Maureen Lewis Research Department World Bank Overseas Development Institute London, UK February 2, 2010

Transcription

1 Maureen Lewis Research Department World Bank Overseas Development Institute London, UK February 2,

2 Based on: Governance in health Care Delivery: Raising Performance World Bank Policy Research Working Paper No (2009) By Maureen Lewis, World Bank Gunilla Pettersson, World Bank/University of Sussex DOCDT,DOCNA,REPNB,DOCTY,LANG,VOLNB,REPNME,VOL_TITLE&sortDesc=OR ASCORE&pageSize=10&docType=0&theSitePK=523679&piPK= &sort Orderby=ORASCORE&pagePK= &menuPK= &sType=2 2

3 Outline of Presentation Why is governance an issue in health care? What makes good institutions and why is it relevant to performance in health systems? Measuring performance Indicators and measurement Directions for reform 3

4 Why is governance an issue in health care? Health systems are the institutions that deliver health care Good governance underlies performance in health care delivery The focus on health care has been on raising financing and ensuring inputs: critical but not enough Delivery effectiveness is implicitly assumed, but data and evidence are scarce Ultimate impact measure is often IMR, but link between service delivery and IMR in the S.T. is weak Poor governance disproportionately affects the poor 4

5 What are the problems in public health care delivery in developing countries? Lack of performance measures to examine how resources are used and programs are implemented Poor quality services: provider absenteeism; lack of professional administrators; lack of drugs and supply Inefficiency: financial and operational mismanagement Corruption: theft, inappropriate procurement Few direct incentives for sound performance, and no benchmarks No accountability: to government officials, parliaments, regulators or citizens 5

6 Building sound institutions in public health care delivery entails: Having standards, basic information on performance, incentives for good performance, and Real accountability, where officials are called to account and to answer for responsibilities and conduct (OED 1989) Avoiding corruption: use of public office for private gain 6

7 The Governance Process: there must be benchmarks and accountability Institutional performance Parliament: Government policy Ministry of health: Health policy Local government Provider performance Service delivery quality & Health outcomes Beneficiaries & Stakeholders direction of incentives direction of accountability direction of potential influence direction of influence direction of potential accountability 7

8 How to measure performance in public health care systems Emphasize easily measured indicators where data collection is relatively easy and low cost Piggyback existing surveys or data collection Rely on simple quantitative and qualitative surveys Establish pilots with evaluation (Re)think management Indicators need to reflect performance Need measures that reflect system performance, and some that are comparable across countries 8

9 Indicator range and topic area 1. Budget and resource management Budget credibility, leakages, purchasing and spending 2. Individual providers Credentials, absenteeism, clinical performance 3. Health facilities ALOS, bed occupancy, Apgar scores, patient satisfaction 4. Informal payments Frequency of under-the-table payments 5. Corruption perceptions 9

10 CORRUPTION PERCEPTIONS INFORMAL PAYMENTS HEALTH FACILITIES INDIVIDUAL PROVIDERS BUDGET AND RESOURCE MANAGEMENT AREA ISSUE KEY INDICATORS Budget processes Budget leakages Payroll irregularities In-kind supply leakages Job purchasing Physician credentials Health worker absenteeism Health worker performance PEFA indicators track budget credibility, comprehensiveness, transparency, execution, recording, reporting, and external audits and scrutiny. Discrepancy between public budgeted health funds and the amounts received by health providers. Discrepancy between payroll roster and health workers on site. Differences in price paid for similar medical supplies/equipment across health facilities. Type of procurement used for drugs and supplies. Frequency of illegal side-payments/bribes influencing hiring decisions and of payments for particular assignments. Existence and enforcement of licensing requirements and of continuing education programs. Fraction of physicians or nurses contracted for service but not on site during the period(s) of observation. Direct observation of adherence to treatment protocols, medical knowledge test scores, and patient satisfaction ratings. Facility performance Average length of stay, bed occupancy, infection and mortality rates, Apgar scores, and patient satisfaction ratings. Under-the-table payments to individuals Frequency of illegal charges for publicly provided health services. Perceptions of corruption Fraction of households, citizens or public officials reporting corruption in health. Relative ranking of health sector on corruption indices. Source: Authors. Institutional quality The Country and Policy Institutional Asessements (CPIA) for health. 10

11 Using Public Expenditure and Financial Analysis to measure efficiency of budget management (1-5) Bangladesh Dominican Republic Macedonia Mozambique Ukraine Aggregate expenditure outturn compared to original approved budget Effectiveness of payroll controls Availability of information on resources received by service delivery unit Source: PFM assessments (various years). 11

12 Leakage Rates for Health Care in Selected Countries from Expenditure Tracking Surveys YEAR LEAKAGE RATE TYPE OF EXPENDITURE Ghana % Non-salary budget Peru Glass of Milk Program Tanzania Non-salary budget Uganda Drugs and supplies Source: Lindelow, Kushnarova, and Kaiser,

