Faculty of Medicine - PowerPoint Presentation

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Faculty of Medicine Public Health (31505291) الصحة العامةLecture 18Health policy and management, Health priorities

By Hatim JaberMD MPH JBCM PhD5-8 -2018

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The global health impact of mental health and mental diseases. Drug abuse and Addictive substancesGlobal overview of communicable diseases Global overview Non- Communicable Diseases(NCDs) The global health impact of Hepatitis, Tuberculosis and HIV/AIDS The global health impact of Cardiovascular Diseases , Diabetes and ObesityHealth policy and management, Health prioritiesHealth policies and management within a global health perspectiveHealthcare service delivery in developed and developing countries

Healthcare systems and financing Quality of care and effectiveness in different health services systemsViolence and Injuries Migration and Travelers' healthSlide3

Presentation outlineTimeIntroduction of concepts :General Concepts in Management Sciences

09:15 to 09:25Health Systems and Policies Introduction to Health Systems

09:25 to 09:35

Health Systems and Policies Introduction to Health policies

09: 35 to 09:40

Making Public Health Policies

09:40 to 09:50

Health priorities09:50 to 10:15

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Definition of AdministrationWe can define sound administration as:“ The process of achieving defined goals at a defined time through the guidance, leadership, and control of the efforts of a group of individuals and the efficient utilization of non-human resources bearing in mind

adequacy, speed, and economy to the utmost possible level.”4Slide5

Health Administration Sound administration is essential for the success of any public health program whether on the national, intermediate or the local level. 5Slide6

Elements of Administration:PlanningOrganizationStaffingDirectingCoordinatingReportingBudgeting

Supervising Evaluation6Slide7

Levels of Administration

CentrallevelIntermediatelevel

Local Level

Ministry of health

directorates of health

e.g. health office,

Hospital, health

care unit

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ManagementManagement is the operational part of administration.It is defined as:“ It is a set of interactive processes through which the utilization of resources results in the

accomplishment of organization objectives.”It is through “management” that the objectives of the health care organization are achieved by gathering and positioning of resources

.It is a

“

conversion mechanism

”

.

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10Definitions and conceptsMANAGEMENT is both a SCIENCE and ARTAs a SCIENCE, management has basic rules and principles.As an ART, successful managers learn through experience, they follow

flexible, adaptive, innovative approaches to fulfill objectives.Slide11

11DefinitionsManagement is getting things effectively done to achieve desired objectives through proper planning, efficient implementation and evaluation to identify the needs for re-planning.Management is thus a dynamic

process.Slide12

12Effectiveness is the degree to which a stated objective is being achieved.Efficiency is the optimized (balanced) use of resources (Human resources, equipment, supplies, money, space, time & information). Slide13

13DefinitionsManagement is a decision making process translating the policies into plans, implementing t

hose plans, and evaluate the plans and the interventions to re-plan to achieve better results Slide14

Good ManagementHighlights prioritiesAdapts services to needs and to changing situations (dynamic)Makes most of limited resourcesImproves the standard and quality of servicesMaintains high staff morale14Slide15

PRINCIPLES OF MANAGEMENTManagement by objectives: Setting targets (goals and objectives) Learning from experience Teamwork Proper use of resources Putting priorities

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16Management Process I. Planning II. Implementation:OrganizingStaffingLeading/Directing

Controlling /Monitoring III. EvaluationSlide17

A systems view of management

Process

Inputs

Outputs

Human resources

Non-human resources

Conversion

mechanism

Objectives

achievement

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18Management SkillsTechnical skillsHuman skillsConceptual skills+Political skills

Technical skills

Mainly firs

level

Human / interpersonal skills

All levelsConceptual skills

Mainly top levelSlide19

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Health Care Management 1. A Health Care System and its components (Macro level)2. Levels of Health care, and the main approaches to health care provision, in addition to Resources, and Financing.

3. Introduction to Management in health care organizations (Micro level ).4. The Four Functions of Management: Planning, Organizing, Leading and Controlling. Slide21

Health Policy DefinedHealth policies are public policies or authoritative decisions that pertain to health or influence the pursuit of healthHealth policies affect or influence groups or classes of individuals or organizationsSlide22

Public vs. Private PolicymakingPublic PolicyPolicy that is established by the federal, state, and local levels of governmentPrivate PolicyPolicy that is established by private organizationsFor example, MCOs and JCAHOSlide23

Forms of Health PoliciesThere are five main forms of health policiesLawsRules/RegulationsOperational DecisionsJudicial DecisionsMacro PoliciesSlide24

Macro PoliciesMacro policies are broad and expansive and help shape a society’s pursuit of health in fundamental waysExample FDA regulation of pharmaceuticalsSlide25

