Health Systems: Goals, Functions, Actors Leadership ... · 9/27/2019 · 27 September 2019 Leadership, Governance and Stewardship 9 Governance describes the process through which

Health Systems: Goals, Functions, ActorsLeadership, Governance and Stewardship

Daniel OpokuDepartment of Health Care Management, Technische Universität Berlin

(WHO Collaborating Centre for Health Systems Research and Management)European Observatory on Health Systems and Policies

227 September 2019 Leadership, governance and stewardship

Outline of the course

1st Semester – Week 1

1W1 Monday (23.09.) Tuesday (24.09.) Wednesday (25.09.) Thursday (26.09.) Friday (27.09.)

08:00 -

10:00

Public Holiday

+

Arrival of non-KNUST

student participants

Frameworks 2/Financing (triangle) Service delivery

10:30 -

12:30

Campus tour for

exchange students/short

course participants

FinancingMedical products and

technologies

13:00 -

15:00

Introduction, expectations,

groupsHealth workforce

Group work (triangle Ghana

health system)

Leadership, governance,

stewardship

15:30 -

17:30Frameworks 1 Information

Optional supervised group

workPreliminary summary

1st Semester – Week 2

1W2 Monday (30.09.) Tuesday (01.10.) Wednesday (02.10.) Thursday (03.10.) Friday (04.10.)

08:00 -

10:00Improved health

Efficiency and

responsiveness

10:30 -

12:30Access and coverage

Financial protection and equity in

financing

Health system performance

assessment (summary)

13:00 -

15:00

Group work (access,

coverage – Ghana health

system in cube)

Group work (health system goals,

ranking, weighting)Revision

Departure of non-KNUST

student participants15:30 -

17:30

Group work presentation

(graded)Quality and safety Self-study for mid-Sem Exam

Mid-term exam (30 min) +

final questions

NB: Lecturer (by colour) = PD Dr. Wilm Quentin Dr. Daniel Opoku W. Quentin + D. Opoku

WHO 2007

25 Sept

25 Sept

26 Sept

26 Sept

27 Sept

01 Oct

02 Oct

02 Oct

03 Oct

03 Oct

3

Guiding framework for the module

01 Oct

Summary: 27 Sept Performance assessment: 03 Oct

& other frameworks: 24/25 Sept

25 Sept

Good health services are those which deliver effective, safe, quality personal and non-personal health interventions to those who need them, when and where needed, with minimum waste of resources.


Overview

• Definitions, components and developmentstewardship→ governance

• Underlying values, sub-functions/ principles and goals of governance

• Hospital governance/ regulation of healthfacilities


The WHO Health system framework (WHR 2000)

“Stewardship is one of the four main health systems functions and is arguably the most important one.”


Stewardship and regulation

“Rowing less, steering more“ –clear division of compentencieswith role of state = stewardship:

◆ Health policy formulation – defining the vision and direction for the health system

◆ Intelligence – assessing performance and sharing information

◆ Regulation – setting fair rules of the game with a level playing field (including possibly promotion of entrepreneurial activity!)

... but not providing care!


Access to services

Financing I:Raising resources/

funding

Financing III: Purchasing/ contracting/

paying providers

Third-party Payer

ProvidersPopulation

Collector of resources

Functions

7

Steward/ Regulator

Coverage:Who? What?How much?

Regulation

Financing II:Resource pooling & allocation

Provision of services

Policy formulation, Intelligence & Regulation


WHO 2007

WHO 2007 building blocks

- The concept of “stewardship” did not grasp the complexity of health systems, association with strong leadership alone, e.g. “steer the ship of state”.

- In 2007, changed to “leadership and governance”, with several subcategories: “ensuring that strategic policy framework exists and is combined with effective oversight, coalition building, regulation and attention to system-design and accountability.”

“Am Steuer,” Kladderadatsch, vol. 32, No. 27 (June 15, 1879), p. 108.


Leadership, Governance and Stewardship 927 September 2019

Governance describes the process through which state and non-state actors interact to design and implement policies within a given set of formal and informal rules through which authority in a country is exercised.

World Bank, 2017

Governance is how societies make and implement collective decisions

Greer et al. 2016

More general definition of governance

• Understanding governance is complex because multiple actorsare involved at various levels of government.

