CHAPTER THREE ealth services lell Chosen, Well organized? Health services aim to protect or improve health. Whether they do so effe tively depends on which services are provided and how they are organized Resources should be used for interventions that are known to be effective, in accordance with national or local priorities. Because resources are limited, there will always be some form of rationing but prices should not be the chief way to determine who gets what care. Both hierarchical bureaucracies and fragmented, unregulated markets have serious flaws as ways to organ ize services: flexible integration of autonomous or semi-autonomous health care providers can mitigate the problems
Health Services: Well Chosen, Well Organized? 47 CHAPTER THREE ealth ervices: ell hosen, ell rganized? Health services aim to protect or improve health. Whether they do so effectively depends on which services are provided and how they are organized. Resources should be used for interventions that are known to be effective, in accordance with national or local priorities. Because resources are limited, there will always be some form of rationing but prices should not be the chief way to determine who gets what care. Both hierarchical bureaucracies and fragmented, unregulated markets have serious flaws as ways to organize services: flexible integration of autonomous or semi-autonomous health care providers can mitigate the problems. 47
HEALTH SERVICES WELL CHOSEN, WELL ORGANIZED? ORGANIZATIONAL FAILINGS ust as the principal objective of a health system is to improve people's health, the chief function the system needs to perform is to deliver health services. The other ns matter partly because they contribute to service provision. It is therefore a major failing of the system when effective and affordable health interventions do not reach the populations that would benefit from them. Sometimes this happens because the providers have inadequate skills, or because of a lack of drugs and equipment: these are the conse- quence of failures of training and investment, as discussed in Chapter 4, or of purchasing, as discussed here and in Chapter 5. Sometimes services are not delivered to potential bene ficiaries because of price barriers: this is the result of a failure to finance the services fairly,as discussed in Chapter 5. But often a failure of service delivery is due to dysfunctional organi- zation of the health system, even when the needed inputs exist and financial support is dequate and fairly distributed. Such an organizational failing can result from the wrong arrangements among different parties involved in service delivery, which in turn creates perverse incentives and leads to mistaken choices about what services to provide, to whom to deliver them, or how to ration when it is not possible to meet everyones needs or wants This chapter considers how to choose which services to provide, how to organize provision d how to assure the right incentives for providers The complexities of organizing service provision are illustrated by the following exam- le, which is not at all unusual. a poor young woman walks to a rural government health post with her sick baby. There is no doctor at the post, and there are no drugs. But a nurse gives the mother an oral rehydration kit and explains how to use it. She tells the mother to come back in a couple of days if the baby's diarrhoea continues. The nurse sees only ha dozen patients that day. Meanwhile, at the outpatient clinic of a community hospital about an hour's drive away, several hundred patients are waiting to be seen. Some are given cursory examinations by the doctors there and are able to obtain any prescribed drugs at hospital dispensary. When the outpatient clinic closes, even though it is still early in the day, patients who have not been seen are asked to return the next day, without being given appointments. Some of the doctors then hurry off to work in a private"nursing home"o clinic to supplement their salaries The doctors' low pay and the absence of more qualified staff and drugs at the health post night be shrugged off as the consequences of spending too little. But a lack of resources cannot be blamed for the maldistribution of those resources between the health post and he hospital, the low productivity of the nurse, the under-utilization of the hospital when its
Health Services: Well Chosen, Well Organized? 49 3 HEALTH SERVICES: WELL CHOSEN, WELL ORGANIZED? ORGANIZATIONAL FAILINGS ust as the principal objective of a health system is to improve people’s health, the chief function the system needs to perform is to deliver health services. The other functions matter partly because they contribute to service provision. It is therefore a major failing of the system when effective and affordable health interventions do not reach the populations that would benefit from them. Sometimes this happens because the providers have inadequate skills, or because of a lack of drugs and equipment: these are the consequence of failures of training and investment, as discussed in Chapter 4, or of purchasing, as discussed here and in Chapter 5. Sometimes services are not delivered to potential beneficiaries because of price barriers: this is the result of a failure to finance the services fairly, as discussed in Chapter 5. But often a failure of service delivery is due to dysfunctional organization of the health system, even when