Decentralization in Health Care – is there evidence for it? Guest lecture at School of Public Health, National University of Kyiv-Mohyla Academy by Axel Hoffmann, PhD Swiss Tropical and Public Health Institute

1. Teaching & Training
Decentralization in Health Care –
is there evidence for it?
Guest lecture at
School of Public Health, National University of
Kyiv-Mohyla Academy
Kiev, 18 February 2014
Axel Hoffmann, PhD
Swiss Tropical and Public Health Institute

2. Overview
• Recapitulation: what is a health system?
• What are global challenges for health
• How can a decentralized system work?
• Will it solve problems of inequity and quality?
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3. Health systems
A framework of building block sub-systems
Source: de Savigny and Adam (2009)
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4. Basic health system framework
INPUTS & PROCESSES
Governance
Finances
Human resources
Medicines,
technologies &
infrastructure
Information
INPUTS & PROCESSES
Governance
Finances
Human resources
Medicines,
technologies &
infrastructure
Information
OUTPUTS
Service delivery
• efficiency
• access
• availability
• affordability
• acceptability
• quality
• safety
OUTPUTS
Service delivery
• efficiency
• access
• availability
• affordability
• acceptability
• quality
• safety
OUTCOMES
Increased
• effective coverage
• responsiveness
OUTCOMES
Increased
• effective coverage
• responsiveness
IMPACTS
Improved
• survival
• nutrition
• equity
Reduced
• morbidity
• impoverishment
due to health
expenditures
IMPACTS
Improved
• survival
• nutrition
• equity
Reduced
• morbidity
• impoverishment
due to health
expenditures
• OTHER DETERMINANTS OF HEALTH
• (Economic, Social, Political, Environmental)
• OTHER DETERMINANTS OF HEALTH
• (Economic, Social, Political, Environmental)
Modified from: WHO Everybody’s business, 2008 & Health Metrics Network Framework, 2008
But is
this
sim
ple
linear logic
the
way
things
really
work?
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5. Four basic health systems
1. Beveridge model (quite similar to Semashko-Model)
1. Named after William Beveridge who designed the UK National
Health Service
2. Health care for all provided and financed by government from
taxes
3. Most facilities owned by government; most health workers
employed by government
E.g. UK, Cuba, Spain, New Zealand, Scandinavia; Semashko model in Russia,
Ukraine
1. Bismarck model
1. Named after 19th century Prussian Chancellor
2. Health care for all from non-profit insurance system financed
jointly by employers and employees by payroll deduction
3. Providers are private but tightly regulated
E.g. Germany, France, Belgium, Japan, some Latin America
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6. Four basic health systems
3. National Health Insurance model (NHI)
1. Combines Beveridge and Bismark
2. Health care for all financed by a non-profit, single payer,
government run insurance
3. All employed citizens contribute
4. All providers are private
5. Tightly regulated with high cost control (single payer)
E.g. Canada, South Korea, Taiwan
3. Out-of-Pocket (OOP) model
1. Health care for few, financed only by and for those who can
afford it
E.g. Most of the rest of the world
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7. Which country
in each pair has higher child mortality?
Sri Lanka or Turkey
Poland or South Korea
Cuba or Russia
Pakistan or Vietnam
Thailand or South Africa
Germany or Singapore
Romania or Chile
United States or Slovenia
Seychelles or Mexico
Sudan or Cambodia
Pairs chosen where one country has > twice the child mortality rate of the other
Circle country with at least 2x higher mortality in each pair (10 circles)
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8. Sri Lanka or Turkey
Poland or South Korea
Cuba or Russia
Pakistan or Vietnam
Thailand or South Africa
Germany or Singapore
Romania or Chile
United States or Slovenia
Seychelles or Mexico
Sudan or Cambodia
Countries having > twice the child mortality rate of the other
14 29
12 6
7 16
101 19
21 68
5
20
3
9
8 4
2713
70 143
>2 x Higher mortality in the pair
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9. 14 March 2014 9
= 37%
98%
Effective universal coverage:
How health systems loose traction
Example of ACT anti-malarial treatment in Rufiji District, Tanzania in 2006
Efficacy
X Access
X Diagnostics
X Provider compliance
X Patient adherence
Effectiveness
X 95%
X 95%
X 70%
X 60%
Health system
factors
Averages mask inequities
Data source: TEHIP and IMPACT Tanzania. Effectiveness (effective coverage) data are actual.