13 Pharmaceutical Procurement and Distribution Problems WHO estimates 25% of drugs in low income countries are counterfeit or substandard China 30% of drugs are expired or counterfeit Procurement often troubled Collusion in bidding Prices paid vary widely for same product Drugs often go missing Costa Rica 32 of users are aware of theft Uganda drug leakage in 10 rural clinics averaged 73% Expired drugs common Distribution problematic 13

14 2. Individual provider performance: absenteeism Dominical Republic (1996)* Physicians Bangladesh (2004) Bangladesh (2004) Physicians Physicians clinics Bangladesh (2004) Health staff Uganda (1997) Rural physicians Uganda (2002/03) Health staff Peru (2002/03) Indonesia (2002/03) Health staff Health staff Absentee rate (%) India (Udaipur dist.) (2004) India (2002/03) Health staff Health staff rural clinics Honduras (2001) Health staff Chad (2004) Health staff Cameroon (2003) Health staff Bangladesh (2002) Health staff Note: *Santo Domingo Hospital. Sources: Chaudhury et al. (2006); Chaudhury and Hammer (2005); World Bank (2001); Gauthier (2006); Lewis, La Forgia, and Sulvetta (1996); McPake et al. (1999); and Banerjee, Deaton, and Duflo (2004). 14

15 Individual providers Higher salaries not necessarily effective Reward and discipline performance Discard seniority as basis for pay and promotion Payment system reform to link performance and pay Contract out with oversight 15

16 3. Facility performance Performance measures hamstrung by an absence of performance incentives, lack of managerial authority, and accountability, poor data and no benchmarks Need to reward and discipline managers (Brazil) Payment system critical because they offer incentives for good performance of providers DRGs/ 16

17 Ratio of highest to lowest price Comparison of Purchase Price Difference for Medical Supplies Across Public Hospitals in Four Latin American Countries Bolivia (1998) Argentina (1997) Colombia (1998) Venezuela (1998) Saline solution Cotton Dextrose Penicillin Source: Di Tella and Savedoff (2001). 17

18 Facility performance in Brazil: public vs contracted hospitals 12 contracted-out public hospitals 12 traditional public hospitals Quality median median General mortality Surgical mortality Clinical mortality Pediatric mortality Efficiency: Descriptive Statistics Bed turnover rate Bed substitution rate Bed occupancy rate ALOS ALOS surgery Technical Efficiency: (discharges/bed) General Surgical Clinical GYN/OB Annual Spending (in R$000) Expenditures/bed Expenditures/discharge Source: Adapted from La Forgia and Couttolenc (2008). 18

19 Key features of Brazil and other successful models Autonomous managerial authority Incentives for efficiency, cost containment and equity Flexible HR management: hire and fire staff Strategic purchasing Contract monitoring and enforcement Robust information environment Accountability of managers and staff 19

20 4. Informal payments Definition: charges for health services or supplies meant to be provided for free, or payments to obtain specific favors or advantages Qualitative studies suggest informal, underthe-table, payments in health care are common in many countries 20

21 Albania Armenia Belarus BiH Bulgaria Croatia Czech Rep. Georgia Hungary Macedonia Montenegro Poland Romania Russia Serbia Bangladesh India Nepal Pakistan Sri Lanka Users reporting informal payments in health (percent) Informal payments in health in ECA/SAS, Source: Thampi 2002; USAID Vitosha 2001; Balbanova et al. 2002; Central and Eastern European Health Network (various years). 21

22 Benin Botswana Cape Verde Ghana Kenya Lesotho Madagascar Malawi Mali Mozambique Namibia Nigeria Senegal South Africa Tanzania Uganda Zambia Zimbabwe Users reporting informal payments in health (percent) Informal payments in health in Africa, Source: Afrobarometer (2006). 22

23 5. Corruption perceptions Perceptions: Percentage of Households Perceiving Corruption in the Health Sector Sierra Leone (2002) Honduras (2002) Haiti (2004) Colombia (2002) Romania (2000) Guatemala (2005) Benin (2006) Peru (2001) Paraguay (2006) Kyrgyz (2001) Ghana (2000) Mozambique (2004) Zambia (2003) Indonesia (2001) Kazakhstan (2001) Source: World Bank Governance and Anti-Corruption Diagnostic Surveys 23

24 Purchasing of Positions Benin (2006) Indonesia (2001) Colombia (2002) Guinea (2005) Sierra Leone (2002) Ghana (2000) Zambia (2003) % of public officials' reporting that job purchasing in health is common or very common Source: World Bank Governance and Anti-Corruption Diagnostic Surveys (various years). 24

25 6. In summary, improving public performance in health: incentives and adding accountability Pay for performance: often does not work for individuals (US, UK) as it becomes part of earnings; more promising when tied to hospital earnings: Plan Nacer Argentina province hospitals (WB project) Philippines 30 hospitals Contract out and hold hospital director ultimately accountable - Sao Paulo, Brazil (WB evaluation) Community control and oversight/citizen report cards: evidence not encouraging Address corruption 25

26 Going forward Governance matters for public health system performance Need to reconsider incentive structures, accountability and enforcement of rules World Bank examples Indicators are key for management and accountability Need benchmark countries to set standards Need more evidence, agreed national indicators and data for those indicators 26

27 THANK YOU 27