A Senior Management Course for Health Managers in Kenya Unit 1.3: Key Principles of Health Care...

A Senior Management Course for Health Managers in Kenya

Unit 1.3: Key Principles of Health Care Delivery and their Application

Health Systems Management

2nd edition July 2014 senior management course for health managers

Purpose

•This unit introduces participants to the principles

underpinning provision of quality health care.

•It discusses how the principles affect service delivery,

including their application: access, coverage, quality,

safety, equity, effectiveness, efficiency, lifecycle

approaches, rights based approaches/client centered

approaches and sustainability.


Objectives

By the end of this unit, the participant should be able to:

•Describe the Kenya Essential Package for Health (KEPH);

•Explain the health care delivery principles, and their relationship to the health system;

•Apply the principles and concepts in health service delivery.


Overview

Description of the Kenya Essential Package for Health (KEPH) – levels and services.

There are nine (9) principles of health care delivery categorised as:

a) Affecting intermediate outcomes (4):

– access, coverage, quality and safety.

b) Affecting final outcomes (5):

– equity, efficiency, effectiveness, client centeredness, sustainability.


Overview (Cont’d)

For each principle:

•Describe the principle;

•Outline how the principle relates to the building blocks;

•Interpret its application to Kenya Essential Package for Health.


Session 1.2

Introduction to Principles of

Health Care Delivery and KEPH


The Nine Principles of Health Care Delivery

Affecting intermediate outcomes:1.Access;2.Coverage;3.Quality;4.Safety.Affecting final outcomes:5.Equity;6.Efficiency;7.Effectiveness;8.Client Centredness;9.Sustainability.


Application of the Principles

•The focus is to help participants understand:

– Who is responsible for individual health;

– What should determine the level of basic health care; and

– How health care costs can be contained.

•This requires a clear understanding of the scope of services that need to be delivered in the country.

•The service package/scope in Kenya is defined in the Kenya Essential Package for Health (KEPH).


Restructured KEPH in KHSSIP III 2013-2018

This represents the need for:

• Better integration of all health programmes into a single package that focuses its interventions towards the improvement of health across the life course and emphasises inter-connectedness of the various phases in human development;

• More accurate data and information for target setting, planning and monitoring performance, especially MDGs;


Restructured KEPH in KHSSIP III 2013-2018 (Cont’d)

• Harmonisation and clear definition of

KEPH interventions for each cohort;

• Incorporation of new strategic

imperatives in the Kenya Health

Policy Framework 2012-2030 and

Constitution of Kenya, 2010.


Structure of Health Services

In Kenya, health services are organised based on:

1. Type;

2. Cohorts (Target group );

3. Tiers (Level)


1. Structure of Health Services by Type

The KHSSIP III 2013–2018 defines the

Kenya Essential Package for Health

(KEPH) to comprise the following types

of health services:

• Promotive;

• Preventive;

• Curative; and

• Rehabilitative.2nd edition July 2014 senior management

course for health managers

2. Structure of Health Services by Cohorts (Target)

•KEPH revised cohorts represent the life-cycle approach to health service management.

•Each age group has special needs that relate to the development phase they are passing through.

•Services based on five (5) life cohorts and cross-cutting interventions, encompassing the expectations of persons in Kenya are:


Structure of Health Services by Cohorts (Target) (Cont’d)

– Pregnancy and the new born (up to 28 days);

–Early childhood (29 days – 59 months);

–Late childhood and youth (5 – 19 years);

–Adulthood (20 – 59 years);

–Elderly (60 years and over);

–Cross cutting interventions (all cohorts).

•Specific interventions by cohort and tier are defined in the KHSSIP III.


Structure of Health Services by

Tiers (Levels)

•KEPH services are defined for each of the six (6) cohorts for the newly defined four (4) tiers of the Health System (KHSSP III 2013- 2018):

– Tier 1: Community level;

– Tier 2: Primary care level (Health Centres/Dispensaries);

– Tier 3: County level /Sub county

– Tier 4: National level.2nd edition July 2014 senior management course for health managers

Part I:

Principles Affecting the

Intermediate Health

Outcomes


Principles Affecting Intermediate Outcomes

These are:

1. Access;

2. Coverage;

3. Quality;

4. Safety.


Session 1.2

PRINCIPLE 1: ACCESS


Definition of Access to Health Services

• Is a measure of the ability of a person or

community to receive health care services.

• Defines the capacity, and factors

influencing entry into, or use of the health

care system.

• Implies health care services unrestricted by

geographic, economic, social, cultural,

organisational, or linguistic barriers.

• A prerequisite to high utilisation of health

services.


Definition of Access to Health Services (Cont’d)

• Describes the link between the potential client and the health system.

• The access dimensions are:

1. Availability;

2. Accessibility;

3. Affordability;

4. Adequacy; and

5. Acceptability.2nd edition July 2014 senior management


1. Availability

• Indicates how well the defined health

services meet the needs of the

clients / target population.

• Health care interventions address the

needs of the clients.

• NB. At times, the provided

interventions are not necessarily

related to the needs.2nd edition July 2014 senior management course for health managers

2. Accessibility: Geographical Access

• Implies the location of supply of services is in line with the location of the clients.

• Geographical access is determined by distribution of facilities, public transport, referral systems, sufficient community health services and degree of collaborations with other services providers.

• The WHO recommends an average distance of five (5) kms to reach the nearest health facility.


2. Accessibility: Geographical Access (Cont’d)

• Geographic access is measured by modes of transportation, distance, travel time, and any other physical barriers that could keep the client from receiving care.

• Imbalanced distribution of health facilities is related to numbers and types of facilities and lack of defined norms and standards for infrastructure development.


