Assignment: Health Care Delivery Services

Assignment: Health Care Delivery Services
Describes methods for promoting health care delivery services in a rural community and justifies methods with supporting evidence.
Culturally Sensitive, Evidence-Based Strategies for Working with A Diverse Rural Population
Explains culturally sensitive, evidence-based strategies for working with a diverse rural population, including forms of communication and alternative forms of health care. Assignment: Health Care Delivery Services
Potential Barriers to Health Care for A Rural Community Population
Explains potential barriers to health care for a rural community population and considers the expected outcomes if barriers are not overcome, or describes evidence-based strategies to overcome barriers.
Recommended Communication Strategies and Techniques for An Interdisciplinary Health Care Team Working with A Rural Community Population
Recommends evidence-based communication strategies and techniques for an interdisciplinary health care team working with a rural community population and explains how good communication will result in quality health care outcomes. Assignment: Health Care Delivery Services
The health system of the United States with either Germany, France, or Japan.
Students are to find a minimum of four (4) current peer-reviewed resources published within the last 5-7 years.
Paper criteria includes:
What are the benefits/limitations of their health care system vs. the United States system?
What issues are faced by each system related to:
Quality?
Access?
Cost of health care?
Is the overall health of this country’s population better or worse compared to the United States?
Benchmarks can be used, such as: infant mortality rates, mortality rates for cardiovascular disease, life expectancy for males and females, percentage of people with normal body mass, etc.
What percentage of GDP (gross domestic product) does each country spend on health care expenditures?
Does a larger percentage automatically mean better health care? Explain why or why not.
Challenges In Managing Healthcare Delivery System Health Essay
ABSTRACT:
The healthcare sector is a central part of our society, often in focus and often questioned. The sector is difficult to govern and conservative whilst rapid technical development challenges the ability of organizations to adapt. To a great extent, the organization of the healthcare sector is anachronistic and potential improvements spread slowly if at all. Understanding the elements of organizing, managing and governing, have central implications for developing tomorrow’s healthcare systems and the focus is further on underlying mechanisms and positions.
The requirement for collaboration across stakeholders including support of regulators, policy makers, decision makers and health system leaders is clear. There is a need for private sector actors to engage these players to demonstrate the health impact and not just the financial impact. Innovators face challenges when scaling, transferring and replicating private sector health innovations – creating dialogue and a mutual ground is essential.
Within developing countries, access to basic healthcare services is seen to be extremely limited and many simply lack access to even the most basic services; the social impact on life expectancy is large with high mortality rates due to diseases where preventative measures and treatment exists. Within emerging economies growth in healthcare is not keeping up with economic and demographic growth, leading to vast unmet needs where health care is only reaching a sub-set of the population.
There is an opportunity to make a step-change impact on healthcare delivery around the world by looking to examples where a step-change impact, albeit usually in small pockets, has been achieved. There are examples, in resource-constrained settings, where innovative healthcare entrepreneurs are developing creative approaches to care delivery that improves access to quality care at affordable costs.
Key Words: entrepreneur, Innovative healthcare
INTRODUCTION:
HEALTHCARE – An Integral Part
The healthcare sector is a central part of our society, often in focus and often questioned. The sector is difficult to govern and conservative whilst rapid technical development challenges the ability of organizations to adapt. To a great extent, the organization of the healthcare sector is anachronistic and potential improvements spread slowly if at all. In short, it is a complicated equation, where the central issues seem to persist. Understanding the elements of organizing, managing and governing, have central implications for developing tomorrow’s healthcare systems and the focus is further on underlying mechanisms and positions. Furthermore, there is also unanimity that demographic trends, with a growing number of old people and less scope for more resources, which present us with a complicated equation for the future.
The role of health in influencing economic outcomes has been well understood at the micro level. Healthier workers are likely to be able to work longer, be generally more productive than their relatively less healthy counterparts, and consequently able to secure higher earnings than the latter, all else being the same; illness and disease shorten the working lives of people, thereby reducing their lifetime earnings. Better health also has a positive effect on the learning abilities of children, and leads to better educational outcomes (school completion rates, higher mean years of schooling, achievements) and increases the efficiency of human capital formation by individuals and households (Strauss and Thomas 1998; Schultz 1999).
