mlewis1@worldbank.org February 2, 2010 1 Based on: Governance in - - PowerPoint PPT Presentation

Maureen Lewis Research Department World Bank mlewis1@worldbank.org

1

Overseas Development Institute London, UK February 2, 2010

2

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

• f 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

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

7

Ministry of health: Health policy Local government Provider performance Service delivery quality & Health

• utcomes

Beneficiaries & Stakeholders Institutional performance direction of incentives direction of accountability direction of potential influence direction of potential accountability Parliament: Government policy direction of influence

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

1.

Budget and resource management

 Budget credibility, leakages, purchasing and spending

2.

Individual providers

 Credentials, absenteeism, clinical performance

3.

Health facilities

 ALOS, bed occupancy, Apgar scores, patient satisfaction

• 4. Informal payments

 Frequency of under-the-table payments

5.

Corruption

 perceptions

9

AREA ISSUE KEY INDICATORS Budget processes PEFA indicators track budget credibility, comprehensiveness, transparency, execution, recording, reporting, and external audits and scrutiny. Budget leakages Discrepancy between public budgeted health funds and the amounts received by health providers. Payroll irregularities Discrepancy between payroll roster and health workers on site. In-kind supply leakages Differences in price paid for similar medical supplies/equipment across health facilities. Type of procurement used for drugs and supplies. Job purchasing Frequency of illegal side-payments/bribes influencing hiring decisions and of payments for particular assignments. Physician credentials Existence and enforcement of licensing requirements and of continuing education programs. Health worker absenteeism Fraction of physicians or nurses contracted for service but not on site during the period(s) of observation. Health worker performance Direct observation of adherence to treatment protocols, medical knowledge test scores, and patient satisfaction ratings. HEALTH FACILITIES Facility performance Average length of stay, bed occupancy, infection and mortality rates, Apgar scores, and patient satisfaction ratings. INFORMAL PAYMENTS Under-the-table payments to individuals Frequency of illegal charges for publicly provided health services. Perceptions of corruption Fraction of households, citizens or public officials reporting corruption in health. Relative ranking of health sector on corruption indices. Institutional quality The Country and Policy Institutional Asessements (CPIA) for health.

Source: Authors.

BUDGET AND RESOURCE MANAGEMENT INDIVIDUAL PROVIDERS CORRUPTION PERCEPTIONS

10

• 1. Using Public Expenditure and Financial Analysis

to measure efficiency of budget management (1-5)

11

Source: PFM assessments (various years).

1 2 3 4 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

12

Leakage Rates for Health Care in Selected Countries from Expenditure Tracking Surveys

YEAR LEAKAGE RATE TYPE OF EXPENDITURE Ghana 2000 80% Non-salary budget Peru 2001 71 “Glass of Milk” Program Tanzania 1999 40 Non-salary budget Uganda 2000 70 Drugs and supplies

Source: Lindelow, Kushnarova, and Kaiser, 2005

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

10 20 30 40 50 60 70 80 Bangladesh (2002) Cameroon (2003) Chad (2004) Honduras (2001) India (2002/03) India (Udaipur dist.) (2004) Indonesia (2002/03) Peru (2002/03) Uganda (2002/03) Uganda (1997) Bangladesh (2004) Bangladesh (2004) Bangladesh (2004) Dominical Republic (1996)* Absentee rate (%)

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).

Health staff Health staff Health staff Health staff Health staff Health staff Health staff Health staff Health staff Health staff rural clinics Rural physicians Physicians Physicians clinics Physicians

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

17

Comparison of Purchase Price Difference for Medical Supplies Across Public Hospitals in Four Latin American Countries

5 10 15 20 25 30 35 40 Saline solution Cotton Dextrose Penicillin Ratio of highest to lowest price Bolivia (1998) Argentina (1997) Colombia (1998) Venezuela (1998)

Source: Di Tella and Savedoff (2001).

18

Facility performance in Brazil: public vs contracted hospitals

12 contracted-out public hospitals 12 traditional public 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 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 General 60 46 Surgical 71 44 Clinical 86 53 GYN/OB 96 58 Expenditures/bed 177 187 Expenditures/discharge 2.9 4.3 Efficiency: Descriptive Statistics Technical Efficiency: (discharges/bed) Annual Spending (in R$000)

Source: Adapted from La Forgia and Couttolenc (2008).

19

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

• 4. Informal payments

 Definition: charges for health services or

supplies meant to be provided for free, or payments to obtain specific favors or advantages

 Qualitative studies suggest informal, under-

the-table, payments in health care are common in many countries

20

21

Informal payments in health in ECA/SAS, 2000-02

20 40 60 80 100 120 Albania Armenia Belarus BiH Bulgaria Croatia Czech Rep. Georgia Hungary Macedonia Montenegro Poland Romania Russia Serbia Bangladesh India Nepal Pakistan Sri Lanka Users reporting informal payments in health (percent)

Source: Thampi 2002; USAID Vitosha 2001; Balbanova et al. 2002; Central and Eastern European Health Network (various years).

22

Informal payments in health in Africa, 2006

2 4 6 8 10 12 14 16 Benin Botswana Cape Verde Ghana Kenya Lesotho Madagascar Malawi Mali Mozambique Namibia Nigeria Senegal South Africa Tanzania Uganda Zambia Zimbabwe Users reporting informal payments in health (percent)

Source: Afrobarometer (2006).

• 5. Corruption perceptions

23

Perceptions: Percentage of Households Perceiving Corruption in the Health Sector

0.0 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 Kazakhstan (2001) Indonesia (2001) Zambia (2003) Mozambique (2004) Ghana (2000) Kyrgyz (2001) Paraguay (2006) Peru (2001) Benin (2006) Guatemala (2005) Romania (2000) Colombia (2002) Haiti (2004) Honduras (2002) Sierra Leone (2002) Source: World Bank Governance and Anti-Corruption Diagnostic Surveys

Purchasing of Positions

10 20 30 40 50 60 Zambia (2003) Ghana (2000) Sierra Leone (2002) Guinea (2005) Colombia (2002) Indonesia (2001) Benin (2006)

% of public officials' reporting that job purchasing in health is common or very common

Source: World Bank Governance and Anti-Corruption Diagnostic Surveys (various years).

24

• 6. In summary, improving public performance in

health: incentives and adding accountability

 Pay for performance: often does not work for individuals

(US, UK) as it becomes part of earnings; more promising when tied to hospital earnings:

 Plan Nacer – Argentina province hospitals (WB project)  Philippines 30 hospitals

 Contract out and hold hospital director ultimately

accountable - Sao Paulo, Brazil (WB evaluation)

 Community control and oversight/citizen report cards:

evidence not encouraging

 Address corruption

25

26

 Governance matters for public health system

performance

 Need to reconsider incentive structures,

accountability and enforcement of rules

 World Bank examples

 Indicators are key for management and

accountability

 Need benchmark countries to set standards  Need more evidence, agreed national indicators

and data for those indicators

Going forward

27

THANK YOU