Public health policies are grouped into two categories1-Allocative2-Regulatory1-Allocative PoliciesDesigned to provide net benefits to some distinct group of class of individuals or organizations, at the expense of others(?), in order to ensure that public objectives are metIn general, allocative policies come in the form of subsidiesExamplesMedicare and Medicaid policies, Federal aid to medical schoolsSlide26

2-Regulatory PoliciesPolicies designed to influence the actions, behaviors, and decisions of others to ensure that public objectives are metFive main categories of regulatory policiesSocial regulations :Environmental protection, Childhood immunization requirements, No smokingQuality controls on the provision of health services: FDA regulation of pharmaceuticals, New Pay for Performance (P4P) regulationsMarket-entry decisions: Certificate of Need programs Physician credentialing (Hospital privileges)Rate or price-setting controls on health service

providers :The federal government’s control of the rates of reimbursement to hospitals that participate in the Medicare programMarket-preserving controls: Antitrust legislation

Public health policies are grouped into two categories

1-Allocative

2-RegulatorySlide27

WHO Supportan increase in effective services to all people in need, including service delivery management and support improved patient safety, efficacy of services and financial protection increased efficiency and building of financial, human, institutional, and knowledge capacities coordinated, participatory and accountable policy formulation and implementation. Slide28

Where is the problem?Problems with health systems are not confined to poor countries. Some rich countries have large populations without access to care because of inequitable arrangements for social protection. Others are struggling with escalating costs because of inefficient use of resources.Slide29

Planning cycle1- Analysis of health situation. Involve collection ,assessment and interpretation of information to provide a clear picture of health situation eg. population structure , mortality , morbidity , Epidemiological and geographical distribution ,medical care facilities , hospital or PHC and man power to defined the problem

2- Establishment of objectives and goals. Objective must be established at all level .3- Assessment of resources.

Man power , money , material , skills , knowledge.Slide30

4- Fixing priorities. Once the problem, resources and objectives have been determined, the second most important step in planning is establishment of priorities according to many factors for example : magnitude , resources, cost, time needed, mortality , morbidity, political and community interests and pressures . 5- Write up of formulated plan.

preparation of the detailed plan or plans . For each proposed health progamme , the resources (input) required are related to the results (output) expected. 6-Programming and implementation. Once the health plan has been selected and a proved programming and implementation are begunSlide31

7- Monitoring · Monitoring refers to the assessment of the day to day functioning of theprogram· Any suggestions for improvement should be implemented8- Evaluation· Evaluation refers to the assessment of the final outcome of the plan· A good plan should have an in built evaluation systemSlide32

Prioritization in HealthcareSlide33

Prioritization in HealthcarePriority-setting is the act of deciding which health interventions to carry out, and can occur at several levels of granularity.Slide34

What is Priority Setting?Process of assigning rank ordersIndividual disease or health states and interventions or approaches

To mitigate specific health situations,Based on their relative contribution to quality of life, and cost effectiveness of interventions.

Complex calculations are complex and

Often fraught with controversiesSlide35

Priority Setting — ConceptsPrecedence, established by order of importance or urgency.Establishment of the order of precedenceRationing and Resource AllocationRationing - Taking care of existing demands when the supply of resources constrainedResource allocation —

Limited resources (time, money) invested systematicallySlide36

Priority-setting can occur at the following levelshealth budget level (i.e. deciding how much to spend on health overall)overall strategy level (i.e. selective primary healthcare  versus primary healthcare versus more general health systems strengthening)disease level

(i.e. deciding which disease to alleviate)intervention level within each disease (i.e. restricting to a specific disease and prioritizing among interventions for that disease)drug levelresearch level (i.e. which health research to carry out)Slide37

In global health, priority-setting is a term used for the process and strategy of deciding which health interventions to carry out. Priority-setting can be conducted at: the disease level (i.e. deciding which disease to alleviate), the overall strategy level (i.e. selective primary healthcare versus primary healthcare versus more general health systems strengthening),

research level (i.e. which health research to carry outSlide38

How to compare interventions Various metrics have been used to compare interventions. These include:Disability-adjusted life year per unit cost (used by e.g. Disease Control Priorities Project), quality-adjusted life year, and other forms of cost-effectiveness analysisReasons that the disease burden has persistedAdequacy of fundingSlide39

