FLGP M 3

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In the Name of God

• Health Sector Reform
• Why, What, How ?
• THE BASICS

• Equity, Quality, Ethics
• Efficiency Politics
• Family Physician
• Referral System
• Control Knob
• behavior
• Health

Dr Kambiz Monazzam
Lorestan Khoramabad May 2005
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Review of Health Sector Reform The Basics

• May 18-21, 2005
• Khoramabad - Lorestan

Dr Kambiz Monazzam
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Reform Definition

• sustained, purposeful and fundamental change
• Sustained in the sense that it is not a "one
  shot" temporary effort that will not have
  enduring impacts
• Purposeful in the sense of emerging from a
  rational, planned and evidence-based process
• Fundamental in the sense of addressing
  significant, strategic dimensions of health
  systems .

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Why do we Reform?

• Health problems/Health System Problems

• Who find the Problems...?!

• Unhappy People
• ....!
• ?

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What Starts The Cycle of Reform?

• Economic crisis
• Political change
• External pressure
• Unhappy interest groups

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Main Goals of Health Sector Reform

• Equity
• Efficiency
• Quality
• Sustainability

• Fiscal Impact
• Satisfaction
• Access

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What do we need R or r ?

• It depends on degree, severity complexity of
  our problems

!?
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Reform Cycle

• Is there any space for politics?

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Define The Problem
Evaluate
Identify Causes
The Health Systems Reform Cycle
Implement
Develop Options
Decide What to Do
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Problem Definition
Evaluation
Diagnosis
The Simplified Policy Cycle
Implementation
Policy Development
Political Decision
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Problem Definition
P O L I T I C S
Evaluation
E T H I C S
Diagnosis
The Political Policy Cycle
Implementation
Policy Development
Political Decision
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Economics HSR

• If someone asked you to find one problem of
  all human which is the most important to them,
• What problem do you address?
• If someone asked you to find one problem of all
  Governments which is the most important to them,
• What do you say?

Needs / wishes they cant reach
Lack of Enough Money
People Needs they cant meet
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Economics?

• Definition ?

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Gifted shared 100,000 to

• How do you do with 100,000 ?
• How do you divide 100,000 between 5 people?
• between 1000 people?
• between 1000,000 people?

Money
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People is different

• Individual desires preferences
• Social desires preferences
• Individual behavior
• Importance of the issue

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Decision making

• How decision could be made?
• Who Decide?

Values
Organization
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Management?

• Plan to Reform / Change
• Through ?
• Five Control Knobs
• Financing
• Payment (Incentive Structure)
• Macro-Organization of Provision
• Regulation
• Persuasion (Behavior)

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Reform Cycle
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Define The Problem
P O L I T I C S
Evaluate
Identify Causes
E T H I C S
The Health Systems Reform Cycle
Implement
Develop Options
Decide What to Do
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Define The Problem
Whats the problem?
Is there any problem?
P
Goals
Current
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Define The Problem
How many? How much?
Real or Opinion?
YES
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Goals
Define The Problem
Intermediate Goals
Ultimate Goals
Functions the system performs
Responsiveness (to non-medical expectations)
EQUITY
Stewardship (oversight)
ACCESS
EFFICIENCY
Creating resources (investment and training)
Delivering services (Provision)
Health
FISCAL IMPACT
Financing (collecting, pooling and purchasing)
Fair Financial Contribution
QUALITY
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What Constitutes the Health System?

• Care providers
• Financial intermediaries
• Input producers
• Planners and regulators
• Preventive service providers
• Other actors producing system outcomes

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Characteristics of Health Systems

• Complexity multiple actors with multiple
  connections
• Conflict different participants have different
  objectives
• Politics matters decisions inevitably reflect
  political process
• Societal context matters conditions and options
  reflects culture, history and social norms

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Define The Problem
How Should WeDefine Problems?

• The health system is a means. Reformers need to
  think deeply about the ends
• Problems should be defined based on poor
  performance in terms of outcomes

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Define The Problem
How Should WeDefine Problems? Cont

• Aspects of the system only need to be changed if
  the changes contribute to improving poor
  performance
• Defining the problem has to be done carefully
  because it will influence what solutions you
  choose

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Define The Problem
How Do We Know Which Aspects of Performance
Matter?

• Different groups will have different views
• Political processes often produce an uneasy
  compromise
• Reformers can influence those processes
• Reformers have to consider ethics and values to
  know what performance problems to focus on

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Define The Problem
The Role Of Ethics In Problem Definition

• Deciding what aspects of performance matter is
  not just a technical question
• Deciding what matters requires values
• Exploring ethical theory allows us to clarify
  both our assumptions and their implications
• The problem definition influences all that follows

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Define The Problem
How do you find to meet the goals?

• Which Indicators?

• Equity
• Efficiency
• Quality
• Sustainability
• Fiscal Impact
• Satisfaction
• Access

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Review of Health Sector Reform Diagnosis
Option appraisal

• May 18-21, 2005
• Khoramabad - Lorestan

Dr Kambiz Monazzam
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Identify Causes
How many problems do you have in the health /
system !?
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Identifying Causes The Diagnostic Journey
Identify Causes

• Start with performance problems
• Ask why five times
• Go from causes, to causes of causes, etc.
• Work backwards
• Be evidence based

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Start with problems

• Where they are?
• Who can find the problems? people have different
  ideas!
• Which Problem is more important than the others?
• Who can exactly define the problem?
• Experts, Managers, People, Data
• Which areas are important?