However, more recent research has also established a strong causal association running from health to aggregate economic performance. Thus Bloom, Canning and Sevilla (2004) report evidence from more than a dozen cross-country studies and all these studies, with a single exception, show that health has a positive and statistically significant effect on the rate of growth of GDP per capita. The causal relationship does not run in only one direction-from health to aggregate economic performance- and there is strong case for considering a reverse link, running from ‘wealth to health’. Higher incomes potentially permit individuals (and societies) to afford better nutrition, better health care and, presumably, achieve better health. There is some cross-country evidence that such a relationship holds at the national level (Pritchett and Summers 1996; Bhargava et al. 2001). Several experts believe, however, that the causal direction from health to economic performance is stronger.
Around the world Regulators, Policy Makers and Decision Makers are grappling with a similar question – how do you improve access to quality care at affordable costs?
The requirement for collaboration across stakeholders including support of regulators, policy makers, decision makers and health system leaders is clear. There is a need for private sector actors to engage these players to demonstrate the health impact and not just the financial impact. Innovators face challenges when scaling, transferring and replicating private sector health innovations – creating dialogue and a mutual ground is essential.
THE CHALLENGE IN EMERGING ECONOMIES
Within developing countries, access to basic healthcare services is seen to be extremely limited and many simply lack access to even the most basic services; the social impact on life expectancy is large with high mortality rates due to diseases where preventative measures and treatment exists. Within emerging economies growth in healthcare is not keeping up with economic and demographic growth, leading to vast unmet needs where health care is only reaching a sub-set of the population.
The causes can be enumerated as below:
Lack of sufficient and/or adequate infrastructure in health systems including hospitals and care centres
Inadequately trained medical workforce (i.e., doctors and nurses) and/or limited supply of trained workforce
Improper and unsustainable funding mechanisms both in public and private systems to deliver the required care to patients
Mismatch in quality where either standards are lacking or higher costs is not leading necessarily to higher quality
Inadequate level of incentives for innovation within health specifically in products, services and the effective use of technology
In the developed world, growth in healthcare costs out-strips GDP in various nations and an unsustainable burden is being created today that could cripple developed nations in the future.
DELIVERY OF HEALTHCARE – Indian Perspective
Are Health Systems An End In Themselves Or A Means To Achieving Certain Ends?
Worldwide, there seems to be a consensus on measuring health systems in terms of improving the health status, enhancing patient satisfaction and providing financial risk protection. In 2000, the World Health Organization (WHO) further expanded the definition to include a reduction in disparities for improving health status, being mindful of the patient’s need for privacy & confidentiality and providing services promptly and with courtesy as characteristics of a responsive system; and sharing the financial burden in accordance with the ability to pay as being a fair form of health financing (World Health Report, WHO, 2000). There is, however, little consensus on what constitutes an ideal health system in universally acceptable terminology to enable better inter country comparisons. This is because, unlike any other sector, health systems are highly contextualized and influenced by various exogenous factors such as societal values, epidemiology and disease burden, availability of financial resources, technical capacity, individual preferences and the nature of demand.
Health systems have five aspects that interact with each other and influence its basic nature and direction:
financial (tax, user fees, out-of-pocket expenditure, insurance)
payment systems (how providers are paid: salary, per service rendered)
organizational (manner in which the delivery systems are organized/structured)
legal (regulatory frameworks) and
social (access to health information, advertising) (Hsiao 2000)
The effectiveness with which these instruments of state policy are designed and used determines the extent to which the health system is equitable, appropriate or fair.
The health system in India consists of a public sector, a private sector and an informal network of providers of care operating within an unregulated environment, with no controls on what services can be provided by whom, in what manner, and at what cost, and no standardized protocols to help measure the quality of care. There are wide disparities in access, further worsened by the poor functioning of the public health system.
