International HealthLeadership Program

Policy Context for Reform

Pam Garside

University of Cambridge

Values

Evidence Based Medicine/Policy

Accountability

International Health Leadership Program VALUES AND ACCOUNTABILTY

What are the values to guide design and implementation of the health care system?

What is the model of accountability for performance?

Policy Challenges and Core Competencies Needed

Making explicit the basic values Management

Evidence-based medicine -reasonable?

Accountability

Need for Reform of Health Systems

Arguments Humanitarian argument - health care is public

good Economic advantage/vitality

Issues Resource constraints Inequity of access Mal-distribution of resources Uneven quality of care Political problem

Unstable Health Care Systems

Increasing Complexity

Inadequate capacity to plan and manage

Weakened resource base (financial and human capital)

Declining System Performance

Health worker stress

Gaps between science and practice

Disparities/Inequities

Reduced public confidence

Dramatic shifts inorganization and financing

Core Competencies of SustainableHealth Care Systems

Policy/Planning Making explicit the basic value framework Environment assessment/strategic planning/forecasting Legislative and regulatory Developing essential infrastructure; workforce, IT, etc.

Management Resource allocation and management Integrate

Intersectoral Public and private

Prudent use of technologies Develop/organize human resources Generate public good will

Evaluation Monitor performance Foster accountability Implement change

WHO Health-For-All in the 21st Century

(HFA) Policy

“Value Positions” Health is a prerequisite for human development A notion of equity or fairness should be at the core of all health

system development Health systems need to adapt and respect the local context and

respond to the needs of the population New mechanisms for transparent policy dialogue priority setting

accountability need to be established Aggregate population based need better expresses societies

priorities in health than patient based demand Health systems must be conceived as an operationally linked to

other elements of a countries social and economic development Health interventions should have a strong evidence base Case for the individual must be integrated within public health

functions that address population needs

Values

SolidarityEquityFairnessAutonomy (Personal)Autonomy (Professional)EfficiencyEffectivenessChoice (Individual)

Values: Discussion

What if any values are missing? What are three most important for

design and management of health care systems?

What values are inherently inconsistent or trade-offs?

Evidence-Based Medicine(and Policy?...)

Evidence-Based Medicine(and Policy?...)

The application of science and

related knowledge to:

Medical decision making at the individual level

Organization of/and delivery of health care at the population level

Evidence-Based Medicine: Limitations/Risks

Financial/affordability Knowledge gap Cultural insensitivity Equity/fairness

Evidence-Based Medicine: Merits

Science-based/logical Effective: achieves desired outcomes Rational: for distribution/ management of resources Inclusive/transparent

Evidence-Based Medicine

What is reasonable?

Accountability

The obligation to provide a justification and to be held responsible for

its actions by another interested party.

Accountability - For What?

Medical decision-making Financial Individual respect

Patient vulnerability Confidentiality Cultural uniqueness

Practitioner/Institutional behavior Equity/fairness Procedure for resolving dilemmas

Regulation and Accountability: Methods

Professionalism Market competition/choice Disclosure Accreditation/Licensure Legal

(individual and institutional litigation)

Legislation/regulation

Accountability: Models

Conception Domain Methodsof patients of accountability

Professional Recipient of Patient, physician Licensure, Certificationprof. services Prof. Association Malpractice suit

Economic Consumer of Marketplace and Choice and “exit”health care regulationcommodity

Political Citizen Government “Voice” and receivingreforms and government pressurepublic good actions

Adapted from Emanuel and EmanuelAnnals of Internal Medicine, Jan 15, 1996

Accountability

What are pros and cons of 3 models?

Which model is most predictable to serve public interest?

What are implementation issues?

Characteristics of Optimal Health Care Systems

Sustainable financing Prudent resource management Attention to quality of care Respect for individual

needs/choices Accountability