2. Accessibility: Geographical Access (Cont’d)

Reasons for poor transport services:

• Inadequate ambulances;

• Inadequate budgetary provisions;

• Poor preventive maintenance;

• lack of standard transport guidelines

that are in line with the expected

functions and workload.2nd edition July 2014 senior management


3. Affordability: Financial Access

• Is concerned with how well the price of services fits the clients’ income, and ability to pay.

• Economic barriers to access include user fees, low household income, low prioritisation of health at household level and low allocation of resources by the state to the health sector.

• The Abuja declaration recommends

governments to allocate 15% of

expenditure budget to health.


3. Affordability: Financial Access (Cont’d)

• Health expenditure of at least USD34 per capita is considered fair investment, while a household expenditure on health care above 40% of total disposable income limits financial access.

• Measures to improve availability of affordable services:

– introduction of National Social Health Insurance Fund;

– reviewing the cost sharing strategy;

– community pre-payment schemes and developing a criteria for allocation of public funds.

• Universal access to essential care package can be improved through stronger partnership among governments, pharmaceutical companies, civil society, and consumers.


4. Adequacy

• Concerned with how well the organisation of health care meets the expectations of the clients.

• Service organisations that hinder access include:

– Services available at a time when the clients are not;

– A service placed in a facility located where clients are not

comfortable using.


Application of Principle 1:

ACCESS


Measuring Access

• Concerned with increasing the proportion of those in need of services actually accessing the service.

• The vision of health system is to achieve universal coverage e.g. HIV/AIDS services for vulnerable groups.

• The expected scope of interventions to be provided is defined in the Kenya Essential Package for Health (KEPH).

• A district should have a medium term strategic approach to improve access and coverage.


Measuring Access (Cont’d)

•The strategy is to ensure the full scope of KEPH for its level of care, to the full population within its area of responsibility.

•To define and measure these two elements, monitoring and assessment should be done.


Planning for Improvements in Access, and Coverage at

District/Zone LevelThis is a three-step process that aims to:

1. Define critical problem areas in access to, and coverage of the KEPH;

2. Identify the specific solutions to addressing these; and

3. Prioritise the solutions over the period of the strategic approach for the planning unit.


Step 1: Identifying Critical Problem Areas

•Drawn from the situational description in the planning process.

•Depends on the presence or lack of health facilities, and the scope of services they provide.

•Health activities and care levels for specific population groups defined on the basis of the need for equity and efficiency in carrying out the activities.

•Norms and standards define populations requiring each facility type.

•District map should be drawn based on the needs that identify the catchment areas for the different levels of care.


Step 1: Identifying Critical Problem Areas Illustrated


Step 2: Identifying Solutions

• Norms and standards define the process for a district to identify areas where additional facilities will be needed.

• Catchment areas and the scope of services provided in each of the existing facilities need to be assessed.

• Possible scenarios in the district for improving access, and coverage are based on either of the following:

– the ‘activity’ approach;– the ‘facility’ approach.


Activity 1.2.2.1: Group Work (30 minutes)

Table 3: Categorisations of catchment areas: In groups, participants categorise the catchment areas in their districts, according to the six situations described overleaf. The dummy table provided below can be used. From this assessment, the district information is then summarised in a table similar to the one below.

KEPH

Type of solution Fully

implemented Partially

implemented Not

implemented

Facility Present 1 2 3 ‘Activity’ type

solutions

Absent 4 5 6 ‘Facility’ type

solutions

2nd edition July 2014 senior management


Identification of Critical Problem Areas in a District/ County

Name Location / catchment

area

Sub locations (or villages, if necessary)

Name Health Unit (if existing)

Health Unit Level

Owner-

Ship

KEPH delivery scope by cohort (yes/no)

Situation category (1 – 6)

Name Population 1 2 3 4 5 All


Troubleshooting

• If more than one facility is in a location: catchment areas are sub-divided by sub-location / by village.

• If facility is not a government facility: all facilities should be treated equally – FBO/NGO facility can be responsible for a given catchment area in the district.

• If some cohort services are being provided: only score service delivery as YES if ALL the services are being provided. If any expected service is not being provided, then the area scores a ‘no’.


Step 3: Prioritising Solutions

•Mechanism to prioritise the catchment areas in terms of when to address their solutions is provided.

•A set of criteria for prioritising the areas selected require:

• A specific description of the criterion;

• A score (for instance from 1 to 3-1 being the least favourable and 3 the most favourable condition) is further used to appraise each criterion for each catchment area.



Participants fill, for each catchment area, the criteria and calculate the total

score using the dummy table below.

Copy to TLA UNIT 1.3.3


Step 3: Prioritising Solutions (Cont’d)

Ranking of catchment areas for revitalisation

Catchment area name

Score– (1 – 3) Total score Rank

Population Access to

local funds

Inputs required

Type of solution


Step 3: Prioritising Solutions (Cont’d)

Ranking of catchment areas for establishment of facilities

Catchment area name

Score– (1 – 3) Total score Rank

Population Access to local funds

Inputs required

Access to other facilities

Type of solution


Session 1.2.3

PRINCIPAL 2: COVERAGE


Introduction

• Concerned with improving the range of services and population able to benefit from the services.

• The actual services and their characterisation are defined in the access dimensions.

• Coverage is therefore a measure of level of utilisation of the available health services.

• The major focus of improvement in coverage is on extending the defined package of health services to more populations.

• Adequate coverage is thus attained when there is universal coverage by the service.

• Overall sector coverage monitoring indicators are shown in the table below.


