Introduction to the Flagship Framework Marc J. Roberts Professor of Political Economy and Health Policy Harvard School of Public Health Africa Flagship Kigali, June 21, 2010

The Flagship Framework is Action Oriented It offers a way to think about health systems designed to support reform efforts So two of the key components are: The things policy makers can change—the “Control Knobs” The results policy makers are seeking to achieve— the “Ultimate Outcomes” of health status, citizen satisfaction and risk protection

The Flagship Framework Calls Attention to the Role of Values All reformers do not agree on goals and priorities Deciding what goals to pursue is not a purely technical matter Instead it is also a matter of ethics and politics The flagship framework therefore: Considers various ethical and philosophical views Explores how politics works, and how it can be used by reformers to achieve their goals

The Flagship Framework Encourages Critical Thinking It begins by asking “What is the problem?”—that is, what is it about the performance of the health system that needs improvement It proceeds to an explicit diagnostic analysis– designed to clarify the causes of the identified problem It fosters the use of evidence in choosing and designing solutions

The Flagship Framework Fosters Conceptual Clarity The framework calls attention to the need to define key terms It clarifies that some system characteristics are intermediate goals– not ends-in-themselves but important causes of ultimate performance Efficiency Quality Access

The Flagship Framework Respects Variations Among Countries The framework assumes that variations in economic, social and political factors will influence a policy’s impact International experience must be joined with local knowledge to design effective interventions Thus all advice should be “conditional” on local circumstances

The Flagship Framework Presumes That Details Matter in Policy Design The “within policy” variation in impact, as a result of the details of policy design, can be greater that the “among policy” variation Thus choosing a broad reform approach is not enough—”The Devil is in the Details” Some examples: The impact of a pay for performance scheme will depend on how performance is measured The risk protection provided by an insurance scheme will depend on the design of the benefit package

The Flagship Framework Recognizes the Importance of Implementation Much of the “within policy” variation in impact comes from variations in implementation Such variations are due to variations in: Agency leadership -- Available resources Technical expertise -- Institutional design Political support -- Stakeholder response Reformers thus must consider implementation issues in a program’s design, and be prepared to monitor and manage its implementation

The Flagship Framework Emphasizes the Need for Evaluation Evaluation may influence program design—experimental or demonstration strategies Evaluation has to be a considered before implementation if appropriate data are to be collected Issues of data cost, quality and reliability need to be considered Program managers may need different (and more rapidly available) data than long-term evaluations provide

Why Think Systematically About Health Systems Reform? Clear thinking is more likely to produce good results Avoid unintended results Anticipate likely problems Clarify goals and priorities Facilitate accountability and transparency Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

Successful Reform Is Difficult The health system is complicated and poorly understood The consequences of policies are difficult to predict Doing better on one goal may mean doing worse on another Those who benefit from the system are powerful and resist change. Countries are limited by their economic and administrative capacity Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

The Health Reform Cycle IDENTIFY THE PROBLEM MONOTOR AND DIAGNOSE THE EVALUATE CAUSES IMPLEMENT DEVELOP A PLAN GET POLITICAL APPROVAL

Understanding the Health Reform Cycle The cycle is a description of what would/should happen in an ideal world Actual reform processes often begin with the solution rather than the problem Systematic analysis is often not done International consultants and agencies have their favorite recommendations “To a man with a hammer everything looks like a nail”

The Diagnostic Journey: Identifying the Causes of Problems Start with performance problems –that is undesirable outcomes Ask “why” five times Work “backwards”-- from causes, to causes of causes, and so on… Be “evidence based” Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

The Role Of Ethics In Problem Definition Deciding what aspects of performance matter is not just a technical question, it requires values Reforms always incorporate value judgments— whether implicitly or explicitly Public discussion about ethical principles may or may not be desirable from a political perspective Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

Developing Reform Strategies Strategies should be based on an explicit analysis of what can be changed and how performance is likely to change as a result Imitate but adapt – learn from others but consider local conditions The process of strategy develop may matter as much as the content Influences the political acceptability of the plan Influences the quality of the plan Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

The Health System “Control Knobs” Financing—where the money comes from Payment– how doctors, hospitals and other providers are compensated Organization—both the macro aspects of who does what and the micro aspects of internal managerial structures Regulation—coercive requirements imposed by the state Persuasion—efforts to influence both providers and consumers

Reaching A Political Decision Health sector reform is unavoidably political throughout the reform cycle Doing better requires political skill, not just political will Stakeholder analysis is a starting point Successful reformers move from “mapping” political force to develop strategies to affect political outcomes Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

For Obvious Reasons Many Reform Efforts are not Effectively Implemented Ministers and their staffs lack administrative experience and managerial sophistication Leaders turn over quickly Implementation – and its time and costs -- are not considered in program design Entrenched interests resist Political attention turns elsewhere Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

Why Does the Cycle Often Begin Again? Poor design or flawed implementation leads to unsatisfactory results Even successful reforms often create new problems Actors defend their interests in unanticipated ways Social, economic or political conditions change Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2

Health System Reform Requires Skills Many needed skills can be taught Skills are developed by practice Rules can help, but specific situations require judgment Learning requires effort and active participation Flagship Course: Cycle of Reform, Monday - October 29, 2007, Session 2