Maureen Lewis Overseas Research Department Development Institute World Bank London, UK mlewis1@worldbank.org February 2, 2010 1
Based on: Governance in health Care Delivery: Raising Performance World Bank Policy Research Working Paper No. 5074 (2009) By Maureen Lewis, World Bank Gunilla Pettersson, World Bank/University of Sussex http://www- wds.worldbank.org/external/default/main?query=wps5074&dAtts=ORASCORE, DOCDT,DOCNA,REPNB,DOCTY,LANG,VOLNB,REPNME,VOL_TITLE&sortDesc=OR ASCORE&pageSize=10&docType=0&theSitePK=523679&piPK=64620093&sort Orderby=ORASCORE&pagePK=64187835&menuPK=64187283&sType=2 2
Outline of Presentation Why is governance an issue in health care? What makes good institutions and why is it relevant to performance in health systems? Measuring performance Indicators and measurement Directions for reform 3
Why is governance an issue in health care? Health systems are the institutions that deliver health care Good governance underlies performance in health care delivery The focus on health care has been on raising financing and ensuring inputs: critical but not enough Delivery effectiveness is implicitly assumed, but data and evidence are scarce Ultimate impact measure is often IMR, but link between service delivery and IMR in the S.T. is weak Poor governance disproportionately affects the poor 4
What are the problems in public health care delivery in developing countries? Lack of performance measures to examine how resources are used and programs are implemented Poor quality services: provider absenteeism; lack of professional administrators; lack of drugs and supply Inefficiency: financial and operational mismanagement Corruption: theft, inappropriate procurement Few direct incentives for sound performance, and no benchmarks No accountability: to government officials, parliaments, regulators or citizens 5
Building sound institutions in public health care delivery entails: Having standards , basic information on performance , incentives for good performance, and Real accountability , where “ officials are called to account and to answer for responsibilities and conduct ” (OED 1989) Avoiding corruption: “use of public office for private gain” 6
The Governance Process: there must be benchmarks and accountability Institutional performance Parliament: Government policy Local Service government delivery quality Provider Ministry of & performance health: Health Health policy outcomes Beneficiaries & direction of incentives Stakeholders direction of accountability direction of potential influence direction of influence direction of potential accountability 7
How to measure performance in public health care systems Emphasize easily measured indicators where data collection is relatively easy and low cost Piggyback existing surveys or data collection Rely on simple quantitative and qualitative surveys Establish pilots with evaluation (Re)think management Indicators need to reflect performance Need measures that reflect system performance, and some that are comparable across countries 8
Indicator range and topic area Budget and resource management 1. Budget credibility, leakages, purchasing and spending Individual providers 2. Credentials, absenteeism, clinical performance Health facilities 3. ALOS, bed occupancy, Apgar scores, patient satisfaction 4. Informal payments Frequency of under-the-table payments Corruption 5. perceptions 9
AREA ISSUE KEY INDICATORS PEFA indicators track budget credibility, comprehensiveness, BUDGET AND RESOURCE Budget processes transparency, execution, recording, reporting, and external audits and scrutiny. MANAGEMENT Discrepancy between public budgeted health funds and the Budget leakages amounts received by health providers. Payroll irregularities Discrepancy between payroll roster and health workers on site. Differences in price paid for similar medical supplies/equipment In-kind supply leakages across health facilities. Type of procurement used for drugs and supplies. Frequency of illegal side-payments/bribes influencing hiring INDIVIDUAL PROVIDERS Job purchasing decisions and of payments for particular assignments. Existence and enforcement of licensing requirements and of Physician credentials continuing education programs. Fraction of physicians or nurses contracted for service but not on Health worker absenteeism site during the period(s) of observation. Direct observation of adherence to treatment protocols, medical Health worker performance knowledge test scores, and patient satisfaction ratings. FACILITIES HEALTH Average length of stay, bed occupancy, infection and mortality Facility performance rates, Apgar scores, and patient satisfaction ratings. INFORMAL PAYMENTS Under-the-table payments Frequency of illegal charges for publicly provided health services. to individuals CORRUPTION PERCEPTIONS Fraction of households, citizens or public officials reporting Perceptions of corruption corruption in health. Relative ranking of health sector on corruption indices. Institutional quality The Country and Policy Institutional Asessements (CPIA) for health. 10 Source: Authors.
