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

2. 2 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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4. 4 Why Discuss Inputs ?  This is where the money goes: –Capital/ recurrent expenditures –Personnel –Infrastructures –Equipment –Consumables … And there are opportunity costs

5. 5 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

6. 6 Health system inputs, from financial resources to health interventions. Source: World Health Report 2000, p. 75

7. 7 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

8. 8 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)

9. 9 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

10. 10 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

11. 11 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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13. 13 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

14. 14 Allocation of Health Budget Type of expenditure CapitalRecurrent Personnel ? 60-90% Infrastructures/ equipment 5-40%0-15% Consumables ---- 10-25%

15. 15 024681012 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 populationRatio of nurses and midwives to physicians 5 5 6 4 4 3 3 2 2 1 1 00 ABCDEFGHABCDEFGH A B C D E F G H

16. 16 Discussion with participants

17. 17 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

18. Capital Investment Impact on Health Services Infrastructures Equipment Human Resources

19. 19 Break

20. 20 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

21. 21 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 ?

22. The Boutima Center Problem Causes/Contributing factors Action

23. 23 Synthesis

24. 24 Typical input problems (1) Over/under supply Inadequate mix Imbalances: regional, institutional, gender Relevance of education Variations in quality No continuing education Neglected areas

25. 25 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

26. 26 Take-home Messages  Inputs are critical to the production of appropriate services

27. 27 Take-home Messages Inputs are critical to the production of appropriate services  Decisions are complex, difficult, not to be left to the market

28. 28 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

29. 29 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

30. 30 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

31. 31 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

32. 32 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

33. 33 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

34. Needs/ Objectives/Outcomes Health needsHealth outcomes Services needsServices objectives Inputs needsInputs objectives (Source: Pineault. Daveluy, 1995)

35. 35 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

36. 36