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Service delivery

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In any health system, good health services are those that deliver effective, safe, good-quality personal and non-personal care to those that need it, when needed, with minimum waste. Services – be they prevention, treatment or rehabilitation – may be delivered in the home, the community, the workplace or in health facilities.[1]

Although there are no universal models for good service delivery, there are some well-established requirements. Effective provision requires trained staff working with the right medicines and equipment, and with adequate financing. Success also requires an organizational environment that provides the right incentives to providers and users. The service delivery building block is concerned with how inputs and services are organized and managed, to ensure access, quality, safety and continuity of care across health conditions, across different locations and over time.

Primary care as a hub of coordination: networking within the community served and with outside partners[2]

Attention should be given to the following:

  • Demand for services. Raising demand, appropriately, requires understanding the user’s perspective, raising public knowledge and reducing barriers to care – cultural, social, financial or gender barriers.
  • Package of integrated services. This should be based on a picture of population health needs; of barriers to the equitable expansion of access to services; and available resources such as money, staff, medicines and supplies.
  • Organization of the provider network. This means considering the whole network of providers, private as well as public; the package of services (personal, non-personal); whether there is oversupply or undersupply; functioning referral systems; the responsibilities of and linkages between different levels and types of provider, including hospitals.
  • Management. Whatever the unit of management (programme, facility, district, etc.) any autonomy, which can encourage innovation, must be balanced by policy and programme consistency and accountability. Supervision and other performance incentives are also key.
  • Infrastructure and logistics. This includes buildings, their plant and equipment; utilities such as power and water supply; waste management; and transport and communication. It also involves investment decisions, with issues of specification, price and procurement and considering the implications of investment in facilities, transport or technologies for recurrent costs, staffing levels, skill needs and maintenance systems.

This section of the health system profile is structured as follows:

Contents

Analytical summary

Despite clear policies on decentralization in most countries, the ability to provide comprehensive, equitable, continuous and people-centred health services at district level continues to be limited.[3] Most countries in the WHO African Region organize health service delivery in accordance with the level and size of health facilities.

These are normally categorized as primary, secondary and tertiary health facilities. Nomenclature of the health facilities in each category may differ from country to country, depending on organizational method and historical influences.

Packages of services in health care interventions are seen as the most effective method of delivering basic services to poor populations. However, most of these packages do not specify time limits for mitigating the diseases or health conditions they target. Nor are they always adequately funded. Filling the gap, the private sector constitutes over 30% of the health facilities in some countries, with contractual arrangements through public and private health care providers being common. These frequently target communicable diseases as well as maternal and child health services such as immunization, antenatal care and delivery.

The concept of creating primary care hubs to coordinate health services for well-defined populations is just starting to gain momentum. However, universal access to a complete package of essential health services is a goal yet to be realized in the Region. Owing to long waiting times for patients, shortage of medical supplies and an often inadequately motivated health workforce, shadow practices still exist within public health facilities whereby patients are required to pay health workers directly in order to get rapid attention.

There is insufficient use of routine data, including vital statistics, to measure progress towards attainment of long-term targets such as the Millennium Development Goals on health.

All these aspects of poor governance compromise the quality, equity and coverage of essential health services. Greater challenges to health service delivery occur in conditions of war, internal strife, and population displacement due to natural or man-made disaster and its aftermath.

Essential health interventions remain unavailable to large segments of African populations. It is estimated that less than half of those with common illnesses obtain the treatment they need. For example, only 38% of those needing treatment for pneumonia and diarrhoea obtain treatment.

Only 40% of those with malaria obtain treatment and, on average, only 3% of these use the recommended artemisinin-based combination therapy, with rates ranging from <1% to 13%.[4] Only 29.5% of mothers exclusively breastfeed their babies for the first 6 months of life.[5]

In addition, resource allocation favours high-cost curative services, with smaller budgets allocated to primary prevention and health promotion measures that could prevent up to 70% of the disease burden in many African countries.

Organization and management of health services

Despite clear policies on decentralization in most countries, districts have limited capacity to provide comprehensive, equitable, continuous and people-centred health services.[6]

Health service provision needs to be organized and managed in ways that optimize the availability and continuity of services. Health service organization takes into account the need to ensure smooth referral of patients, and complementary measures to promote, restore and maintain health. Most countries of the WHO African Region organize their health service delivery in relation to the level and size of health facilities – normally categorized as primary, secondary and tertiary health facilities. Nomenclature may differ from country to country depending on the organizational method used. In some countries, the primary care level is divided into two categories, namely health posts and health centres.