the needed inputs exist and financial support is adequate and fairly distributed. Such an organizational failing can result from the wrong arrangements among different parties involved in service delivery, which in turn creates perverse incentives and leads to mistaken choices about what services to provide, to whom to deliver them, or how to ration when it is not possible to meet everyone’s needs or wants. This chapter considers how to choose which services to provide, how to organize provision and how to assure the right incentives for providers. The complexities of organizing service provision are illustrated by the following example, which is not at all unusual. A poor young woman walks to a rural government health post with her sick baby. There is no doctor at the post, and there are no drugs. But a nurse gives the mother an oral rehydration kit and explains how to use it. She tells the mother to come back in a couple of days if the baby’s diarrhoea continues. The nurse sees only half a dozen patients that day. Meanwhile, at the outpatient clinic of a community hospital about an hour’s drive away, several hundred patients are waiting to be seen. Some are given cursory examinations by the doctors there and are able to obtain any prescribed drugs at the hospital dispensary. When the outpatient clinic closes, even though it is still early in the day, patients who have not been seen are asked to return the next day, without being given appointments. Some of the doctors then hurry off to work in a private “nursing home” or clinic to supplement their salaries. The doctors’ low pay and the absence of more qualified staff and drugs at the health post might be shrugged off as the consequences of spending too little. But a lack of resources cannot be blamed for the maldistribution of those resources between the health post and the hospital, the low productivity of the nurse, the under-utilization of the hospital when its
The World Health Report 2000 clinic closes early, the failure to have some doctors on duty over a longer interval, and the waste of people's time in waiting and then having to return another day because there is no nd of both in initial investments and training and then in service delivery or the lack thereof. If the story has a happy ending for the mother and baby, it is only because the child was lucky to have diarrhoea and not malaria or some other condition the nurse could not recognize or could not treat, or requiring care which the mother would have to pay for out of pocket. Getting even limited care for free may also be the reason the mother goes to a public facility rather than to one of the private pharmacies or traditional healers, patronized by large numbers of people This chapter looks at how to set priorities for which services health systems should provide, and at the choices and mechanisms involved in rationing so as to make priorities effective. It then considers the organizational factors that help to make sure that the services reach people at the right time PEOPLE AT THE CENTRE OF HEALTH SERVICES The story of the mother and baby illustrates another fact about health systems: service delivery is where people meet most directly, as providers and users of interventions. But people play more than those two roles, as Figure 3.1 indicates. At the centre of service delivery is the patient, in the case of clinical interventions, or the affected population, in the ase of non-personal public health services. People are also consumers, because they be- have in ways that influence their health, including their choices about seeking and utilizing health care. The consumer may be the patient, or someone such as a mother acting on his Figure 3. 1 The multiple roles of people in health systems Contributors Patients and populations Production of goods nd services Providers
50 The World Health Report 2000 clinic closes early, the failure to have some doctors on duty over a longer interval, and the waste of people’s time in waiting and then having to return another day because there is no system of appointments. These problems reflect failures of priority and of organization, both in initial investments and training and then in service delivery or the lack thereof. If the story has a happy ending for the mother and baby, it is only because the child was lucky to have diarrhoea and not malaria or some other condition the nurse could not recognize or could not treat, or requiring care which the mother would have to pay for out of pocket. Getting even limited care for free may also be the reason the mother goes to a public facility rather than to one of the private pharmacies or traditional healers, patronized by large numbers of people. This chapter looks at how to set priorities for which services health systems should provide, and at the choices and mechanisms involved in rationing so as to make priorities effective. It then considers the organizational factors that help to make sure that the right services reach people at the right time. PEOPLE AT THE CENTRE OF HEALTH SERVICES The story of the mother and baby illustrates another fact about health systems: service delivery is where people meet most directly, as providers and users of interventions. But people play more than those two roles, as Figure 3.1 indicates. At the centre of service delivery is the patient, in the case of clinical interventions, or the affected population, in the case of non-personal public health services. People are also consumers, because they behave in ways that influence their health, including their choices about seeking and utilizing health care. The consumer may be the patient, or someone such as a mother acting on his Figure 3.1 The multiple roles of people in health systems Contributors Financing Patients and populations Production of goods and services Providers Consumers Health care behaviours Stewardship Citizens
