TARGETS, VOICE OR CHOICE: TARGETS, VOICE OR CHOICE: OPTIONS FOR THE HEALTH OPTIONS FOR THE HEALTH

SECTORSECTOR

Anne MillsAnne MillsHealth Economics and Financing ProgrammeHealth Economics and Financing Programme

London School of Hygiene and Tropical London School of Hygiene and Tropical MedicineMedicine

THE CONTEXTTHE CONTEXT

‘‘Scaling upScaling up’’ services to meet the health services to meet the health ––related related MDGsMDGs

Low coverage of interventions known to Low coverage of interventions known to be effective (full use made of current be effective (full use made of current technologies would reduce under 5 technologies would reduce under 5 deaths by 63% and maternal deaths by deaths by 63% and maternal deaths by 74%)74%)

Focus on ensuring universal access to Focus on ensuring universal access to ‘‘basicbasic’’ servicesservices

THE REALITYTHE REALITY(data from Catherine Goodman)(data from Catherine Goodman)

Treatment seeking for malaria Treatment seeking for malaria (fever) in rural Tanzania(fever) in rural Tanzania

7% visited private facility7% visited private facility26% visited government health 26% visited government health facilityfacility65% visited a shop65% visited a shop

WHY DO PEOPLE USE SHOPS?WHY DO PEOPLE USE SHOPS?

Convenience Convenience Drug availability Drug availability Confidence in selfConfidence in self--treatment for treatment for malaria/fevermalaria/feverPoor quality in health facilitiesPoor quality in health facilities

ACCESSIBILITY OF DRUG ACCESSIBILITY OF DRUG SOURCES IN RURAL TANZANIASOURCES IN RURAL TANZANIA

1 facility / 5222 people1 facility / 5222 people

1 retailer selling drugs / 260 people1 retailer selling drugs / 260 people

1 retailer selling antimalarials / 931 people1 retailer selling antimalarials / 931 people

POOR QUALITY IN GOVERNMENT POOR QUALITY IN GOVERNMENT HEALTH FACILITIESHEALTH FACILITIES

Frequent drug stock outsFrequent drug stock outs

Limited opening hours & long waiting Limited opening hours & long waiting timetime

Very short consultationsVery short consultations

Poor infrastructurePoor infrastructure

Rude or inattentive staffRude or inattentive staff

Official and/or unofficial chargesOfficial and/or unofficial charges

Inappropriate drugs & doses Inappropriate drugs & doses

Ineffective drugs due to:Ineffective drugs due to:

drug resistancedrug resistance

poor drug qualitypoor drug quality

Inadequate diagnosis & advice from sellerInadequate diagnosis & advice from seller

Inadequate labelling & instructions on Inadequate labelling & instructions on drugsdrugs

POOR QUALITY IN SHOPSPOOR QUALITY IN SHOPS

COMPARISON OF TREATMENT COMPARISON OF TREATMENT QUALITYQUALITY

Effective Effective antimalarialantimalarialobtained at:obtained at:

46% visits to 46% visits to private facilitiesprivate facilities29% to drug stores29% to drug stores22% to government 22% to government facilitiesfacilities1% to general 1% to general storesstores

Minimum dose of Minimum dose of effective effective antimalarialantimalarialobtained at:obtained at:

41% visits to private 41% visits to private facilitiesfacilities19% to drug stores19% to drug stores17% to government 17% to government facilitiesfacilities0.5% to general 0.5% to general storesstores

CONSTRAINTS TO SCALING UP (CMH CONSTRAINTS TO SCALING UP (CMH WG5)WG5)

Communityand household

Inadequate demand for effectiveinterventions; barriers to use of effectiveinterventions

Healthservicesdelivery

Shortage and maldistribution of qualifiedstaff; low pay; poor motivation; inadequateavailability of drugs and medical supplies

Health sectorpolicy &strategicmanagement

Weak drug policies and supply systems;weak management systems; competingdonor programmes

Public policiesacross sectors

Rigidities of government bureaucracy;limited communications and transportinfrastructure

Environmentalcharacteristics

Poor governance; political instability;unfavourable physical environment

WOULD ONE, OR A WOULD ONE, OR A COMBINATION OF, COMBINATION OF,

TARGETS, VOICE OR TARGETS, VOICE OR CHOICE HELP?CHOICE HELP?

TARGETSTARGETSProblematic given management capacityProblematic given management capacity

Only part of health care lends itself to Only part of health care lends itself to outcomeoutcome--based targets (based targets (egegimmunisation)immunisation)

Severe risk of perverse incentives Severe risk of perverse incentives (sterilisation in India)(sterilisation in India)

Risk of further Risk of further demotivatingdemotivating staffstaff

Scope for targets in context of Scope for targets in context of contracting NGOs?contracting NGOs?

