"Ask the Expert" Series
Below are the initial questions we have encountered and the responses from the lead discussants:
What are the major bottlenecks to making known, affordable and effective interventions widely available?
(G. Murindwa) Major bottlenecks include inadequate and inappropriately distributed health systems inputs to support the delivery of effective interventions. In Uganda, before the introductions of Sector-Wide Apporaches to health development, there was limited access to basic health facilities by the population. Only 49% of the population was living within the recommended 5 kilometer radius of a health facility. The few available health facilities were poorly staffed with trained health workers. Only 33% of the established posts were filled with trained health workers by 2000; the rest of the positions were either vacant or occupied by untrained health workers (called nurses aides). There were frequent and prolonger shortages of essential medicines and health supplies.
With the introduction of Sector-Wide Approaches and comprehensive health sector planning there was better targeting of health sector resources to health sector priorities resulting in a more appropriate balance of health sector inputs - many health facilities were constructed and renovated, many trained health workers were recruited and deployed and a number of pay reforms were introduced. In addition, increased funding for procurement of medicines and health supplies was available accompanied by medicine management reforms.
Access to health facilities has increased from 49% in 2000 to 85% in 2005. The proportion of approved posts filled by trained health workers has improved from 33% in 2000 to 68% in 2005. The proportion of health facilities without stock-outs of essential medicines and health supplies has improved from 30% in 2000 to 47% in 2005. The combination of improved access to basic health facilities, improved staffing levels of health facilities, a good supply of medicines and the removal of inancial barriers to access (user fee abolition) resulted in increased utilization and consumption of health care interventions by the population.
However, there continue to be challenges to deal with. There must be an appropriate balance of inputs. Construction of health facilities was out of step with the production of health workers resulting in many of the new facilities staying unutilized for namy years due to staff and equipment shortages. Improvements in maternity have been much slower.
(E. Bolastig) What appears to be one of the major bottlenecks is the challenge of ensuring intra- and intersectoral collaboration for health. While there have been considerable advances in public-public and public-private partnerships, much remains to be desired in terms of ensuring that the various key players are in the same ballgame so that the cost-effective interventions are made available in the broadest possible sense, in order to achieve commonly desired health outcomes.
In the Philippines, what accounts for this divide is the fragmentation of the healthcare system that resulted from the devolution of health services from the national health agency, the Department of Health, to the numerous local government units (LGUs) in 1991. With increased local government autonomy, the delivery of basic health services, together with social welfare, agriculture and agrarian reform, have become part of the responsibilities of a number of local chief executives (LCEs) such as mayors in 117 cities and around 1,500 municipalities, and governors in 79 provinces. Since then, the acceptance, buy-in and implementation of said health interventions have now become subject to the will of the incumbent politicians and the interests that they serve. LGUs with visionary leaders tend to adopt cutting-edge health reform measures and achieve better health outcomes while others lag behind.
Meanwhile, in some Caribbean countries that have decentralized the delivery of health services to Regional Health Authorities (RHAs), ensuring that the RHAs conform to national policies could, at times, be hampered by weaknesses in the contractual relationship between the semi-autonomous RHAs and the Ministry of Health. The RHAs themselves may also face challenges in terms of its managerial and technical capabilities to effectively and efficiently run the health facilities within their respective jurisdictions.
In both settings, what is crucial to making these relationships work is how the vision and intent of policymakers are translated into the delivery of health services or the implementation of health programs that would utilize what are known to be affordable and effective interventions.
What measures must be put in place to ensure that known, affordable and effective interventions are widely available?
(G. Murindwa) The health sector must develop and disseminate the Minimum Service Standards of care for different health care interventions and for different levels of care, such that there is uniformity in the delivery of the interventions throughout the country. In addition, the sector must develop an effective monitoring and evaluation system to track the delivery of health care interventions. There should be frequent analysis of information to ensure that all areas of the country and all social economic groups have equal access to basic health care interventions.
(E. Bolastig) Outlined below are some key measures to ensure that known, affordable and effective interventions are widely available:
Evidence-based policymaking – Firstly, policymakers should be properly appraised of the relevance and importance of any proposed intervention. Policy decisions should be based on sound evidence, such as those coming from systematic reviews, impact evaluations, health technology assessments, best practices, and other sources of evidence.