Coverage Sector Monitoring

Indicators Cohort Result Sample index indicators

1

Cohort 1 – Pregnancy and newborn (up to 28 days)

aMothers are kept healthy during pregnancy

% pregnant women attending four ANC visits% pregnant women receiving IPT 2x

bMothers are able to have normal deliveries

% deliveries conducted by skilled health staff in facility% maternal deaths in planning unit audited% WRA receiving FP commodities

c

All newborns (up to 2 weeks) receive protection against immunisable conditions

% neonatal deaths (up to 28 days) in planning unit% HIV + pregnant women receiving PMTCT% pregnant women receiving TT (2 doses)

2 & 3

Cohort 2& 3 – Early ;and late childhood and youth(29 days to 59 months) and (5 – 19 years)

aChildren receive protection against immunisable diseases

% children fully immunised at 1 year of age

% children receiving DPT/HepB/Hib 3

bChildren are able to survive childhood illnesses

% deaths amongst under 5’s in planning unit % under 5s new visits with weight / age above lower line (PR)% children receiving Vitamin A (1-2 doses)

cChildren are protected against exploitation and abuse

% under 5 new visits with height / age above lower line (PR)% Community Units under planning unit providing health promotion services targeting exploitation and abuse of children

dHealthy lifestyle is adopted amongst children

% under 5 attending Growth Monitoring Clinic (New visits)% children de-wormed at least once / year



COVERAGE



Discuss the barriers to access and coverage in relation to KEPH service

delivery in your district/county.

How would you mitigate against these barriers?

Copy to TLA UNIT 1.3.32nd edition July 2014 senior management


Session 1.2.4

PRINCIPLE 3: QUALITY OF CARE AND QUALITY SERVICE DELIVERY


Quality of Care and Service Delivery

•Quality is defined as conforming to the ‘requirements’, ‘fitness for use’ (Juran, 1988).

•The degree of quality is a measure of the extent to which the care provided is expected to achieve the most favorable balance between risks and benefits.

•Based on its characteristics, a service can be categorised into three, namely:


Quality of Care and Service Delivery (Cont’d)

1. Structure: the personnel,

equipment, buildings, record systems, finance, supplies and facilities

2. Process: all aspects of the performance of activities of care; and

3. Outcome: the end results of care/service.

All three categories need to be considered to obtain a balance of quality.


Quality of Care vs Quality of Service Delivery

• Quality of care is often confused with quality of

service delivery.

• Quality of service delivery encompasses:

–the traditional inputs into health services (human resources, medical products, and finances);

–the process elements (i.e. the production process of services), such as the tools necessary for the resources to be effective and efficient (guidelines and instruments to ensure rational performance); and

–the result elements which imply that the service product will be priority determined and regularly measured. 2nd edition July 2014 senior management


Quality of Care vs Quality of Service Delivery (Cont’d)

• The technical quality of service delivery does not

necessarily match with what people may perceive as

‘quality of service delivery’.

• People may demand for injections or lab tests even

when it is ‘technically speaking’ not necessary.

• The responsibility of the service provider is to try to

convince the client of the unnecessary, and possibly

the damaging effects of this demand.

• Measurement of quality of service delivery should

take into consideration all its dimensions, and ensure

it is differentiated from quality of care.2nd edition July 2014 senior management


Elements of Quality of Care

• Refers to the characteristics of the system of health care that enable it to take care of the client, taking into account all their socio-economic and disease dimensions.

• The ‘system’ quality of care refers to health care as it is delivered in a functional ‘system’.

• These system qualities of care are:

1. Relevance and acceptability;

2. Continuity of care;

3. Integration of care;

4. Comprehensive/holistic approach and the involvement of individuals, households and communities.


1. Relevance and Acceptability

To meet this requirement, health care must:

•Take account of the demand for care and respond to the real and priority needs of the population;

•Be responsive to the cultural and social realities of the communities; and

•Take into account user satisfaction elements in the health care delivery equation.


2. Continuity of Care

• This implies that when a person seeks assistance

in a health system for any health problem,

his/her need is taken care of from the start of the

illness or the risk episode until it is resolved.

• This calls for the existence of a functional

referral and counter-referral system to ensure

referral services for a sick person or a person at

risk who needs it.

• This includes the active follow-up of certain

patients at risk because of the critical need to do

so for the patient or for the community at large.2nd edition July 2014 senior management course for health managers

3. Integration of Care

• One health unit with one team in the community takes care of all health problems of this community through curative, rehabilitative, preventive and promotive activities.

• Every contact with individuals, households and communities is used to ensure this set of activities.

• This is different from using ‘every opportunity to do everything’.


4. Comprehensive/Holistic Approach

• The health problems of an individual are taken care of while considering all the dimensions of the individual and her/his environment (i.e. the household, community, and their social, cultural, economic and geographic characteristics).

• The health teams at community-based health units have to know the population in order to consider a permanent interaction and dialogue with individuals, households and community at large. 2nd edition July 2014 senior management


Involvement of Individuals, Households and Communities

• Creates a sense of ownership of all that the people have undertaken relating to their health.

• This involvement includes:

- individual participation in the health activities of the health unit; and

- collective participation through management of the health facilities.



QUALITY OF CARE


Activity 1.2.4.1 (45 minutes)

Discuss what constitutes quality of care in your facility and how it is applied.COPY TO TLA UNIT 1.3.3


Assessment of Quality and Quality Control

• Involves assessment of the difference

between expected and actual performance

to identify opportunities for improvement.

• The quality of health services depends on

the effectiveness of service processes.


Tools/Methodology of Measuring Quality

These include:

– Checklists e.g. the KQM master

checklist and supervision checklists;

– Client exit survey tools and suggestion

boxes.

•These aim to measure the level of quality of

current practice against a given standard

from the technical perspective and the client

perspective.


