health system inputs: policies on human resources, facilities, equipment, consumables gilles...
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Health System Inputs: Policies on Human Resources, Facilities,
Equipment, Consumables
Gilles Dussault/Eva Jarawan
WBIHD/MNSHD
19 September 2001
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Structure of the Session
• Why discuss inputs ?
• What is their relation to services, to outcomes ?
• Discussion:the importance of capital investments
• Case example:the utilization of HR
• Synthesis, take-home messages
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Health System Actors, Functions and Outcomes
People
Demand
FinancingRevenue Generation
Risk PoolingAllocation & Purchasing
Input ManagementHuman Resources Knowledge
Pharmaceuticals TechnologyConsumables Capital
Private Sector ActorsFor ProfitNon-Profit
Traditional Healers
Health Status
Financial Protection
OversightPolicy Setting Information, Disclosure & Advocacy Developing Partnerships Regulation & Standard SettingMonitoring & Evaluation Strategic Incentives
The State: government atvarious levels:
national, province, localDonors
Consumer Responsiveness
Service DeliveryPublic Health Services
Ambulatory CareInpatient Care
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Why Discuss Inputs ?
This is where the money goes:– Capital/ recurrent expenditures – Personnel– Infrastructures– Equipment – Consumables
… And there are opportunity costs
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Why Discuss Inputs ?
• This is where the money goes
They are the ingredients for the production of services
…And the accessibility, efficiency, effectiveness, quality, sustainability of services depend on them
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Total financialresources
Capital
Recurrent
Trainingof people
InvestmentIn buildings& equipment
Expenditurecategories
Labor costs
Budget elements
Maintenance
Other recurrent
Humanresources
Physicalcapital
Health systeminputs
(retirement,redundancy)
(Depreciation,obsolescence)
Consumables
(expiry, loss)(Reduction of inputs shownIn parentheses)
Production of healthinterventions
Health system inputs, from financial resources to health interventions.
Source: World Health Report 2000, p. 75
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Why Discuss Inputs ?
• This is where the money goes: capital, recurrent expenditures
• They are the ingredients for the production of services
Allocation is not optimal: market and government failures
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Market and Government Failures
• Inverse care law: resources are distributed in an inverse proportion to needs
• Branded vs generic drugs
• Failures of central planning and management (ex: postings, transfers, promotions)
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Why Discuss Inputs ?
• This is where the money goes: capital, recurrent expenditures
• They are the ingredients for the production of services
• Allocation is not optimal
Time lag between decisions and their effects
… and they have long lasting consequences
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Inputs-services-outcomes
The mix, volume, quality of inputs and the context and process of
their utilization and management will determine the contribution of
RH services to achieving the desired health outcomes
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At Issue …
• Allocation of financial resources ? important variations
• What is the right combination of inputs ? mix, volume, quality, distribution ?
• Utilization/management of inputs ?
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Health expenditures in your country ($US)
Benin, Cameroon, China, Cote d'Ivoire, Ethiopia, Gambia Ghana, Haiti, India, Kenya, Malawi,Mali,Mongolia, Nigeria, Pakistan, Senegal,Tanzania, Uganda, Yemen
20-99
Egypt, Nicaragua, Philippines,
Venezuela, West Bank/Gaza
100-300
Canada, U.K., Uruguay, U.S.A. 850-3724
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Allocation of Health Budget
Type of expenditure
Capital Recurrent
Personnel ? 60-90%
Infrastructures/ equipment
5-40% 0-15%
Consumables ---- 10-25%
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0 2 4 6 8 10 12
Beds per 1,000 population
Formerly socialist of Europe ----
Established Market Economies -
Middle Eastern Crescent ---------
Latin America & the Caribbean
Other Asia & Islands -------------
China ---------------------------------
India ----------------------------------
Sub-Sahara Africa ---------------
Physicians per 1,000 population Ratio of nurses and midwives to physicians
5
5
6
4
43
32
2
1 1
0 0
ABC
D
E
FG
H
A B C D E F G H A B C D E F G H
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Discussion with participants
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The importance of capital investments
Give One Example Each, for Human Resources, Infrastructure and Equipment, of How Investment
Decisions Matter for RH Services and Outcomes
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Capital Investment Impact on Health Services
Infrastructures
Equipment
Human Resources
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Break
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Case example: Stormy Atmosphere at the Boutima Center
• Real life case (2000)
• Focus on human resources issues
• 25 minutes discussion in small groups
• Plenary discussion facilitated by Eva
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Stormy Atmosphere at the Boutima Center
• Identification of HR problems
• Individual, organizational, systemic factors contributing to those problems
• Based on your experience, what would you suggest to change ?
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Problem Causes/Contributing factors
Action
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Synthesis
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Typical input problems (1)
• Over/under supply
• Inadequate mix
• Imbalances: regional, institutional, gender
• Relevance of education
• Variations in quality
• No continuing education
• Neglected areas
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Typical input problems(2)
• Low productivity
• Quality maintenance
• Over use of doctors and hospitals
• Poor management
• Absence of control of resources
• Systems of incentives
• Low remuneration
• Multi-employment
• Career prospects
• Labor relations
• Low satisfaction
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Take-home Messages
Inputs are critical to the production of appropriate services
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Take-home Messages
• Inputs are critical to the production of appropriate services
Decisions are complex, difficult, not to be left to the market
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Decisions About Inputs Are
Difficult, Because …• Health services comprise a wide and
complex range of services
• Need to find the right combination
• Decisions have long lasting effects
• Information is scarce
• High political contents
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Take-home Messages
• Inputs are critical to the production of appropriate services
• Decisions are complex, difficult, not to be left to the market
There are tools which can help make better decisions
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Tools/Strategies to improve decisions relative to inputs (Stock)
• Data collection and projections
• Regulation of the stock of providers: intake (numbers, profile), surpluses and shortages
• Deployment: incentives (access to training, to information, family-friendly measures), removal of disincentives
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Tools/Strategies to improve decisions relative to inputs (competencies)
• Philosophy of education: community-oriented programs (e.G., UNI program in LA)
• Methods: problem-based and competency-based learning
• Incentives in favor of continuing education
• Accreditation of programs and schools
• Certification and (re?), Licensure of providers
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Tools/Strategies to improve decisions relative to inputs (management)
• Economic, professional incentives
• Professionalization of management
• Delegation, substitution, team work
• Quality assurance and improvement
• Accreditation of institutions and regulation of individual providers
• Workers’ participation in definition of working conditions
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Take-home Messages
• Inputs are critical to the production of appropriate services
• Decisions are complex, difficult, not to be left to the market
• There are tools which can help make better decisions
Policies, decisions, practices relating to inputs to be subordinated to services objectives
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Needs/ Objectives/Outcomes
Health needs Health outcomes
Services needs Services objectives
Inputs needs Inputs objectives
(Source: Pineault. Daveluy, 1995)
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Take-home Messages (HR)
HR issues must be addressed in all their dimensions: planning, education/training, deployment, management
HR policies and practices are transversal, not vertical
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