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Service delivery

This is the central process inside a HS: the delivery of services is the immediate output of all the inputs into the delivery system. The organisation of this delivery determines to a large extent if the inputs lead to the desired output: access to quality care. Delivery of health services is produced at the interface with the population. The most atomised product of this is the interaction between a single health provider and patient. However, in the perspective of a (national or local) HS perspective, it comprises the sum total of services in a specified area. The word ‘health service’ can refer both to the organisation that supplies care and to the specific product which is delivered.
The boundaries between providers and population are not very strict and both elements partly overlap; the population is also a ‘producer’ of health and provider of care. In these paragraphs, we will focus on the professional side of supply.

When we talk about health services, we mean all services that have as primary purpose the improvement of health. The term includes general health care and services that are aimed at specific health problems; disease control interventions and services responsive to suffering of individuals; preventive and curative services; personal health services and population-based activities. There are many other terms with a different focus, for instance on the level of care or on the package of services. Examples of other terms are ‘health care’, ‘primary health care’, ‘essential services’ or ‘priority interventions’. We will use ‘service’ as a generic term, which can refer to all of the above.

Health services are thus very diverse in nature. In addition, these services are delivered to the population via multiple modes and channels.

Health services and delivery platforms

Health services can be classified along different characteristics. An economic classification can use the degree to which health services are transaction-intensive (how much professional input is needed); discretionary (similar for everybody or customised to the individual); and the level of information asymmetry (to what extent are both parties equally able to judge the transaction in terms of quality and appropriateness). Individual-oriented clinical care is transaction intensive, discretionary and having a high degree of information asymmetry. Immunisation services might be transaction-intensive but are less discretionary and have little information asymmetry (Soucat 2004). Other criteria for classification are the need for permanent availability or the possibility for intermittent scheduling, and the focus on individuals or on the total population (Van Damme et al. 2008).
Health services can be delivered to the population (and, in some cases, by the population) via specific modes and channels. Examples are different types of health facilities providing health services (such as clinics, health posts, health centers, district hospitals, a.o.), but also outlets for health-related goods (such as pharmacies, informal drug outlets, mobile drug peddlers a.o.), and other entities (such as mobile teams, community health workers, vaccination campaign teams, etc). These can be classified in a variety of ways. Examples are family-oriented community-based services; population-oriented schedulable services; individual-oriented clinical services at different levels (primary level, first referral level and second referral level). Another term for these channels or modes is “delivery platforms”, which we will use from now on (Van Damme et al. 2010).
Specific services can be delivered via different platforms. The list of potential health services in a health system is indefinite, but in the context of scarce resources, the rationing of services and the drive for optimisation of results, there will often be choices to be made, which leads to a selection of prioritised interventions. Some services will flow through delivery platforms partly or completely outside the HS. Residual insecticide spraying, for instance, is done outside the HS; bed nets are delivered partly via HS delivery platforms (health centres, drug outlets) but also in general supermarkets. At the same time, people will come to places where health services are provided with all kinds of problems that will often not be part of the priorities set by planners. Providers will thus also provide services in response to this demand (the parts of the horizontal bars that don’t overlap with the vertical bars in figure 5). The number of delivery platforms is not indefinite. The household level itself can also be considered a platform through which health services are delivered. Not all health services, can, are or should be delivered via all delivery platforms. It depends on the nature of the service, the capacity of the delivery platforms and other context factors such as regulation, which delivery platforms are most appropriate for which health services.

The term ‘integration’ is generally used to describe the extent to which Disease Control Programme (DCP) activities are bundled with the general services of a health system and a health care organisation, rather than being implemented by a separate entity. Several frameworks exist to describe integration more specifically at national level (Atun et al. 2010) and at the operational level of health service delivery (Coulibaly et al. 2008). Often, the term ‘integration of disease control activities’ into general health services’ is a simplification of the complex mix of services and delivery platforms, as we visualized them above. The choice which delivery platform to use for which health service depends on various factors, such as the added value to bundle different services, the possibility to standardise and delegate activities and the capacity of a specific delivery platform (Unger et al. 2003a) . It is important to optimise the articulation between the different approaches, so that duplication and distortion and imbalance take place as little as possible (Criel et al. 2004). We believe that a strong HS is composed of a mix of all such platforms, and that the optimal mix depends on contextual issues (such as disease burden) and is highly path-dependent, but that the resulting overall health system should somehow be balanced. This also implies the need for strong coordination between these platforms.

