community part 3 b .Sc. nursing course FOR the reform in health system . sustained purposeful change to improve the efficiency equity and effectiveness of the health sector.
2. INTRODUCTION
• Reform in health system is an ongoing process in all countries.
• Health system reform is a sustained process of fundamental
change in policies and institutional arrangements of the health
sector, usually guided by the government, this process lays down a
set of policy measures covering the four main core functions of
the health system, viz., governance, provision, and financing and
resource generation.
-WHO
3. DEFINITION
• “Sustained purposeful change to improve the efficiency equity and
effectiveness of the health sector”.
-Peter Berman(1995)
• “Defining priorities, refining policies and reforming the
institutions through which policies are implemented”.
-Cassels(1997)
5. WHAT DO WE MEAN BY “PROBLEMS” IN
“PROBLEMS DEFINITIONS”
• The health system is a mean reformers need to be clear about the
ends;
• Problems should be defined based on poor performance in terms
of out comes;
• Focus on changing things that contribute to improving poor
performance
• Defining the problem is a critical step often ignored or assumed
6. WHICH PROBLEMS MATTER?
• System reforms mean a strategic view of problem still how wide to
case the net?
• Problem(out comes)affect people whose burden matters?
• Politics usually sorts this out…but political processes may be
suspect or inadequate
• Smart reformers try to influence problem definition
7. 1.THE ROLE OF ETHICS IN PROBLEM
DEFINITION
• Deciding what aspects of performance matter is not a technical
questions, it requires values
• Reformers always incorporate value judgement in problem
definition-but often cannot will not be explicit about them
• Explicit consideration of ethical theory leads to clearer thinking
about problem definition
• Public discussion about ethical principles may or may not be
desirable from a political perspective.
8. 2.IDENTIFYING THE CAUSES OF PROBLEMS
• Start with performance problem as outcomes
• Ask “why” five times
• Work “backwards” from causes to causes of causes and so on
• Be “evidence based”
9. 3.DEVELOPING STRATEGIC AND OPTIONS
STRATEGIC SHOULD BE BASED ON
• An explicit model of what causes health system performance to
be the way it is
• What can be changed and how performance should change as
result
• Imitate but adapt –learn from other but consider local condition
• The process of strategy develop may matter as much as the
content
• Influences the political acceptability
• Influences the quality of the plan
10. 4.REACHING A POLITICAL DECISION
• Health sector reform is unavoidably political
• Politics matters throughout
• Doing better requires political skill not just political will
• Stakeholder analysis is a starting point
• Successful reforms move from mapping politics to strategies to
affect politics
11. 5.MANY HEALTH SECTOR REFORM EFFORTS HAVE
FAILED AT THE STAGE OF IMPLEMENTATION
• Ministers often lack administrative experience and their staff may
lack the right kind of experience
• Leader turn over quickly
• Implementation- and its time and cost- are not considered in
program design. politics demands quick results.
• Entrenched interest resist-reform is rarely easy
• Encountering opposition, political attention may turn elsewhere.
12. 6.KEYS TO A SUCCESSFUL EVALUATION
• Evaluation does not always mean a large, independent study, less
formal results tracking also useful
• Design an evaluation strategy early, before implementations
begins
• Collect baseline data
• Build in redundancy in evaluation design
• Create incentives for good evaluation
13. WHY DOES THE CYCLE OFTEN BEGIN
AGAIN?
• Poor design or execution leads to unsatisfactory results
• Even successful reforms often create new problems
• Actors defend their interests in unanticipated ways
• Social, economic or political condition change
• Health and health system change
14. HEALTH SYSTEM REFORM REQUIRES SKILLS
• Many needed skills can be taught
• Skill are developed by practice
• Rules can help but specific situation require judgement
• Learning requires effort and active participation
15. STAKEHOLDERS FOR REFORM
• Stakeholders are person, group, organization or system who affect
and can be affected by an organizational action.
• The major stakeholders in the health care system are patients,
physicians, insurance companies, pharmaceutical firms and
government.
16. POTENTIAL STAKEHOLDER GROUPS FOR
NATIONAL-LEVEL HEALTH REFORM POLICY;
• MOH(central, regional, local, facility levels)
• Ministry of finance
• National institute of social security
• Health facility directors
• For profit/non profit organizations
• Politicians
• International donors
• Organized community groups
17. CONT…..
POTENTIAL STAKEHOLDER GROUPS FOR FACILITY-LEVEL HEALTH
REFORM POLICY;
MOH(central, regional, local facility levels)
Ministry of finance
National unions connected with facility
Facility board
Facility nurses
19. SPECIFIC STAKEHOLDER CAN BE IDENTIFIED
FROM THE FOLLOWING SECTORS;
• International/ donors
• National political(legislators, governors)
• Labor(unions, medical, associations)
• Public(MOH, social security, Ministry of finance)
• Private for profit, and nonprofit(nongovernmental organizations,
foundation
• Civil society is also an important sector to consider if the community or
consumers have a direct link in the policy. It is important to consider the
potential stakeholders in different geographical or administrative areas
within one organization.