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Process of decision-making
Information Decisions
DonorsBudgets
Politicians
MediaCommunity
Special
interests
Inertia
Peer
pressure
NGOs
Health
workers
Adapted from Lippeveld et al WHO 2000
Lack of evidence-based decision-making…

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Most important conditions
affecting health worldwide
Communicable, maternal,
perinatal, and nutritional
conditions
Non-Communicable Diseases
(NCD)
Injuries

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Global Health Challenges: some statistics…
1 Billion people lack access to health care
systems
Around 11 million children under age 5 die from
malnutrition and mostly preventable diseases
each year
In 2002, almost 11 million people died of
infectious diseases alone
In 2004, 4 million people died of unintentional
injuries (90% in LMIC)
Cancer causes more deaths than AIDS, malaria
and TB combined

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The planning dilemma
tertiary
secondary
primary
Population Health ResourcesLevel of Care
9%
90%
1%
15%
45%
40%

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Decentralication - why
• More rational organization: confined geographical and
administrative area
• More involvement of communities (district as interface
between top – bottom)
• Cost containment: no duplication of services
• Reduce inequalities: e.g. urban – rural
• Coordination at level of action
• Reduce communication problems: delays in supply,
information, feedback

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Financial
resources for
PHC are not
enough
Quality is low and
services provided
are not enough
Population prefers
to use hospitals
Financial
resources flow
to hospitals
Qualified personnel
prefers to work at
hospitals, quality
improves at hospitals
Population prefers
not to use PHC

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Financial
resources for
PHC are not
enough
Quality is low and
services provided
are not enough
Population prefers
to use hospitals
Financial
resources flow
to hospitals
Qualified personnel
prefers to work at
hospitals, quality
improves at hospitals
Population prefers
not to use PHC Increase in
funding
Quality improvement, eg
clinical pathway,
monitoring supervision
Service package
tailored to the need and
demand of people
Increase funding for
PHC
Training
Better status
and higher pay
of staff
Publicity for CHS:
social marketing, IEC

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Four pillars of decentralization
• Deconcentration
• Administrative authority
• Devolution
• Strengthening of Local Government
• Delegation
• Managerial responsibility
• Privatization
• Transfer of governmental functions

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Decentralisation – How?
 Adopt national policies
 Provide support for districts - rayons
 Decentralize
 Responsibility and power for each function to level of system to reach
flexibility within districts in adapting national policies for resource use
according to local priorities
 Develop district leadership
 Create district health teams (DHT) – all providers and users represented.
 Develop district planning process
 Define objectives and set targets
 Define activities based on objectives and targets
 Budget activities and specify and mobilize financing from all sources
 Strengthen community involvement
 By creating appropriate mechanisms by strengthening the knowledge and
skills of communities in solving health and development problems –
“creative listening”

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Decentralisation – How? (cont.)
 Promote inter-sectorial action
 By creating mechanisms to give health concerns higher priority on the
agenda of district development and helping each sector define its role in
health activities
 Redefine the role and functioning of hospitals
 Within a district as integral parts of the district health systems: First contact
versus referral function
 Ensure sustainability
 By integrating all programmes into the district health system and improving
the basic management skills of DHTs/health personnel
 Ensure equity between districts
 By allocation of national resources on the basis of need
 Use health systems research
 As a tool for solving problems of the district health system

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Possible changes at rayon level
Reallocate staff and partly drugs
Inefficiencies, inequity
Reassess resource combination & PHC packages
Quality of care, community satisfaction
Change service delivery strategies
Quality of care, community satisfaction
Improve supervision and monitoring
Performance, satisfaction of users & providers

21. Main focus of SRC Community
Health programmes
NGOs
MoH
Regional Health
Authorities
District Health System
Self-help Groups / Community Based Organisations (formal and informal)
Communities / Families / Citizens
Traditional Health System
National Government
Regional / Province
Government
Local / District
Government
PrivateSector
© SRK 2008
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Planning Process…
V
GP GP GP GP
BLOCK BLOCK BLOCK
DIST DIST
STATE Integrate
Integrate
Integrate
Integrate
VV VVVV V V V V V
Village
Health
Committees
Block Health
Committees
District
Health
Committees
State
Planning &
Appraisal
Committee
Source: EPOS India, 2006

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Systems matter…
From community effectiveness to equity effectiveness
Systems factors major risk factors
 Delay and quality of care
 Ensuring Access - equity
 Introduction of new tools
 Tailoring strategies
 Lack of evidence based decisions
Equity effectiveness
“More authorities are becoming aware that campaigns
for the control of diseases will have only temporary
effects if they are not followed by the establishment of
permanent health services to deal with day-to-day
work in the control and prevention of disease and the
promotion of health.” (DG WHO) 1951