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Introduction to the Flagship Framework

Marc J. RobertsProfessor of Political Economy and Health Policy

Harvard School of Public Health

Africa Flagship Kigali, June 21, 2010

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The Flagship Framework isAction Oriented

• It offers a way to think about health systems designed to support reform efforts

• So two of the key components are: The things policy makers can change—the

“Control Knobs”The results policy makers are seeking to achieve—

the “Ultimate Outcomes” of health status, citizen satisfaction and risk protection

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The Flagship Framework Calls Attention to the Role of Values

• All reformers do not agree on goals and priorities• Deciding what goals to pursue is not a purely

technical matter• Instead it is also a matter of ethics and politics• The flagship framework therefore:

Considers various ethical and philosophical viewsExplores how politics works, and how it can be

used by reformers to achieve their goals

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The Flagship Framework EncouragesCritical Thinking

• It begins by asking “What is the problem?”—that is, what is it about the performance of the health system that needs improvement

• It proceeds to an explicit diagnostic analysis– designed to clarify the causes of the identified problem

• It fosters the use of evidence in choosing and designing solutions

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The Flagship Framework Fosters Conceptual Clarity

• The framework calls attention to the need to define key terms

• It clarifies that some system characteristics are intermediate goals– not ends-in-themselves but important causes of ultimate performanceEfficiencyQualityAccess

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The Flagship Framework Respects Variations Among Countries

• The framework assumes that variations in economic, social and political factors will influence a policy’s impact

• International experience must be joined with local knowledge to design effective interventions

• Thus all advice should be “conditional” on local circumstances

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The Flagship Framework Presumes That Details Matter in Policy Design

• The “within policy” variation in impact, as a result of the details of policy design, can be greater that the “among policy” variation

• Thus choosing a broad reform approach is not enough—”The Devil is in the Details”

• Some examples:– The impact of a pay for performance scheme will depend

on how performance is measured– The risk protection provided by an insurance scheme will

depend on the design of the benefit package

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The Flagship Framework Recognizes the Importance of Implementation

• Much of the “within policy” variation in impact comes from variations in implementation

• Such variations are due to variations in:– Agency leadership -- Available resources– Technical expertise -- Institutional design– Political support -- Stakeholder response

• Reformers thus must consider implementation issues in a program’s design, and be prepared to monitor and manage its implementation

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The Flagship Framework Emphasizes the Need for Evaluation

• Evaluation may influence program design—experimental or demonstration strategies

• Evaluation has to be a considered before implementation if appropriate data are to be collected

• Issues of data cost, quality and reliability need to be considered

• Program managers may need different (and more rapidly available) data than long-term evaluations provide

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Why Think Systematically About Health Systems Reform?

• Clear thinking is more likely to produce good results

• Avoid unintended results

• Anticipate likely problems

• Clarify goals and priorities

• Facilitate accountability and transparency

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Successful Reform Is Difficult

• The health system is complicated and poorly understood

• The consequences of policies are difficult to predict

• Doing better on one goal may mean doing worse on another

• Those who benefit from the system are powerful and resist change.

• Countries are limited by their economic and administrative capacity

The Health Reform Cycle

IDENTIFY THE PROBLEM

MONOTOR AND DIAGNOSE THE EVALUATE CAUSES

IMPLEMENT DEVELOP A PLAN

GET POLITICAL APPROVAL

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Understanding the Health Reform Cycle

• The cycle is a description of what would/should happen in an ideal world

• Actual reform processes often begin with the solution rather than the problem

• Systematic analysis is often not done

• International consultants and agencies have their favorite recommendations

“To a man with a hammer everything looks like a nail”

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The Diagnostic Journey: Identifying the Causes of Problems

• Start with performance problems –that is undesirable outcomes

• Ask “why” five times

• Work “backwards”-- from causes, to causes of causes, and so on…

• Be “evidence based”

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The Role Of Ethics In Problem Definition

• Deciding what aspects of performance matter is not just a technical question, it requires values

• Reforms always incorporate value judgments—whether implicitly or explicitly

• Public discussion about ethical principles may or may not be desirable from a political perspective

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Developing Reform Strategies • Strategies should be based on an explicit analysis of

what can be changed and how performance is likely to change as a result

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

• The process of strategy develop may matter as much as the content

– Influences the political acceptability of the plan

– Influences the quality of the plan

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The Health System“Control Knobs”

• Financing—where the money comes from• Payment– how doctors, hospitals and other providers

are compensated• Organization—both the macro aspects of who does

what and the micro aspects of internal managerial structures

• Regulation—coercive requirements imposed by the state

• Persuasion—efforts to influence both providers and consumers

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Reaching A Political Decision

• Health sector reform is unavoidably political throughout the reform cycle

• Doing better requires political skill, not just political will

• Stakeholder analysis is a starting point

• Successful reformers move from “mapping” political force to develop strategies to affect political outcomes

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For Obvious Reasons Many Reform Efforts are not Effectively Implemented

• Ministers and their staffs lack administrative experience and managerial sophistication

• Leaders turn over quickly

• Implementation – and its time and costs -- are not considered in program design

• Entrenched interests resist

• Political attention turns elsewhere

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Why Does the Cycle Often Begin Again?

• Poor design or flawed implementation leads to unsatisfactory results

• Even successful reforms often create new problems

• Actors defend their interests in unanticipated ways

• Social, economic or political conditions change

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Health System Reform Requires Skills

• Many needed skills can be taught

• Skills are developed by practice

• Rules can help, but specific situations require judgment

• Learning requires effort and active participation