F UNCIÓN S OCIO C ULTURAL DE LA E DUCACIÓN P OPULAR

Literature on the development of health service delivery models is limited. The literature review search identified 15 studies with a focus on development of health service delivery models (Table 11). The literature gives suggestions on some of the essential elements that need to be considered during the planning phase of any health service model. To date, this has largely been informed by literature on the development of nursing care delivery models in high income countries (Armstrong and Stetler 1991;Girard 1993;Walter and Robinson 1994) and primary health care models in developed countries (Abelson and Hutchison 1994;Lomas 1986;Wakerman et al. 2008). The phrases “health service delivery models” and “health service delivery systems” are sometimes used interchangeably in the literature to describe the provision of health care (Walter and Robinson 1994). Articles with titles reading “health service delivery models” more often discuss health service delivery systems and organisational changes that have occurred within the health system. An example of such an article is that by Lomas 1986 “Health

care delivery models: emerging trends in the delivery of health services” which discusses organisational changes that have occurred in developed countries in the delivery of health services. The article discusses the emergence of cost-consciousness and the different regulatory approaches that have been put in place by developed governments (USA, Britain and Canada) to reduce the cost of health care, while ensuring equity of both funding and access to services. It is observed that cost containment regulatory activities have targeted institutions as opposed to health care providers and that cost has become the primary motivator for most health policies and health reforms (Lomas 1986). The focus has also been shifting to health promotion and prevention rather than the traditional illness and curative models (Bendell 1997).

2.5.1 Key components of a health care delivery model

A model is a schematic description or presentation of phenomenon (system or theory). It depicts how the phenomenon works and clearly shows the interrelationships and inter-linkages between different components (Girard 1993). Girard (1993) outlines essential features which need to be considered during the development of new nursing care models. These include understanding the social, political, organisational culture, financial and technical system of the institution. Other aspects of significance which need to be considered during health service model development include: the identification of assistive factors, barriers and boundaries as illustrated in Figure 3 below. Assistive factors are those

62 elements that contribute to the planning, development and implementation of the model, while barriers are elements that affect the ability of one to provide good quality care and should be removed or negotiated upon. Boundaries are factors present that may or may not be changed (Girard 1993). Health care delivery models can also be described within the context of primary health care (PHC).

A systematic review of innovative models of comprehensive primary health care services in rural and remote areas of Australia identified five models of PHC which were categorised as: i) discrete primary care service models, ii) integrated service models, iii) comprehensive primary health care service models, iv) outreach models, and v) telemedicine or tele-health models (Walkerman 2008). In addition to this, the review identified essential elements necessary for the success and sustainability of each model which included the following: a supportive policy environment conducive to change, community involvement and participation, supportive and adequate workforce, consistent funding, good governance, management and leadership, proper infrastructure and information and communication (Wakerman et al 2008). All of these form the building blocks of an effective health system (WHO 2007d). Literature review on primary health care delivery models in Canada does point to an “ideal model” but identifies appropriate

Derived from (Girard 1993)

Assistive factors

 Individual nurse motivation

 Supportive administration

 Presence of leadership

 Planners capability

 Knowledge and skills of health care providers

Barriers

 Communication channels

 Incentives

 Availability of supplies and equipment

 Policies and procedures

 Availability of support and auxiliary personnel

 High patient volumes

 Low staffing ratios

 Increasing patient acuity

 High technological care

Boundaries

 Patient population type or target population

 Source of finances

 Education of health care professional and other cadres

 Institutional infrastructure

 Institution type of management (private for profit, non-profit)

 Power invested in the nurses

Development of nursing care models

Social system and political policies Organisational cultural system Technical system (workforce) Financial resources

63 mechanisms that may improve service delivery such as the use of multidisciplinary group practices, reforms to the payment of provider schemes and increased accountability (Abelson and Hutchison 1994). Other health service delivery models are defined on the basis of whether or not they are patient driven services. In patient-centred services, health care services are organised and executed at the convenience of the client, rather than the convenience of the health service provider. Such a set-up underscores the importance of involving users in the management of their own illness, the “expert-client” concept, as well as involving the users in the decision making process of health service organisation (Clarke 2004). Health social networks are other patient-driven models of health care that are emerging. Through such networks, patients use the internet to get and share information about their condition, receive emotional support and have questions answered through “question-answer” sessions with physicians. Health social networks are primarily designed for patients but other consumers also have access to the information (Swan 2009)