Healthcare as an industry in India has grown to become one of the most promising and progressive sectors in recent times. A variety of factors such as growing population and economy, increasing life expectancy, expanding middle class, higher income levels, rise in incidence of diseases, increased Government outlays and better awareness about health are expected to further the growth to make India’s healthcare a US$ 280 billion industry by 2020 [1] . Besides the presence of corporate hospitals, the availability of highly qualified doctors and scientists, their expertise and state-of-art technology have helped India become an attractive destination globally for medical tourists, clinical studies and research and development
Despite this growth, healthcare delivery and services in India continue to be lacking. India houses 16% of the world population, 21% of the global diseases and the largest burden of communicable diseases in the world, yet its healthcare infrastructure is one of the weakest and not comparable with other developing nations [1]
• For every 1000 Indians there are 0.9 beds; whereas countries such as Russia, China and Brazil have 9.7, 4.1 and 2.4 beds respectively [2]
• India’s current situation of 0.6 physicians per 1000 population is not very encouraging in comparison to BRIC countries and some other South East Asian countries [3]
Government expenditure in India as a percentage of GDP is also amongst the lowest in the world at 0.9% and as a result, private spending is high – the share of the private sector healthcare spending is the largest among the BRIC countries.
Health insurance – both government sponsored and private – is also minimal. Only 14% of India’s population is covered by insurance schemes [4] . This makes affordability of quality healthcare a serious issue given India’s low per capita income and sizable population below the poverty line.
The situation is worse for the urban poor and rural population. The growth in the healthcare sector over the last decade has been lop-sided and restricted to largely the private sector, in major metropolitan and urban areas. Only 13% of the rural population has access to a primary healthcare centre and 9.6% to a hospital. [2]
Research indicates that a strong and inclusive healthcare environment is one of the prerequisites for sustainable economic development. A healthy population is more productive which contributes to better economic growth.
“INCLUSIVE”
Inclusive is a term used in the context of growth to mean ‘broad-based’, ‘all encompassing’ or sometimes even ‘pro-poor’. Along the same lines, in context of healthcare, inclusive implies an equitable allocation of healthcare resources with benefits accruing to every section of society.
Inclusive healthcare can drive sustainable development only when everyone has access to adequate healthcare services and this entails addressing questions like:
• Are healthcare services available when and where required?
• Is healthcare affordable for every individual?
• Is the quality of healthcare delivered of acceptable quality?
In India, this concept means offering healthcare services to the entire population of nearly 1.2 billion, i.e. including those that are currently excluded from healthcare services. In order to accomplish this, critical challenges of availability, affordability, and quality need to be addressed in a long-term and sustainable manner.
OPPORTUNITY
There is an opportunity to make a step-change impact on healthcare delivery around the world by looking to examples where a step-change impact, albeit usually in small pockets, has been achieved. There are examples, in resource-constrained settings, where innovative healthcare entrepreneurs are developing creative approaches to care delivery that improves access to quality care at affordable costs. Imagine the impact if these solutions could be scaled-up, transferred and replicated more broadly:
Aravind Eye Care delivers quality eyecare in India at a fraction of the cost through the use of focussed ‘factories’ that eliminate any waste in the system, increase the productivity of expensive assets and trained work-force and focus on straightforward standardized procedures including cataract surgery and spectacle fitting. They have reached ~12 million in India (10% of total blind) and, costs are only 1% of the equivalent service in the UK (albeit not adjusted for country specific factors) with surveys showing outcome quality is higher in India [3]
Health Stores has created a network of franchised micro-clinics run by trained community healthcare workers providing essential, quality medicine for the most common and serious diseases in Africa. This scalable model brings quality care to the poor via strict protocols, standardized processes, central procurement and effective training. It also contributes to social and economic development by creating business opportunities for locals who run the stores. The network has 80+ clinics across Kenya, has penetrated Rwanda and serves over half a million customers a year with aspirations of growing across Sub-Saharan Africa
Minute Clinic is focused on providing a more affordable option for customers in the USA where the cost of health is significantly higher than any other country in the world. By establishing clinics in pharmacies, right skilling the workforce through hiring nurse practitioners and setting very clear guidelines and protocols, Minute Clinic has built a low-cost model saving the average user 7% of typical total health spend through their services that are 40-80% less than other settings. There are over 550 clinics across 26 states with the aspiration of 1,000 clinics by 2015 and are currently focusing more heavily on prevention [4]
