Health System Inputs: Policies on Human Resources, Facilities, Equipment, Consumables Gilles Dussault/Eva Jarawan WBIHD/MNSHD 19 September 2001.

Health System Inputs: Policies on Human Resources, Facilities,

Equipment, Consumables

Gilles Dussault/Eva Jarawan

WBIHD/MNSHD

19 September 2001

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Structure of the Session

• Why discuss inputs ?

• What is their relation to services, to outcomes ?

• Discussion:the importance of capital investments

• Case example:the utilization of HR

• Synthesis, take-home messages

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Health System Actors, Functions and Outcomes

People

Demand

FinancingRevenue Generation

Risk PoolingAllocation & Purchasing

Input ManagementHuman Resources Knowledge

Pharmaceuticals TechnologyConsumables Capital

Private Sector ActorsFor ProfitNon-Profit

Traditional Healers

Health Status

Financial Protection

OversightPolicy Setting Information, Disclosure & Advocacy Developing Partnerships Regulation & Standard SettingMonitoring & Evaluation Strategic Incentives

The State: government atvarious levels:

national, province, localDonors

Consumer Responsiveness

Service DeliveryPublic Health Services

Ambulatory CareInpatient Care

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Why Discuss Inputs ?

This is where the money goes:– Capital/ recurrent expenditures – Personnel– Infrastructures– Equipment – Consumables

… And there are opportunity costs

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Why Discuss Inputs ?

• This is where the money goes

They are the ingredients for the production of services

…And the accessibility, efficiency, effectiveness, quality, sustainability of services depend on them

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Total financialresources

Capital

Recurrent

Trainingof people

InvestmentIn buildings& equipment

Expenditurecategories

Labor costs

Budget elements

Maintenance

Other recurrent

Humanresources

Physicalcapital

Health systeminputs

(retirement,redundancy)

(Depreciation,obsolescence)

Consumables

(expiry, loss)(Reduction of inputs shownIn parentheses)

Production of healthinterventions

Health system inputs, from financial resources to health interventions.

Source: World Health Report 2000, p. 75

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Why Discuss Inputs ?

• This is where the money goes: capital, recurrent expenditures

• They are the ingredients for the production of services

Allocation is not optimal: market and government failures

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Market and Government Failures

• Inverse care law: resources are distributed in an inverse proportion to needs

• Branded vs generic drugs

• Failures of central planning and management (ex: postings, transfers, promotions)

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Why Discuss Inputs ?

• This is where the money goes: capital, recurrent expenditures

• They are the ingredients for the production of services

• Allocation is not optimal

Time lag between decisions and their effects

… and they have long lasting consequences

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Inputs-services-outcomes

The mix, volume, quality of inputs and the context and process of

their utilization and management will determine the contribution of

RH services to achieving the desired health outcomes

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At Issue …

• Allocation of financial resources ? important variations

• What is the right combination of inputs ? mix, volume, quality, distribution ?

• Utilization/management of inputs ?

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Health expenditures in your country ($US)

Benin, Cameroon, China, Cote d'Ivoire, Ethiopia, Gambia Ghana, Haiti, India, Kenya, Malawi,Mali,Mongolia, Nigeria, Pakistan, Senegal,Tanzania, Uganda, Yemen

20-99

Egypt, Nicaragua, Philippines,

Venezuela, West Bank/Gaza

100-300

Canada, U.K., Uruguay, U.S.A. 850-3724

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Allocation of Health Budget

Type of expenditure

Capital Recurrent

Personnel ? 60-90%

Infrastructures/ equipment

5-40% 0-15%

Consumables ---- 10-25%

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0 2 4 6 8 10 12

Beds per 1,000 population

Formerly socialist of Europe ----

Established Market Economies -

Middle Eastern Crescent ---------

Latin America & the Caribbean

Other Asia & Islands -------------

China ---------------------------------

India ----------------------------------

Sub-Sahara Africa ---------------

Physicians per 1,000 population Ratio of nurses and midwives to physicians

5

5

6

4

43

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2

1 1

0 0

ABC

D

E

FG

H

A B C D E F G H A B C D E F G H

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Discussion with participants

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The importance of capital investments

Give One Example Each, for Human Resources, Infrastructure and Equipment, of How Investment

Decisions Matter for RH Services and Outcomes

Capital Investment Impact on Health Services

Infrastructures        

Equipment       

Human Resources        

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Break

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Case example: Stormy Atmosphere at the Boutima Center

• Real life case (2000)

• Focus on human resources issues

• 25 minutes discussion in small groups

• Plenary discussion facilitated by Eva

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Stormy Atmosphere at the Boutima Center

• Identification of HR problems

• Individual, organizational, systemic factors contributing to those problems

• Based on your experience, what would you suggest to change ?

Problem Causes/Contributing factors

Action

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Synthesis

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Typical input problems (1)

• Over/under supply

• Inadequate mix

• Imbalances: regional, institutional, gender

• Relevance of education

• Variations in quality

• No continuing education

• Neglected areas

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Typical input problems(2)

• Low productivity

• Quality maintenance

• Over use of doctors and hospitals

• Poor management

• Absence of control of resources

• Systems of incentives

• Low remuneration

• Multi-employment

• Career prospects

• Labor relations

• Low satisfaction

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Take-home Messages

Inputs are critical to the production of appropriate services

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Take-home Messages

• Inputs are critical to the production of appropriate services

Decisions are complex, difficult, not to be left to the market

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Decisions About Inputs Are

Difficult, Because …• Health services comprise a wide and

complex range of services

• Need to find the right combination

• Decisions have long lasting effects

• Information is scarce

• High political contents

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Take-home Messages

• Inputs are critical to the production of appropriate services

• Decisions are complex, difficult, not to be left to the market

There are tools which can help make better decisions

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Tools/Strategies to improve decisions relative to inputs (Stock)

• Data collection and projections

• Regulation of the stock of providers: intake (numbers, profile), surpluses and shortages

• Deployment: incentives (access to training, to information, family-friendly measures), removal of disincentives

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Tools/Strategies to improve decisions relative to inputs (competencies)

• Philosophy of education: community-oriented programs (e.G., UNI program in LA)

• Methods: problem-based and competency-based learning

• Incentives in favor of continuing education

• Accreditation of programs and schools

• Certification and (re?), Licensure of providers

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Tools/Strategies to improve decisions relative to inputs (management)

• Economic, professional incentives

• Professionalization of management

• Delegation, substitution, team work

• Quality assurance and improvement

• Accreditation of institutions and regulation of individual providers

• Workers’ participation in definition of working conditions

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Take-home Messages

• Inputs are critical to the production of appropriate services

• Decisions are complex, difficult, not to be left to the market

• There are tools which can help make better decisions

Policies, decisions, practices relating to inputs to be subordinated to services objectives

Needs/ Objectives/Outcomes

Health needs Health outcomes

Services needs Services objectives

Inputs needs Inputs objectives

(Source: Pineault. Daveluy, 1995)

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Take-home Messages (HR)

HR issues must be addressed in all their dimensions: planning, education/training, deployment, management

HR policies and practices are transversal, not vertical

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