Role of Referral Hospitals

1
Role of Referral Hospitals

• DCP2 workshop Tanzania 21-23 August
• Max Price
• Martin Hensher
• Sarah Ademakoh

2
What are we talking about?

• Almost all levels are referral
• Tertiary Specialist, sub-specialist, high cost
• Size 300 to 1500
• Academic
• Linked to Faculty of Health Sciences
• Teaching
• Research
• Outreach
• Support
• Inconsistency in National Accounts

3
Debate What value ?What resources?

• LESS
• Consume too large a share of budget
• Benefit very few
• Urban bias
• Middle class bias
• Dont address major public health problems

• MORE
• Then why do we continue to spend on RH?
• Politics? Power of Drs?
• Or
• Rational basis
• Cost-benefit is positive
• Need referral system
• Training needs
• Indirect benefits

4
Cost-Benefit/Utility Analysis approach to
Resource Allocation

• Analyse QALYs for each intervention
• Particularly favours childhood interventions,
  preventive care, PHC
• Other ways of valuing benefits
• e.g. willingness-to-pay, human capital approach
• Rank all interventions most to least cost
  effective
• Aggregate to budget limit
• Therefore minimal tertiary care!

5
Can Cost/QALY Analysis be applied to referral
hospitals?

• Complex economies of scope and scale
• Multiple outputs indirect contribution to QALYs
• Training health workers, specialists
• Referral and support to lower levels
• Research, piloting technologies and interventions
• Quality assurance throughout hospital system
• Countering brain drain from public sector and
  country
• Fails to capture critical dimension of utility
  and social welfare

6
Theory of Peace of Mind

• e.g. Kidney transplant service
• Actual no. of patients benefiting few hundred a
  year ? High cost per QALY, low public health
  impact
• BUT, in principle, whole pop (millions) benefit
• Reassured that available if needed
• Willing to pay cf. insurance
• Social Welfare, aggregate utility high
• Paradox The more expensive the intervention, and
  the rarer the disease, the higher the aggregate
  benefit-cost ratio

7
Indirect benefits

• Referral and support
• Quality Assurance in hospitals
• Training
• Research
• Emergency care
• Public confidence in the health system
• Foreign confidence investors, tourism, 2010
• Economic benefits
• Question Should this be left to Private Sector?

8
General Guidelines

• Linked to per capita GDP
• Linked to level of Health Service Development
• Availability of specialised personnel
• Balance will always need some referral and
  tertiary but how much?
• Population size, density, distance between main
  centres
• Demographic and epidemiologic transition
• Ensure adequate referral system and gatekeeping
  to ensure equitable access this usually means
  more investment in Urban services!
• Provide enough resources to do outreach, quality
  assurance, support