health systems and the cycle of health system reform prof. peter berman the world bank
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Health Systems and the Cycle of Health System Reform
Prof. Peter Berman
The World Bank
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What Is A Health System?“…all the activities whose primary purpose is to
promote, restore, or maintain health” WHO, 2000
• Health System…or Health Care System?• Activities? Or people, institutions who carry out
these activities?, E.g.
• Treatment providers – individuals and institutions• Preventive service providers• Financial intermediaries• Input producers• Planners, administrators, and regulators• Other actors producing system outcomes
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Some Important Characteristics of Health Systems
• Complexity: Many products, many actors, complex connections
• Conflict: Different participants have different objectives…not always “positive sum”
• Embedded in Social Context: Technology conditioned by culture, history, and social norms
• Political: Current condition reflects power in society; change incurs political process
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What Do We Mean by “Health System Reform”?
• Not everything that changes, or causes change, is a health system reform
• Purposeful efforts to change the system to improve its performance
• “little r” reforms; Small changes to one or a few features of the system
• “Big R” reforms; Large changes to more than one feature of the system
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Why Is Successful Reform Difficult?
• The consequences of actions are difficult to predict
• Health systems have multiple goals. Doing better on one goal dimension may mean doing worse on another. The choices are truly difficult.
• Those who benefit from the system are powerful and resist change. Those who benefit from change are often less powerful
• Countries are limited by their economic and administrative capacity
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Why Think Systematically About Health Systems Reform?
• Clear thinking is better than muddled thinking
• Avoid unintended results
• Anticipate likely problems
• Clarify goals and priorities
• Facilitate accountability and transparency
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What Starts The Cycle of Reform?
• Fiscal and economic change -- crisis and/or opportunity
• Political change -- crisis and/or opportunity
• External pressure
• Unhappy interest groups
• Inspired leadership…usually NOT rational analysis
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Define The Problem
Evaluate Identify Causes
Implement Develop Options
Decide What to Do
The Health SystemsReform Cycle
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Problem Definition
Political Decision
ETHICS
POLITICS
Implementation
Policy Development
Diagnosis
Evaluation
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Key elements of our approach
• Understand the ethical basis of values we bring to reform
• Consider politics throughout• Define problems in terms of health system
outcomes• Develop an evidence-based causal analysis for
health system performance• Build reform strategies based on determinants of
system performance that can be changed by policy• Implementation matters
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What Do We Mean By “Problems” in “Problem Definition”?
• The health system is a means. Reformers need to be clear about the ends.
• Problems should be defined based on poor performance in terms of outcomes.
• Focus on changing things that contribute to improving poor performance.
• Defining the problem is a critical step often ignored or assumed.
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Which Problems Matter?
• Systems reform means a strategic view of problems. Still, how wide to cast the net?
• Problems (outcomes) affect people and groups of people. Whose burden matters?
• Politics usually sorts this out…but political processes may be suspect or inadequate.
• Smart reformers try to influence problem definition.
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The Role Of Ethics In Problem Definition
• Deciding what aspects of performance matter is not just a technical question, it requires values
• Reformers always incorporate value judgments in problem definition – but often cannot or will not be explicit about them
• Explicit consideration of ethical theory leads to clearer thinking about problem definition
• Public discussion about ethical principles may or may not be desirable from a political perspective
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The Diagnostic Journey: Identifying the Causes of Problems
• Start with performance problems as outcomes
• Ask “why” five times
• Work “backwards”-- from causes, to causes of causes, and so on…
• Be “evidence based”
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Developing Strategies and Options
• Strategies should be based on: – An explicit model of what causes health system performance to
be the way it is– What can be changed and how performance should change as a
result
• Imitate but adapt – learn from others but consider local conditions
• The process of strategy develop may matter as much as the content – Influences the political acceptability– Influences the quality of the plan
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Reaching A Political Decision• Health sector reform is unavoidably political
• Politics matters throughout
• Doing better requires political skill, not just political will
• Stakeholder analysis is a starting point
• Successful reformers move from “mapping” politics to strategies to affect politics
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Many Health Sector Reform Efforts Have Failed at The Stage of Implementation
• Ministers often lack administrative experience and their staff may lack the right kinds of experience
• Leaders turn over quickly
• Implementation – and its time and costs -- are not considered in program design. Politics demands quick results.
• Entrenched interests resist – reform is rarely easy
• Encountering opposition, political attention may turn elsewhere
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Keys To A Successful Evaluation
• Evaluation doesn’t always mean a large, independent study. Less formal results tracking also useful
• Design an evaluation strategy early, before implementation begins
• Evaluate process and outputs as well as outcomes
• Collect baseline data
• Build in “redundancy” in evaluation design
• Create incentives for good evaluation
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Why Does the Cycle Often Begin Again?
• Poor design or execution leads to unsatisfactory results
• Even successful reforms often create new problems
• Actors defend their interests in unanticipated ways
• Social, economic or political conditions change
• Health and health systems change
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Health System Reform Requires Skills
• Many needed skills can be taught
• Skills are developed by practice
• Rules can help, but specific situations require judgment
• Learning requires effort and active participation
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Problem Definition
Political Decision
ETHICS
POLITICS
Implementation
Policy Development
Diagnosis
Evaluation