1. Using Public Expenditure and Financial Analysis to measure efficiency of budget management (1-5) 4 3 2 1 0 Bangladesh Dominican Republic Macedonia Mozambique Ukraine Aggregate expenditure outturn compared to original approved budget Effectiveness of payroll controls Availability of information on resources received by service delivery unit 11 Source: PFM assessments (various years).
Leakage Rates for Health Care in Selected Countries from Expenditure Tracking Surveys YEAR LEAKAGE TYPE OF RATE EXPENDITURE Ghana 2000 80% Non-salary budget “Glass of Milk” Peru 2001 71 Program Tanzania 1999 40 Non-salary budget Uganda 2000 70 Drugs and supplies Source: Lindelow, Kushnarova, and Kaiser, 2005 12
Pharmaceutical Procurement and Distribution Problems WHO estimates 25% of drugs in low income countries are counterfeit or substandard China 30% of drugs are expired or counterfeit Procurement often troubled Collusion in bidding Prices paid vary widely for same product Drugs often go missing Costa Rica 32 of users are aware of theft Uganda drug leakage in 10 rural clinics averaged 73% Expired drugs common Distribution problematic 13
2. Individual provider performance: absenteeism Dominical Republic (1996)* Physicians Physicians Bangladesh (2004) clinics Bangladesh (2004) Physicians Bangladesh (2004) Health staff Uganda (1997) Rural physicians Uganda (2002/03) Health staff Peru (2002/03) Health staff Absentee rate (%) Indonesia (2002/03) Health staff India (Udaipur dist.) (2004) Health staff rural clinics India (2002/03) Health staff Honduras (2001) Health staff Chad (2004) Health staff Cameroon (2003) Health staff Bangladesh (2002) Health staff 0 10 20 30 40 50 60 70 80 Note: *Santo Domingo Hospital. Sources: Chaudhury et al. (2006); Chaudhury and Hammer (2005); World Bank (2001); Gauthier (2006); Lewis, La Forgia, and Sulvetta (1996); McPake et al. (1999); and Banerjee, Deaton, and Duflo (2004). 14
Individual providers Higher salaries not necessarily effective Reward and discipline performance Discard seniority as basis for pay and promotion Payment system reform to link performance and pay Contract out with oversight 15
3. Facility performance Performance measures hamstrung by an absence of performance incentives, lack of managerial authority, and accountability, poor data and no benchmarks Need to reward and discipline managers (Brazil) Payment system critical because they offer incentives for good performance of providers – DRGs/ 16
Comparison of Purchase Price Difference for Medical Supplies Across Public Hospitals in Four Latin American Countries 40 Bolivia (1998) 35 Argentina (1997) Colombia (1998) 30 Ratio of highest to lowest price Venezuela (1998) 25 20 15 10 5 0 Saline solution Cotton Dextrose Penicillin 17 Source: Di Tella and Savedoff (2001).
Facility performance in Brazil: public vs contracted hospitals 12 contracted-out 12 traditional public public hospitals hospitals Quality median median General mortality 3.3 5.3 Surgical mortality 2.6 3.6 Clinical mortality 11.6 12.0 Pediatric mortality 2.8 2.6 Efficiency: Descriptive Statistics Bed turnover rate 5.2 3.3 Bed substitution rate 1.2 3.9 Bed occupancy rate 81 63 ALOS 4.2 5.4 ALOS surgery 4.8 5.9 Technical Efficiency: (discharges/bed) General 60 46 Surgical 71 44 Clinical 86 53 GYN/OB 96 58 Annual Spending (in R$000) Expenditures/bed 177 187 Expenditures/discharge 2.9 4.3 Source: Adapted from La Forgia and Couttolenc (2008). 18
Key features of Brazil and other successful models Autonomous managerial authority Incentives for efficiency, cost containment and equity Flexible HR management: hire and fire staff Strategic purchasing Contract monitoring and enforcement Robust information environment Accountability of managers and staff 19
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