In the Name of God Lorestan – Khoramabad May 2005 Dr Kambiz Monazzam.

In the Name of God

Lorestan – Khoramabad May 2005

Dr Kambiz Monazzam

Review of Health Review of Health Sector Reform:Sector Reform:

The Basics The Basics

May 18-21, 2005Khoramabad - Lorestan

Dr Kambiz MonazzamDr Kambiz Monazzam

ReformReform: Definition: Definition““sustained, purposeful and fundamental sustained, purposeful and fundamental

changechange””

““Sustained”Sustained” in the sense that it is not a "one in the sense that it is not a "one shot" temporary effort that will not have shot" temporary effort that will not have enduring impacts; enduring impacts;

““Purposeful”Purposeful” in the sense of emerging from a in the sense of emerging from a rational, planned and evidence-based process; rational, planned and evidence-based process;

““Fundamental”Fundamental” in the sense of addressing in the sense of addressing significant, strategic dimensions of health significant, strategic dimensions of health systems .systems .

Why do we Reform?Why do we Reform?

Health problems/Health System Health problems/Health System ProblemsProblems

Unhappy PeopleUnhappy People ....!....! ??

Who find the Problems...?!Who find the Problems...?!

What Starts The What Starts The Cycle of Reform?Cycle of Reform?

Economic crisisEconomic crisis Political changePolitical change External pressureExternal pressure Unhappy interest groupsUnhappy interest groups

Main Goals of Main Goals of Health Sector ReformHealth Sector Reform

EquityEquity EfficiencyEfficiency QualityQuality SustainabilitySustainability

Fiscal ImpactFiscal ImpactSatisfactionSatisfactionAccessAccess

What do we needWhat do we need “ R ” or “ r ” ? “ R ” or “ r ” ?

It depends on It depends on degreedegree, severity & , severity & complexity of our complexity of our problemsproblems

!?

Reform CycleReform Cycle

Is there any space for politics?Is there any space for politics?

Define The Problem

Identify Causes

Develop Options

Implement

Evaluate

Decide What to Do

The Health SystemsReform Cycle

Economics Management

Politics

Health Sector Reform

Health Sector Reform Context

Problem Definition

Diagnosis

Policy Development

Implementation

Evaluation

Political Decision

The SimplifiedPolicy Cycle

Problem Definition

Diagnosis

Policy Development

Implementation

Evaluation

Political Decision

The PoliticalPolicy Cycle

POLITICS

ETHICS

EconomicsEconomics & HSR & HSR

If someone asked you to find one problem of If someone asked you to find one problem of all all humanhuman which is the most important to them, which is the most important to them,

What What problemproblem do you address? do you address?

If someone asked you to find one problem of all If someone asked you to find one problem of all GovernmentsGovernments which is the most important to them, which is the most important to them,

What do you say?What do you say?

Needs / wishes they can’t reach

People Needsthey can’t meet

Lack of Enough Money

Economics?Economics? Definition ?Definition ?

Gifted shared 100,000 to Gifted shared 100,000 to

How do you do with 100,000 $ ?How do you do with 100,000 $ ?

How do you divide 100,000 $ How do you divide 100,000 $ between 5 people?between 5 people?

between 1000 people? between 1000 people? between 1000,000 people?between 1000,000 people?

Money

People is differentPeople is different

Individual desires & Individual desires & preferencespreferences

Social desires & preferencesSocial desires & preferences Individual behaviorIndividual behavior Importance of the issueImportance of the issue

Decision makingDecision making

How decision could be How decision could be made?made?

Who Decide?Who Decide?

Values

Organization

Management?Management? Plan to Reform / ChangePlan to Reform / Change

Through: ?Through: ? Five Control KnobsFive Control Knobs

FinancingFinancing Payment (Incentive Structure)Payment (Incentive Structure) Macro-Organization of ProvisionMacro-Organization of Provision RegulationRegulation Persuasion (Behavior)Persuasion (Behavior)

Reform CycleReform Cycle

Define The Problem

Identify

Causes

Develop Options

Implement

Evaluate

Decide What to Do


POLITICS

ETHICS

Define The Problem

CurrentCurrent GoalsGoalsPP

What’s the problem?What’s the problem?