Role of Committees in Quality Assurance

Roles of various committees include:

• Assuring quality of health care delivery;

• Ensuring that finances available are utilised in the most cost effective way and that supplies meet standards required for delivery of care;

• The HMT has the overall supervisory role of assuring quality of care.


Roles of Regulatory Bodies in Assuring Quality

• The regulatory bodies include:

–The Medical Practitioners and Dentists Board;

–The Nursing Council of Kenya;

–The Clinical Officers Council;

–The Pharmacy and Poisons Board;

–The Radiation Protection Board

–Kenya Medical Laboratory Technicians & Technologists Board, etc.

• They are involved in:

assuring quality of personnel, supplies and equipment; and

providing the legal framework for implementing and enforcing quality.


Clients Perspective of Quality

• Client satisfaction surveys assess the extent

to which services are of the level of quality

that the client expects.

• Recommendations from these surveys are

then utilised to address the issues of quality

of care.

• The surveys target populations using, or

potentially using health services.


Role Quantitative Research Methods in Assuring Quality

• Three methods of collecting data:

– Observation visits;

– exit interviews; and

– face to face interviews.

• Quantitative research allows for gathering

of information that is scientifically

representative of the entire population

under assessment.2nd edition July 2014 senior management course for health managers

Systems Perspective of Quality

•A technical assessment by the health system.

•Different variables affecting quality of care are reviewed in an objective, or subjective manner by the immediate supervising level.

•Tools applied in the supervision process are from 3 sources:

–HMIS unit;

–Kenya Health Quality Assurance Model;

–Hospital reform supervision tools.2nd edition July 2014 senior management


PRINCIPLE 4: PATIENT SAFETY


Definition of Safety of Health Services

• Safety is a principle that aims to ensure the care

provided does not become a cause of ill health.

• The WHO estimates that health care errors affect

one in ten patients worldwide.

• Patient safety aims to limit or eliminate

preventable adverse effects of care, whether or

not these are evident or harmful to the patient.


Areas Affecting Patient Safety

• There are three factors that can adversely

affect patient safety:

1. Human errors;

2. Medical complexities; and

3. System failures.

• Measures aimed at adequate patient

safety need to address these three (3)

areas. 2nd edition July 2014 senior management course for health managers

1. Human Factors

• They are attributed to ‘human error’ during the provision of health services.

• They are due to:

–Variations in healthcare provider training and experience, fatigue, and burnout;

–Diverse patients, unfamiliar settings, time pressures;

–Failure to acknowledge the prevalence and seriousness of medical errors.


2. Medical Complexities

• These are attributed to a mismatch between the care providers, and the technology available.

• The technology being used may not be appropriate for the services being provided.

• They include:

– complicated technologies;

– powerful drugs;

– intensive care;

– prolonged hospital stay.2nd edition July 2014 senior management course for health managers

3. System Failures

• They are due to overall mismatching of investments in the system that leads to compromised patient safety.

• They include:– Poor communication or unclear lines of

authority amongst the care providers; – Increased patient to health worker staffing

ratios;– Disconnected and weak reporting and

accountability systems - fragmented systems in which numerous handing-off of patients results in lack of coordination and errors;


3. System Failures (Cont’d)

• Drug names that look alike or sound alike;

• Poorly designed cost-cutting measures;

• Environment and design factors; for example, in emergency situations, care may be rendered in areas poorly suited for safe monitoring; and

• Infrastructure failures.


Measuring Safety

•The science of measurement of patient safety is still in its infancy.

•The main focus is around hospital based services, where clients with hospital acquired ill health are followed up.

•In the public health field, cases of adverse effects following immunisation are followed up .

•Measurement of patient safety should cover the three areas affecting patient safety outlined above.2nd edition July 2014 senior management



PATIENT SAFETY


Introduction

Addresses the principle of:

• safety of health services;

• Safety of patients; and

• input safety and solutions


Patient Safety Solution

Patient safety solution is any system designed or intervention that has demonstrated the ability to prevent or mitigate harm to patient arising from the processes of health care delivery.


Areas of Patient Safety Solution

•Look alike-sound alike (LASA) medication names.

•Patient identification.

•Communication during patient hand-overs.

•Performance of correct procedure at correct body site.

•Control of concentrated electrolyte solutions.

•Assuring medication accuracy at transitions in care.

•Avoiding catheter and tubing mis-connections.

•Single use of injection devices.

•Improved hand hygiene to prevent health care - associated infection. 2nd edition July 2014 senior management


Activity 1.2.5.1: (30 minutes)

Propose actions that the County HMT’s medicines and therapeutics sub-

committee will follow up on the relevant patient safety issues outlined above in

your district.

Use the template in the table below for compiling this. This will serve as the work plan for the therapeutics committee with

regards to patient safety issues.

Copy to TLA unit 1.3.32nd edition July 2014 senior management course for health managers

Recommendations on Patient Safety

Patient safety solution Relevant actions (from above) Activities of Therapeutics Committee for follow up

Look-alike, sound-alike (LASA) medication namesPatient identification

Communication during patient handoversPerformance of correct procedure at correct body siteControl of concentrated electrolyte solutionsAssuring medication accuracy at transitions in careAvoiding catheter and tubing misconnectionsSingle use of injection devices

Improved hand hygiene to prevent health care associated infection


Part II:

Principles Affecting the Final Health

Outcomes


Principles Affecting the Final Health Outcomes

These are:

5.Equity

6.Efficiency

7.Effectiveness

8.Client centeredness

9.Sustainability


Session 1.2.6

PRINCIPLE 5: EQUITY


Equity in Health Care: Definition

• Refers to the absence of systematic disparities in health (or in the major social determinants of health) between social groups who have different levels of underlying social advantage/ disadvantage - i.e., different positions in a social hierarchy.

