Faculty of Medicine

Public Health (31505291) الصحة العامة Lecture 17

Health policy and management, Health priorities

By

Hatim Jaber MD MPH JBCM PhD

16 - 7-2017

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1. The global health impact of mental health and mental diseases. Drug abuse and Addictive substances

1. Global overview of communicable diseases 2. Global overview Non- Communicable Diseases(NCDs) 3. The global health impact of Hepatitis, Tuberculosis and HIV/AIDS 4. The global health impact of Cardiovascular Diseases , Diabetes and

Obesity

1. Health policy and management, Health priorities 2. Health policies and management within a global

health perspective 3. Healthcare service delivery in developed and developing countries 4. Healthcare systems and financing 5. Quality of care and effectiveness in different health services systems 1. Violence and Injuries 2. Migration and Travelers' health

Presentation outline

Time

Introduction of concepts :General Concepts in Management Sciences

08:00 to 08:10

Health Systems and Policies Introduction to Health Systems

08:10 to 08:20

Health Systems and Policies Introduction to Health policies

08: 20 to 08:30

Making Public Health Policies 08:30 to 08:40

Health priorities 08:40 to 09:00

09:00 to 09:15

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Definition of Administration

• We can define sound administration as:

“ The process of achieving defined goals at a defined time through the guidance, leadership, and control of the efforts of a group of individuals and the efficient utilization of non-human resources bearing in mind adequacy, speed, and economy to the utmost possible level.”

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Health Administration

Sound administration is essential for the success of any public health program whether on the national, intermediate or the local level.

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Elements of Administration:

• Planning

• Organization

• Staffing

• Directing

• Coordinating

• Reporting

• Budgeting

• Supervising

• Evaluation

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Levels of Administration

Central level

Intermediate level

Local Level

Ministry of health

directorates of health

e.g. health office, Hospital, health care unit

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Management

• Management is the operational part of administration.

• It is defined as:

“ It is a set of interactive processes through which the utilization of resources results in the accomplishment of organization objectives.”

It is through “management” that the objectives of the health care organization are achieved by gathering and positioning of resources.

• It is a “conversion mechanism”.

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Definitions and concepts

MANAGEMENT is both a SCIENCE and ART

• As a SCIENCE, management has basic rules and principles.

• As an ART, successful managers learn through experience, they follow flexible, adaptive, innovative approaches to fulfill objectives.

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Definitions

Management is getting things effectively done to achieve desired objectives through proper planning, efficient implementation and evaluation to identify the needs for re-planning.

Management is thus a dynamic process.

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• Effectiveness is the degree to which a stated objective is being achieved.

• Efficiency is the optimized (balanced) use of resources (Human resources, equipment, supplies, money, space, time & information).

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Definitions

Management is a decision making process

translating the policies into plans, implementing those plans,

and evaluate the plans and the interventions to re-plan to achieve better results

Good Management

• Highlights priorities

• Adapts services to needs and to changing situations (dynamic)

• Makes most of limited resources

• Improves the standard and quality of services

• Maintains high staff morale

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PRINCIPLES OF MANAGEMENT

1. Management by objectives: Setting targets

(goals and objectives)

2. Learning from experience

3. Teamwork

4. Proper use of resources

5. Putting priorities

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Management Process

I. Planning

II. Implementation: – Organizing

– Staffing

– Leading/Directing

– Controlling /Monitoring

III. Evaluation

A systems view of management

Process

Inputs Outputs

Human resources

Non-human resources

Conversion mechanism

Objectives achievement

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Management Skills

Technical skills

Human skills

Conceptual skills

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Political skills

Technical skills Mainly firs level

Human / interpersonal skills

All levels

Conceptual skills Mainly top level

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Health Care Management

1. A Health Care System and its components (Macro level)

2. Levels of Health care, and the main approaches to health

care provision, in addition to Resources, and Financing.

3. Introduction to Management in health care organizations

(Micro level ).

4. The Four Functions of Management: Planning, Organizing,

Leading and Controlling.

Health Policy Defined

• Health policies are public policies or authoritative decisions that pertain to health or influence the pursuit of health

• Health policies affect or influence groups or classes of individuals or organizations

Public vs. Private Policymaking

• Public Policy

– Policy that is established by the federal, state, and local levels of government

• Private Policy

– Policy that is established by private organizations

• For example, MCOs and JCAHO

Forms of Health Policies

• There are five main forms of health policies

– Laws

– Rules/Regulations

– Operational Decisions

– Judicial Decisions

– Macro Policies

Macro Policies

• Macro policies are broad and expansive and help shape a society’s pursuit of health in fundamental ways

• Example

– FDA regulation of pharmaceuticals

•Public health policies are grouped into two categories 1-Allocative 2-Regulatory

1-Allocative Policies • Designed to provide net benefits to some

distinct group of class of individuals or organizations, at the expense of others(?), in order to ensure that public objectives are met

• In general, allocative policies come in the form of subsidies

• Examples – Medicare and Medicaid policies, Federal aid to

medical schools

• 2-Regulatory Policies

• Policies designed to influence the actions, behaviors, and decisions of others to ensure that public objectives are met

