1. Harvard School of Public Health
Objectives and Policy Process of Health Reforms: The Harvard/Flagship Approach
Thomas Bossert, Ph.D.
Harvard School of Public Health
Russian ????
December 15, 2009

2. Why Objectives are Important
Many reforms begin with the solution rather than the problem:
“We need social health insurance.”
“We need pay for performance”
“We just need more money.”
Before this makes sense we need to ask:
“What are the problems we want to solve?”
4/25/2019
Flagship Approach Russia

3. Harvard’s definition of Objectives
Like most involved in public health:
Improve health status of priority health problems
However we are also concerned with:
Assuring the patients and the public are satisfied with the services they receive
We reduce financial risk of those who get sick
4/25/2019
Flagship Approach Russia

4. Why public satisfaction?
Legitimacy of the health system is needed for public to support it
Devote taxes to solve health problems
Willingness to pay for services that are valued
If people are not satisfied they tend not to do thing that care for or promote their own health (our first objective)
4/25/2019
Flagship Approach Russia

5. Why reduce financial risk?
Risk of illness is not evenly distributed throughout the population
People are willing to spend for care:
If free public services are not seen as having needed quality
Even if they are poor
Often will go into bankruptcy and become a drag on the economy
4/25/2019
Flagship Approach Russia

6. Out of Pocket Payments and Poverty in Bangladesh
Van Doorslaer et. al. The Lancet 2006
4/25/2019
Flagship Approach Russia

7. Intermediate Objectives
Access
Efficiency
Quality
4/25/2019
Flagship Approach Russia

8. Objectives become “problems to solve”
But first we need to identify the “causes of the problems”
We use a “diagnostic tree” to identify the causes of specific problems
Asking “why” four or five times
Only then can we begin to think of what the solutions are:
Policy changes that will address the causes of problems
4/25/2019
Flagship Approach Russia

9. Example: High Maternal Mortality
Unhealthy/high-risk behavior(s)
Performance problem
High Maternal Mortality
Inadequate health care
Chronic diseases
Broad Cause(s)
4/25/2019
4/25/2019
Bossert Diagnostic Tree
Flagship Approach Russia 9

10. Broad Cause of High Maternal Mortality: Inadequate Health Care
Poor clinical quality of care
Insufficient quantity of services consumed
Broad Cause
Next linked cause(s)
4/25/2019
4/25/2019
Bossert Diagnostic Tree
Flagship Approach Russia 10

11. Poor Clinical Quality of Care
Next Linked Causes:
Poor Clinical Quality of Care
Inadequate skill or decision making
Poor clinical quality of care
Lack of equipment and supplies
Organization of services
Next linked cause
Further linked problems and causes
4/25/2019
4/25/2019
Bossert Diagnostic Tree
Flagship Approach Russia 11

12. Further Linked Problems and Causes
Poor Training
Inadequate skill or decision making
Lack of Motivation
Insufficient total resources
Lack of equipment and supplies
Inappropriate allocation of resources
Institutional incentives
Organization of services
Poor Management
Organizational Design
4/25/2019
4/25/2019
Bossert Diagnostic Tree
Flagship Approach Russia 12

13. An Illustration of Means, Intermediate and Ultimate Objectives
Health Status
Financing
Payment
Organization
Regulation
Persuasion
Access
Quality
Efficiency
Public Satisfaction
Financial Risk
Protection
Equity
4/25/2019
Flagship Approach Russia

14. Overview of the “Control Knobs”
Financing
Payment
Organization
Regulation
Persuasion and Behaviour Change
4/25/2019
Flagship Approach Russia

15. The Financing Control Knob
Each option can be seen as an “ideal type”
General revenue
Social insurance
Private insurance
Out-of-pocket payment
Community financing
International aid
Many real systems depart from any one “ideal type”
Most nations use a mix of financing options
4/25/2019
Flagship Approach Russia

16. The Payment Control Knob
Every payment system includes a unit or basis
for payment and a rate
Payment options
Hospitals
Patient day
Admission
Global budget
Line item budget
Fee for service
Doctors
Fee for service
Salary
Salary plus bonus
Capitation
Capitation plus bonus
4/25/2019
Flagship Approach Russia

17. The Organization Control Knob
Macro level
who does what; the set of delivery organizations and their functions
the interactions among those organizations
the incentives these interactions create
Micro level
internal structure of delivery organizations
Policymakers have only a limited capacity to make changes inside delivery organizations outside the public sector
4/25/2019
Flagship Approach Russia