Knowledge management – Information regarding such interventions should be widely disseminated by the use of knowledge management tools that would allow for knowledge exchange and transfer in order to improve the likelihood of these interventions to gain acceptance and grounding at the national and local levels.
Linking financing with regulation – The financing of these interventions should not only be adequate and equitable, but should also be linked to the existing regulatory framework of the country. This is to ensure that the providers implement the proposed interventions according to generally acceptable quality standards and procedures.
Monitoring and Evaluation – Two-way feedback is critical in ensuring that all systems that are needed to implement the interventions are in place, so that problems and challenges at any level will be addressed expeditiously.
How do we ensure the sustainability of such interventions?
(G. Murindwa) Government must develop sustainable and equity funding mechanisms for health care. In addition there should be proper planning and prioritization of resource allocation. There should be deliberate attempts to involve communities in the planning, management of the health care interventions.
Partnership with the private sector is essential to sustaining and increasing access of the population to health care interventions. In Uganda, a genuine Public Private
Partnership with especially the Private Not For Profit (PNFP) sector (which are mainly religious based institutions) has been established. Government provides funding to the PNFP facilities in order to subsidize the costs of health care. The PNFP organizations in return reduce the charges for health care to the population. Government subsidies have been increasing over the last years.
With reduced charges for health care, more people are able to access care from PNFP in areas where there are not government facilities. Working with PNFP require an effective supervision and monitoring system to ensure that funds are used as agreed in the work-plan and the agreed deliverables are attained as spelt out in Memorandum of Understanding.
(E. Bolastig) Health Financing - The Sector-wide approach (SWAp), or what is locally known in the Philippines as Sector Development Approach for Health (SDAH), is seen as a mechanism to ensure that such health interventions are sustained over time and in a coordinated and timely manner. SDAH was adopted in 2005 in 16 pilot provinces participating in the Four-mula One for Health (the second phase of the Health Sector Reform Agenda, or HSRA, which was launched in 1998). There are 21 more roll-out sites that are expected to join the bandwagon in the next couple of months.
In the case of the Philippines, such interventions should be included in the Local Government Unit (LGU) Investment Plans that will be funded through Four-mula One, and indicators should be developed to monitor their implementation, together with the jointly defined set of Programs, Projects and Activities (PPAs) for the LGUs.
Continued support from other government organizations, development agencies, civil society partners, and other stakeholders through joint coordinative mechanisms should be put in place in order to allow for the effective pooling and mobilization of greater resources for health.
In Trinidad and Tobago, the development of the country's health financing system through a largely government-funded, tax-based National Health Service is underway. In the same vein, these effective and affordable interventions should be included in the essential basket of services that will be financed through the NHS. A quality assurance system is envisioned to regulate the delivery of said services, while a health financing framework is being developed to govern the operations of the NHS.
Investing in Human Resources for Health (HRH) development - People are the most important assets of any given healthcare system. Hence, investments should be made in the continuous training and education of a country’s health workers.
In the Philippines, a number of innovative strategies have been identified and developed to address this issue. Among these are:
- Introductory Course on Health Sector Reform for both national and local government officials and health administrators, including topics on health regulation, health economics and financing, among others;
- An MBA-Health degree programme administered by a top Business school in the country for select doctors deployed in doctorless municipalities (Doctors to the Barrios Programme);
- Continuing Professional Educational programmes of the respective professional organizations;
- Basic and Advanced Training of village or barangay health workers (BHWs) who man the village clinics and conduct Primary Health Care activities;
- Scholarship and training programmes;
- A selection, promotions and salary increment system that is based on continuing education.
In Trinidad and Tobago, as in the rest of the Caribbean states, where there is not only a lack of health professionals but also limitations in existing or available skill sets, there have been several measures that have been initiated:
- Free tertiary education for its citizens, including health courses;
- A National Health Careers Fair to introduce students to a variety of courses in the health sector;
- Partnership between the Ministry of Health and degree-granting Universities offering health courses;
- Scholarships and bursaries for health workers and professionals wanting to pursue specialization in identified areas of expertise;
- A Programme for returning health professionals trained or working abroad;
- Recruitment of UN Volunteer Medical Specialists, and health professionals (doctors, nurses, pharmacists) from the Philippines and Cuba on contractual basis (adopted only as a temporary or stop-gap solution and not seen as being sustainable in the long run, unless the mentoring aspect of the programme is strengthened, or enhanced with a more acceptable exchange programme)
Unlike the Philippines, however, where there exists a medium- to long-term National HRH Development Plan, many countries in the Caribbean still need to develop these plans, including transforming the HR offices in their health ministries to expand their HR scope and capabilities, especially in terms of comprehensively managing and developing their HRH on a national scale, beyond simply those employed within the MOH.