2.5.2 Sexual reproductive health care delivery models

According to the WHO guidelines, adolescent friendly services can be provided in health facilities, schools and the community (WHO 2002a). This includes having services offered in already existing hospitals or health centres, youth specific health centres (for example in urban areas or shopping centres), already existing youth centres which have other youth development programmes, health centres linked to schools and outreach services using mobile services to rural and remote areas (WHO 2002a). Tylee et al (2007) outlines six service models for providing SRH services to young people depending on the setting: i) centres specialising in adolescent health located in hospitals and providing inpatient, drop-in services also acting as referral points; ii) community-based health facilities that provides general health care to the whole community including adolescents; iii) school-based or college-based health services; iv) community-based centres which provide health services, education services and recreational services to young people only; v) pharmacies and shops which also sell condoms and contraceptives; and vi) mobile outreach services (Tylee et al 2007). Three key health prevention and promotion strategies have been documented as being essential elements in adolescent health service provision. These include: i) ensuring access to quality clinical reproductive health services including contraception, ANC/PNC, and STI prevention, diagnostic and treatment services; ii) the development of evidence-based and curricular- grounded sex education programmes which include training in life-skills, interpersonal communication and decision making; and iii) youth development programmes which also enhance youth education, their economic capacities and participation in their own health promotion (Bearinger, Sieving, Ferguson, & Sharma 2007). The 2009 FIGO/WHO pre-conference workshop gave recommendations to stakeholders to ensure that both boys and girls have access to a full range of SRH information and confidential services,

64 and that adolescent girls were protected from all forms of sexual violence. In addition the conference put emphasis on ensuring the integration of the age-specific problems of adolescents in the training curricular of health care providers, the service delivery process, including monitoring, supervision and quality assessment (Mbizvo and Zaidi 2010).

The WHO guidelines (WHO 2002a) also outline essential elements that need to be in place in order to regard a health facility “adolescent-friendly”. These include:

 friendly policies that respect adolescents rights and take into account adolescents special needs while guaranteeing privacy and confidentiality and also ensuring services are either free or affordable

 adolescent friendly procedures including client registration and record keeping, short waiting time and drop-in services

 adolescent friendly health care providers who are technically competent, are non-judgemental, respectful, motivated and have good interpersonal skills; and support staff who are friendly

 adolescent friendly facilities that have a welcoming and safe environment, offer comprehensive services, have appropriate guidelines, have friendly working hours, offer appropriate information and education

 Other components include: having adolescent involvement, community participation, and an effective monitoring and evaluation system (WHO 2002a).

2.5.3 Costs of reproductive health service delivery

Evidence shows that the benefits of investing in family planning (FP), maternal and newborn health (MNH) are enormous and essential to the achievement of the Millennium Development Goals. For example in sub-Saharan Africa, it has been estimated that meeting the FP and MNH service needs of women would result in a 70% reduction in maternal deaths, 57% reduction in new born deaths and 75% reduction in unintended pregnancies. In addition significant savings (of $1.5 billion) would be made if investments were made in both FP and MNH compared to investing in only MNH services (Guttmacher Institute 2010;Susheela et al. 2009). Another estimate, using WHO clinical guidelines, shows that annual resources needed to either moderately or rapidly scale up MNH interventions, within the MDG context, are US$3.9 billion and US$5.6 billion respectively. Annual increments gives a figure of US$39.3 billion and US$55.7 billion for the interventions to be implemented either moderately or on a rapid scale, respectively, over a ten year period (2006-2015) (Johns et al. 2007). While advocating for the scaling up of effective health interventions, attention should be paid to improving the health system in general. A functioning close-to-client health system is essential for the scaling up of any health intervention and this