• Governance applies to different policy areas and concerns a range of values and principles.

10

The difficulty in making sense of governance

14 May 2019 Week 6: Leadership, Governance and Stewardship

• Public sector, private sector, NGOs as health service provider, civil society

A) Actors being governed

• European level, national level, sub-national, regional level or community level

B) Levels of governance

• Pharmaceutical market, planning of human resources, pooling and spending of health expenditures

C) Areas (sectors) to be governed

• Transparency, anti-corruption, effectiveness, accountability, rule of law, ethics, inclusiveness

D) Values and principles

Classifying dimensions of“governance”

/ principles

/ goals


Components, functions and tools of governance: 4 x C

12

Components (Sub-) functions Tools / strategies

control Accountability (Performance-based) contracts, Capacity to sanction performance of individuals and organizations, external audits (financial, clinical, quality)

Formulating policy and strategies

National health plans, medical guidelines, priority setting of goals

Regulation Rules, procedures, decrees; self-regulation by statutory bodies (e.g. professional associations)

coordination Organizational adequacy and system design

Monitoring and evaluation plan,Annual operational budgets, training

Generating information/ intelligence

Health technology assessment, audits, reportsPatient reported outcome measures

collaboration Participation and consensus

Open meetings, sector-wide approaches – “Health in all policies”, consultation in health legislation

Partnerships Inter-ministerial committees, integrated budgets, information systems, common workforce training and qualification

communi-cation

Transparency Releasing performance indicators, satisfaction surveys, watchdog committees


Strategies of good governance, sorted according to “attributes” (= [sub-]functions or principles): the TAPIC framework

Transparency Accountability Participation Integrity Policy Capacity

- Watchdogcommittees/ inspectorates- Reporting requirements- Performance measurement- Freedom of informationprovisions- Public informationefforts

- Standards & code of conduct- Conflict of interest policies- Competitivebidding- Contracts- Financial mechanisms- Choice mechanisms- Regulationstategies- Organizationalseparation

- Client surveys- Stakeholder forums- Advisory committees- Consultation- Representation(appointed orelected)- Legal remedies- Partnerships

- Internalaudit- Budget- Financial audit- Legislative mandate- Clear organizational roles and purposes- Personnelpolicies

- Intelligence on performance- Intelligence on processes- Research and analysis capacity- Staffrecruitment and retention

13

Source: based on Greer et al. 2016


In theory, “good governance” is easy

14

Source: World Development Report 2017. Governance and the law.

- Successful reforms are not just about “best practice” or copying efforts of another country

- Power asymmetries can undermine policy effectiveness

- Data availability tomeasure success of a policy (or identifyproblem)

- A policy can belimited because of a lack of financialmeans, short time period, lack of commitment, …


Leadership, governance and stewardship27 September 2019

But there are traps and governance failures

15

World Development Report 2017. Governance and the law

Health systems are foundexceptionally prone tocorruption and informal payment- This persists also with

European countries

→ Problems for accessibility, leading to inequities in health outcomes and sustainability of health expenditures

16

Measurement of governance is not straight-forward

14 May 2019 Week 6: Leadership, Governance and Stewardship

Measurement of governance is not straight-forward

17

Source: Greer et al 2016.

Examples: outcome-based indicators

Human Resources: Health worker absenteeism in public health facilities.

Health Financing: Proportion of government funds which reach district-level facilities.Health Service Delivery: Proportion of informal payments within the public health care system.Pharmaceutical Regulation: Proportion of pharmaceutical sales that consist of counterfeit drugs.


Hospital governance(regulation of health facilities)


Type 1 facility

In an entrepreneur’s ideal world, one could set up a facility, determine how to run it and be responsible for all losses and profit.

The right to establish a facility would include the freedom to choose a location, to determine the size and to decide on the range of technology and services offered. One could also decide whether services to deliver on an in- or out-patient basis, set price levels and refuse to accept certain patients.

Also, one had the right to decide on staffing numbers and qualification mix, the working conditions of the employees and their salaries.