Is there any problem?

Define The Problem

How many?How many?How much?How much?

Real or Opinion?

YES

Define The Problem

Goals

Stewardship(oversight)

Financing(collecting, pooling

and purchasing)

Creating resources(investment and training)

Delivering services

(Provision)

Responsiveness(to non-medical

expectations)

Fair FinancialContribution

Health

Functions the system performs

EQUITY

EFFICIENCY

QUALITY

FISCAL IMPACT

ACCESS

Ultimate GoalsIntermediate Goals

What Constitutes the What Constitutes the Health System?Health System? Care providersCare providers Financial intermediariesFinancial intermediaries Input producersInput producers Planners and regulatorsPlanners and regulators Preventive service providersPreventive service providers Other actors producing Other actors producing

system outcomessystem outcomes

Characteristics of Characteristics of Health SystemsHealth Systems

Complexity:Complexity: multiple actors with multiple actors with multiple connectionsmultiple connections

Conflict:Conflict: different participants have different participants have different objectivesdifferent objectives

Politics matters:Politics matters: decisions inevitably decisions inevitably reflect political process reflect political process

Societal context matters:Societal context matters: conditions conditions and options reflects culture, history and and options reflects culture, history and social normssocial norms

Define The Problem

How Should WeHow Should WeDefine Problems?Define Problems?

The health system is a The health system is a meansmeans.. Reformers need to think deeply Reformers need to think deeply about the about the endsends

Problems should be defined Problems should be defined based on poor based on poor performanceperformance in terms of in terms of outcomesoutcomes

Define The Problem

How Should WeHow Should WeDefine Problems? Define Problems? Cont’Cont’

Aspects of the system only need to Aspects of the system only need to be changed be changed ifif the changes the changes contribute to improving poor contribute to improving poor performanceperformance

Defining the problem has to be Defining the problem has to be done done carefullycarefully because it will because it will influence what solutions you chooseinfluence what solutions you choose

Define The Problem

How Do We Know How Do We Know Which Aspects of Which Aspects of Performance Matter?Performance Matter? Different groups will have different viewsDifferent groups will have different views Political processes often produce an Political processes often produce an

uneasy compromiseuneasy compromise Reformers can influence those processesReformers can influence those processes Reformers have to consider ethics and Reformers have to consider ethics and

values to know what performance values to know what performance problems to focus onproblems to focus on

Define The Problem

The Role Of Ethics The Role Of Ethics In Problem DefinitionIn Problem Definition

Deciding what aspects of performance Deciding what aspects of performance matter is not just a technical questionmatter is not just a technical question

Deciding what matters requires valuesDeciding what matters requires values

Exploring ethical theory allows us to clarify Exploring ethical theory allows us to clarify both our assumptions and their implicationsboth our assumptions and their implications

The problem definition influences all that The problem definition influences all that followsfollows

Define The Problem

How do you find to meet the goals?

Which Which Indicators?Indicators?

EquityEquity EfficiencyEfficiency QualityQuality SustainabilitySustainability

Fiscal ImpactFiscal ImpactSatisfactionSatisfactionAccessAccess

Review of Health Review of Health Sector Reform:Sector Reform: Diagnosis & Diagnosis &

Option appraisalOption appraisalMay 18-21, 2005

Khoramabad - Lorestan


Identify CausesHow many problems do you have in the health / system !?