• Inequities in health systematically put groups of people who are already socially disadvantaged at further disadvantage with respect to their health.


Equity in Health Care: Definition (Cont’d)

• Implies a fair opportunity to all to attain their full health potential, and that:

– no one should be disadvantaged from achieving this potential.’

• Concerned with creating equal opportunities for health down to the lowest level possible without bringing health differentials.


Dimensions of Equity

The dimensions of equity are in two different forms:

1. The way investments are made to ensure equity: –equal utilisation for equal need, for equal quality of care for all, or equitable end state distributions;

2. The end state distribution being sought by equity: –allocate the same amount of resources to people in similar situations (horizontal equity), but–different amounts of resources to people in different situations, according to their difference in need (vertical equity).


How Equity is Determined

• There is no single agreed method for distributing a health care good.

• Health care “goods” are different e.g.:

– health insurance;

– health care services;

– health outcomes.

• The nature of a good affects its equitable distribution:

– the physical nature of the good;

– the degree to which a good has customised vs. generalised value across members of the community;

– prevailing cultural beliefs about the good and its appropriate means of distribution.2nd edition July 2014 senior management


What Affects Equity?

Analysis of equity focuses on three basic critical issues:

1. Identifying the appropriate policy focus;

2. Defining characteristics of potential recipients.

3. Defining the goods to be distributed and their characteristics.


Identifying Appropriate Policy Focus

•Policy focus on equity is concerned with:– how to allocate (i.e., equitable processes); and– the acceptability of the resulting allocations (i.e.,

equitable end-states). •Equity objectives can be defined in terms of fair processes, fair end-states, or both.•Two policy focuses for ensuring fair resource allocation include:

– focus on developing fair processes for distributing goods; and

– focus on specifying fair end-states in the final distribution of goods.

•Health policy analysts can be concerned with either or both issues. 2nd edition July 2014 senior management


Characteristics of Potential Recipients that might Justify their Claims to Particular Health Goods

•Recipients may be grouped either as individuals, populations or groups.

•Need is the discriminating characteristic most frequently used to define equitable distribution of health care:

–often understood in terms of an individual's or population's ability to benefit from health care;

–as the needs can be enormous, policy makers allocating limited resources must decide whose needs will be met, and whose will not.


Characteristics of Potential Recipients that might Justify their Claims to Particular Health Goods

(Cont’d)•A need may be conceived differently depending on the “good” to be distributed. If the “good” is:

– financial subsidisation of services, then neediness may be defined in part by degree of poverty;

– fair distribution of health services, then the population will be divided by degree of health care need, but such information is seldom directly available.

•Analyses of equity commonly compare distributions of goods between wealthy vs. poor, old vs. young, one ethnic group vs. another, urban vs. rural, etc.



EQUITY


Importance and Determinants

• Equity ensures that all inhabitants of a

given region/area not only have equal

access to health services, but also use

them equally for equal need.

• Important determinants are

geographical, demographic (age and

gender), socio-cultural features, and

economic.


Assessment of Equity

•To ensure an adequate health stock, analysis and planning of interventions is done at 3 levels of care.

•The first level is the direct causes of ill health and/or death:

-These are the actual disease conditions that impact on the health of the individual.

•The second level relates to underlying factors that exist to allow the direct causes to express themselves.

–They are individual, household, or community based factors.2nd edition July 2014 senior management


Assessment of Equity (Cont’d)

•The third level relates to the basic, socio-cultural issues that influence the uptake and use of services targeting the direct or underlying causes:

-These factors relate to poverty and underdevelopment.

•Other dimensions include powerlessness, exclusion, lack of opportunity, discrimination, marginalisation, deprivation of basic services and infrastructure.

•Distal factors include social conflict, especially wars and political instability.


Determinants of Level and Distribution of Health

SOCIO-CULTURALISSUES

PovertyLiteracy

UrbanisationSecurityExclusionPowerless

UNDERLYING FACTORS

Health ServicesNutritionPersonal Factors

Safe waterSanitation

DIRECT CAUSES OF MORBIDITY/MORTALITY

Communicable conditionsNon-communicable conditions

Injuries / violence

HEALTH STOCKLevel of

distribution

Primarily influence level

of health

Primarily influence

distribution of health


Conceptual Framework

• Equity planning and assessment is based on reviewing the impact the different social determinants are having on the service coverage attained.

• For different coverage indicators, assessment is done comparing achievement of districts distinguished by different social determinants:

–Level of education - analysis of literacy level differences;


Conceptual Framework (Cont’d)

Social determinants cont’d:

–Level of empowerment of vulnerable groups - analysis of gender development index differences;

–Physical access to services - analysis of urban/non urban differences, and the arid/non arid disaggregation (access is generally low in the more arid areas of the country);

–Level of poverty (in all its dimensions) - analysis of level of Human Poverty Index.



In your county or planning unit, review information on different equity variables, highlighting the variables most likely to affect achievement of health outcomes.

Copy to TLA Unit 1.3.3


Session 1.2.7(a)

PRINCIPLE 6: EFFICIENCY


Introduction

• Efficiency ensures that the least amount is spent to generate

the desired health outputs or that maximum amount of

health outputs is generated with available funds.

• It ensures that the health system is producing health services

in the quantities and qualities that society wants (allocative

efficiency), and that it produces them at the lowest cost

possible (technical efficiency).


Introduction (Cont’d)

Efficiency is therefore a measure of:

•Whether what we are spending money on is correct (allocative efficiency);

•Whether we are producing it correctly (technical efficiency).


Application of Allocative Efficiency

•Public Expenditure Review process:₋Annual assessment of planned, and actual expenditures;₋Assumes planned expenditures were allocatively correct, and so ensures actual expenditures were as planned.