What are the organizational and management reforms (or arrangements) that must be undertaken to ensure that know, affordable and effective interventions are widely available?
(G. Murindwa) Decentralization of decision-making and resource allocation to lower levels and defining the roles and responsibilities of different levels of care is critical in making known, affordable and effective intervention widely available.
In Uganda, the delivery of health care along with other social services were decentralized to the districts. Recently this responsibility has been further decentralized to the Health Sub-Districts (sub-division of district into smaller functional health zones). Decentralization of the management and delivery of health services has greatly improved the delivery of health care interventions. Districts and Health Sub-Districts are better placed to plan and manage the delivery of health care interventions and ensure that populations within their service areas (catchment areas) are reached with cost effective health care interventions. Government has therefore massively invested in the decentralized integrated services and strengthened the management capacity of the decentralized districts.
Decentralized health service delivery however requires an effective supervision and monitoring system to ensure adherence to standards and mentoring.
(E. Bolastig) The organizational set up must be restructured in such a way that it responds to both the needs of the national as well as the local levels, including that of other key stakeholders working towards the commonly desired objectives or health outcomes.
In the case of the Philippines, a re-clustering of the health bureaucracy from national to local levels has been undertaken to reflect the various identified key focus areas. These areas are:
Governance and Management Support
a. Sectoral Management and Coordination Team - responsible for the overall development, monitoring and coordination of policies, mechanisms and guidelines for the health sector, encompassing financing, regulation, service delivery and governance concerns.
b. Internal Management and Support Team - responsible for implementing financial, procurement and logistics management reforms, including building the information and communication technology infrastructure and other management support services.
Policy and Standards Development and Technical Assistance
Policy and Standards Development Team for Regulation - has the mandate and function to ensure the quality and affordability of health products and services. This pertains to the development of policies, standards and guidelines, as well as technical capability for regulating health products, including drugs and medicines, and health facilities and services, in tandem with the accreditation and quality assurance systems.
Policy and Standards Development Team for Service Delivery - ensures the development of policies, standards and guidelines for health programs and the provision of technical assistance to health service providers. This includes the development of disease surveillance systems, program design for essential health packages and specialized health services, health promotion and advocacy, and upgrading of health facilities, among others.
Policy and Standards Development Team for Financing - ensures that the health financing system is further strengthened by expanding social health insurance coverage, improving benefits and leveraging provider payments on quality of care. The PSD Team for Financing is expected to coordinate with the PSD Team for Regulation with regard to the harmonization of regulatory systems and processes.
Field Implementation and Coordination
a. Regional Implementation and Coordination Teams (RIC Teams)
- Provide technical assistance to define the package of minimum health care for the LGUs;
- Strengthen technical and managerial capability at the local level to improve LGU performance;
- Facilitate compliance to accreditation requirements of health facilities, products and services;
- Provide venues for inter-agency coordination, including other players in the health sector in a given locality;
- Monitor and evaluate the LGU performance through the LGU scorecard;
- Develop incentive mechanisms for LGUs towards better performance in the delivery of health care; and
- Rationalize the role of DOH hospitals to complement health care services provided by the LGUs and the private sector.
On the other hand, the contractual relationship between the MOH and RHAs in a British-type NHS model in come Caribbean states, such as Trinidad and Tobago, is hoped to be strengthened by drawing up Annual Service Agreements that should define the specific deliverables from the repsective RHAs for every health dollar appropriated to achieve certain health outcomes. A regular reporting system that includes key idicators should be drawn up and linked to these service agreements, in conformity with national policies, while allowing for creativity and innovation in the discharge of their service delivery functions.
However, the present situation requires instruments stronger than mere Memoranda of Agreement or Understanding (MoUs) between the contracting parties. Perhaps, a more legally enforceable instrument may be used, that would allow either of the parties involved to sue or be sued in a court of law for breach of contract.
The bottom line for the effective organizational management of any given healthcare system is its ability to utilize good governance measures that are appropriate to its setting, ensuring that accountability, transparency, effectiveness, efficiency, equity and quality are continuously built into the system.