In most countries, primary health services include a wide range of preventive health care, basic curative care and health promotion. Most health promotion activities take the form of community-managed interventions, supported by community health workers. Some primary care services require the involvement of highly qualified health personnel that are not available within the community. Ambulatory and outreach services for peripheral communities are therefore commonly managed from health centres and district hospitals.

In most countries, the district hospitals comprise the secondary level health services. Some health facilities supported by the private sector or faith-based organizations may be as large or larger than government-funded district hospitals. They may also be in a position to provide more advanced health services, creating a situation where the district hospital may not serve as the highest level of referral for secondary level health services in that district.

The organization of services by level may fail to recognize that different entry points to primary care services are required according to sex and age group. For example, the primary care service most needed for a child aged under 5 years may be immunization; elderly persons may require hypertension and diabetes treatment; while primary care for women needs to include screening for cervical cancers. Strong ambulatory and outreach services are therefore needed to ensure provision of primary health care to all, as close as possible to where they live.

Tertiary health services are provided through highly specialized hospitals. Many countries of the Region define these as one central and several regional or provincial hospitals. At tertiary level, hospitals are expected to provide sophisticated diagnostic, surgical, medical, paediatric, obstetric, gynaecological, ophthalmic, dermatological and rehabilitative services. This service level should be in a position to ensure an equitable distribution of specialized services, and their management must ensure cross referral and co-management of patients requiring more than one service at a time.

The sophistication of services offered at tertiary level depends on the overall level of development within a country. Those with more advanced tertiary services may find themselves treating patients from neighbouring countries with lesser capacities. These cross-border referrals drain foreign exchange earnings from the receiving country and may generate a vicious circle whereby the less-developed countries continue to trail behind in respect of the quality of their own tertiary care.

With respect to the HIV/AIDS pandemic, tertiary care for this disease is now being provided through home-based care. Family and community members participate in the management of AIDS patients by directly observing the intake of antiretroviral medicines and providing moral and social support.

Package of services

While it is imperative to make every effort to meet the right to health by ensuring that everyone has constant access to health services, this goal is likely to remain aspirational for a long time to come. Efforts to achieve it have given rise to the concept of prioritizing a package of essential health services that can be made consistently accessible to everyone during a specified period.

The aim of these packages is to reduce the conditions and diseases that are responsible for at least 80% of the morbidity and mortality in that country. The financing arrangements envisage the sharing of costs and risks. However, many countries in the WHO African Region have decided to reprioritize, creating a basic package in the hope that all interventions it contains can be made continuously available through prepayment arrangements.

Most of the essential health packages are not fully or adequately implemented due to inadequate resource allocation. It is therefore not uncommon to find that diseases of public health concern do not diminish to the expected level within the epidemiologically feasible time frame. At times, the use of methods such as sequencing the seriousness of the disease in terms of mortality, morbidity and disability may result in a very different list of the top 10 problems of public health concern from that produced by using other burden of disease measurement methods, including disability-adjusted life years, healthy- adjusted life years, healthy-adjusted life expectancy and quality-adjusted life years.

Elaboration process of packages of services

The process of developing the packages involves epidemiological, economic and political considerations. Epidemiologists determine the conditions that are responsible for over 80% of morbidity and mortality in the destination countries and the most effective interventions to deal with those conditions. They also categorize which interventions of the package can be performed at different levels of the health system. Economic considerations govern the cost of the package and how it can be financed, taking into account annual cost increases. Policy directions determine the final elements of the package and the resource envelope.

However, it is not uncommon to find some degree of mismatch between the package contents, the proposed resource envelope and the modality of overall financing. For instance, it is possible to ensure universal access to the package if out-of-pocket expenditure is the intended means of financing it. Other distortions may result from lobbying by specific vested interests that can result in inclusion of interventions that do not necessarily respond closely to identified public health needs.

Secondary and tertiary care services

African Partnerships for Patient Safety is a programme that focuses on using a hospital-to-hospital partnership approach to patient safety improvement in the WHO African Region. The programme is framed around 12 patient safety action areas defined by the WHO African Region in 2008. More information about the programme and the range of co-developed resources can be found on the African Partnerships for Patient Safety webpage.

Public and private health care providers

Most countries of the WHO African Region have two main types of health provider, namely government and private. While prepayment is a commonly used mechanism within government-run health services, the private sector refinances its health services through out-of-pocket expenditure.

However, sustainable financing of health packages can only be ensured through prepayment. In this context, a number of countries have initiated processes to allow the use of nongovernmental health services through prepayment. In this arrangement, government and insurance firms prepay the services, which patients can then access at their closest health facility, regardless of whether it is public or private.