•Annual Work Plan reviews(AWP):₋Assessment of expenditures across key building block areas in the sector; ₋AWP analysis compares investments, across these building blocks.


Application of Technical Efficiency

• Efficiency is measured against different decision making units (DMUs).

• DMUs represent a unit of management that has some level of authority and/or capacity to affect efficiency levels.

• There are two methods of assessing technical efficiency:1. Ration Analysis;2. Frontier Analysis.


1. Ratio Analysis

• Involves piecemeal analysis of key measures of performance, e.g.:

–Average cost per inpatient day;

–Bed occupancy rate;

–Average length of stay (ALOS) per inpatient admission.

• Currently applied in AWP reviews, to compare efficiency of different DMUs.


1. Ratio Analysis (Cont’d).

• Comparison of DMUs is done graphically using the following:₋ Average Length of Stay (ALOS);₋ Bed Occupancy Rate (BOR); ₋ Bed Turnover Ratio (BTR).

• DMUs’ values for BOR and BTR ratios are plotted on a graph, with one on x axis, and the other y axis.

• Once all hospital values are mapped, 4 quadrants/zones are described, with the 50% value on each axis as the cut off point.


DMU Mapping and Interpretation of Ratio Analysis using BTR and BOR

Zone II (high BTR, low OCC) Excess bed capacityUnnecessary hospitalisationMany patients admitted for observationPredominance of normal deliveries

Zone III (high BTR, high OCC) Good quantitative performanceSmall proportion of unused beds

Zone I (low BTR, low OCC) Excess bed supplyLess need for hospitalisationLow demand/utilisation

Zone IV (low BTR, high OCC) Large proportion of severe casesPredominance of chronic casesUnnecessarily long stays

Bed

tu

rnover

(pati

en

ts/b

ed

)

Occupancy rate (%)


Interpretation Based on Ratio Analysis

• Method is easy and based on a single input and single output situation.

• Outputs are interpreted according to the zone in which the DMUs lie.

• Planning units (hospitals) in zone III are the most efficient hospitals:

– Highest BTR, and high occupancy.• DMUs in zone I, II and IV are inefficient according to

this method.


Possible Reasons for Inefficiencies

Causes of inefficiencies Possible reasons for inefficiencies

Failing to minimise the physical inputs used • Excessive hospital length of stay• Poor scheduling of diagnostics and procedures• Prescribing interventions or diagnostic tests of no therapeutic value or

relevance• Over-prescription of drugs• Wastage of stocks• Over-staffing

Failing to use the cheapest possible combination • Inappropriate use of more expensive staff relative to less expensive staff

• Use of branded drugs when generics are available.• Failure to secure lowest cost supply• Using paramedic-staffed emergency ambulances to transport patients

home from hospital

Operating at the wrong point on the short-run average cost curve

• Implementing budget cuts that protect salaries at the expense of other expenditure items

• Not filling vacant posts• Limited local demand (e.g. demand for hospitalization)• Inadequate drug supply

Operating at the wrong point on the long-run average cost curve

• Planning to provide full pathology laboratory facilities at every hospital when lab services usually demonstrate economies of scale and should therefore be concentrated centrally

• Planning to build a 1,500-bed teaching hospital when diseconomies of scale are know to operate in hospitals over 600 beds.


Key Weakness of Ratio Analysis Approach

• Simplifies performance to a few ratios; performance in health is a function of many more variables.

• Method cannot provide decisive evidence of the level of efficiency at which a given hospital is operating.

• Some hospitals may appear inefficient due to patient characteristics, e.g. psychiatric hospitals will have low turnover, and high occupancy due to nature of their patients, not inefficiencies.


2. Frontier Analysis

•A statistical approach based on mathematical programming.

•Addresses weaknesses of the ratio analysis.

•Applied in determining overall sector performance.

•Allows use of multiple inputs and multiple outputs to be analysed to generate a similar scenario.

•Information on a series of inputs, and outputs is used to generate an expected level of efficiency (efficiency frontier) for DMUs being assessed.


2. Frontier Analysis (Cont’d)

•Each DMU is compared against this frontier.

•Frontier is the “production function” – a mapping of different levels of inputs for which outputs are efficient.

•Assuming we determine efficiency in use of two inputs (No. of nurses and number of facility beds) compared against a single measure of output.

•A number of DMUs with a similar achievement of the output, but employing different sets of the two inputs are used.


2. Frontier Analysis (Cont’d)

•The different facilities are plotted on a graph as shown in the figure. •Facilities A, E, G, and H are all efficient (least inputs of either nurses, or beds), and so form the frontier of efficiency. •Other facilities are compared against the resulting frontier.•DMUs e.g. “C” are deemed inefficient.•Measure of inefficiency is based on distance from the frontier.


Illustration: Generation of an efficiency ‘frontier’ for 2 inputs – nurses & beds


Advantages of Frontier Analysis

• Allows use of many inputs, and outputs – which

is more realistic in the health sector.

• Programme generates analysis; only input from

you is to enter the data.

• Allows many efficiency targets to be sought

(different combinations of nurses and beds are

efficient, as long as they lie along the frontier).


Activity 1.2.7.1- 45 minutes

•Using the information in the table (Technical Learning Aid), carry out a ratio analysis to determine the efficiency of the different

hospitals.

•Present the outputs in a table, showing which hospitals are in zone I, zone II, zone III and

zone IV of the efficiency scoring.

•Provide solutions for focus, for each group of hospitals.

•Note: A table showing a list of hospitals is provided separately

(Copy to TLA)2nd edition July 2014 senior management course for health managers

Session 1.2.7(b)

PRINCIPLE 7: EFFECTIVENESS


Introduction

• Measures how well an intervention restores the individual to

as near his prior healthy state as possible.