Identify Causes
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Start with problems

• Find
• Research
• Situation analysis
• Experts view
• List Classify
• Affinity diagram
• Logical cause effect Diagram
• Problem Tree

Identify Causes

• Time
• Money
• Expertise

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Problem identification (What)

• What exactly is the problem?
• Who or what is most affected by this problem?
• How serious/important is the problem?
• What supportive data/facts do you have to
  demonstrate this severity or importance?
• Is this problem manageable in scope?
• Is this problem more important and devastating
  than any other problems?
• Is this problem more influential/crucial to the
  current situation than any others?
• Can you afford to ignore this problem for the
  time being?

Identify Causes
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Problem analysis - (why)
Identify Causes
Problem analysis is to understand why there is a
problem or what are the factors that contribute
to the problem and the interrelationship between
these factors.
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Tools / Techniques
Identify Causes

• Problem Tree
• Fishbone Diagram
• Force Field Analysis
• SWOT or SWOC Analysis
• The 7s Model
• Problem Web.

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Finding Root Causes

• Problems have a cause effect relationship or
  other inter relationship between them.
• At last In health you reach a specific tree,
  which have multiple roots
• Go backward, find evidence
• Red line

Identify Causes
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Logical vs. political way of thinking to solve
problems
Identify Causes

• Logical
• Political

• Problem Tree
• Fishbone Diagram

• Force Field Analysis
• Decision Space
• .

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Tools for Political Analysis

• How do people think about political processes for
  policy change and implementation?
• When decisions are made Policy process sequences
• How decisions are made Decision-making models
• Who makes decisions Stakeholder analysis
• Boundaries Governance rules and Broader Contexts

Identify Causes
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Policy Process Sequence
Signaling
Evaluation Feedback
Consultation and Formulation
Implementation
Aggregation
Ratification
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Ethical Side
Political Side
The Health Systems Reform Cycle
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Developing Options

• Build on a sound model of
• a) what drives health system performance
• b) what can be changed

Develop Options
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Developing Options

• Imitate but adapt
• - learn from others but consider local conditions

Develop Options
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Developing Options

• Process matters
• how you go about this task will influence the
  political acceptability and the quality of the
  plan

Develop Options
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Reaching A Political Decision

• Health sector reform is unavoidably political

• Doing better requires political skill, not
  just
• political will

Decide What to Do
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Reaching A Political Decision

• Stakeholder analysis as a starting point

• From mapping
• to strategy

Decide What to Do
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Review of Health Sector Reform Treatment

• May 18-21, 2005
• Khoramabad - Lorestan

Dr Kambiz Monazzam
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• Implementation

Good ideas are not worth much IfThey can not
be implemented
Implement
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Resistance to change is almost always present

• The old adage,
• Better the devil you know than the devil you
  dont,
• embodies this idea.

Implement
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Resistance to change is almost always present

• Psychological
• New procedures and structures are strange and
  unfamiliar.
• For many, the mere fact of newness creates
  anxiety and resistance

Implement
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Resistance to change is almost always present

• change can bring costs to specific groups and
  individuals.
• New procedures and arrangements take time and
  effort to learn.
• Existing hierarchies can be upset.

Implement
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Resistance to change is almost always present

• Those who benefited from the old system can lose
  greatly.
• those most successful under the old system have
  the most to lose hence, the currently powerful
  are often the most opposed to reform.

Implement
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Resistance to change is almost always present

• Thinking Behavior
• Difficulty we all have in giving up familiar
  ways of thinking
• Past, can have a strong hold over us
• Established patterns are potent fixed, If one
  want to do differently, feels extreme pressure

Implement
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Many Health Sector Reform Efforts Have Failed at
The Stage of Implementation

• Ministers often lack administrative experience
• Leaders turn over quickly
• Implementation is not considered in program
  design
• Entrenched interests resist
• Political attention turns elsewhere

Implement
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Reaching A Political Decision

• Health sector reform is unavoidably political
• Doing better requires political skill, not just
  political will
• Stakeholder analysis as a starting point
• From mapping to strategy

Implement
Decide What to Do
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• sophisticated leadership
• Monitoring
• appropriate reporting system

Implement
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Evaluation Plan
Evaluate
how well it has achieved?

• Before designing and conducting an evaluation,
  the evaluator needs to be clear on the issues
  such as
• Why evaluation is needed
• To whom the evaluation results will be required
  and useful
• What data is needed and where and how to collect
  it
• What comparative exercise should be made.

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Keys To A Successful Evaluation
Evaluate

• Design an evaluation strategy in advance
• Anticipate likely problems
• Collect data before you begin
• Create incentives for good evaluation

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Keys To A Successful Evaluation
Evaluate

• Before-and-after comparison
• Control group
• Similar neighboring country

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Evaluate

• Collect baseline data
• Data is not free
• Data cost on people
• Time consuming
• Over-collection

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Define The Problem
P O L I T I C S
Evaluate
Identify Causes
E T H I C S
The Health Systems Reform Cycle
Implement
Develop Options
Decide What to Do
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The last point

• Five Core Elements
• Importance of ethical theory
• Explicitly identified health system performance
  objectives
• Systematic approach to health system diagnosis
• Use of the health system control knobs
• Political analysis

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Political linkage
Social movement
Knowledge generation