Providers of health services

The delivery platforms indicate modes or channels of delivery (processes or structures). The providers are the organisation or persons who actually deliver the service. When we zoom in on providers of services, we can characterise them as private or public, for-profit or not–for-profit, formal or informal, professional or non-professional, allopathic or traditional, remunerated or voluntary. The distinctions between these categories are seriously blurred in many countries, to the point that some consider the use of these categories as obsolete or counter-productive (Giusti et al. 1997). In most health systems, providers constitute a complex mixture (often referred to as ‘pluralistic health systems’), partly as a result of planning and organisation and partly due to personal initiative or spontaneous evolutions. In many countries the backbone of the health system is formed by a public system, often owned and managed by the state. In many LICs, this public system has historically been quite dominant, even monolithic. In others, it has always co-existed with a private sub-system (often faith based). The past couple of decades have seen an important shift, mainly due to the fast expansion of a Private For-Profit (PFP) sub-system and the proliferation of Non Governmental Organisations (NGOs) as part of the Private Not-For-Profit (PNFP) sub-system. The distinctions between these three sub-systems within the HS are often blurred which may partly explain the confusion in debates around the public and private roles and realities in health systems.
To better understand how different providers deliver services, we can focus on the meso level, that of a local health system. This is an administratively or geographically bounded area, for example a district, which can be considered a subsystem of a national HS, with a defined population, a governance structure and health services and resources. In figure 6 we visualise the variety of health providers in such a local health system.

The hypothetical district in this figure has a ‘backbone’ public health care system with hospitals, health centres, health posts and community health workers. The PNFP sub-system in this area is composed of mission and NGO hospitals, health centres and clinics as well as some semi-formal community clinics and community health workers. The PFP sub-system in this district is dominated by drug vendors and clinics. The composition of this picture will vary according to the context. In sparsely populated very poor areas, there are often very few formal health facilities at all and the gap might be filled with community health workers; in densely populated areas in which the private sector can develop freely, the number of private facilities and drug vendors can be very high.  