18. The Regulation Control Knob
The use of the coercive power of the State to get actors in the health sector to change their behaviour
This power may be delegated to non-state actors
Purposes of regulation
Establish markets
Protect consumers
Correct market failures
Achieve non-market goals
4/25/2019
Flagship Approach Russia

19. The Persuasion Control Knob
Both patient and provider behavior are relevant—political persuasion is a different issue
Many possible communication channels: free media, paid media, individual contact, groups, big events, etc.
Information alone does not change behavior. Messages need to be sophisticated as advocated by “social marketing”
4/25/2019
Flagship Approach Russia

20. Reaching A Political Decision
Health sector reform is unavoidably political
Politics matters throughout
Doing better requires political skill, not just political will
Stakeholder analysis is a starting point
Successful reformers move from “mapping” politics to strategies to affect politics
4/25/2019
Flagship Approach Russia

21. Flagship Approach Russia
4/25/2019
Flagship Approach Russia

22. Flagship Approach Russia
4/25/2019
Flagship Approach Russia

23. Flagship Approach Russia
Rationing of Care
One of the major problems in most reforms is how to prioritize some health problems over others
All systems have to ration:
There is never enough money
Ration by price – free market but hard on the poor
Ration by waiting lines or informal preferences for specific elites
Explicit rationing – social insurance coverage only for priority problems (other problems covered by out of pocket payment in market)
4/25/2019
Flagship Approach Russia

24. Health Status Priorities
Use “burden of disease” to determine which health problems cause the most loss of life (and disability) – Using Disability Adjusted Life Years (DALYs) methods
Cost Effective Interventions – choose the interventions that maximize the impact on total DALYs
4/25/2019
Flagship Approach Russia

25. Limited Benefits Packages
Select the most cost effective interventions that maximize the DALYs within the budget allowed by tax or social insurance financing.
Priority list of interventions and their estimated costs with cut off depending on total budget available
4/25/2019
Flagship Approach Russia

26. Limited Benefits vs. Guaranteed Benefits
Most systems use limited benefits packages which leaves out some health problems and causes financial risk and public dissatisfaction
Chile introduced a “guaranteed benefits package” which prioritizes but does not exclude
4/25/2019
Flagship Approach Russia

27. Chilean Alternative: AUGE
Costing a BP: Chile’s case 27
Chilean Alternative: AUGE
Universal Access with Explicit Guarantees (Acceso Universal con Garantías Explicitas)
Explicit Benefits Package with 4 kinds of guarantees to nearly all citizens:
Access to treatment for 56 common health problems
Treatment according to strict clinical protocols.
Treatment available with maximum waiting times.
Copayment < a certain % of the household monthly income.
4/25/2019
Flagship Approach Russia

28. Examples of 56 Health Problems
High cost chronic problems like:
End-stage chronic renal failure
Variety of Cancers and Heart Disease
HIV/AIDS
Common problems of elderly
Cataract surgery
Hip replacement
Common Primary Care
Ambulatory care lower ARI (under 5 years of age)
Prevention and education for oral health (6 years old)
Mental Health
Schizophrenia
4/25/2019
Flagship Approach Russia

29. Quality and Timeliness Guarantees
Quality: Each health problem has a specific protocol developed in a process of reviewing clinical guidelines and adjusting to available human and technical resources – designed to be as high quality as is realistic in Chilean conditions.
Timeliness: Protocols have maximum times for diagnosis, treatment and follow-up. If provider fails to meet the timing, it is required to pay an alternative provider.
4/25/2019
Flagship Approach Russia

30. Process of AUGE Priority Setting
Implementation issues 30
Process of AUGE Priority Setting
1. Importance according to burden of disease
2. High cost effectiveness of available treatment
3. Realistic Capacity of Health system to Provide treatments
4. Importance of financial burden to households
5. Social consensus on priorities
Included in the current AUGE plan
4/25/2019
Flagship Approach Russia

31. Flagship Approach Russia
Results in Chile
Significant increase in cataract surgery
Reduction in mortality from heart attacks
Public opinion of AUGE is very high
Decrease in population using private insurance
Rise in opposition from medical association and parliamentary opposition
Survey in 2010 expected to give evidence of impact on outcomes
President Bachelet wants to increase AUGE conditions to 80
4/25/2019
Flagship Approach Russia

32. Flagship Approach Russia
Lessons for Russia
Start with objectives/problems, not with solutions
Specify the causes of your problems
Think through the most effective combination of “control knobs” for addressing the causes of problems
Involve the stakeholders to build political support
Consider the issues of rationing and options that maximize health status, financial protection and public satisfaction.
4/25/2019
Flagship Approach Russia