Identify Causes

Identifying Causes: Identifying Causes: The Diagnostic JourneyThe Diagnostic Journey

Start with performance Start with performance problems problems

Ask “why” five timesAsk “why” five times Go from causes, to Go from causes, to

causes of causes, etc.causes of causes, etc. Work “backwards”Work “backwards” Be “evidence based”Be “evidence based”

Identify Causes

Start with problems:Start with problems:

Where they are?Where they are? Who can find the problems? Who can find the problems?

people have different ideas!people have different ideas! Which Problem is more important Which Problem is more important

than the others?than the others? Who can exactly define the Who can exactly define the

problem?problem? Experts, Managers, People, Data Experts, Managers, People, Data

…… Which areas are important?Which areas are important?

Identify Causes

Start with problems:Start with problems:

FindFind ResearchResearch Situation analysisSituation analysis Expert’s view Expert’s view

List & ClassifyList & Classify

Affinity diagramAffinity diagram Logical cause & effect DiagramLogical cause & effect Diagram Problem Tree

Time Money Expertise

Identify Causes

Problem identification – (What)

What exactly is the problem?Who or what is most affected by this problem?How serious/important is the problem?What supportive data/facts do you have to demonstrate this severity or importance?Is this problem manageable in scope?Is this problem more important and devastating than any other problems?Is this problem more influential/crucial to the current situation than any others?Can you afford to ignore this problem for the time being?…

Identify Causes

Problem analysis - (why)

Problem analysis is to understand why there is a problem or what are the factors that contribute to the problem and the interrelationship between these factors.

Identify CausesProblem TreeFishbone DiagramForce Field AnalysisSWOT or SWOC AnalysisThe 7s ModelProblem Web.

Tools / Techniques:

Identify Causes

Finding Root Causes:

•Problems have a cause & effect relationship or other inter relationship between them.

•At last: In health you reach a specific tree, which have multiple roots

•Go backward, find evidence•Red line

Identify Causes

Logical vs. political Logical vs. political way of thinking to way of thinking to solve problemssolve problems

•Logical:Logical:

•Political:Political:

Problem Tree Fishbone

Diagram

Force Field Analysis

Decision Space …….

Identify CausesHow do people think about How do people think about political processes for policy political processes for policy change and implementation?change and implementation?• When decisions are made: When decisions are made:

Policy process sequencesPolicy process sequences• How decisions are made: How decisions are made:

Decision-making modelsDecision-making models • Who makes decisions: Who makes decisions:

Stakeholder analysisStakeholder analysis • BoundariesBoundaries: : Governance rules Governance rules

and Broader Contexts and Broader Contexts

Tools for Political AnalysisTools for Political Analysis

Policy Process Sequence

Signaling

Evaluation & Feedback Consultation and Formulation

AggregationImplementation

Ratification

Ethical Side

Political Side


Develop Options

Developing OptionsDeveloping Options Build on a sound model Build on a sound model

of of a) what drives health a) what drives health system performance system performance

b) what can be changedb) what can be changed

Develop Options

Developing Options Developing Options

““Imitate but Imitate but adapt” adapt”

- learn from others but consider - learn from others but consider

local conditionslocal conditions

Develop Options

Developing OptionsDeveloping Options ““Process matters” Process matters”

– – how you go about this task how you go about this task will influence the political will influence the political acceptability and the quality acceptability and the quality of the planof the plan

Decide What to Do

Reaching A Political DecisionReaching A Political Decision

Health sector reform Health sector reform is unavoidably is unavoidably politicalpolitical

Doing better Doing better requires : requires : political political skillskill, , not justnot just

political political willwill

Decide What to Do

Reaching A Political DecisionReaching A Political Decision

Stakeholder analysis Stakeholder analysis as a starting point as a starting point

From “mapping” From “mapping”

to strategyto strategy

Review of Health Review of Health Sector Reform:Sector Reform:

Treatment Treatment

May 18-21, 2005Khoramabad - Lorestan


Implement

Good ideas are Good ideas are not worth muchnot worth much

IfIf

They can not be They can not be implementedimplemented

ImplementationImplementation

Implement

The old adage,The old adage,

“ “Better the devil Better the devil you know than the you know than the devil you don’t,”devil you don’t,”

embodies this idea.embodies this idea.

