District Health system

Management:
Wed. 30.09.09
BEHS III

Mangwi R. Ayiasi
 Introduction
• How do you think the Museveni bush war was
organised and won?

• How was the 1979 Uganda Liberation war

executed?

• What strategies did both ‘liberation wars’

employ?
2
 Introduction...
• Have you ever been to hospital for any conditions?

• Have you ever attended to your relative or dear one at

hospital?

• What was your experience while in Hospital-what did you

like/dislike about the hospital, the people and the
treatment?

• What would you like to see done in the health care

setting?
3
 Think about this

• The trees versus the forest

• The disease in the person or... the person with
the disease
• Individual or people or communities

4
 Introductions

• In Europe life-expectancy started to drop

before antibiotics or vaccines
• Diseases have certain determinants:
– Ecological
– Social & Gender
– ....
5
 Introductions: Thinking about the poor
• Less likely to seek care
– Distance from health care
– Out-of-pocket expenditure & the poverty cycle!
• Susceptibility to ill health:
– Access to clean water

– Safe housing & medical care

– Information
– Adequate nutrition
6
 Content:
• History & Evolution of the health system-Global,
National
• & Definition (s) of the health system

• Goals and Principles of health systems

• Structure of the Health system

• The district Health System in Uganda
• Challenges of the health system
• Which ways to go in our health system
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 HS=A Quasi-Military Apparatus
 Just like any army aiming to win a battle, behind
them:
• The frontline fighters must be adequately trained,
informed, supplied, inspired and led
• Treat the population whom they are to protect well
• Teach the “civilians” how to protect themselves and
their families against ill health
• And to fairly share the burden of the war

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 The HS=A Quasi-Military Apparatus:
• “Fighting” Malaria, HIV & TB

• Immunisation “Campaign”

• “Combating” Small Pox

• “Elimination” of Polio, Measles

• “Silver bullets” against Cancer

• Likewise health workers can be considered “Frontline”

troops “defending” populations against disease

9
 History of Health systems:

• Throughout history health systems have existed

• People have always tried to keep healthy or attempt
to treat disease
• Traditional/Modern methods continue to co-exist
• Traditional medicines still main source of care: the
modern one not well understood, mistrust,
expensive, ....

10
 History of modern health system Uganda..

• Initially by the colonial masters

• Located in the urban areas
• Specifically to serve the colonialists and a few of
their workers and their families
• Health workers were initially the colonialists
• Later training of the indigenous to perform the
‘lowly’ work
• Wound dressers, medical assistants, assistant doctor
BUT NOT Medical Officer!
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 History...
• A few dispensaries and sub dispensaries

• Independence/post independence-maintained the

hospital structures with dispensaries

• More emphasis on hospitals less attention to

dispensaries-Sir Albert Cook Hospital

12
 History...
• Quarantine centres: Leprosy, SS,...
• Note that:
- Hospital maintenance is very costly
- But also most of our diseases burden could be
adequately managed at the health centres

13
 History...
• Globally, the realisation that disease killed more than
the many wars: American civil war, Crimean & Boers
wars
• Post WWI,II, Development of payment system-
Bismarck, National health services and spread to Rest
of Europe

• Importance to treat tropical diseases-following return

from Africa

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 History...

• Importance of the Political History of Uganda

right from the 1900 agreement
• Wars, armed conflicts & rebellions
• Destruction, hunger etc
• Introduction of Parallel political and
administrative structures-LC, RDC, CAO

15
 History-Reforms...

• Structural Adjustment Program-SAPs

- Introduction of User fees/Abolition
- own-sizing the public service
• Donor Funding-New Money
- Aid alignment-Paris Declaration
• Decentralisation strategy
- Fiscal decentralisation strategy-FDS
- Local councils-I-V

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 Changing landscapes-Today’s Health Systems
• Financing mechanisms-US-The Obama health reforms
• Africa-User fees, abolition, exemption; Asia equity funds
in Cambodia, Community health Insurance; Social health
insurance in Africa & Asia
• Social Health Insurance (SHI)
• Migration of health workers-Brain Drain
• Aid Alignment-Budget Support, Sector Support
• Global Health Initiatives (GHI)

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 Health system-definition
• All actors,..
• institutions,...
• resources that undertake...
• health actions-with the primary intent...
• to improve health.
• Broader than the health actions typically under the
direct control of a health ministry

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 Principles of the health system-PHC
• Equity, Universal access, Community
Participation, Inter-sectoral Approaches
• Account for a broader Population Health issues
• Conditions for effective provision of services to
the poor and excluded groups
• Provision of integrated care
• Continuous evaluation for improvement

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 Health inequalities

• A child in Japan can not only expect to get reasonable

access to health care throughout her life,...