Population Services International (PSI) began 15 years ago and is now the world’s largest social franchisor of health services offering quality products at low prices. Interventions cover HIV counseling and testing; prevention of mother-to-child transmission; Ante-Natal Care; Vaccinations; and treatment for malaria, pneumonia, and TB. PSI’s model delivers care where the patient goes (e.g., local stores), establishes simple and standardized operating processes and shifts tasks from doctors to nurses. PSI has more than 10,000 franchise sites in 19 countries in the developing and emerging world focusing on the bottom of the socio-economic pyramid
These cases are not successful by chance or good fortune – each model reinvents the logic of delivery and changes the underlying economics. Six factors characterize these solutions, with each doing some or all of the following:
Get close to the patient and follow established behaviour patterns: E.g., Aravind has engaged in out-reach strategies – taking care straight to the villages
Reinvent the delivery model by using proven technologies disruptively: E.g., MinuteClinic’s IT platforms under-pinning clinical procedures and decision making
Confront professional assumptions and right skill the workforce: E.g., The use of community health workers at HealthStores reduces expenditure
Standardise operating procedures wherever possible: E.g., Aravind, HealthStores, MinuteClinic and PSI have all standardised their procedures
Borrow someone else’s assets: E.g., HealthStores relies on already established sitesto base their micro-clinics
Open new revenue streams across sectors: E.g., PSI has shown its possible to cross sector boundaries to create new market opportunities in franchising [5]
INDIA: Assignment: Health Care Delivery Services
India’s challenges with respect to availability of healthcare are multi-fold. They include lack of infrastructure, weak connectivity and lack of resources. With respect to infrastructure, we already know that India has only 0.9 beds per 1000 Indians. But that’s not where it ends. Often times, functionality of the available infrastructure are also a huge concern. In many facilities in India, especially public health facilities in rural areas, the building structures themselves are old, dilapidated, and sometimes unsafe. Equipments are many times not in working condition. Such issues, in effect, render ‘available’ assets unusable.
Connectivity, both physical and virtual, is also an issue. A villager seeking healthcare services in a typical Indian village has to travel about 10 km and spend an entire day to avail care. The situation in cases of medical emergencies isn’t much better. Although there are some cases of efforts that have helped drive better connectivity through technology, the general landscape, especially in rural areas, still needs considerable improvement.
Finally, India has a dearth of skilled human resources. On average, we have 0.6 physicians per 1000 individuals and the issue is more serious in rural areas where only 20% of the doctors, but 70% of the population reside. The lack of infrastructure, coupled with issues of connectivity, etc. result in reluctance of doctors wanting to practice in rural areas, further impairing the issue of availability.
Taboos and restrictions on some social groups – such as lower castes and women – are also prevalent in some parts of the country and availability of care for these sections of society is almost absent. All these issues related to availability of healthcare services are compounded by the fact that the private sector is less willing to enter these areas, largely because of the absence of supportive infrastructure and appropriate incentives as well as low purchasing power of the local population.
Some efforts are being made by both public and private players to address these issues. Examples include:
The government’s National Rural Health Mission program that is aimed at making infrastructure and resources available and functional. Steps like a compulsory rural stint, contracting private sector doctors for Government facilities, offering better salaries for rural posting have been initiated
Focussed educational programmes such as Bachelor of Rural Healthcare and Rural MBBS are also on the anvil
Emergency and referral transport initiatives such as EMRI, 108 and Janani express
Streamlining procurement of drugs and consumables to improve availability at all public
healthcare facilities
Use of medical mobile units, e.g., the ‘Akha Boat’ initiative in Assam that provides basic healthcare services through mobile boats to the remote riverine islands of Assam
Public-Private partnerships for operating healthcare infrastructure and medical equipment
Set up of tertiary care corporate hospitals in Tier II and III cities and use of telemedicine by private players to reach a larger section of the country
“In healthcare you don’t do one big thing and reduce the price but have to do 1000 small things” – Dr. Devi Shetty Chairman, Narayana Hrudayalaya
Costs of healthcare services in India have been rising for several years. The bulk of these costs are borne by consumers – 74% of all healthcare expenses in India are out of pocket, one of the highest in the world. A very small portion of the Indian population, only 14%, has some kind of health insurance that helps share the burden of these rising costs. Trends such as increasing incidence of diseases, especially lifestyle diseases, and the lack of focus on preventive care clearly indicate that the issue of rising costs will get more acute over the coming years, unless serious measures are taken to curb it.