Person-centredness and characteristics of primary health care services

Implementing a package of services using several levels of the health system may be costly and creates challenges in respect of accurate and systematic record-keeping. The concept of people-centredness has resurfaced as a component of health service delivery reforms, in an effort to ensure that every community has a primary health care workforce accountable for its health literacy and health status.

The primary care team is expected to ensure the provision of comprehensive and continuous services, serving as a coordination hub for the communities under their responsibility. If the team itself is unable to perform any of the duties it is tasked with, it is required to refer patients on to the most appropriate health care providers.

This concept of primary care hubs was formalized through the 2008 World Health Report on Primary Health Care and through technical documents adopted by the WHO Regional Committee for Africa. Discussion on ways and means of operationalizing this concept as part of the process of revitalizing primary health care is taking place in various countries. However, implementation remains at a preliminary stage in most countries of the WHO African Region.

Shadow practices

Quality of health services

Health services can be considered of good quality if they are provided by a technically competent health workforce and they are equitable, safe, efficient and effective. Communication about the services, and during treatment, should employ acceptable and culturally appropriate interpersonal skills, in an environment that reduces stress among patients or the general public. A warm reception, clean toilet facilities, adequate privacy, and effective logistical organization of services within an institution so as to maximize access and minimize patients’ movements are all part of ensuring quality of care.

However, in most African countries, more emphasis is laid on technical competence than on other aspects of quality. The environment in which services are provided is just as important as the competence of the health workers themselves. The availability or lack of water, electricity and telecommunication facilities in health facilities influences the quality of care as well as health outcomes. However, in many cases, it continues to be assumed that competent health workers will create an enabling environment for both patients and themselves without further dedicated measures, and resource restrictions bolster that belief.

Priorities and ways forward

Health service delivery determines how people access their right to the highest possible level of health. Consistent monitoring and review of the management and organization of health service delivery is necessary to ensure that updating and replacement of models takes place on a regular basis, and that delivery models remain as efficient and affordable as possible. Adoption of primary care hubs will depend on the extent to which current service delivery models are reviewed and challenged.

Another priority is to assess the adequacy of financing and implementing essential health packages. This process should ensure the inclusion of a time frame for achieving results from the application of packages. New packages will also need to be developed as public health challenges become resolved and new health threats are identified.

What works and why?

Effective priority-setting mechanisms, integration of service provision, and harmonization with and alignment to a single national health strategic plan are critical to resolving major public health concerns. Demonstrated success in addressing major diseases and epidemics enhances confidence within the health sector. A confident health system will most effectively tackle emerging health concerns and adopt or adapt new health technologies to improve the quality of services and quality of lives.

Others

Endnotes: sources, methods, abbreviations, etc.

1. Health systems strengthening: improving district health service delivery, and community ownership and participation (pdf 229.52kb). Brazzaville, World Health Organization Regional Office for Africa, 2010 (AFR/RC60/7)
http://www.afro.who.int/index.php?option=com_docman&task=doc_download&gid=5435

2. Countdown to 2015. Tracking progress in maternal, newborn & child survival. The 2008 report (pdf 8.94Mb). New York, United Nations Children’s Fund, 2008 http://www.who.int/pmnch/Countdownto2015FINALREPORT-apr7.pdf

3.World health statistics 2009 (pdf 5.77Mb). Geneva, World Health Organization, 2009 http://www.who.int/gho/publications/world_health_statistics/EN_WHS09_Full.pdf

4.Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action (pdf 843.33kb). Geneva, World Health Organization, 2007 http://www.searo.who.int/LinkFiles/Health_Systems_EverybodyBusinessHSS.pdf

References

  1. Everybody’s business. Strengthening health systems to improve health outcomes. WHO’s framework for action (pdf 843.33kb). Geneva, World Health Organization, 2007
  2. Framework and standards for country health information systems, 2nd ed (pdf 1.87Mb). Geneva, World Health Organization and Health Metrics Network, 2008
  3. Health systems strengthening: improving district health service delivery, and community ownership and participation (pdf 229.52kb). Brazzaville, World Health Organization Regional Office for Africa, 2010 (AFR/RC60/7)
  4. Countdown to 2015. Tracking progress in maternal, newborn & child survival. The 2008 report (pdf 8.94Mb). New York, United Nations Children’s Fund, 2008
  5. World health statistics 2009 (pdf 5.77Mb). Geneva, World Health Organization, 2009
  6. WHO. Health systems strengthening: improving district health service delivery, and community ownership and participation. Brazzaville, World Health Organization, Regional Office for Africa, 2010 (AFR/RC60/7)