The linkage with other elements of the Health System

Service delivery is closely linked with all other elements in the HS. The availability of resources and the organisation of their use determine the possibilities for service delivery. Health service delivery can be organised in various way, using more or less resources. The transaction intensity of many health services makes professional staff one of the scarcest resources in many HSs. The more delivery can be simplified and standardised, the more opportunities for efficiency gains are possible, for instance in task-delegation and rationalisation of drugs use. However, not all tasks of health service delivery, especially in clinical care, can be simplified and there is a trade-off between simplification (standardisation) and a customised approach. It is a governance task to determine the optimal delivery models for different health services in society.
Another crucial element of governance in relation to service delivery is the steering and motivation of providers to deliver health services according to the desired outcomes and goals of the HS. The different possibilities of steering are elaborated in the chapter on governance. The oversight and steering function is usually executed by a public authority, but the extent of influence into the private sub-systems varies and is often very weak. There is often a lack of balance in the services delivered and a poor coordination between the actors (Bloom et al. 2001). In these contexts, the organisation of health care delivery is only partly the result of planning, but also determined by the preferences and behaviour of the population and health care providers. All providers react to a variety of incentives, motivators, demotivators and disincentives. Governing involves steering both population and provider behaviour, which links especially with the elements of human resources and population. Apart from public authorities, there might be also a governance role for professional organisations towards the behaviour of their own professional group, but this is mostly the case in countries with a tradition of medical professionalism such as Europe and the Americas.
The linkage between health services and the population comprises many dimensions. We will discuss their role of producers of care and users of care in the chapter on population. Here, we discuss the dimensions of trust and of accountability between health providers and the population, since health providers bear great responsibility in ensuring these two dimensions. Trust between health providers and the population (meso level) or patients (individual level) is important for quality of care (both a determinant and a consequence) and for the acceptability of health care providers and the health seeking behaviour of people (see under population). Trust of the population/patient is influenced by the behaviour of providers, but also by the institutional set-up of the health provider organisation, for instance the impression of truthfulness, solidarity and fairness in the organisation (Gilson et al. 2005). These determinants are linked to governance and the organisation of human resources.
The HS as a whole and the health services themselves have the responsibility to be accountable towards the population. Any health provider is accountable to his patients, for the services that he provides or does not provide. Since this relationship is characterised by a high degree of information asymmetry and power imbalance, there should be systems in place to correct this imbalance and to enable the patients to claim their rights. This is a function of governance. However, the accountability of health providers goes beyond individual patients; health care organisations are supposed to be accountable to the population they serve. Various structures exist to create channels for this accountability. The classical participation structures such as health committees have had different degrees of success. The introduction of third party payer arrangements has also resulted in institutional mechanisms for control, which can include procedures for users to hold the provider accountable. New information technologies, especially in information and communication, have a great potential to increase the information to users and the voice of users towards health providers. At higher level, that of the local or national health system, decision-makers are supposed to be accountable to the population. The decisions about priorities, financing, packages of care, etc. are taken by a mix of people, bureaucrats and politicians, influenced by academics, pressure groups, the public opinion and many actors outside the HS. Important guarantees for accountability are general democratic principles, such as free press, absence of corruption, elections and transparency of information and decision-making.

Our perspectives on the local organisation of a health system

Organisation of health care delivery implies decisions about which services can be best provided by which delivery platforms and by which providers. These decisions depend on the characteristics of interventions, the capacity of providers, the burden of disease, etc. Apart from these technical criteria, both population and providers will have their own preferences and behaviours. The organisation of health care delivery is partly the result of planning, but also determined by these preferences and behaviour of the population and health care providers that is not under full control of planners. Nevertheless, we believe there are some principles for the optimal organisation of a health system at local level.
A local health system has a defined population, which could be called the catchment population or the population of responsibility. The latter term implies that the authorities in the system have a responsibility for reaching outcomes and goals for the people in that area. We believe that such a local HS should function as an integrated system. With this, we mean that all actors coordinate so that there are no gaps in access and that there is an optimal flow of patients and information is created, where the patient is helped at the most appropriate level. In order to ensure access, and to use all opportunities of contact between people and health services to deliver priority interventions, there might be overlaps in delivery platforms offering services, but efficiency considerations should be taken into account. The opposite of an integrated system is a fragmented system. The following guidelines can help in planning and steering local health systems: development of tiers with a certain degree of homogeneity and specificity; a minimum package of services/activities; responsibility for a well-defined population; legitimacy and accountability towards a population; and planning based on rational criteria and pragmatism (Unger et al. 1995).
In our view, the first line health services (health centres, GP practices, clinics and the like) are at the very core of the local health system. It is at that level that the majority of the health problems that people face should be able to find an adequate solution. A primary care provider is the first contact to this system for the patient, a gatekeeper to other providers in the system and a hub and coordination for the patient to navigate the system, as also visualised by the WHR 2008 (World Health Organisation 2008a). We call this hub also the synthesis function (referring to the fact that the generalist first line provider can make a ‘synthesis’ of people’s health problems at any point in time on their journey through life).
The first line is therefore decentralised (i.e. physically close to the people they serve), permanently accessible and staffed with versatile (teams of) health workers, who are capable of addressing a wide range of health problems. Other health services, and other social services for that matter, can then be organised around the first line facility. More specialised referral services are usually more centralised, and some of them can operate on a basis of periodic rather than permanent access.