• Measured by comparing the situation before, and after the

intervention.

• Actual outcome of the interventions (health state) usually

difficult to ascertain, so intermediate outcomes are usually

used;

–such as, malaria cases averted, TB treatment

completion rates, children vaccinated, etc.


Measuring Effectiveness using the Health Index

• Set of different effectiveness indicators to know impact on a given sector result / goal:– Designed based on KEPH results;– 30 indicators used across the different cohorts

and result areas;– Fixed number of indicators per cohort, and result

area;– Each indicator contributes same weight to overall

index, to limit ‘fixing’ of the index (focus on high-weighted indicators);


Measuring Effectiveness using the Health Index (Cont’d)

₋No information captured as zero value for the indicator;₋All indicators converted to percentage, with values from zero to 100%;₋All indicators interpreted similarly, with 0% being poor performance, and 100% good; ₋Indicators where less achievement is desired, such as mortality indicators, are reversed.


Measuring Effectiveness using the Health Index (Cont’d)

•The index value is the average value derived, from the data.•Expected comparisons include:

₋Overall effectiveness of services at different points in time;₋Effectiveness of services in different cohorts of care;₋Effectiveness of services by Medical Services and Public Health and Sanitation;₋Different levels of care (counties, districts) against each other;₋Different ownership of services (government, FBO/NGO, private services).


Activity 1.2.7.2: 45 minutes

•Using the information in the table, carry out an assessment of the effectiveness in health care delivery in different districts.

•Which district is deemed most effective overall, and for each cohort of services?

•For each district, where should their efforts be made to improve effectiveness?

•Copy to TLA unit 1.3.3


Session 1.2.8

PRINCIPLE 8: CLIENT CENTREDNESS

(RIGHTS-BASED APPROACH & ETHICS)


Human Rights-Based Approach

• Human rights are indivisible, universal and interdependent.

• Claim-holders have a right and are entitled to claim that right from those that have the duty to implement it (duty-bearers).

• Human rights imply corresponding duties and obligations. – Implies that the claim-holders should hold

the duty- bearers accountable for the realisation of the right – in this case, access to health care.


Human Rights-Based Approach (Cont’d)

Important international human rights instruments with implication on health include:

•The Convention on the Rights of the Child (CRC);

•The Convention on the Elimination of All Forms of Discrimination against Women (CEDAW);

•The Programme of Action of the International Conference on Population and Development; and

•The International Covenant on Economic, Social and Cultural Rights (ICESCR).



• Ministries of health and their staff working at all

levels need to be well prepared in the adoption

and implementation of the human rights

approach to health services delivery.

• The Legislative and institutional frameworks

should be geared towards safeguarding and

promoting rights to health care.



•Human resources and other resources and policies

should aim to ensure that “every health facility and

its staff are committed to providing high quality

health care services to all patients or clients with

dignity, professionalism and within the shortest

time possible”.


Ethics in Health

• Ethics- based approach aims to apply moral values and judgments as they relate to health care.

• These are monitored and managed through the various councils.

• Seeks to ensure that the aim of health care is “to do good to others, and have them, and society, benefit from this”, and not “to do good, and benefit from it".

It is based on values of:

1. Autonomy;

2. Beneficence (doing good);

3. Non-Malefficence (doing no harm);

4. Double effect.2nd edition July 2014 senior management


1. Autonomy

•During a patient’s illness, the level of autonomy is

an indicator of both personal well-being, and the

well-being of the professional.

•Ethics tries to find a beneficial balance between the

activities of the individual and its effects on a

collective.

•By considering autonomy as a parameter for

assessing (self) health care, the medical and ethical

perspective both benefit from the implied reference

to health.2nd edition July 2014 senior management


2. Beneficence (doing good):

•Healing should be the sole purpose of medicine;

any actions beyond this are not considered part of

the process of care.


3. Non-Maleficence (doing no harm)

•Implies maintenance of patient safety even when providing treatments that carry some risk of harm.

•In desperate situations where the outcome without treatment will be grave, risky treatments that stand a high chance of harming the patient will be justified, as the risk of not treating is also very likely to do harm.

•So, the principle of non-maleficence is not absolute; it must be balanced against the principle of beneficence (doing well).

•"Non-maleficence" is also defined by its cultural context, as each has its own cultural collective definitions of 'good' and 'evil'.


4. Double Effect

• Some interventions can create a positive

outcome while foreseeable, but unintentionally,

doing harm.

• The combination of these two circumstances is

known as the "double effect".

• An example is the use of morphine in the dying

patient, which eases pain, while ‘arguably’

suppressing the respiratory drive, potentially

accelerating death.2nd edition July 2014 senior management



CLIENT CENTREDNESS (RIGHTS-BASED APPROACH & ETHICS)


Application of Rights-Based Approach

• This approach implies fairness in the way we distribute and use available health resources.

• Equity is a rights based principle as it ensures that health resources are shared fairly.

• Equity is looked at in all its dimensions, including geographical, gender, age, vulnerability and others.

• The supply-side measures should be complemented by strengthening the demand-side of the provision of care.


Application of Rights-Based Approach (Cont’d)

Steps to promote rights based approach:

•Standards, protocols and guidelines need to be developed and used to:

₋Strengthen patients’ rights;

₋Revitalise and strengthen the relationships between the Ministries of Health and the various professional bodies to ensure ethical practice.


Application of Rights-Based Approach (Cont’d)

Steps to ensure protection of clients rights:

•Annual review of citizens health charter;

•Posting treatment fees and exemption schemes in clear view in all health facilities;

•Ensuring that proper complaints procedures are in place and known to the public.


Application of Ethics Approach to Service Delivery

•Health managers must model and promote an understanding of ethical and legal issues relating to the use of technology.