20. SUPPLIES AND RESOURCES NEEDED FOR
REFORM
• In every health system, organization have to perform four basic
function; financing, provision, stewardship and resource
development(human, physical and knowledge;) Every health
system grapples with the problems of designing, implementing,
evaluating and reforming the organization and institution that
facilitate these function.
1.FINANCING
o Revenue collection
o Fund pooling
o Purchasing
21. 2.PROVISION OF HEALTH SERVICES
• Personal health services
• Non-personal health services
3.Resource generation
4.Stewardship
5.Vertical integration
22. 1.FINANCING
• Health system financing is the process by which revenues are
collected from primary and secondary sources, accumulated in
find pools/groups and allocated to specific activities of particular
providers.
• For the purpose of analysis, it is useful to subdivide health system
financing into three sub-function; revenue collection , fund
pooling and purchasing.
23. REVENUE COLLECTION
• Revenue collection refers to the transfer of money from primary
sources(household and firms) and secondary sources(governments
donor agencies). fund can be mobilization through eight basic
mechanism;
1.Out-of pocket payments
2.Voluntary insurance rated by income
3.Voluntary insurance rated by risk
25. FUND POOLING
• Fund pooling refers to the accumulation of revenue for the
common advantage of participants indeed, pooling means that
financial resources in the pool are no longer tied to a particular
contributor.
• In the language of insurance, pooling means that contributors
share financial risk.
26. PURCHASING
• Purchasing is the process through which revenues that have been
collected and placed in fund pools which are allocated to
institutional or individual providers in order to deliver a specified
set of interventions.
27. 2.PROVISION OF HEALTH SERVICES
The goal of health services provision is to improve health
outcomes in the population and to respond to people’s
expectations, while reducing inequalities in both possible quantity
and quality determine production costs.
They are of two types ; personal health services and non-personal
health services.
28. CONT….
PERSONAL HEALTH SERVICES
It refers to the services that an individual receives from others to
address health problems or for health promotion and disease
prevention.
29. NON-PERSONAL HEALTH SERVICES
• Any health service other than a personal health service.
• Conceptually, the same categories of issues apply to non-personal
as to personal health services.
• Nevertheless, in most countries the public sector, often the
ministry of health, takes a dominant role in the provision of non-
personal health services.
30. 3.RESOURCE GENERATION
• Resource generation implies the investment efforts of the system,
which can be understood as the monetary sacrifices to obtain
future benefits.
• It requires training healthcare professionals with strong
managerial components alongside technical proficiency,
appropriate supervision, development of team work, and
implementation of incentives to good performance.
31. 4.STEWARDSHIP
• It is the job of supervising or taking care of something such as an
organization or property.
• It concentrated on how government actors take responsibility for
the health system and the wellbeing of the population, fulfill
health system functions, assure equity, and coordinate interaction
with government and society.
32. 5.VERTICAL INTEGRATION
• A vertical integration is an arrangement whereby a health care
organization offers, either directly or through others, a broad
range of patient care and support services.
• It will improve care coordination, eliminate redundancies, reduce
waste, and improve care quality.
• For example, hospitals can buy physician groups or health systems
can form drug companies.
33. BARRIERS/OBSTACLES
WHY IS SUCCESSFUL REFORM DIFFICULT?
• The consequences of actions are difficult to predict
• Health system have multiple goal doing better on one goal
dimension may mean doing worse on another. The choices are
truly difficult.
• Those who benefit from the system are powerful and resist
change. Those who benefit from change are often less powerful.
• Countries are limited by their economic and administrative
capacity.
34. BIGGEST BARRIERS
1.Continued use of fee for service payment in reform
2.Expecting providers to be accountable for cost they cannot
control
3.Health providers compensation based on volume, not value
4.Lack of data for setting
5.Lack of patient/clients engagement
6.Inadequate measures of the quality of care
7.Negative impacts on health service centers
35. CONT….
8.Policies favoring large provider organization
9.Lack of neutral convening and coordination mechanisms
10.Country cultural barrier
36. COMMON AREAS FOR REFORM
o The common areas of health sector reform are;
• Regulation
• Financing
• Resource allocation
• Provision
• Quality assurance
• Decentralization
• Convergence
• Public private partnership
37. REGULATION
• The changes law need to strengthen regulations but attempts to
tighten regulation are frequently powerful interest group, it is
needed to;
Generalizing laws regarding the private health sectors and
introducing incentives for improved efficiency and equity.