Various stakeholders involved in healthcare delivery – government, private companies including providers and pharmaceuticals, technology providers, etc. must focus on implementing new ideas and driving innovation in two broad areas to help increase affordability of healthcare services –
Reducing costs of healthcare services
Increasing purchasing power of individuals through wider insurance coverage
Initiatives focused on reducing costs of healthcare services: Assignment: Health Care Delivery Services
Low cost or “no frills” hospitals that are functional and frugal
Innovative healthcare delivery models such as day care surgery centres and self-care or minimal care programs
Cost reduction through frugal innovations in medical technologies such as X-rays and ECG machines
Innovations in drug development such as a Hep-B vaccine for less than $1 per dose
Cost management through bigger and better economies of scale
Other initiatives focused on driving wider insurance coverage: Assignment: Health Care Delivery Services
Other social health insurance schemes such as Yeshaswini (Karnataka), and Kalaignar Kappittu Thittam (Tamilnadu)
Janani Shishu Suraksha Karyakram scheme under NRHM which provides cashless deliveries and newborn care – including free transport, drugs, diagnostics, and blood transfusions if required – at public health facilities
Increasing purchasing power in the hands of the people through Social Insurance
The Rashtriya Swasthya Bima Yojna (RSBY), launched in 2008 is Indian Government’s social insurance initiative where the private sector provides health services at pre-determined prices for the common man. The objective of the scheme is to make healthcare available to Below Poverty Line (BPL) families. Under this scheme, over 7,000 public and private hospitals have been empanelled to provide services to the BPL population. The scheme provides hospitalization cover of INR 30,000 with the beneficiaries having to pay only ~Rs 30 as registration charges. Government pays the premium to insurance companies who in turn administer the scheme in different states. While the actual pricing and returns may be lower, private players stand to get large volumes. Besides increasing purchasing power in the hands of people and making healthcare affordable, this has also encouraged smaller private players to set up hospitals in small towns.
INDIA – NEWER MODELS OF HEALTHCARE DELIVERY
Day Care Surgery Centers – Nova Medical Centers (www.novamedicalcenters.com)
Short Stay Surgeries take anywhere between 24 – 72 hours from admission to patient discharge and may include Day Care Surgeries in which the patient is discharged within a day. Success of day care surgery can be attributed to advances in surgical technologies and in the field of anaesthesiology. Advances in surgical technologies that made outpatient surgery and minimally invasive surgery possible include various endoscopic procedures i.e. laparoscopy, arthroscopy, laser and shock wave lithotripsy, laparoscopic cholecystectomy, vaginal hysterectomy, thyroidectomy, shoulder, knee and ankle repair.
The decision as to where should the surgery be performed depends upon the levels of ambulatory surgery. The levels of ambulatory surgery is classified as follows :
a) Minor ambulatory surgery (under local anaesthesia )
b) Major ambulatory surgery (under G.A., central neuroaxial block with or without I.V. sedation)
c) In-patient ambulatory surgery
Nova Medical Centers develops and manages Short Stay Surgery Centers in partnership with physicians. These Centers provide world class medical, surgical and diagnostic services in modern convenient facilities throughout India. Each Nova center is multi-specialty, fully equipped surgical facility located conveniently in the neighbourhood. Their internationally trained physicians provide patients easy access to quality, affordable healthcare by using leading edge medical technology and equipment.
At Nova, doctors use minimally invasive equipment and advanced anesthesia techniques to improve recovery time and reduce hospitalization. Nova Medical Centers have pioneered this unique healthcare delivery model in India. Our partner physicians are committed to delivering care in an outpatient setting which enables them to increase efficiency and contain costs. This innovative combination of excellence and affordability is a health delivery model without parallel.
Apart from cost containment, other benefits of out patients surgery are :
decompression of busy hospital beds
less nosocomial infections
early recovery in home environment with the family. Thus, there is less disruption of personal lives
acceptance of day care surgeries by insurance companies has resulted in a win-win situation for all – the claim amount of the insurance companies have gone down (because of an economical healthcare delivery model) which has been transferred to the end customers in terms of reduction of premium payable
Social Franchising – Merrygold Health Network (www.merrygold.org.in)
Merrygold Health Network is an innovative Social Franchising Program in India providing essential health care services to the poorer sections in the society. The program is being implemented through a Public Private Partnership (PPP) in an endeavor to make health care services accessible for the underprivileged in the state of Uttar Pradesh. The state of Uttar Pradesh has a high reliance on private health care providers for access to health facilities. The private providers are focused on curative care, which has limited their role in preventive and promotive health care. USAID has been supporting implementation of health franchising programs in various developing countries wherein the private sector is engaged as a partner for providing the essential health care services. USAID and State Innovations in Family Planning Project Service Agency (SIFPSA) has developed an innovative social franchising program though consultations with various national and international experts.