Health Services: Well Chosen, Well Organized or her behalf, or simply a person making choices about diet, lifestyle and other factors that affect health Sometimes the roles of consumer, patient and provider are all combined into one per- son and one moment, as happens when a woman gives birth with little or no assistance Every minute, thousands of women across the world are giving birth. In countries where the attendance by trained staff is low(9% in Nepal, 8% in Bangladesh and Ethiopia, 5% in Equatorial Guinea, 4% in Gabon and Mauritania, 2% in Somalia), births usually take place in the presence of lay birth attendants or family members. Even when the delivery is by caesarian section with a trained provider, each woman must still actively participate in birth Often the choices people make, particularly about seeking care, are influenced by the responsiveness of the system as described in Chapter 2 Utilization does not depend only on the consumer's perception of need or of the likelihood of benefiting from a service Although marked differences exist between societies, the basic tenets of ethical provider- patient relations usually include similar elements of consent, confidentiality, discretion, veracity and fidelity(1). Calling the elements of dignity, autonomy and confidentiality that go into responsiveness"respect for persons"underscores the importance of people, and not imply patients, as the recipients of health services People also play the role of contributors to financing the system. Millions of poor people pay for all of the services they receive at the time they are ill. In health systems with fairer contribution arrangements, people who are not sick contribute most to financing the health system, through taxes or health insurance contributions, so that the contributor may or may not be the patient or the consumer. Finally, as citizens and particularly as officials whose job it is to represent citizens and protect their interests- people participate in the system as stewards. In the same way that all four functions have to be carried out in order for the system to perform well, people have to play all these roles in order for the potentia benefits to reach the patients and populations at the centre. People act as providers, consumers, contributors and stewards of the health system dur- ng their adult working lives. In contrast, they can assume the role of patients at any time from before birth right up to death. The need to deliver services for people at all ages greatly complicates the choice of what services to emphasize and how to organize them, because people are exposed to different risks at different ages, and priority to any particular inter vention is at least in part also a priority for a particular age group. These differences are what make a demographic transition-lower mortality and longer life -into an epidemio logical transition -a change in the relative importance of different threats to health, par- ticularly a shift from communicable to noncommunicable diseases. Besides the variation with age, there are marked differences in disease pattens amon regions, countries and specific population groups. For example, in Africa infectious diseases account for nearly 70% of the disease burden, as Annex Table 4 shows. In Europ account for less than 20%. The poor suffer more from infectious diseases than the rich(2) but over the next 20 years even the poor will be vulnerable to cardiovascular and cerebro vascular diseases linked to tobacco use(3). It may seem natural to focus health system choices on the causes that account for a large share of the disease burden, either because they affect large populations or because they cause substantial health loss for each victim However, all that health systems can actually do is to deliver specific services or inter- mentions. Even if a first choice is made to concentrate on one or more particular diseases, it is still necessary to decide what to do-that is, which specific interventions to emphasize The number of interventions available greatly exceeds the number of diseases, and the
Health Services: Well Chosen, Well Organized? 