Lastly, there would be no restrictions on business relationships with suppliers and other hospitals, including the right for mergersand horizontal and vertical takeovers. 1927 September 2019 Leadership, governance and stewardship

Type 2 facility

In the other end of the spectrum, the national government (or a subordinated public body such as a Health Authority) establishes facility where and at what size deemed necessary according to a public plan.

The planning authorities determine the technology installed and the range of services offered. Services are delivered free to all citizens at the point of service, hence no prices need to be set.

Staffing and working conditions are decided by the public authorities and standard public salaries apply.

As the hospitals are part of the public health services infrastructure, they have no independent relationships with other actors and no room for mergers or takeovers.


Two types of “non-regulation“

Both facilities are not regulated: (1) There are intentionally no regulations to restrict the market behaviour of the facility owners and/ or managers.(2) The facility is subject to public sector ”command-and-control”.

+„Private“

facility

„Public“

facility +


In practice, most hospitals in many countries fall some-where between the two extremes and require more regulation than these two.

Core publicbureaucracy

Privateorganization

Autonomy Few decision

rights

Full autonomy

Market exposure None At full risk forperformance

Residualclaimant

Public purse Organization

Accountability Hierarchicaldirect control

Regulation andcontracting

Social functions Unfundedmandate

Explicitlyfundedmandate


Core public sector

Broader public sector

Markets/ private sector

Budgetary

Autonomous

Corporatized

Privatized

From „A Conceptual Framework for the OrganizationalReform of Hospitals“ (A. Harding/ A. Preker, Worldbank)


What are the objectives of facilityregulation?

• To enable healthcare provision: establishment and availability of facilities, capacity and technology

• To promote and protect the population‘s health

• To specify and reward services: access, types, payment, quality …

• To get value-for-money/ not waste public resources

• To protect health sector employees

• To steer the business behaviour of facilities


Enabling healthcare provision

• Planning of capacities (by area, specialty):ex-ante (= before facilities are built) orex-post (= contracts for existing facilities)

• Combining planning with money for investments

• “Certificate of need“ for high technology


…

Protect population‘s healthRequire

• accreditation,

• internal quality management,

• participation in external quality assurance (QA) programmes,– possibly with public disclosure of results (e.g. ranking

lists)


Specifying and rewardinghealthcare services

• Access: disallow patient selection, mandate non-scheduledadmissions, require physician staffing around the clock, allowpatient choice

• Types of services: There may be a case to restrict certainambulatory services if they can be delivered more efficientlyoutside the facilities.

• Payment: uniformity of payment units (eg. FFS, capitation, DRGs) crucial for transparency, uniform prices less so

• Quality: minimum volume thresholds, inclusion of quality intopayment


…

Get value-for-money

• Require Health Technology Assessment for all (new) technologies

• Include technologies meeting pre-defined threshold or beingprioritised into publicly financed benefit basket (provision publicor private)

• Disallow technologies with harm > benefit even in private sector

• Regulate payment scheme with efficiency (among otherobjectives) in mind


…

Protecting health sector employees(with relevant EU regulation in place)

• equal treatment, opportunities and pay for men and women (76/207/EEC and 75/117/EEC)

• right to part-time work (97/81/EC; 98/23/EC)

• safeguarding of employees’ rights in the event of transfers of undertaking, businesses or parts of businesses (77/187/EEC; 98/50/EC)

• working times (93/104/EC)


…

Steering thebusiness behaviour of facilities

• Restrict (horizontal) mergers and acquisitions ofother facilities

• Restrict (vertical) mergers, acquiring andoperating other healthcare institutions

• Mandate minimum financial reserves

• Restrict advertisements


…

Conclusion

• Governance is about “how things are done” and how to achieve goals in a complex societal interaction.

• There are several problems to governance: as “too little, too much or the wrong kind”, but also short-sightedness, inefficiencies and unintended consequences.

• Governance is shaped by contextual factors, e.g. austerityafter 2008 economic crisis

• Health system governance is a complex process, and thevariation of governance performance and quality is likelyto contribute to health inequalities across the world


Documents

Health Systems: Goals, Functions, Actors Leadership ... · 9/27/2019 · 27 September 2019 Leadership, Governance and Stewardship 9 Governance describes the process through which