CONTRACTING DISTRICT HEALTH CONTRACTING DISTRICT HEALTH SERVICES IN CAMBODIA SERVICES IN CAMBODIA (Schwartz and (Schwartz and BhushanBhushan))

CONTRACTING DISTRICT HEALTH CONTRACTING DISTRICT HEALTH SERVICES IN CAMBODIA SERVICES IN CAMBODIA (Schwartz and (Schwartz and BhushanBhushan))

VOICEVOICE

Currently very weakCurrently very weak

Greatest need in local service Greatest need in local service delivery settings to improve health delivery settings to improve health worker responsivenessworker responsiveness

Best way to do it unclear Best way to do it unclear –– stronger stronger local accountability mechanisms in local accountability mechanisms in context of greater decentralisation of context of greater decentralisation of management authority?management authority?

SOUTH AFRICA: PATIENT COMPLAINTS SOUTH AFRICA: PATIENT COMPLAINTS MECHANISMS IN PRIMARY CAREMECHANISMS IN PRIMARY CARE (Mills in press)(Mills in press)

GPs W.Cape

GPs E.Cape

Public

% patients not knowingwho to complain to

89 90 >70

% patients noopportunity to comment

84 82 68

% patients unaware ofcommunity healthcommittee

89 91 89

SOUTH AFRICA: PATIENT SOUTH AFRICA: PATIENT POWERLESSNESS POWERLESSNESS (Schneider and Palmer 2002)(Schneider and Palmer 2002)

““If you feel unhappy you can just tell them. You donIf you feel unhappy you can just tell them. You don’’t t have to be afraidhave to be afraid””

““We get it for free so we have no choice in the matterWe get it for free so we have no choice in the matter””

““A white person always winsA white person always wins””

““They treat you according to class so the man that is They treat you according to class so the man that is really down there, he just accepts itreally down there, he just accepts it””

““We have complaints but we just accept things as they We have complaints but we just accept things as they are because there is nowhere else to goare because there is nowhere else to go””

““I went to speak to one of the community leaders and I went to speak to one of the community leaders and he said hehe said he’’ll call a meeting. And whatll call a meeting. And what’’s happened s happened since then? Nothing.since then? Nothing.””

CHOICECHOICE

Being exercised already, with Being exercised already, with adverse effects on peopleadverse effects on people’’s s livelihoodslivelihoods

Can people be helped to exercise Can people be helped to exercise informed choice?informed choice?

Can funds be channelled to support Can funds be channelled to support choice? choice? EgEg vouchers for insecticide vouchers for insecticide treated nets. High transactions treated nets. High transactions costs?costs?

CONCLUSIONSCONCLUSIONSCannot treat health care as homogenous Cannot treat health care as homogenous sectorsector

Approach depends on characteristics of Approach depends on characteristics of product/service:product/service:

Simple productsSimple products

Complex servicesComplex services

For simple products, explore ways of working For simple products, explore ways of working with private retail sector; NGOswith private retail sector; NGOs

For complex services, build on motivations of For complex services, build on motivations of health workers to obtain satisfaction in their health workers to obtain satisfaction in their work work –– but can government systems achieve but can government systems achieve this? this?

More evidence needed!More evidence needed!

REFERENCESREFERENCES

Commission on Macroeconomics and Health, Working Group Commission on Macroeconomics and Health, Working Group 5. (2002) 5. (2002) Improving health outcomes of the poor.Improving health outcomes of the poor. Geneva: Geneva: WHO.WHO.

Mills A (in press) Mills A (in press) Missing areas in health reform: an Missing areas in health reform: an academicianacademician’’s perspective. s perspective. In In EdsEds NitayarumphongNitayarumphong S, Mills S, Mills A, A, TangcharoensatienTangcharoensatien V, V, PongsupapPongsupap Y. Y. What is talked about What is talked about less in Health Care Reformless in Health Care Reform. Bangkok: Ministry of Public . Bangkok: Ministry of Public Health.Health.

Schneider H and Palmer N (2002)Schneider H and Palmer N (2002) Getting to the truth?Getting to the truth?Researching user views of primary health care.Researching user views of primary health care. Health Health Policy and PlanningPolicy and Planning 17(1):17(1): 3232--41.41.

Schwartz JB and Schwartz JB and BhushanBhushan I (2004) I (2004) Cambodia: using Cambodia: using contracting to reduce inequity in primary health care contracting to reduce inequity in primary health care deliverydelivery. HNP Discussion paper, Reaching the Poor Program . HNP Discussion paper, Reaching the Poor Program paper no 2. Washington DC: The World Bank.paper no 2. Washington DC: The World Bank.