Resistance to change is Resistance to change is almost always presentalmost always present

Implement


PsychologicalPsychological New procedures New procedures and structures are and structures are strange and strange and unfamiliar.unfamiliar. For many, the mere For many, the mere fact of newness fact of newness creates anxiety and creates anxiety and resistanceresistance

Implement


change can bring costs change can bring costs to specific groups and to specific groups and individuals.individuals.

New procedures and New procedures and

arrangements take time arrangements take time and effort to learn.and effort to learn.

Existing hierarchies can Existing hierarchies can be upset.be upset.

Implement


Those who benefited Those who benefited from the old system can from the old system can lose greatly. lose greatly.

those most successful those most successful under the old system under the old system have the most to lose; have the most to lose; hence, the currently hence, the currently powerful are often the powerful are often the most opposed to most opposed to reform.reform.

Implement


Thinking BehaviorThinking Behavior Difficulty we all have in Difficulty we all have in giving up familiar ways of giving up familiar ways of thinkingthinking Past, can have a strong Past, can have a strong hold over ushold over usEstablished patternsstablished patterns are potent & fixed, If one want If one want to doto do differently, feels differently, feels extreme pressureextreme pressure

Implement

Many Health Sector Reform Efforts Have Many Health Sector Reform Efforts Have Failed at The Stage of ImplementationFailed at The Stage of Implementation

Ministers often lack Ministers often lack administrative experience administrative experience

Leaders turn over quicklyLeaders turn over quickly Implementation is not Implementation is not

considered in program considered in program designdesign

Entrenched interests Entrenched interests resist resist

Political attention turns Political attention turns elsewhereelsewhere

Implement

Reaching A Political DecisionReaching A Political Decision Health sector reform Health sector reform

is unavoidably is unavoidably politicalpolitical

Doing better requires Doing better requires political political skillskill, not , not just political just political willwill

Stakeholder analysis Stakeholder analysis as a starting point as a starting point

From “mapping” to From “mapping” to strategystrategy

Decide What to Do

Implement

sophisticated leadership

Monitoring

appropriate reporting system

Evaluate

Evaluation Plan Evaluation Plan

Before designing and conducting an Before designing and conducting an evaluation, the evaluator needs to be evaluation, the evaluator needs to be clear on the issues such as:clear on the issues such as:

Why evaluation is needed;Why evaluation is needed; To whom the evaluation results will be To whom the evaluation results will be

required and useful;required and useful; What data is needed and where and how What data is needed and where and how

to collect it;to collect it; What comparative exercise should be What comparative exercise should be

made.made.

how well it has achieved?how well it has achieved?

Evaluate

Keys To A Keys To A Successful Successful EvaluationEvaluation

Design an evaluation strategy in Design an evaluation strategy in advance advance

Anticipate likely problemsAnticipate likely problems Collect data before you beginCollect data before you begin Create incentives for good evaluationCreate incentives for good evaluation

Evaluate

Before-and-after comparison

Control group

Similar neighboring country

Keys To A Keys To A Successful Successful EvaluationEvaluation

Evaluate

Collect baseline data Data is not free Data cost on people Time consuming Over-collection

Define The Problem

Identify

Causes

Develop Options

Implement

Evaluate

Decide What to Do


POLITICS

ETHICS

Five Core Elements:Five Core Elements:

Importance of ethical theoryImportance of ethical theory Explicitly identified health system Explicitly identified health system

performance objectivesperformance objectives Systematic approach to health Systematic approach to health

system diagnosissystem diagnosis Use of the health system control Use of the health system control

knobsknobs Political analysisPolitical analysis

The last point:The last point:

Knowledgegeneration

Social movement

Political linkage

The that moves the mountain

In the Name of God Lorestan – Khoramabad May 2005 Dr Kambiz Monazzam.

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Transcript of In the Name of God Lorestan – Khoramabad May 2005 Dr Kambiz Monazzam.