• but also to receive medicines worth, on average, $550

per year (and more if necessary)

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 Inequities of access in the Health System

• Inverse care:
– Rich-Poor
– Urban-Rural/Urban rich-Urban Poor (slum)
– Educated-Less/not Educated
– Male female
– Adult-children
– Politically Powerful-Powerless
– Ethnicity
– Minority communities

21
 Goal of the health system
• The ultimate goal of the health system is to improve
health-population,
• Reduce inequalities in population health
• Enhance the responsiveness of the health system-non
health expectations: respect of persons, client
orientation, inequalities within population
• Fairness in financial contributions-the poor paying
less; the rich paying more

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 Three Goals of the health system
 Improve health as a primary objective
• What about the Education sector?
• Road sector....?
• Water department?

23
 Fairness in $ contribution
 Fairness in financial contribution-Financial Protection
or economic sense “you get what you pay for!”
• Ill health is unpredictable, and costs are unpredictable
• Danger of exhausting all your savings/Assets to ill
health
• Catastrophic health care expenditure
• Who should pay for health care and how should this
payment be organised?

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 Responsiveness
 Responsiveness: Respect for:

• dignity,

• autonomy &

• confidentiality-

 A Social Goal!

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 A means to good health

 A Health system has to be utilised...but this will happen

only when it is:
• Accessible
• Affordable
• Acceptable
• Sustainable
• Of Good quality
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 Health systems functions

• 1. Financing
• 2. Service provision
• 3. Resource generation
• 4. Stewardship

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 1: Financing

• Revenue collection
• Pooling of finances
• Purchasing
• Consider the case of Uganda-how is the health system
financed?
• What could be the better option for financing?

28
 2: Health Service provision
• Combined inputs to allow delivery of interventions

– Personal: individual, diagnostic, rehabilitative

– Non-personal: collective-health education,
legislation or non-human-basic sanitation
• Formal and informal services
• Private or public service providers

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 2. Service provision

• Work Force and Incentives: Economic,

psychological, Social
• Essential Medicines-Supply chain
management
• Intelligence/Information Gathering-HMIS,
Surveillance
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 Service Provision: The Agent & Principal
• Definitions
– “The Principal” =the one who makes the request

– “The Agent”=the one requested

– “A Contract”=an offer by the principal to the

agent to offer incentives to perform a task

– Who is the ‘Principal’ & ‘Agent’ in Uganda?

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 3:Resource generation

• Workforce through-Educational institutions &

Research centre

• Buildings and Equipments/Construction firms

• Technology: pharmaceuticals, equipment

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 4: Stewardship

 Careful and responsible management of something

entrusted to ones care:

• Setting rules/Regulations

• Implementing the rules

• Monitoring the rules

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 4: Stewardship...

• Assuring a level playing-ground among all

actors
• Vision/Defining strategic directions for the
health system
• Intelligence gathering/information sharing

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Health systems function & Objectives

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 Nature of health systems

• Health systems are complex open systems

– Contain a high number of interdependent and
interacting components
– Interact also with elements from the
environment : highly context dependant
– Results of these multiple interactions are to some
extent unpredictable
36
 Health systems performance!!

• HS are constantly concerned about performance and

therefore efficiency!
• Resources are scarce-they have to be allocated
efficiently and utilised efficiently
• Numerous competing priorities-emerging (e.g.)
diseases, re-emerging diseases (e.g.)
• Strong demand from populations and governments

• Culminates in resources management

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 Health systems performance

• IMPACT &

• REACH

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 Health system performance

• Structure

• Process

• Output

• Outcome

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 Health systems Performance...??

• How much of the goals can the health system attain

with the given resources?
• How much can be demanded from the health system?
• How much has the health system achieved in terms of
the goals?
• How do they carry out their functions

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The Last Mile Problem
•High capacity
conduits
•Centralized
•Easily manipulated

•Low capacity
conduits
•Spatially disbursed
•Costly to access
 Health systems performances!!
• How can health systems be:
- Fair
- More inclusive
- More Equitable

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 Health Systems Performance!
• We still witness
- A mother die from complications of labour
- A child still missing immunisation
- Children being disabled by polio
- People dying from preventable RTA
- Impoverishment from high cost of
healthcare
- ...

