Delivering Health Services

In the previous lectures we were discussing the various influences on health and the role of the health system in achieving universal health coverage. There are many influences on people’s health, not only within the, the health sector, but also other sectors  concerning agriculture, education, water and sanitation, housing, income levels. So the broad health system includes all those social determinants of health, which those of us interested in improving public health must get involved in. However, it clearly is the case that the health sector, delivering health services has an impact on people’s health[1]. And the whole movement towards universal health coverage recognizes this. In stressing that people should be covered by a broad spectrum of health services from preventive health services to curative services, rehabilitative services, and palliative care for people’s ends of lives. And it’s also important that we look not only at people consuming services, but that this is a mechanism to them reducing impoverishment. Now looking at the way that health services impact on health outcomes, one would have thought intuitively, it’s the case that the more that people consume health services, the better impact there is on health outcomes. But surprisingly, the, the evidence on, on that score has been relatively limited. But recently some pioneering research done by Peter Smith and Rodrigo Moreno-Serra, written up in, in The Lancet showed that in a 153 countries, countries that have higher coverage of services actually do indeed have better health indicators, lower mortality rates. Also, more recent research has showed that rapid reductions in child mortality in Africa in the last decade were largely due to scaled up health service coverage. And in particular, coverage of one preventive health measure of mass distributions of bed nets to, to counteract malaria. So literally children being covered by these important preventive health measures has reduced mortality. Now WHO have done more work looking at the way that the health system functions and how health services impact on health outcomes. And building on their previous work, they now identify six basic building blocks or functions that lead to improved performance. Firstly, the leadership and governance issue that I’ll describe in a subsequent lecture. Then around the information that is required to run the health sector efficiently. Also, health workforce and human resources for health, vital inputs to running health systems properly. Medicines and medical products and technologies are also vital elements in the armory in improving health system performance. Combining those inputs efficiently through improved service delivery is another key function of the health system. And finally and I’ll deal with this topic in another lecture, financing the health system, another key function that needs to be taken into account. WHO and many in the public health world also emphasize the vital importance of primary healthcare in improving health systems. And here we’re talking about essential healthcare based on values of universal access, equity, participation and intersectoral action, working with other sectors that impact on health. With this particular emphasis on the primary or first contact level where people first interact with the overall health system. So looking at service delivery, we’re really talking about how these inputs are organized and managed to ensure improved access to services, that services are of good quality, that they’re safe for people to consume. And also that there’s a continuity of care across services as people interact with the health system. So for example, making a primary healthcare contact, being referred to more specialist care, and then maybe continuing rehabilitative care back in the community. But it’s not just really about the supply side. We should also be concerned about raising appropriate demand for services so people access services when they need them. But also that people don’t inappropriately use services. For example, consuming antibiotics when they don’t need them. It’s vital too that the services are integrated. And as you can see, there’s a broad spectrum of services and it’s important that all the elements work well together and efficiently together. Government should also be concerned about the overall management of the provider network and making sure that it’s supervised properly and people doing the jobs that they’re meant to do and not providing inappropriate services or for example, charging for services that they shouldn’t be doing. And finally the other important element is making sure that the whole infrastructure is organized properly and distributed so that everyone can benefit from the health services that they need. And that the logistical systems work so that medicines are, are available in the health centers and health workers are paid on time. And mentioning health workers, one of the key inputs and functions of the, of the system that I was mentioning with human resources for health, which WHO identified recently as what they regard as the most important input for the health system. One of the main reasons for this is it’s the most costly and typically governments are spending over 50% of their health expenditure on human resources. And it’s vital for an effectively running health system. But unfortunately in many countries the, the availability of health workers is inadequate. And in fact 83 countries have been identified as not having the basic minimum of around 23 skilled health workers per 10,000 population. So it’s very important that we scale up the availability of qualified health workers and improved their distribution across the country so that health workers aren’t just working in say urban centers, catering for the elite but are reaching populations right across the country. It’s also important that there’s an appropriate skill mix between you know the different professions of doctors and nurses and midwives and ancillary staff as well. And maybe the countries you know trying to improve the efficiency of the system should look to shift tasks that can be done by lower paid workers and free up time for specialists to do the services that they’re trained to do. Now in ensuring that the health workers are you know working efficiently and safely, it’s very important that they’re trained adequately, both before they start their work, but also that there’s regular in service training so people are kept up to date with the developments in their field. And the whole health workforce requires extensive management of the health labor market and governments to be involved in the recruitment of health workers, retaining them and making sure that they’re working in places where they benefit the population, providing incentives for them to do the correct work and you know making sure that they don’t do things that are going to adversely affect people’s health. And this also requires keen supervision of the work that health workers do and making sure that when health workers don’t behave appropriately, that there are sanctions as well. Now one area that, that a number of countries are looking to expand is, is that of community health workers to insure that health services really do reach remote rural populations. Community health workers are usually recruited from local communities and provide particularly primary healthcare services, both of preventive and curative nature as well. And it’s been estimated there are around 1.3 million community health workers at the moment and there’s a growing campaign for there being lots of more of the community health workers. Some very good examples of those have been in China where there are the famous barefoot doctors program which started in the 1960s and ’70s, was very effective and efficient way of getting primary healthcare services to rural populations. More recently in Ethiopia, they’ve recruited over 30,000 community health workers and they’ve been extremely effective in improving child health outcomes and indeed Ethiopia is on track to achieve its child health MDGs. Another very important area is insuring that there are efficient health information systems, because the generation in strategic use of information is an integral part of the stewardship function. It’s practically impossible to run an efficient health system if you don’t know what’s going on and you therefore need good information. So countries need to generate both population data about the health status and health needs of the population, but also information on the way that the health system is responding and facility based data, tracking where people are being treated and whether these services are having an impact. And there are a number of ways of generating this information through censuses, surveys, civil registration systems, public health surveillance systems, medical records and also, systems that measure the performance of health units. Now one area where it’s obviously vital to be detecting and using information is, is that looking at public health security. And the recent Ebola outbreak in West Africa is a very good example of needing rapid information about the spread of communicable disease. But it’s also vitally important that in generating all this information, that it’s synthesized and used strategically. And therefore that the management really uses this information to change systems performance. And finally, when one looks at service delivery and improving services, it’s vital to address the issue of the quality of services, because just measuring whether people come to an outpatient clinic or they deliver their babies in a health unit, isn’t good enough, because these services will only have an impact on people’s health if they are effective, they work. And therefore they must be of good quality. And in measuring the quality of services, it’s also not just good enough to look at the technical quality, whether the medicines work, but also there’s vital elements about the consumer’s perception of quality. Are they treated with dignity? Are they seen on time? Those more sort of customer friendly aspects. Because unless health systems look at those, those customer perceptions, people simply won’t go to the health facilities and use the services and therefore they’ll be useless in impacting people’s health.

[1] http://www.capacityproject.org/framework/

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