Health System Analysis for Better Health System Strengthening Peter Berman The World Bank Jakarta, Indonesia February 8, 2011 Based on Berman and Bitran forthcoming 2011
Health Systems Analysis: Can be specified and defined as a distinct area of policy analysis and policy development Has identifiable methods with theoretical and technical basis There is evidence that it has led to better health system strengthening As defined, has been widely used by the World Bank and others Has areas where further development is needed and feasible More concerted effort and widespread application will likely contribute to better health system strengthening
Life expectancies and health expenditure in selected countries: Health System Performance 24,00 Better outcome, lower expenditure Better outcome, higher expenditure Deviation from predicted life expectanc cy (years) 14,00 4,00-6,00-16,00 Kuwait China Angola Belize Chile Morocco Ireland Nicaragua South Africa Timor-Leste United States Burundi Rwanda -26,00 Worse outcome, lower expenditure Equatorial Guinea Lesotho -9,00-7,00-5,00-3,00-1,00 1,00 3,00 5,00 7,00 9,00 Deviations from predicted percentage of GDP spent on health Worse outcome, higher expenditure
Health System Analysis Defined Analysis to understand the causes and determinants of health system and the likely effects of policy change to improve that in order to develop better policies and strategies for reform. Health system analysis involves: the gathering of information on health system inputs, processes, and outputs, the analysis of how they combine to produce the outcomes other important dimensions of the health system environment such as politics, history, and institutional arrangements. Health system analysis seeks to derive hypotheses about the causes of poor health system and about how reform policies and strategies can improve. It includes proposals about how reforms can be implemented and what their possible effects might be.
The Logic of Health Systems Analysis Health system Ultimate outcomes (level and distribution) Health status Financial protection Customer satisfaction Intermediate outcomes Access Quality Efficiency Performance assessment Good Poor Hypotheses/analyses of the causes of Specific areas of health systems Financing Delivery Governance Institutions Policy interventions to improve Health Systems Control Knobs Financing Payment Organization Regulation Persuasion Effects of policy interventions on health system functioning and
The Methods of Health Systems Analysis {Structure Reflects Health Systems Performance Causal Framework} Health system Ultimate outcomes (level and distribution) Health status Financial protection Customer satisfaction Intermediate outcomes Access Quality Efficiency Performance assessment Good Poor Hypotheses/analyses of the causes of Specific areas of health systems Financing Delivery Governance Institutions Policy interventions to improve Health Systems Control Knobs Financing Payment Organization Regulation Persuasion Effects of policy interventions on health system functioning and Health system measurement/ assessment OECD 2003 WHR 2000 Smith 2010 Benchmarking, Ranking, Country-based valuations Evidence on how the structure and functions of health systems affects Policy and institutional analysis Analytical evidence of how health policy change affects health systems (structure, functions, Analysis of politics and governance Predictive evidence, e.g., Models Projections
Different questions, different methods Three types of health system analysis questions (after Hsiao and Siadat, 2010) Description Analysis of causation of and mechanisms of determinants of Prediction/modelling Different methods For description measurement of health system components Comparative health systems work WHO s building blocks ; USAID s health system assessment For analysis development and testing of causal hypotheses developing theories of determinants of health system Frameworks of hypotheses: e.g. GHRR/Flagship framework Case studies: e.g. OECD s reports, World Bank s HSA Statistical analysis of larger samples of countries, e.g. WHR 2000 For prediction of the effects of health system reform policies Simulation models
HSA Better HSS? While we believe that more systematic analysis can make a difference in health-sector reform efforts, we are not naïve about the difficulties. Health systems are extremely complex, and they often react in unanticipated ways to policy initiatives Still, we believe that an increase in both the breadth and the depth of thinking about reform can lead to better outcomes ( Roberts et al p. vii) In the design, implementation, and evaluation of its reform, Mexico has made intensive use of the best available evidence, which has been derived from national analysis and knowledge-related global public goods, such as systematic comparisons of the experiences of other countries, measurement methods, and conceptual frameworks. (Frenk, J., 2006) Examples from Mexico, Ethiopia, Turkey