Their 20 bed Merrygold hospitals provide maternal and child health services. Merrygold hospitals also provide emergency obstetric care facility. The Merrysilver clinics provide basic obstetric care, family planning services, and counseling and immunization services. The MerryAYUSH provide health-counseling, condoms, Oral Contraceptives, Oral Rehydration Salts and Iron and Folic Acid tablets.
This network aims at providing the health services at 50-60% of the private sector prices. The specialization on obstetrics and high volume will ensure that hospital could offer sub market prices and become sustainable. Assignment: Health Care Delivery Services
Free Home Pregnancy Test Kit – Nishchay
Reproductive health is a crucial part of general health and a central feature of human development. Among women of reproductive age (15-49 years), the burden of reproductive ill-health is far greater than the disease burden from tuberculosis, respiratory infections, motor vehicle injuries, homicide and violence. Women run the risks of pregnancy, childbirth and unsafe abortion, take most of the responsibility for fertility regulation and are socially and biologically more vulnerable to reproductive tract infections and sexually transmitted diseases.
The National Population Policy (India), 2000, affirms the commitment of government towards voluntary and informed choice and consent of citizens while availing of reproductive health care services, and continuation of the target free approach in providing family planning services. [6]
The Ministry of Health and Family Welfare (MOHFW), Government of India, through its National Rural Health Mission (NRHM) has introduced the rapid home pregnancy test kits (Nishchay). The Nishchay program is not a program for the promotion of the pregnancy test kit alone, but is an entry point to RCH and family planning services for women seeking quality and assured RCH and FP services.
Important key issues addressed by Nishchay are:
1. Low percent of women starting ANC in first trimester due to late detection
2. Contraceptive Provisioning (IUD/Pill) not started after ruling out pregnancy
3. High unsafe abortions due to late detection of pregnancy
The key strategies of the program are community awareness, especially among eligible couples, on Home Based Pregnancy Test Card and RCH services, increased utilization of RCH and FP services, following the test results. Important activities include capacity building of ASHAs (Accredited Social Health Activist) through resource persons with field and NGO experience, brand and logo visibility using mass media campaign, community outreach activities using mid –media campaign, and integrating the card into the monitoring system of NRHM/RCH-II. Implementation of the program is in all Indian States and UT’s. The states have been classified into high, medium and low priority groups based on the NFHS-3 data on birthrate and institutional deliveries. In the first phase, the program is launched in the following 11 high priority states – Uttar Pradesh, Bihar, Madhya Pradesh, Uttarakhand, Chattisgarh, Jharkhand, Rajasthan, Assam, Meghalaya and Nagaland.
Thus while Merrygold Health Network handles the obstetrics part, Nishchay empowers the women to take a decision – a well informed, timely decision.
Single Speciality Hospitals: Assignment: Health Care Delivery Services
Single speciality hospitals are a small but rapidly growing genre among today’s hospitals in India. The growing number of speciality centres and hospitals signals a move towards maturity of the healthcare industry with an increasing complexity of business and consumer affordability. Assignment: Health Care Delivery Services
Care: Assignment: Health Care Delivery Services
Speciality hospital formats range from low-risk speciality including eye care, dermatology, mother and child to high-end speciality including cardiology, cancer and transplant medicine. The mid-level specialities are offered in a multi speciality hospital format. The low-risk speciality models require low capital expenditure and have comparatively low operating costs as in-patient stay is rarely required for day procedures. This reduces the need for support infrastructure and offers easy replication. Consumers expect convenience and are not willing to travel too far for such speciality services. Assignment: Health Care Delivery Services
There are several advantages to Single Speciality Hospitals
Cost efficiency due to higher volumes
Provide higher quality