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 Health systems performance
• Globally, there is improvement in population
health
• But, some countries are completely left
behind
– “The Bottom Billion!”
– Also inequalities within countries

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 Health systems Performances...

1. The overall level of health

2. Distribution of health in the population
3. Overall level of responsiveness
4. The distribution of responsiveness
5. The distribution of financial contribution
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 Efficiency as an absolute measure
• For example: Life expectancy of Sweden: Uganda
almost twice because Sweden spends about 35 times
more than Uganda

• But Pakistan: Uganda-Pakistan has 25 years higher

life expectancy yet they spend just about the same
amount per capita for health

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 Current challenges in the health systems

• Unstable and changing systems-Reforms

-Shifting roles between the centre and the
district & sub districts
- Conflicting roles-management & curative
services
• Increasing importance of the private sector-less
regulation
– Financing-commercialisation
• Globalisation-Migration of the workforce
– Inequity in workforce distribution
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A booming private sector-at the expense of the
pubic sector-’Marketosis!’

• Unregulated private sector-informal

privatisation
• From informal payment systems to cost
recovery
• “Services here are free, but please go and buy
these medicines”
• Moonlighting among public workers
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 ...A booming private sector

• Those who cannot afford are excluded

• Those who can afford may not necessarily get
the care they need
• Asymmetry of information
• Supplier induced demand
• Most often too much of what is not needed
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 ...A booming private health sector

• The quest for treatment

• Through a succession of ineffective therapies
– Consider someone with a chronic disease
• Consumption of savings and other assets
• Eventually poverty-two pathways
– 1. through death or inability
– 2. Excessive expenditure sale of assets etc
• Iatrogenic poverty! Recall iatrogenic diseases
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 Health systems challenges-Decentralisation:

• Shifting roles
• Personnel: Recruitment-deployment-retention
• Revenue mobilisation
• Inter-sectoral collaboration
• Financial management
• Supply chain management
• Global Health Initiative (GHI)
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 Health systems challenges-the workforce
motivations-Active & Reactive-Make choices :

• Recruitment-deployment-retention-attrition
• Housing for workers
• Health workers salaries
• Training for health workers-Per diems
• Recreation centres
• Electricity and water
• Migration
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 Challenges in the Health systems-
support systems

• Health management Information Systems

(HMIS)-timeliness, completeness-utilisation
• Supply chain management-Essential
medicines-selection, procurement, storage,
distribution and use
• Frequent stock-outs
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 Challenges in the health systems-absence
of research
• Bizarre concept of research at the sub national
and sub district level!
• Yet managers must make decisions-evidence-
based decision
• In the absence of information-erratic decisions
are made
• Basic principals of Action research...
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 Challenges of the health system-New Money
(GHI), Bilateral Org. & NGOs

• GFTAM, GAVI, PEPFER, PREFA, ...

• TASO, JCRC, ...
• Vertical Programs
• Ultimately-a fragmented system,
• Duplication of services and activities-accounting,
supervision-increased transaction costs
• Competition among programs
• Poaching of workers
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 Challenges with New moneys

• Service delivery is only for programs with

money-’Darling Diseases!’ in ‘Darling locations!’
• People then become mere program targets
• Instead of looking at the people with the disease,
programs look at the disease in people

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 Challenges to the system
Globalisation
Urbanisation
Government/MOH responses
– Inadequate response
– Too much response and
– In the wrong direction
– Single/individual disease targets-instead of a systems
approach
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 Ingredients must be combined
• Primary clinics take things that aren’t medical care
and make them into medical care
– Drug on the shelf is not medical care until you’ve
handed it to a patient who has that disease
– A nurse is not medical care until she is sitting with
a patient putting a bandage on them
• The way this is coordinated requires thought and
management
 The disconnect between service delivery and
Incentives in our system:
• Principal does not (or cannot) specify the nature of
the request in sufficient detail
• Principal does not (or cannot) monitor the agent’s
performance
• The incentive offered is not something that
motivates the agent
• Cultural and legal environment inhibits enforcement
of the contract
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 2. The disconnect in service provision

• Bad contracts lead to unintended consequences

– Agent does not do exactly what principal wants

– Principal wastes incentives

– Agent wastes effort

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 Commonest diseases
• Mis-directed care:

• Most (70%) conditions can be adequately

managed by very cheap and cost-effective
methods:
-IRS
-LLIN
-Sanitation-waste disposal, clean water
-Immunisation
-....
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 ??
• Why then should we spend a lot of money and
other resources in the provision of health care?
• Resource mobilisation, resource allocation and
resource utilisation-efficiency!
• Every day managers are pre-occupied by: How
best can I deploy my resources in order to reap the
optimum benefits?
• Consider your individual budget/resource
management
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 Structure of the district health system
MOH
District LC V
DDHS

Hospital County LC IV

H/C III Sub county LC III

Health
sub district Health
Parish LC II
H/C II sub
district
H/C I Village LC I

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District Health systems management-the Health
Sub District-HSD
• The HSD-‘operational unit’ of the health care system in
Uganda
• Constituted by a Hospital/HCIV as the HQtrs.
• Responsible for
- Supervision
- Management and leadership
• Satellite Health facilities within a geographical area
- Responsible for service provision
- Surveillance
- Routine data collection, analysis, interpretation
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 District Administrative Structure
• District-Local Council V-Chief Administrative
Officer-CAO
• County-Local Council IV-Assistant CAO
• Sub County-Local Council III-Sub County Chief
• Parish-Local Council II-Parish Chiefs
• Village-Local Council I-?
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Organising a district health system

• Using our own experiences with the health

system in Uganda, lets discuss Responsiveness
the way we see it

• Fair Financial contribution-how is it working

in Uganda?
66
 Structure of the district health system
• District-District Health Office-DHO
• District-General Hospitals-Medical
Superintendent
• County-Health Sub Districts-HSD Head of HSD
• Sub County-Health centre III-In charge
• Parish-Health Centre II-In charge
• Village-Health Centre I-VHT

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 Health systems-Decentralisation as an
opportunity

• Autonomy
• Innovations
• Space for decision making-note that, most
decisions are politically motivated
• Short lead time-from decision to
implementation

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 The way to go-Management

• Management and leadership at the sub national

and sub district level
• Relevant management Competences at these
levels-skills, knowledge & behaviours
• Direction-team building
• Integration of services-easier said than done!
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 Way to go-management of district health
system-supervision

• Team building
• Supervision structures
• Feedback mechanisms at the different levels of
care
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 The way to go-Management of district health
systems-Action Research

• Starts with a problem

• Analysis of the problem-magnitude, importance,
causes of the problem, possible solutions
(Hypothesis)
• Testing of the solution(s)
• Evaluation of the actions
• A cyclical process
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 Way to go-management of the district system-
investing in the workforce:
• Delegation-Hands off-eyes-on!
• Giving more challenging tasks
• An asset for health system strengthening
• Responsibility and creativity contributes to better
adapted solutions
• If adequately supported, participation (in the sense of
empowerment, not utilitarian) is likely to contribute to
sustainable and responsive services
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 Organisation of care

• People centred care: expectations, respect and

dignity
• Professionalism-competence in required skills
• Participation-to have a say in how HS should be
organised
• Continuity of care
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 Conclusion-Keep in Mind! REACH-IMPACT-the
POOR

• Power
• Politics &
• Resource distribution
• The poor have no POWER....

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 Conclusions-

• REACH and IMPACT suffer from...

• Last Mile Challenges

• That is where the household is involved

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 Conclusion
• Health systems management-an up-hill task for most
low and middle-income countries

• They are under stress from numerous factors-LICUS

• We need managers at the district and sub district

levels-who can champion the leadership

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 Summary for District HS Management...

• Health systems are complex by nature

– With multiple interactions
– Multiple interdependence

• A sum total of parallel interventions may not

necessarily improve health systems

• A holistic approach is proposed involving

management & leadership at the helm

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Conclusion-District health systems management

• With management competences-knowledge, skills &

behaviours

• Keep in focus goals of the health system good

health, fair financial contribution & responsiveness
• Efficient allocation and utilisation of scarce
resource...
• Priority setting...
• Integrating services as much as possible
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 Bibliography

• WHO-World health report 2000

• WHO-Commission on Microeconomics and health 2001
• WHO-World health report 2003
• WHO-World health report 2008
• WHO-World statistic 2008
• Meessen et al (2003) Iatrogenic poverty. Tropical medicine and
international health (8) 7: pp 581-584

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