65 needs important consideration during any intervention design (Jha et al. 2002). Inadequate financial resources have been a major barrier to the scaling up of effective health interventions in developing countries and there is evidence suggesting that more resources than currently available are needed (Morel et al. 2005). Having a strong health system ensures that there are adequate resources for infrastructural expansion, inputs, distribution, health workforce, awareness and demand creation, human resource development, actual programme costs including monitoring and supervision (Jha et al 2002;Morel et al 2005). For developing countries, government spending on all reproductive health services and commodities currently falls below the internationally standard of US$16 per person needed to ensure availability of modern contraception only (Ha et al. 2011). Public-private partnerships (PPPs) and donor funding are initiatives that aim to narrow this resource gap, however, evidence supporting where to invest in PPPs is lacking (Fryatt et al. 2010) and the sustainability of donor funding is questionable. On the other hand evidence has shown an association between high government expenditure and increased utilization of maternal health services such as skilled birth attendance and caesarean section (Kruk et al. 2007). The taskforce on innovative international financing for health systems (Fryatt and Mills 2010) set up in September 2008 to identify ways of strengthening the health system in 49 poor countries to enable them attain MDGs 4 and 5 recommended innovative ways in which funds could be raised to address health systems challenges. This included using airline tax revenue to reduce market prices of drugs in LMICs, linking tobacco taxes to specific health activities, use of De-tax initiatives (governments forgoing some VAT and businesses forgoing some profit for a health course), expansion of the already existing financing mechanisms to include maternal and child health services such as the International Finance Facility for Immunisation (IFFIm), Global Fund‟s Debt2Health Initiative and the Millennium Foundation (Fryatt, Mills and Nordstrom 2010).

Studies assessing the cost of providing specific components of RH health services show variation between countries and continents with regards to cost to the health sector. For example estimates show that the cost of providing post-abortion care lies between US$83 and US$94 per patient and US$159 million and US$333 million to the health system, per year in Africa and Latin America respectively (Vlassoff et al. 2009). In a study comparing the cost of providing RH services in Zimbabwe and Mexico, the cost of providing RH services was found to be higher in Mexico compared to Zimbabwe especially with regards to surgical procedures. The cost of providing tubal ligation and treatment for STI was found to be $70 and $19 in Zimbabwe and $269 and $29 in Mexico respectively. With regards to providing adolescents with routine examination and iron supplementation, the cost was almost similar, $5 and $4 for Zimbabwe and Mexico respectively (Mitchell et al. 1999). A cost analysis of the three year multi- component ASRH RCT trial implemented in Tanzania (also discussed in section 2.2.2a) estimated the

66 intervention cost to be US$879,032 with 70% of the total cost being utilised in the school-based component. The annual costs per pupil dropped from $16 in 1999 to $10 in 2001, while after full scale up, only an additional $1.54 was needed per pupil per year for continuation of the intervention; although all costs related to research activities and strengthened STI treatment services were excluded from the cost analysis (Terris-Prestholt et al. 2006). Studies costing SRH services for young people are limited and hence there is need to undertake cost evaluation studies so as to ascertain the cost and cost-effectiveness of these interventions.

67 Table 11: Key components of health service delivery models

No. Author, year, country

Objectives Essential elements for health service models

1 Girard 1993 Article introduces readers to the concept of nursing models

Assistive factors:  Staff motivation

 Supportive administration  Credible leadership / planning  Staff knowledge and skills Barriers identification:

 Administrative structure  Staff motivation to change

 Communication channels  Incentives

 Supplies /equipment availability  Policies and procedures

Boundaries identification:  Target population  Financial source

 Institutional infrastructure

 Management type (private for profit, non- profit)

 Decision making

Understanding the social, political, organizational policy of the institution

2 Manthey 1991 A review of health delivery systems and practice models

A delivery system has to answer five basic questions  Who is responsible for making decisions about patient

care? (decision making)

 How long does that person's decision remain in effect?  How work distribution among staff members? By task or

by patient? (task distribution)

 How is patient care communication handled? (communication channels and referral mechanism)  How is the whole unit managed? (management)

 Staffing levels should be determined by acuteness of patients and not the delivery system  Any delivery system can be implemented with

any level and skill-mix of staff and hence there is no need to change the staff levels in order to change the delivery system.