Facilitating regulatory structures
38. FINANCING
• Reform of health financing has been at the top of policy agenda in
many countries.
• Administrative difficulties of fee collection have been significant
barrier to use and exception schemes have been effective and
even if there is ability to pay, people have been unwilling to pay if
service quality doesn't improve interest has therefore developed
in other ways of seeking to ensure that public funds are targeted
on the poorest.
• Reform is concerned on the nature of purchase.
39. RESOURCE ALLOCATION
• Allocation of resources is one of the most sector wide reforms of
creation of purchasing agencies introduction of contractual
relationship and management agreements, reforming payment
systems and specification of essential packages.
• Purchase that mix of intervention that provides the greatest
health gains
• Maximize the proportion of resources spent by agents that are
actually available for providing care
40. CONT….
• Services purchases for similar groups should be in different
geographic areas.
• Services purchase should reflect the different needs of different
groups e.g. elderly vs children.
41. PROVISION
o Reform may seek to increase the influence of users and communities
over health providers to hold them accountable for good performance
key reform themes affecting providers have been
• Decentralization of health services and hospital management
• Encouraging competition and diversity of ownership
• Strengthening primary care
• Evidence based health care and medicine
• Quality improvement measures
• Improved accountability to service users and population
42. MEASURING EFFECTS OF HEALTH SYSTEM
REFORM
• Efficiency(Allocative and technical)
• Equity(Equity in Access and care and equity in finance)
• Financial sustainability
43. ROLE AND RESPONSIBILITIES OF COMMUNITY
HEALTH NURSE IN HEALTH SYSTEM REFORM
1.Clinician: Provide holistic care for the promotive and curative purposes.
2.Advocate: Advocate for child right, women’s right and equality and
equity as well as gender equality.
3.Collaborator: Work in group coordinating and collaborating with
different partner and community leader, social worker, NGOs and INGOs
and other health workers.
4.Consultant: Interaction and two way communication with community
leader at to increase the decision- making power.
44. CONT….
5.Educator: To emphasis on prevention and promotion of health, to
provide health education for groups or individual, as well as training for
the junior staff regarding policies and targets.
6.Researcher: Research on the effectiveness of health system, uses of
health services and planning method, need of basic health for community,
nutritional assessment of community.
7.Case manager: Exercise administrative direction towards
accomplishment of specific goals, planning and organizing to meet those
needs, directing and controlling and evaluation, supervision of auxiliary
staff.
45. COMMUNITY SOCIAL CAPITAL AND RESOURCE
IDENTIFICATION
• Focusing on health capacity in finding solutions for community health,
which depends upon an individual’s own missions, roles and functions.
• Being aware of people who are involved in finding community solutions.
• Identifying social relationship among the community especially in health
care, which creates mutual benefits.
• Appearing trusting of as opposed to fearing, others in the community.
• Requiring timeless communication on a day to day basis, which people in
the social network.
46. ASSESSMENT OF COMMUNITY HEALTH
CONDITION, HEALTH RISKS AND PROBLEMS
• 1.Health problems and risks
• 2.Lifestyle in terms of health behavior and care
• 3.Environment, such as health threats and
• 4.Available and accessible health services and care.
47. COMPREHENSIVE COMMUNITY HEALTH INTERVENTIONS,
CARE, SERVICES, AND PROGRAMME DESIGN AND
IMPLEMENTATION
• Be participatory in nature, especially with stakeholders who are involved
in the provision of interventions, care, services and programs.
• Represent the interactive learning through action process of stakeholder
in designing and implementing the interventions, care, services and
programs;
• Critically select interventions, care, services and programs through on
census building of stakeholder to fit well with their roles and missions
for community health care;
• Be oriented towards the health outcomes of the entire community rather
than service oriented.
48. DEVELOPMENT OF HEALTH POLICIES/
AGREEMENTS
1.Shared understanding of the nature of apparent health care
demands of the people
2.Identifying social capital and resources for possible solutions to
meet the demands in health care and
3.Knowledge about the roles and functions of each stakeholder to
fulfill the missions and scope of work.
49. THE CORE FUNCTIONS OF COMMUNITY
HEALTH NURSING PRACTICE
1.Community social capital including community culture, and
identification of resources as key actors in the community health
care system.
2.Assessment of community health conditions health risks and
problems to identify the health care demands of the people.
3.Design and implementation of comprehensive community health
interventions care services and programs and
4.Health policies/ agreements development at the local community
level to drive policies/ agreements at the state and national levels
for collaborative endeavor's and actions.