51 or her behalf, or simply a person making choices about diet, lifestyle and other factors that affect health. Sometimes the roles of consumer, patient and provider are all combined into one person and one moment, as happens when a woman gives birth with little or no assistance. Every minute, thousands of women across the world are giving birth. In countries where the attendance by trained staff is low (9% in Nepal, 8% in Bangladesh and Ethiopia, 5% in Equatorial Guinea, 4% in Gabon and Mauritania, 2% in Somalia), births usually take place in the presence of lay birth attendants or family members. Even when the delivery is by caesarian section with a trained provider, each woman must still actively participate in birth and the postpartum recovery. Often the choices people make, particularly about seeking care, are influenced by the responsiveness of the system as described in Chapter 2. Utilization does not depend only on the consumer’s perception of need or of the likelihood of benefiting from a service. Although marked differences exist between societies, the basic tenets of ethical provider– patient relations usually include similar elements of consent, confidentiality, discretion, veracity and fidelity (1). Calling the elements of dignity, autonomy and confidentiality that go into responsiveness “respect for persons” underscores the importance of people, and not simply patients, as the recipients of health services. People also play the role of contributors to financing the system. Millions of poor people pay for all of the services they receive at the time they are ill. In health systems with fairer contribution arrangements, people who are not sick contribute most to financing the health system, through taxes or health insurance contributions, so that the contributor may or may not be the patient or the consumer. Finally, as citizens – and particularly as officials whose job it is to represent citizens and protect their interests – people participate in the system as stewards. In the same way that all four functions have to be carried out in order for the system to perform well, people have to play all these roles in order for the potential benefits to reach the patients and populations at the centre. People act as providers, consumers, contributors and stewards of the health system during their adult working lives. In contrast, they can assume the role of patients at any time from before birth right up to death. The need to deliver services for people at all ages greatly complicates the choice of what services to emphasize and how to organize them, because people are exposed to different risks at different ages, and priority to any particular intervention is at least in part also a priority for a particular age group. These differences are what make a demographic transition – lower mortality and longer life – into an epidemiological transition – a change in the relative importance of different threats to health, particularly a shift from communicable to noncommunicable diseases. Besides the variation with age, there are marked differences in disease patterns among regions, countries and specific population groups. For example, in Africa infectious diseases account for nearly 70% of the disease burden, as Annex Table 4 shows. In Europe, they account for less than 20%. The poor suffer more from infectious diseases than the rich (2) , but over the next 20 years even the poor will be vulnerable to cardiovascular and cerebrovascular diseases linked to tobacco use (3). It may seem natural to focus health system choices on the causes that account for a large share of the disease burden, either because they affect large populations or because they cause substantial health loss for each victim. However, all that health systems can actually do is to deliver specific services or interventions. Even if a first choice is made to concentrate on one or more particular diseases, it is still necessary to decide what to do – that is, which specific interventions to emphasize. The number of interventions available greatly exceeds the number of diseases, and the
appropriate strategy for disease control may depend on just one intervention or on a com bination of several activities. To make matters more complicated, a given intervention may be effective against more than one disease or cause, because it works on a common risk factor or symptom. This is especially true of diagnostic activities: taking blood samples, or lems. Thus, emphasizing an intervention, or investing in the inputs necessary for providing it, does not automatically focus effort on just one disease. Setting priorities also involves cular intervention should be used for The range of diagnostic approaches and medical and surgical interventions for many conditions is extensive and likely to expand significantly over the coming decades. This means that services need to be designed and implemented so as to allow for innovation and adaptation to new health challenges and interventions, all the while responding to the needs of people who differ in age, income, habits and health risks. No health system can meet all those needs, even in rich countries So either there must be conscious choices of what services should have priority, or the services actually delivered may bear little relation to any reasonable criterion of what is most important CHOOSING INTERVENTIONS GETTING THE MOST HEALTH FROM RESOURCES The ancient Greeks believed that Asclepios, the god of medicine, had two daughters One, Hygieia, was responsible for prevention, while the other, Panacea, was responsible for cure(4). While some preventive activities are applied to specific individuals-immunization is the clearest example -the distinction between prevention and cure or treatment corre sponds closely to the difference between public health interventions directed to entire populations and clinical interventions directed to individuals. Since there is usually de mand for the latter but there may not be any demand for the former, one of the principal tasks in choosing which services should have priority is that of balancing public health and clinical activities(5) To require the health system to obtain the greatest possible level of health from