ORGANIZATION OF SERVICES AND EFFICIENCY IN HEALTH SYSTEM PERFORMANCE Do we need to focus more attention on PHC? Daniel H. Kress Deputy Director, Global Primary Health Care and Health Financing December 2014, Oxford UK
OUTLINE Traditional efficiency studies useful but not always that actionable. Frequently, we will need to look at other factors beyond the efficiency study to understand how to increase productivity and outcomes (Nigeria example) Increasing evidence that improving health outcomes comes from non clinical services within the control of the health system, frequenty addressed outside the clinic setting and that we need to better measure and understand services beyond inpatient and outpatient visits. (Montana and Mali examples) Growing convergence between approaches to improving health in high performing primary care systems in HICs and models used in LICs, ie CHWs, but more research needed. 2
EFFICIENCY STUDIES Health economists have done many, all very useful Examples: branded vs generics, fixed versus mobile delivery, service delivery costs across multiple facilities Service delivery costing studies, useful but not always actionable Costs based on inputs used in production of services, labor typically 50-60% of total variable costs, costs tend to be relatively uniform based on homogeneity of health centers Outputs, based on units of service delivery, ie outpatient and inpatient services, typically varies greatly by facility, Productivity often low and variable with AC often high and variable: low effective use of care due to barriers like price, distance, perceived quality Some facilities do better, often an 80/20, ie 80% of services delivered in 20% of facilities. Challenges: Labor rarely a fully variable cost so reallocations difficult or impossible. Management often key ingredient Low overall productivity often the result of an allocative inefficiency, ie high user fees 3
COVERAGE OF KEY INTERVENTIONS HAS BEEN STAGNANT IN NIGERIA Nigeria DHS indicators 1990-2013, Percent 70 60 50 40 30 20 10 0 1990 1992 1995 1998 2001 2004 2007 2010 2013 Births attended by skilled provider (% of births) ARI treatment (% of children under 5 for whom treatment was sought from health facility or provider) Diarrhea treatment (% of children under 5 taken to health facility or provider) Immunization, DPT3 (% of children age 12-23 months) Contraceptive prevalence (% of women age 15-49 using any method) Delivery in health facility (% of births) Antenatal care from skilled provider (% of women age 15-49) SOURCE: DHS 1990, DHS 1999, DHS 2003, DHS 2008 and DHS 2013 4
SDI INDICATORS SUGGEST VERY LOW CASELOAD IN PUBLIC SECTOR IN NIGERIA Regional data Source: World Bank Service Delivery Indicators (SDI) SOURCE: SDI
DISTRIBUTION OF PUBLIC SECTOR CASELOAD IS SKEWED BUT LOW OVERALL Number of outpatient visits per medical staff per day per facility, by percentile 8 6 Health Posts / Dispensaries Primary Health Clinic Primary Helath Centers / CHCs 6.1 4 3.5 3.5 2 0 0.7.5.4 1.5 1.0.7 2.2 1.4 2.4 0 5 10 15 20 25 30 35 40 45 50 55 60 65 70 75 80 85 90 95100% SOURCE: World Bank Service Delivery Indicators (SDI) 6
PRODUCTIVITY OF PUBLIC SECTOR PHC IS LOW IN RELATIVE TERMS Average number of outpatient visits per day per PHC health worker 25.0 1.5 8.7 10.0 6.7 Nigeria Benue PPMVs Kebbi PPMVs Kenya Uganda Zambia PPMV comparables in Nigerian states African country comparables 1 Data on client volume is based primarily on recall, not records, and thus may not be reliable. SOURCE: World Bank Service Delivery Indicators (SDI), PPMV/pharmacy survey across Nigeria, Oct 2013 (TNS Global) 7
USERS ARE CHOOSING TO BYPASS PUBLIC PHCs FOR PRIVATE SECTOR PROVIDERS AND HOSPITALS Proportion of total survey respondents 0.06 0.04 0.02 Patients are bypassing public PHC facilities in favor of private and secondary facilities Needed but not sought Other or missing Home or traditional Private hospital Private PHC Private pharm. or chemist Public hospital Public PHC 0 Sought care for new illness or injury over past 4 weeks Had illness or injury but didn t seek care over past 4 weeks SOURCE: GHS, 2013 8