• Five main categories of regulatory policies – Social regulations :Environmental protection, Childhood immunization

requirements, No smoking – Quality controls on the provision of health services: FDA regulation of

pharmaceuticals, New Pay for Performance (P4P) regulations

– Market-entry decisions: Certificate of Need programs Physician credentialing (Hospital privileges)

– Rate or price-setting controls on health service providers :The federal government’s control of the rates of reimbursement to hospitals that participate in the Medicare program

– Market-preserving controls: Antitrust legislation

•Public health policies are grouped into two categories 1-Allocative 2-Regulatory

WHO Support

• an increase in effective services to all people in need, including service delivery management and support

• improved patient safety, efficacy of services and financial protection

• increased efficiency and building of financial, human, institutional, and knowledge capacities

• coordinated, participatory and accountable policy formulation and implementation.

Where is the problem?

• Problems with health systems are not confined to poor countries.

• Some rich countries have large populations without access to care because of inequitable arrangements for social protection.

• Others are struggling with escalating costs because of inefficient use of resources.

Planning cycle 1- Analysis of health

situation. Involve collection ,assessment and interpretation

of information to provide a clear picture of health situation eg. population structure , mortality , morbidity ,

Epidemiological and geographical distribution ,medical care facilities , hospital or PHC and man

power to defined the problem

2- Establishment of objectives and goals.

Objective must be established at all level .

3- Assessment of resources.

Man power , money , material , skills ,

knowledge.

4- Fixing priorities.

Once the problem, resources and objectives have been determined, the second most important step in planning is establishment of priorities according to many factors for example :

magnitude , resources, cost, time needed, mortality , morbidity, political and community interests and pressures .

5- Write up of formulated plan.

preparation of the detailed plan or plans . For each proposed health progamme , the resources (input)

required are related to the results (output) expected.

6-Programming and implementation.

Once the health plan has been selected and a proved programming and implementation are begun

7- Monitoring

· Monitoring refers to the assessment of the day to day functioning of the

program

· Any suggestions for improvement should be implemented

8- Evaluation

· Evaluation refers to the assessment of the final outcome of the plan

· A good plan should have an in built evaluation system

Prioritization in Healthcare

• Priority-setting is the act of deciding which health interventions to carry out, and can occur at several levels of granularity.

What is Priority Setting?

Process of assigning rank orders

• Individual disease or health states and

interventions or approaches

• To mitigate specific health situations,

• Based on their relative contribution to quality

of life, and cost effectiveness of interventions.

• Complex calculations are complex and Often

fraught with controversies

Priority Setting — Concepts

• Precedence, established by order of

importance or urgency.

• Establishment of the order of precedence

• Rationing and Resource Allocation

• Rationing - Taking care of existing demands

when the supply of resources constrained

• Resource allocation — Limited resources

(time, money) invested systematically

Priority-setting can occur at the following levels

1. health budget level (i.e. deciding how much to spend on health overall)

2. overall strategy level (i.e. selective primary healthcare versus primary healthcare versus more general health systems strengthening)

3. disease level (i.e. deciding which disease to alleviate)

4. intervention level within each disease (i.e. restricting to a specific disease and prioritizing among interventions for that disease)

5. drug level 6. research level (i.e. which health research to carry

out)

• In global health, priority-setting is a term used for the process and strategy of deciding which health interventions to carry out.

Priority-setting can be conducted at:

• the disease level (i.e. deciding which disease to alleviate),

• the overall strategy level (i.e. selective primary healthcare versus primary healthcare versus more general health systems strengthening),

• research level (i.e. which health research to carry out

How to compare interventions

Various metrics have been used to compare interventions. These include:

1. Disability-adjusted life year per unit cost (used by e.g. Disease Control Priorities Project),

2. quality-adjusted life year, and other forms of cost-effectiveness analysis

3. Reasons that the disease burden has persisted

4. Adequacy of funding

Who sets the priorities?

Priority-setting can be done by various actors. These include: • Governments: "In most countries, health spending by governments vastly

outpaces international health aid, so governments set most health priorities." • Non-profits and companies that assist governments • If a country is using a Health in All Policy (HiAP) approach, then priority-setting is

done by stakeholders who do not directly deal with health. • International organizations • Foundations • Private donors (including high-net-worth individuals and ultra-high-net-worth

individuals): "A common outcome is a negotiated set of priorities that reflect some domestic needs and some technical, political, and economic considerations defined largely by the interests of donors."[6] In some highly aid-dependent countries, donors "have huge influence on health priorities".[8]

According to Devi Sridhar, professor of global health at the University of Edinburgh,“ the priorities of funding bodies largely dictate what health issues and diseases are studied"

Priority setting in healthcare=

Overview

• Rationing in healthcare

• Economic approach to setting priorities

• Equity & fair innings

Seven forms of rationing • By Denial:

– Patients denied care they need, for example, deemed unsuitable or not urgent enough

• By Selection: – Patients selected because of characteristics, for example, most likely to

benefit from treatment • By Deflection:

– Patients encouraged or turned towards another service, for example, private care

• By Deterrence: – Patients deterred from seeking care, for example, barriers or costs put in

place or not removed.

