change and implementation? When decisions are made: Policy process sequencesWhen decisions are made: Policy process sequences How decisions are made: Decision-making modelsHow decisions are made: Decision-making models Who makes decisions: Stakeholder analysisWho makes decisions: Stakeholder analysis Boundaries: Governance rules and Broader ContextsBoundaries: Governance rules and Broader Contexts Tools for Political Analysis

42. Policy Process Sequence Signaling Evaluation & Feedback Consultation and Formulation Aggregation Implementation Ratification

43. Ethical Side Political Side The Health Systems Reform Cycle

44. Develop Options Developing Options Build on a sound model of Build on a sound model of a) what drives health system performance a) what drives health system performance b) what can be changed b) what can be changed

45. Develop Options Developing Options “Imitate but adapt” “Imitate but adapt” - learn from others but consider local conditions

46. Develop Options Developing Options “Process matters” “Process matters” – how you go about this task will influence the political acceptability and the quality of the plan

47. Decide What to Do Reaching A Political Decision Health sector reform is unavoidably political Health sector reform is unavoidably political Doing better requires : political skill, not just Doing better requires : political skill, not just political will political will

48. Decide What to Do Reaching A Political Decision Stakeholder analysis as a starting point Stakeholder analysis as a starting point From “mapping” From “mapping” to strategy

49. Review of Health Sector Reform: Treatment May 18-21, 2005 Khoramabad - Lorestan Dr Kambiz Monazzam

50. Implement Good ideas are not worth much If They can not be implemented Implementation Implementation

51. Implement The old adage, “Better the devil you know than the devil you don’t,” “Better the devil you know than the devil you don’t,” embodies this idea. Resistance to change is almost always present

52. Implement Resistance to change is almost always present Psychological Psychological New procedures and structures are strange and unfamiliar. New procedures and structures are strange and unfamiliar. For many, the mere fact of newness creates anxiety and resistance For many, the mere fact of newness creates anxiety and resistance

53. Implement Resistance to change is almost always present change can bring costs to specific groups and individuals. change can bring costs to specific groups and individuals. New procedures and arrangements take time and effort to learn. New procedures and arrangements take time and effort to learn. Existing hierarchies can be upset. Existing hierarchies can be upset.

54. Implement Resistance to change is almost always present Those who benefited from the old system can lose greatly. Those who benefited from the old system can lose greatly. those most successful under the old system have the most to lose; hence, the currently powerful are often the most opposed to reform. those most successful under the old system have the most to lose; hence, the currently powerful are often the most opposed to reform.

55. Implement Resistance to change is almost always present Thinking Behavior Thinking Behavior Difficulty we all have in giving up familiar ways of thinking Difficulty we all have in giving up familiar ways of thinking Past, can have a strong hold over us Past, can have a strong hold over us stablished patterns If one want to dodifferently, feels extreme pressure Established patterns are potent & fixed, If one want to do differently, feels extreme pressure

56. Implement Many Health Sector Reform Efforts Have Failed at The Stage of Implementation Ministers often lack administrative experience Ministers often lack administrative experience Leaders turn over quickly Leaders turn over quickly Implementation is not considered in program design Implementation is not considered in program design Entrenched interests resist Entrenched interests resist Political attention turns elsewhere Political attention turns elsewhere

57. Implement Reaching A Political Decision Health sector reform is unavoidably political Health sector reform is unavoidably political Doing better requires political skill, not just political will Doing better requires political skill, not just political will Stakeholder analysis as a starting point Stakeholder analysis as a starting point From “mapping” to strategy From “mapping” to strategy Decide What to Do

58. Implement sophisticated leadership Monitoring appropriate reporting system

59. Evaluate Evaluation Plan Before designing and conducting an evaluation, the evaluator needs to be clear on the issues such as: Before designing and conducting an evaluation, the evaluator needs to be clear on the issues such as: Why evaluation is needed; Why evaluation is needed; To whom the evaluation results will be required and useful; To whom the evaluation results will be required and useful; What data is needed and where and how to collect it; What data is needed and where and how to collect it; What comparative exercise should be made. What comparative exercise should be made. how well it has achieved?

60. Evaluate Keys To A Successful Evaluation Design an evaluation strategy in advance Design an evaluation strategy in advance Anticipate likely problems Anticipate likely problems Collect data before you begin Collect data before you begin Create incentives for good evaluation Create incentives for good evaluation

61. Evaluate Before-and-after comparison Control group Similar neighboring country Keys To A Successful Evaluation

62. Evaluate Collect baseline data Data is not free Data cost on people Time consuming Over-collection

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

64. Five Core Elements: Importance of ethical theory Importance of ethical theory Explicitly identified health system performance objectives Explicitly identified health system performance objectives Systematic approach to health system diagnosis Systematic approach to health system diagnosis Use of the health system control knobs Use of the health system control knobs Political analysis Political analysis The last point:

66. Knowledge generation Social movement Political linkage The that moves the mountain