Who sets the priorities?Priority-setting can be done by various actors. These include:Governments: "In most countries, health spending by governments vastly outpaces international health aid, so governments set most health priorities."Non-profits and companies that assist governmentsIf a country is using a Health in All Policy (HiAP) approach, then priority-setting is done by stakeholders who do not directly deal with health.International organizationsFoundationsPrivate donors (including 

high-net-worth individuals and ultra-high-net-worth individuals): "A common outcome is a negotiated set of priorities that reflect some domestic needs and some technical, political, and economic considerations defined largely by the interests of donors."[6] In some highly aid-dependent countries, donors "have huge influence on health priorities".[8]According to Devi Sridhar, professor of global health at the University of Edinburgh,“ the priorities of funding bodies largely dictate what health

issues and diseases are studied"Slide40
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Priority setting in healthcare= OverviewRationing in healthcareEconomic approach to setting prioritiesEquity & fair inningsSlide42

Seven forms of rationing By Denial: Patients denied care they need, for example, deemed unsuitable or not urgent enoughBy Selection: Patients selected because of characteristics, for example, most likely to benefit from treatmentBy Deflection:

Patients encouraged or turned towards another service, for example, private careBy Deterrence: Patients deterred from seeking care, for example, barriers or costs put in place or not removed.By Delay:

Needs not met immediately, for example, wait for appointments or waiting-lists.By Dilution:

Services

given to all but amount given reduced

, for example, general practitioner consultants.

By Termination: System no longer treats certain patients, for example, cessation of cancer treatmentSlide43

Nature of PrioritizationCore Issues are Political and EthicalHow Resources, Rights, and Responsibilities are distributed.Political considerations underpin why implement validated technical interventions are difficultSlide44

Alternatives to PrioritizationAdd More ResourcesTake out ServicesSlide45

Why Prioritize When Adding Resources Might Work?Assure donors to maintain or increase the flow of fundsPrioritization can itself increase resourcesPrioritization is needed if we are to know that prioritization is insufficientMost important when there is little money

Risk of Spending Too Much on Tertiary Care: Poor Spending PatternUnfunded Primary Care —> Lethal in the poorest countriesSlide46

Challenges of PrioritizationResources are limitedImpossible to provide everyone with every effective interventionLimited resources and unlimited demandsJustice and efficiency

Lack of ConsensusLittle interaction about priority setting among decision makersSlide47

PointsMultiplicity of priorities andLack of institutional mechanisms to rationalize services and spending often results inPoor overall system performance,Low coverage for highly cost-effective health technologiesSlide48

Factors Considered for Priority Setting ExercisesBurden of DiseaseCost effectiveness of InterventionsEquityExisting Capacity to DeliverRisk Pooling :

Some health conditions are rare and too costly for most uninsured individuals to pay out-of-pocketSlide49

Best PracticesUse recent dataAnalysis should be country specificBe based on a well functioning and representative set of information systemsRank Order by Burden and by population subgroup in order to provide useful advocacy information for the different groups

Build Flexibility in BudgetBuild Linkages across servicesEnsure Sufficient time and resources to deliver the interventionsSlide50

DilemmaImagine you have only $1000 to spare to pay for treatmentWho will get treatment?$1000 to Spend

Child with

appendicitis needs an urgent

surgery, overall cost $1000 out of your pocket

You need to

get a root canal treatment done

for a cavity in your tooth

Cosmetic surgery (skin grafting) to cover an old burn scarSlide51

Parent with Three ChildrenYou see a parent. He has diabetes for which he takes medicines, on a diet, and exercise. He works at an office (junior management) and is the sole earning member of the family. They have three children: one suffers from Chronic Asthma and needs regular medication, the second has a congenital heart disease and will need surgery soon, and the

third just got diagnosed with tonsillitis and the doctor wants him operated urgently.What will be your advice to the parent to manage this?Slide52

Clinic DirectorX has set up a clinic around Irbid (an upscale yet recent immigrant dense neighbour hood). The population that the clinic serves is aging (60% above 65 years and 40% are young families (35 years average age with two kids). X wants to set up a suite of services to offer to this community but has resource limitations. What mix of services you will advise him?Slide53

Range of ServicesY is a consultant and wants to work in areas of public health and preventive health services at a rural township where a large farming community exists. The average age of the population is about 55 years, most are locally based farmers, or work in sheep shearing sheds, or have work with farming machineries.With Limited Budget, what kind of services would you advise Y to plan for? Slide54

How to Play GodZ is a venture capitalist and just got an offer from the Bill and Melinda Gates foundation that he has 5 million dollars to spend but has to pick ONLY two disease control/prevention/public health issues in Mafraq . Z comes to you for advice.What will you advise Z? Slide55

Conclusions and CommentsPriority Setting As Balance Between Resources and DemandsNecessary for Best Allocation of ResourcesFrameworks Provide Good Structures to Achieve PrioritizationDiscussions and Comments?