3 Armstrong and Stetler 1991

Strategic considerations in developing a health service delivery model

Staff make up  Cadre  Competencies  Skills-mix Tasks  Specific tasks  Task delegation  Routine work  Comprehensiveness of services  Reporting of communication linkages  Model cost-effectiveness Evaluation criteria  Administrative efficiency  Patient satisfaction  Staff satisfaction  Cost of services Other essential features

 Scientific soundness of the model Desirability and Feasibility

4 Vacek et al. 1978

Paper presents a conceptual model with which functions of health service personnel can be organized

 Problem solving concepts of assessment, diagnosis, intervention and evaluation

 Concepts of

o Goal of health care

o Nature of patient-provider relationship o Organizational structure of the health care

system

 All directed towards individual patients and communities of patients

 Other non-professional activities involve organizing patients records, clerical tasks, ordering supplies

68 No. Author, year,

country

Objectives Essential elements for health service models

5 Fennell 2001 Article aims at defining and elaborating

dimensions of health care delivery services

Components or actors of health care delivery systems Health workforce

Organization structure and coordination Financial source- public or private Types of health care delivery system:

 Primary, secondary, tertiary and rehabilitative

Structural features

 Size, ownership, profit orientation, range of service provision, governance structure Process characteristics

 Service delivery mechanism  Coordination mechanism  Information flow

 Decision making processes  Quality control

 Provider-client communication flow 6 Stevens and van

der Zee 2008

Article describes health- care systems from a comparative perspective

Typical characteristics of a health system

 Functional specificity – systems have shared operational goals

 Structural differentiation - division of labour between elements (persons & organizations)

 Elements coherence - coordination, planning and organization

 Autonomy – self-regulating Four models of health care systems  Free market  Social insurance  NHS  Socialist 7 O'Donnell et al. 2010 Developing a framework for reporting health service models for managing rheumatoid arthritis

Components and Dimensions  Goals of the model

o Why was the health service model founded?  Role of provider(s) and user(s)

o Who is involved and what are their roles?  Setting, country, level of care (community, primary,

secondary, tertiary)

 Method (s) in which the interventions are delivered o How are the services or interventions

implemented?

 Duration of the intervention

o How long is the intervention?  Referral process

o How patients will access the services or interventions?

 Mode(s) of communication between individuals  Sustainability of the model

8 Wakerman et al. 2008

Literature review of innovative models of comprehensive primary health care in rural and remote Australia to identify primary health care models that work well.

Five models identified

 Discrete primary care services  Integrated services

 Comprehensive Primary Health Care services  Outreach models

 Tele-health and telemedicine Enablers of sustainable PHC  Supportive policy  Sustained service funding

 Community participation in planning and delivery of services

Essential requirements

 Workforce – numbers and skills mix  Funding

 Governance

 Management and leadership

 Linkages- service integration within, linkages with other key organizations

 Infrastructural – physical, information, communication technology

9 Abelson and Hutchison 1994

A review of the

international literature on primary health care

 Evaluation of PHC delivery models are scarce  Research evidence does not point to one ideal model

Features to consider in model design  Multi-disciplinary group practice

69 No. Author, year,

country

Objectives Essential elements for health service models

models fee-for-service

 Accountability 10 Wakerman 2009 Paper examines literature

on „innovative‟ primary health care (PHC) models in rural and remote areas of Australia

Key features of PHC models  Financial system- sustainable  Community participation  Health information system  Multi-disciplinary practice  Credible leadership / clear vision 11 Anderson and

Lowen 2010

To identify models of health care delivery that support youth access to health and mental services

Models identified included

 Primary support from parents and family

 Family physicians – youth may not use them for birth control or suspected pregnancy

 School-based services- may be a key setting for delivery of health care to youth

 Community based health centres – linked with hospitals, churches, business, community centres

 Other access points – arts, music, internet, telephone counselling, services, pharmacies

Seven principles for better practices in youth health include:

 Access facilitation, evidence-based practice, youth participation, collaboration, professional development, sustainability, evaluation.

12 Swan 2009 Paper examines three categories of novel health services: health social networks, consumer personalized medicine, quantified self-tracking

Health social networks

 Website for health resources ranging from information, emotional support, information sharing, physicians questions and answers

13 Craig et al. 2008 Article describes complex interventions as inter- ventions containing several interacting components

Steps taken in the development of a complex interventions  Identifying existing evidence: what is known about similar

interventions and what methods were used to evaluate them?

 Identifying and developing theory

 Modelling process and outcomes – pilot testing  Exploring the feasibility- acceptability,

compliance, delivery of the intervention, recruitment and retention, through piloting  Understanding the social context

14 Clarke 2004 Studying the organization and delivery of health services

Patient- and carer- centred services:

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