•New protocols and safeguards to ensure their appropriate and effective use are required.

•There is need to adapt to changes relating to intellectual property rights, fair use, and acceptable use of digital materials and technology.



Brainstorm in Plenary:

•Which steps have been taken in your facility to improve protection and

promotion of clients’ rights?•Is patients’ charter clearly displayed and

attention of clients drawn to it?•Share experiences with the application

and use of the patients’ charter.•Copy TLA unit 1.3.3


Session 1.2.9

PRINCIPLE 9: SUSTAINABILITY


Introduction

• The system or service can be maintained

at a steady state without exhausting the

resources available to support it.

• Involves concepts such as long-term cost-

effectiveness, maintenance of quality,

equity of resource allocation and so on.


Introduction (Cont’d)

Sustainability requires designing and implementing a model of health financing that is affordable, ensures cost containment, special consideration for special groups, focusing on:

•local responsibility and viability (sustainability of systems);

•the generation and/or preservation of demand for health services; and

•the willingness to practice healthy behaviors (sustainability of demand).2nd edition July 2014 senior management


Systems Sustainability Components

Has three components:

1.Financial Sustainability: having enough reliable

funding to maintain planned health services. Looks

at resource mobilisation and efficient allocation and

use of resources;

2.Institutional Capacity: presence of systems likely

to be used irrespective of staffing challenges.

Systems are for planning and management, human

resources, information, and logistics;

3.Enabling Environment: environment needed to

sustain the achievements. Looks at policy and

planning process, coordination and partnership, as

well as community empowerment.


Financial Sustainability

•Requires affordable levels of financial contributions from all partners to support a comprehensive financing and delivery system. This includes:

–Issues of cost, choice and quality for individual, home and community care and support, as well as more aggregated models of delivery;

–Consider new financing solutions while maintaining protections for people with very low incomes;

–Requires cost containment, taking into consideration ethics governing each situation


Financial Sustainability (Cont’d)

• Provider incentives should be aligned so that all stakeholders are pulling together towards affordable, sustainable, quality health care for all people.

• Realignment should ensure that health care providers and payers are not encouraged to provide certain types of care primarily because of the financial reimbursements or consequences associated with that care.

– Emphasis on prevention, early intervention and chronic disease management will be cost-effective in the long term.

• Individual incentives should be aligned to encourage positive participation in their health management.



SUSTAINABILITY


Indicators to Measure System Sustainability

Sustainability area

Variables Indicators

Financial sustainability

Resource mobilisation

% total health expenditure financed by donors% total health expenditure financed from private sources% facility budget programmed / managed at facility

Efficient allocation of resources

% budget allocated for preventive servicesPersonnel expenditure compared to expenditure of commodities / suppliesOperations expenditure as % of total recurrent expenditure

Enabling environment

Policy and planning

Presence of a clear policy and strategy development system and processPresence of specific strategies and programme goals to actualise the strategic approach (detailed investment plan for programme areas)

Coordination and partnership

Existence of a functional coordination mechanism that includes all the health actors

Community involvement

Existence of functional community units that are working through the facilityPresence of health sector representation (CHWs/facility HWs) in community discussion forums



Sustainability area


Institutional capacity

Programme management

Presence of a comprehensive strategic / investment plan

Presence and use of a clear system for preparing yearly operational plans

Presence of a functional mechanism for incorporating needs of clients into activities of the institution

Presence of a manager whose job description includes responsibility for assessing clients. needs and desires, for developing the strategic and operational plan, for revising the plan, and for assessing the operational feasibility of the plan

Human resources

Presence of detailed, accurate, up-to-date job descriptions

Presence of a system for regular staff performance assessmentPresence of a system for the regular assessment of staff training needsPresence of a manager whose job description includes reviewing and revising job descriptions, personnel rules and regulations, and assessing job performance, training needs, and training outcomes



Sustainability area


Institutional capacity

Information systems

Analysed income/revenue data and cash flow analysis for specific service cost categories that is discussed in top managementPresence of a manager whose job description includes reviewing financial data, analysing unit costs, making financial projections and tracking expenditures against budgetsUse of information on clients and services in regular (monthly) management meetings and decisionsPresence of a manager whose job description includes managing the programmatic information system and using information on clients and services for management and policy purposes

Logistics systems

Periodic (quarterly) review of logistical needs and resources of the institution (vehicles, computers, etc.)Presence of a system for tracking commodities and forecasting needs, including a periodic inventory and regular reporting of receipt and distribution of commoditiesPresence of a manager whose job description includes periodic review of resource needs and tracking of commodities


Demand Sustainability

• Focuses on sustaining a sufficient level of demand to maintain uptake of health services and outcomes at acceptable levels.

• Measuring sustainability of demand should focus on how well demand is sustained as local resources replace donor support.

• Has two main components i.e. ability to pay and attitude.

• Specific indicators to show extent of demand sustainability are shown in the table overleaf.


Demand Indicators to Measure Demand Sustainability

Sustainability area

Variables Indicator

Ability to pay Protection mechanisms

Use of exemptions, waivers, and other protection mechanisms (cross-subsidies, government equalisation grants, etc.)

Attitude Community support

Percent of communities having functional local health committees that hold regular meetings

Behaviour change communication

Existence of a long-term behaviour change communication (BCC) strategy for perpetuating demand for health and family planning services

Willingness to pay

% of adult patients utilising exemptions and waivers



•Assess your county or institution against the indicators of demand sustainability that are applicable to you.

•Discuss emerging trends and agree on possible actions to improve sustainability in your institution / county.

•Copy to TLA unit 1.3.3


END


A Senior Management Course for Health Managers in Kenya Unit 1.3: Key Principles of Health Care...

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