IN MANY AREAS, PPMVS ARE ABUNDANT AND CONVENIENTLY LOCATED Mapping of PPMVs and public PHCs in the urban area around Kebbi Public PHCs only PPMVs and public PHCs SOURCE: ACHIEVE PPMV study, NMIS 9
PUBLIC PHCS HAVE POOR PERCEIVED VALUE FOR MONEY, GIVEN HIGH USER FEES (ESPECIALLY FOR DRUGS AND LABS) AND POOR QUALITY Costs to patient by treatment at public primary health care facilities surveyed, USD Consultation Lab Medicine High costs are compounded by poor quality of PHC services Percent of respondents who received free services 62% of Nigeria s population lives on less than $1.25 a day 82% live on less than $2 a day 4.83 0.18 0.92 3.73 Malaria - Follow up visit 4.41 0.12 0.90 3.39 Fever - 1st visit 4.29 0.04 1.80 2.45 Fever - Follow up visit 3.70 3.03 0.42 0.09 2.87 1.14 0.53 0.47 2.13 Antenatal care Adult patients 2.41 Malaria - 1st visit 2.40 Postnatal care 2.54 0.50 0.75 1.29 Family planning 8.23 0.08 5.40 2.75 Diarrhea - Follow up visit 3.30 3.30 2.77 2.77 Upper Diarrhea respiratory - 1st visit tract infection, cough related - Follow up 2.67 0.11 2.56 Measles - 1st visit Child patients 2.40 0.30 2.10 Upper respiratory tract infection, cough related - 1st visit 0.74 0.58 0.15 Immunization 4 2 1 6 9 1 1 1 2 3 0 2 13 1 0.20 0.20 Measles - Follow up visit Only 18% have minimum infrastructure and 25% have minimum equipment Only 45% have minimum list of essential drugs Health workers are absent 29% of the time and have low skills level Only 36% able to correct diagnose common conditions 31% adhere to clinical treatment guidelines 17% correctly manage maternal and neonatal complications SOURCE: World Bank Service Delivery Indicators (SDI), 2013; World Bank Development Indicators 10
PUBLIC SECTOR PHC FACILITIES RECEIVE ALMOST NO CASH SUPPORT PHC facilities require a minimum of $1,200 (180,000 naira) a year to fund operational expenses (excluding drugs) Primary Health Center visited in Kaduna reported needing a minimum of $1,200 (180,000 naira) a year in cash to fund operational expenses (excluding drugs) including: - Laundry detergent - Cleaning supplies - Gauze and other medical consumables - Utilities - Fuel for generator CHCs would require more cash than this minimum threshold Facilities fund operational expenses with user fees or cash loans from facility incharge due to lack of public funding Most facilities received less than $1,200 a year Cash received from government & NGO sources in last fiscal year Percent of facilities surveyed 53 20 8 Minimum cash needed for operational expenses: $1,200 a year $100 a month No cash $0-300/yr $300-600/yr $600-900/yr $900- $1200- $1500-1200/yr 1500/yr 1800/yr ~85% of facilities receive less than minimum level of cash 3 2 2 1 12 $1800+/yr SOURCE: World Bank Service Delivery Indicators (SDI), 2013; Field visits 11
OUTLINE Traditional efficiency studies useful but not always that actionable. Frequently, we will need to look at other factors beyond the efficiency study to understand how to increase productivity and outcomes (Nigeria example) Increasing evidence that improving health outcomes comes from non clinical services, frequenty addressed outside the clinic setting and that we need to better measure and understand services beyond inpatient and outpatient visits. (Montana and Mali examples) Growing convergence between approaches to improving health in high performing primary care systems in HICs and models used in LICs, ie CHWs, but more research needed. 12