• By Delay: – Needs not met immediately, for example, wait for appointments or

waiting-lists.

• By Dilution: – Services given to all but amount given reduced, for example, general

practitioner consultants.

• By Termination: – System no longer treats certain patients, for example, cessation of cancer

treatment

Nature of Prioritization

• Core Issues are Political and Ethical

• How Resources, Rights, and

Responsibilities are distributed.

• Political considerations underpin why

implement validated technical

interventions are difficult

Alternatives to Prioritization

• Add More Resources

• Take out Services

Why Prioritize When Adding Resources

Might Work?

• Assure donors to maintain or increase the flow of funds

• Prioritization can itself increase resources

• Prioritization is needed if we are to know that prioritization is insufficient

• Most important when there is little money

• Risk of Spending Too Much on Tertiary Care: Poor Spending Pattern

• Unfunded Primary Care —> Lethal in the poorest countries

Challenges of Prioritization

• Resources are limited

• Impossible to provide everyone with every effective intervention

• Limited resources and unlimited demands

• Justice and efficiency

• Lack of Consensus

• Little interaction about priority setting among decision makers

Points

• Multiplicity of priorities and

• Lack of institutional mechanisms to

rationalize services and spending often

results in

• Poor overall system performance,

• Low coverage for highly cost-effective

health technologies

Controversies of Prioritization

• Process Affects Who, What, “How Much”,

“When”, and at “What Cost”

• Donors want to see their investments

incorporated into public budgets

• No simple or purely technical answers

• Uncertainties around which values should

guide decisions about Prioritization

Adjudication in the Context of

Prioritization Exercises

• Every Disease Condition is a Priority

• Governments Cannot set policies in vacuum.

• Between many relevant values and that

• People (and disciplines) disagree which values should dominate

• There is no agreed upon normative approach

How to Conduct Priority Setting

Exercises

• Collect information on the costs and benefits of all the interventions to be considered —> creating a common currency for measuring and comparing the benefits

• Use models and assessments, such as the burden of disease and cost-effectiveness, to create a package of services

Factors Considered for Priority

Setting Exercises

1. Burden of Disease

2. Cost effectiveness of Interventions

3. Equity

4. Existing Capacity to Deliver

5. Risk Pooling :Some health conditions are rare

and too costly for most uninsured individuals to pay

out-of-pocket

Approaches to Priority Setting

• Using Formulae or Models

• Using Guidelines or Technology Assessments

• Utilize Explicit Criteria (NZ early 90s, UK, Holland, Oregon)

• Include community needs, community preferences, economic evaluations of cost-effectiveness, public health considerations

• Basic package of services is provided or financed based on an agreed criteria list

• Social preferences can influence how the different benefits are combined and valued

Best Practices

• Use recent data

• Analysis should be country specific

• Be based on a well functioning and representative set of information systems

• Rank Order by Burden and by population subgroup in order to provide useful advocacy information for the different groups

• Build Flexibility in Budget

• Build Linkages across services

• Ensure Sufficient time and resources to deliver the interventions

Dilemma

• Imagine you have only $1000 to spare to pay

for treatment

• Who will get treatment?

$1000 to Spend

Child with appendicitis needs an urgent surgery, overall cost $1000 out of your pocket

You need to get a root canal treatment done for a cavity in your tooth

Cosmetic surgery (skin grafting) to cover an old burn scar

Parent with Three Children

You see a parent. He has diabetes for which he takes medicines, on a diet, and exercise. He works at an office (junior management) and is the sole earning member of the family. They have three children: one suffers from Chronic Asthma and needs regular medication, the second has a congenital heart disease and will need surgery soon, and the third just got diagnosed with tonsillitis and the doctor wants him operated urgently. What will be your advice to the parent to manage this?

Clinic Director

X has set up a clinic around Irbid (an upscale yet recent immigrant dense neighbour hood). The population that the clinic serves is aging (60% above 65 years and 40% are young families (35 years average age with two kids).

X wants to set up a suite of services to offer to this community but has resource limitations.

What mix of services you will advise him?

Range of Services

Y is a consultant and wants to work in areas of public health and preventive health services at a rural township where a large farming community exists.

The average age of the population is about 55 years, most are locally based farmers, or work in sheep shearing sheds, or have work with farming machineries.

With Limited Budget, what kind of services would you advise Y to plan for?

How to Play God

Z is a venture capitalist and just got an offer from the Bill and Melinda Gates foundation that he has 5 million dollars to spend but has to pick ONLY two disease control/prevention/public health issues in Mafraq . Z comes to you for advice.

What will you advise Z?

Conclusions and Comments

• Priority Setting As Balance Between Resources

and Demands

• Necessary for Best Allocation of Resources

• Frameworks Provide Good Structures to Achieve

Prioritization

• Discussions and Comments?