12 World Bank HSAs Country Year Main objective Mozambique 2006 Large health gains in short time span. Scale up health services toward the MDGs through more health resources and also better spending Uganda 2005 Lack of major improvement in health status and persistent inequalities. Provide a better understanding of the connections between health outcomes and poverty in Uganda and the of the health system in targeting the poor Benin 2009 Need to strengthening the health system to combat three priority health problems: (i) malaria among children, (ii) maternal and neonatal mortality, and (iii) child malnutrition Ethiopia 2005 Consolidate knowledge to lay the groundwork for discussing and refining strategies and policies in the health sector in Ethiopia Mongolia 2007 Be a complementary resource for policymakers and practitioners during the implementation of the new Health Sector Strategic Master Plan 2006-2015, by providing a detailed assessment of challenges for the Mongolian health sector, and an in-depth discussion of key strategic issues for medium and long term China 2009 Synthesize WB s analytic & advisory activities in China in response to a request for technical assistance from the Government China 2004 Not shown; background paper for World Bank s China Rural Health Study; critically describe China s health sector with an emphasis on the post-reform era Vietnam 2009 Improve health system further, even though Vietnam has done and continues to do better than might be expected, given its per capita income. Vietnam has a high incidence of catastrophic household health spending (people in Vietnam are receiving quite sophisticated care, but the country s social health insurance program does not yet cover the entire population) Azerbaijan 2005 Dramatic deterioration in health status. Spur policymakers to consider a set of options for reforming the system, thereby enabling them to embark on a long-awaited reform initiative to improve health outcomes Turkey 2003 Carry out a comprehensive review of all aspects of Turkey s health sector, to help the country make the substantial and sustained efforts it will require in the coming years to meet the health targets of the Millennium Development Goals by the year 2015 Egypt 2004 Provide the Government of Egypt and its development partners with a critical assessment of experience to date with the Health Sector Reform Pilot Project India 2002 Inform and facilitate a professional and public discussion on the future directions for India's health system, by answering the two questions: (1) How can India meet the health needs of the most vulnerable segments of its population? And (2) How can the roles of the public and private sectors be structured to better finance and deliver health services?
Analytical Approach in World Bank HSA Explanatory approach From outcomes to causes: How we got to where we are Health status assessment Review of current health status in the country Emphasis varies among countries depending on income level, but tends to be on infant, child, and maternal mortality and morbidity, and HIV/AIDS Review of inequalities among population groups Review of trends over time Comparison of country health status with other, similar countries Analysis of health status determinants Outside of the health sector Within the health sector Determinants of health status other than health care Nutrition Education Alcoholism Fertility and demographics Hygiene Stewardship Health care financing Organization and delivery Recommendations Recommendations Recommendations Conclusions Extent to which health determinants outside of health sector influence health status Policy recommendations about what should be done in other sectors to improve health Phasing Costing (Turkey, Mozambique) Human resources Pharmaceuticals Recommendations Recommendations Predictive approach From processes to outcomes: How change will improve
Turkey: From Problems to Diagnosis The problem Health sector is under-performing in achieving health outcomes Low health status and unequal access to health service (rank far behind most middle-income countries) and disparities in health outcomes Income inequality and inequity in health status and utilization constitute a formidable barrier to meting the MDG Draft Health Sector Reform was developed by MOH in 1992 yet nothing has been implemented by 2002 Without deep policy change the country will not meet the MDGs Study objectives Policy objectives: addressing health sector problems engaging policy makers in discussions and debates on health reforms and bringing about a consensus among them, not only on broad principles but also in terms of approach to implementing reform measures Study objectives: Undertake and intensive review of all aspects of the health sector, for the development of a medium term health sector strategy and a prioritized action plan to improving access, enhancing equity, increasing cost-effectiveness, enhancing quality of care and improve health outcomes overall, with emphasis in coverage of poor and vulnerable groups Financing Payment Organization and delivery Regulation / Behavior / Stewardship Analysis Revenue collection Risk pooling Provider payment Budget allocation Service delivery Health workforce Pharmaceuticals, medical supplies, technology Information for decision making Diagnosis Large segments of population lack adequate health insurance or any other form of financial protection Little is spent on preventive care and on maternal and child health Inequitable distribution of public spending on health Primary health care system is underfunded and ineffective General hospitals run inefficiently Large number of small hospitals is major contributor to inefficient hospital system Many health centers are understaffed Huge gaps in the distribution of health personnel Imbalance between physicians in primary and specialty care Not all who are ill are able to get treatment, in particular the poor Little or no coordination between Ministries of Health and Labor, who control most financing and provision of health care Turkey needs Fundamental and systemic changes in Financing, Delivery, Organization and Management. The reform strategy has to be shaped around five programmatic areas
