ANALYZING EFFICIENCY ACROSS HEALTH PROGRAMS: A WHO DIAGNOSTIC APPROACH

Transcription

1 ANALYZING EFFICIENCY ACROSS HEALTH PROGRAMS: A WHO DIAGNOSTIC APPROACH Antonio Durán and Susan Sparkes Fiscal Space, Public Financial Management and Health Financing: Montreux, Switzerland April 2016

2 Main message: efficiency is a system-level issue, not a program one As with health system goals (and UHC), efficiency needs to be analyzed at level of the system, not at scheme or program level Specific health programs may be well-run, but if they duplicate or misalign functional responsibilities (e.g. contracting with providers, procurement, monitoring, etc.), they impose high costs on the system as a whole The causes of efficiency problems are country-specific; thus, reform has to be tailored

3 1. HOW WE APPROACH THE EFFICIENCY CHALLENGE

4 Analysing efficiency across health programs: a WHO diagnostic instrument Based on prior experience in eastern Europe Applied health systems analysis, driven by concerns that analysis only at program level misses important issues and often go undetected Functional decomposition of all health programs in country Examine for misalignments or conflicting incentives Examine for duplication and overlap, particularly re support systems (information, procurement, supply chain, etc.) Provide tailored assessment to identify and address specific problems

5 Starting place: health systems framework HIV TB HIV TB HIV TB HIV TB Adapted from World Health Report 2000, World Health Organization 2007 and Duran, Kutzin, Martin-Moreno, and Travis

6 Balanced approach Aim to streamline health system architecture across programs while ensuring good results Streamlining in terms of cutting costs but losing out on coverage and results would not be efficient So politically and technically, essential to ensure strong results orientation and accountability while correcting imbalances and duplications 6

7 Piloting the new approach Focus not only on financing but ALL health system functions (or building blocks, or control knobs) Explicit aim to look ACROSS programs, not just within them Aim to inform agenda for BOTH reform and possible investments to strengthen the underlying health system Ensure that any consolidation does not result in loss of focus Minimize unproductive debates or confrontations between the systems and program tribes 7

8 Step-by-step diagnostic process: with application in Estonia General steps Estonia pilot 1. Identify programs 1. HIV, TB, and drug abuse 2. Assess outcomes and relevant stakeholders 2. Outcomes: high rates of MDR/XDR TB and HIV in high-risk populations Institutional stakeholders: NIHD, EHIF, Min. of Social Affairs, Min. of Interior 3. Map health system functions and subcomponents 3. Service production, input generation and organization, financing, stewardship 4. Compare across programs and broader health system to identify critical areas of duplication, misalignment, and overlap 4. Topic for the rest of the presentation

9 2. IDENTIFYING CROSS-PROGRAMMATIC INEFFICIENCIES IN ESTONIA

10 MOJ Prison Health facilities MOJ Prison Health programs Uninsured ARV / TB medicines HIV/AIDS program (HIV) Drug abuse program TB program Other external sources (e.g. EQUAL) County governments, municipalities Estonia 2005: applying the framework to the financing of HIV and TB programs and interventions Sources employees employers self-employed individuals, firms, consumers External sources Compulsory health insurance contributions General tax payments (income, VAT, etc.) Collection General Tax Office/ State Budget Local governments Pooling MoSA NIHD Purchasing EHIF GFATM program Provision Contracted health care providers NGOs providing TB, HIV and drug abuse interventions (separately) Municipal TB & HIV related interventions Source: Alban and Kutzin (2006). Scaling up treatment and care for HIV/AIDS and TB and accelerating prevention within the health system in the Baltic States (Estonia, Latvia, Lithuania). Economic, health financing and health system implications. WHO/Europe.

11 What did the 2005 analysis reveal of the HIV Program in Estonia? Main clients were people who inject drugs concentrated in a few municipalities and the prison population (shared target populations) One implication: HIV and drug abuse programs need to work together Scheme was designed to fund programs rather than reach clients, resulting in inefficiencies Instead of pooling their funds and knowledge to reach their common clients, the HIV and drug abuse programs used their vertical budgets to separately contract with NGOs Nobody was acting to address this (stewardship failure)

12 Estonia Jan 2016: progress but still duplicating functions MOJ Prison Health facilities MOJ Prison Health programs Uninsured ARV / TB medicines HIV/AIDS Drug abuse program TB program County governments, municipalities Sources employees employers self-employed individuals, firms, consumers Compulsory health insurance contributions General tax payments (income, VAT, etc.) Collection General Tax Office/ State Budget Local governments Pooling MoSA NIHD EHIF Purchasing Provision Contracted health care providers and institutions NGOs providing HIV and drug abuse interventions Municipal for general health promotion

13 Exceptions create inconsistencies and inefficiencies Specialized Hospital 1 Specialized Hospital 2 Primary care centres Primary and care doctors centres Primary and care surgeries doctors centres and surgeries facilities

14 Fragmentation contributes to inefficient service delivery System incentivizes testing and treatment in concentrated, specialized units RESULT: Minimal prevention, testing and treatment in primary care Perception that TB, HIV or drug abuse services are related to public health and not personal services RESULT: Ineffective care coordination for target population Limited coordination across specialist physicians RESULT: Treatment delays and adherence problems

15 Other cross-programmatic duplication and misalignment issues in Estonia Input generation and organization Large TB-specific infrastructure and workforce that is not integrated with care for other infectious diseases with only ad hoc collaboration Separate drug procurement systems for HIV AND TB medicines Stewardship One national health plan but no coherent strategic planning across the system and institutions leading to accountability problems Public health institute s activities are diverted from core competency and instead focus on financial issues

16 3. POLICY IMPLICATIONS AND RECOMMENDATIONS

17 Basis for policy recommendations How to align the service delivery system to best meet the REAL needs of clients? How to align the flow of funds to facilitate appropriate organization of service delivery that best packages relevant interventions? How to ensure that roles are defined to enable health system leaders (stewards) to manage across (planning, regulation, monitoring, evaluation) rather than in programmatic silos, because clients are shared? How to ensure the sustainable future supply of key inputs (staff, etc.)?

18 Some possible policy implications of crossprogrammatic inefficiencies identified 1. Consolidate purchasing/payment functions into health insurance fund 2. Establish an institution, department or individual responsible for both tracking resources and achieving results 3. Build capacity and incentivize primary care physicians to prevent, test, and treat HIV, TB, and drug abuse 4. Integrate or better coordinate across infectious disease hospital-based care 5. Explore ways to unify all drug procurement and distribution systems

19 Lessons from the pilot Duplications, overlaps, and misalignments impact efficient allocation and use of resources AND effective coverage of priority interventions Importance of the health systems framework and approach Outcome and accountability orientation Everyone speaking the same language Need a concrete way to walk through how each of the health system functions operates within a program and across programs. Implications of for broader health system reform dialog E.g. primary care, hospital, financing, workforce planning

20 Next steps and feedback Piloting in South Africa in June 2016 Refining and updating instrument Feedback?

21 Thank you