PRODUCTIVITY BEYOND VISITS TO A HEALTH CLINIC The dominant form of health care financing in the United States supports a reactive, visit-based model in which patients are seen when they become ill, typically during hospitalizations and at outpatient visits. That care model falls short not just because it is expensive and often fails to proactively improve health, but also because so much of health is explained by individual behaviors, most of which occur outside health care encounters. Indeed, even patients with chronic illness might spend only a few hours a year with a doctor or nurse, but they spend 5000 waking hours each year engaged in everything else Automated Hovering in Health Care Watching Over the 5000 Hours, David A. Asch, M.D., M.B.A., Ralph W. Muller, M.A., and Kevin G. Volpp, M.D., Ph.D., N Engl J Med 2012; 367:1-3July 5, 2012DOI: 10.1056/NEJMp1203869 13
STATE OF MONTANA EMPLOYEE HEALTH CENTERS Program started in 2012 by Governor Brian Schweitzer Created health centers for State government employees, all of whom had universal coverage already Contracted out to CareHere, company that runs employee health care clinics on a for-profit basis Major emphasis on health screening for risk factors, and addressing risk factors through counseling, nutrition, diet and exercise coaching 14
GROWTH IN CONTACTS FOR MONTANA STATE EMPLOYEES INCREASED ACCESS TO PHC 15
BETTER DETECTION OF CHRONIC CONDITIONS (ASTHMA/COPD, DIABETES, HIGH CHOLESTEROL, HYPERTENSION) 16
COACHING VISITS/CONTACTS 17
MALI, PROJECT MUSO, COMMUNITY HEALTH SYSTEMS STRENGTHENING Johnson AD, Thomson DR, Atwood S, Alley I, et al. (2013) Assessing Early Access to Care and Child Survival during a Health System Strengthening Intervention in Mali: A Repeated Cross Sectional Survey. PLoS ONE 8(12): e81304. doi:10.1371/journal.pone.0081304 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0081304
Figure 1. Patient Visits Before and After the Launch of the Health System Strengthening Intervention. Johnson AD, Thomson DR, Atwood S, Alley I, et al. (2013) Assessing Early Access to Care and Child Survival during a Health System Strengthening Intervention in Mali: A Repeated Cross Sectional Survey. PLoS ONE 8(12): e81304. doi:10.1371/journal.pone.0081304 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0081304
Figure 2. Under-Five Mortality in Muso Catchment Area Compared to Trends in Under-Five Mortality in Urban Areas and Nationally. Johnson AD, Thomson DR, Atwood S, Alley I, et al. (2013) Assessing Early Access to Care and Child Survival during a Health System Strengthening Intervention in Mali: A Repeated Cross Sectional Survey. PLoS ONE 8(12): e81304. doi:10.1371/journal.pone.0081304 http://www.plosone.org/article/info:doi/10.1371/journal.pone.0081304
OUTLINE Traditional efficiency studies useful but not always that actionable. Frequently, we will need to look at other factors beyond the efficiency study to understand how to increase productivity and outcomes (Nigeria example) Increasing evidence that improving health outcomes comes from non clinical services, frequenty addressed outside the clinic setting and that we need to better measure and understand services beyond inpatient and outpatient visits. (Montana and Mali examples) Growing convergence between approaches to improving health in high performing primary care systems in HICs and models used in LICs, ie CHWs, but more research needed. 21
CONVERGENCE IN PHC APPROACHES ACROSS HICS AND LICS Elements of convergence Focus on CHWs, coaching, addressing individual risk factors, greater focus on individual and household behavior Growing demedicalization of health care, shifting from doctors and nurses to care coordinators, coaches, keeping physicians focused on the tough assignments Increasing use of ICT, mobile job aids for CHWs in LICs, automated hovering in HICs Research needs Evidence base for CHWs relatively weak (though HICs going forward without it). More research clearly needed on how CHW/lay health worker engagement contributes to health More research needed on what CHWs/care coaches do and the contribution to health. What is effective? What is cost effective? 22