Turkey: From Diagnosis to Reform Financing Payment Organization and delivery Regulation / Behavior / Stewardship Analysis Revenue collection Risk pooling Provider payment Budget allocation Service delivery Health workforce Pharmaceuticals, medical supplies, technology Information for decision making Recommendation ns 1.Improvements in resource mobilization and allocation 1.Improvements in resource mobilization and allocation 2. Enhanced access to health services 3. Improvements in efficiency in production & delivery of health services 4. Improvements in clinical effectiveness 5. Increase in demand and utilization of health services Strategies Compulsory universal social health insurance (health Fund) with optional supplement al private insurance Targeting delivery to the poor and to underserved regions Strengthening delivery of primary care services Reorganizing public hospitals an providing greater autonomy Staffing rural health facilities Epidemiological surveillance and data collection Quality assurance and control Developing a package of essential services and targeting public spending Consolidating and redefining institutional responsibilities (MOH and MOL) Preparatory phase: Finalization of all legal and institutional requirements (3 to 5 years) Completion phase : Reform measures are actually implemented ( 3 to 5 years)
Table 5 Turkey: From problems to causes to solutions The main problems Problem 1: Problem 2: Problem 3: Problem 4: Problem 5: Low health status and unequal access to health service, clean water, sanitation and education Low level of public spending on health and the available resources are not allocated efficiently and equitably Poor incentives for managers and providers in Public provision of health Delivery of health care is fragmented Potential of private sector is not fully realized The main causes of the problems Main recommendations Cause 1: Not all who are ill are able to get treatment, in particular the poor. Large segments of the population do not have adequate health insurance or any other form of financial protection Compulsory universal social health insurance (health Fund) with optional supplemental private insurance Cause 2: Primary health care system is underfunded and ineffective. Many health centers are understaffed and there are huge gaps in the distribution of health personnel Staffing rural health facilities Strengthening delivery of primary care services Adopt the concept and practice of family medicine Cause 3: General hospitals run inefficiently Reorganizing public hospitals and providing greater autonomy Cause 4: Little or no coordination between Ministries of Health and Labor, who control most financing and provision of health care Consolidating and redefining institutional responsibilities (MOH role in policy formulation and regulatory oversight and MOL role in universal health insurance system)) Epidemiological surveillance and data collection Quality assurance and control Cause 5: The distribution of public expenditures on health is not equitable and little is spent on preventive care and on maternal and child health Developing a package of essential services (maternal and child health oriented, including determinants) and targeting public spending Targeting delivery to the poor and to under-served regions
Today, the health system in Turkey is transformed, not quite to the point of favourable comparison with the rest of the OECD and most of the European Union, but fast closing the gap in health outcomes, responsiveness, and fair financing. Baris et al, British Medical Journal, BMJ 2011; 2011; 342:c7456 Table 1 Health system indicators before (2000) and after (2008) the Health Transformation Programme in Turkey 1 2 6 7 8 9 Health system goals and functions 2000* 2008 Health improvement Life expectancy at birth (both sexes, in years) 70 73 Under 5 mortality (1000 live births) 44 23 Maternal mortality ratio (100 000 live births) 70 19.8 Responsiveness (public sector only) Patient satisfaction, overall (%) 39.5 66.5 In primary care (%) 41 70.6 With Ministry of Health hospitals (%) 39.4 66.6 Financial access Total expenditure on health (% GDP) 3.6 5.6 General government expenditure on health as percentage of total government expenditure 11.5 16.5 Out of pocket expenditures on health as percentage of total health 27.6 19.3 expenditures Health insurance coverage (%) 66 87
Some general findings Objectives and methods of HSA should be selected to meet the specific needs of each situation. Reports offer policy advice but the specificity and detail of that advice is very uneven Policy recommendations are often overly ambitious The evidence base for policy recommendations is not always well articulated and assessment of feasibility not always clear or sufficient. Good practice is to address explicitly the timing and phasing of recommendations Insufficient analysis of the policy context Some parts of HSAs are much more developed conceptually and methodologically than others. There is a need to develop better guidelines and practice experience for the less developed parts. For example: Governance and institutional analysis Organizational analysis and service delivery Health systems analysis of categorical programs
Way Forward? Develop an HSA practice with dedicated expertise Strengthen peer review for reliability and validity Develop more explicit guidelines and methods, especially in the areas of weakness Capacity building for Bank staff and clients Practice Practice Practice