the resources devoted to it, is to ask that it be as cost-effective as it can be. This is the basis for emphasizing those interventions that give the most value for money, and giving less prior- ity to those that, much as they may help individuals, contribute little per dollar spent to the improvement of the populations health. It is the implicit basis of the measure of perform- ance with respect to disability-adjusted life expectancy presented in Chapter 2 and Annex Table 10. So far as the level of health is concerned, the allocative efficiency of the health system could be enhanced by moving resources from cost-ineffective interventions to cost- effective ones (6). The potential gains from doing this are sometimes enormous, because the existing pattern of interventions includes some which cost a great deal and produce few additional years of life. For example, a set of 185 publicly-funded interventionsin the United States cost about $21.4 billion per year, for an estimated saving of 592 000 years of life (considering only premature deaths prevented). Re-allocating those funds to the most cost- effective interventions could save an additional 638 000 life years if all potential beneficiar- ies were reached. At the level of specific services, the cost per year of life saved can be as low as $236 for screening and treating newborns with sickle-cell anaemia or as high as $5.4 million for radionuclide emission control (7). In poor countries all the absolute numbers will be smaller, but the ratio between more and less cost-effective actions may still be very
52 The World Health Report 2000 appropriate strategy for disease control may depend on just one intervention or on a combination of several activities. To make matters more complicated, a given intervention may be effective against more than one disease or cause, because it works on a common risk factor or symptom. This is especially true of diagnostic activities: taking blood samples, or using X-rays or other imaging techniques may be appropriate for a great variety of problems. Thus, emphasizing an intervention, or investing in the inputs necessary for providing it, does not automatically focus effort on just one disease. Setting priorities also involves deciding what a particular intervention should be used for. The range of diagnostic approaches and medical and surgical interventions for many conditions is extensive and likely to expand significantly over the coming decades. This means that services need to be designed and implemented so as to allow for innovation and adaptation to new health challenges and interventions, all the while responding to the needs of people who differ in age, income, habits and health risks. No health system can meet all those needs, even in rich countries. So either there must be conscious choices of what services should have priority, or the services actually delivered may bear little relation to any reasonable criterion of what is most important. CHOOSING INTERVENTIONS: GETTING THE MOST HEALTH FROM RESOURCES The ancient Greeks believed that Asclepios, the god of medicine, had two daughters. One, Hygieia, was responsible for prevention, while the other, Panacea, was responsible for cure (4).While some preventive activities are applied to specific individuals – immunization is the clearest example – the distinction between prevention and cure or treatment corresponds closely to the difference between public health interventions directed to entire populations and clinical interventions directed to individuals. Since there is usually demand for the latter but there may not be any demand for the former, one of the principal tasks in choosing which services should have priority is that of balancing public health and clinical activities (5). To require the health system to obtain the greatest possible level of health from the resources devoted to it, is to ask that it be as cost-effective as it can be. This is the basis for emphasizing those interventions that give the most value for money, and giving less priority to those that, much as they may help individuals, contribute little per dollar spent to the improvement of the population’s health. It is the implicit basis of the measure of performance with respect to disability-adjusted life expectancy presented in Chapter 2 and Annex Table 10. So far as the level of health is concerned, the allocative efficiency of the health system could be enhanced by moving resources from cost-ineffective interventions to costeffective ones (6). The potential gains from doing this are sometimes enormous, because the existing pattern of interventions includes some which cost a great deal and produce few additional years of life. For example, a set of 185 publicly-funded interventions in the United States cost about $21.4 billion per year, for an estimated saving of 592 000 years of life (considering only premature deaths prevented). Re-allocating those funds to the most costeffective interventions could save an additional 638 000 life years if all potential beneficiaries were reached. At the level of specific services, the cost per year of life saved can be as low as $236 for screening and treating newborns with sickle-cell anaemia or as high as $5.4 million for radionuclide emission control (7). In poor countries all the absolute numbers will be smaller, but the ratio between more and less cost-effective actions may still be very large