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Papanicolas I, Rajan D, Karanikolos M, et al., editors. Health system performance assessment: A framework for policy analysis [Internet]. Copenhagen (Denmark): European Observatory on Health Systems and Policies; 2022. (Health Policy Series, No. 57.)

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Health system performance assessment: A framework for policy analysis [Internet].

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Chapter 7Service delivery

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7.1. Introduction

Delivering services is a core function of health systems and this is influenced by and influences governance, financing and resource generation. Service delivery directly impacts intermediate health system objectives and, ultimately, the achievement of overarching health system goals. This chapter builds on the service delivery definition proposed by Murray & Frenk (2000), that is, “the combination of inputs into a production process that takes place in a particular organizational setting and that leads to the delivery of a series of interventions”. Within this, we define three sub-functions of service delivery: public health, primary care and specialist care.

Assessment of service delivery is not straightforward. This is in part because the performance of service delivery depends on, and is influenced by, the performance of other health system functions.

Assessments can also take different perspectives, which might include:

  • service areas, such as primary or secondary care, or a programme, such as HIV or tuberculosis
  • objectives, such as quality, safety, effectiveness, efficiency, accessibility or equity
  • the nature of the organization providing services, for example, the level or mode of care.

This chapter begins by defining the service delivery function within the HSPA Framework for UHC and describing the service delivery sub-functions. It then sets out an approach to assess the performance of these functions and sub-functions that includes proposed indicative measures for each. The chapter concludes with a summary of the key proposals and discussion of the wider opportunities for and challenges of assessing the performance of service delivery as a key function of health systems.

7.2. Understanding the service delivery function

7.2.1. Where service delivery fits in the framework

Fig. 7.1 illustrates the HSPA Framework for UHC and position of the service delivery function within this framework. As this shows, service delivery is a product of the governance, financing and resource generation functions. Within service delivery we distinguish the three sub-functions of public health, primary care and specialist care, as well as the function-related governance mechanisms guiding the planning and operation of services. The framework illustrates how service delivery impacts directly on the intermediate objectives of effectiveness, safety and user experience, along with efficiency and equity of service delivery, and access. Together, these drive the achievement of final health system goals and make service delivery a means of assessing the core areas of health system performance.

Fig. 7.1. Service delivery sub-functions.

Fig. 7.1

Service delivery sub-functions. Source: Authors’ compilation.

7.2.2. Defining service delivery

As noted in the introduction, Murray & Frenk (2000) identified the provision of health services as one of the four core functions of health systems, defining it as “the combination of inputs into a production process that takes place in a particular organizational setting and that leads to the delivery of a series of interventions”. This definition builds on earlier work by Londoño & Frenk (1997) who spoke more specifically about “outputs (health services) which generate an outcome (changes in the health status of the consumer)”, rather than interventions.

So, while service delivery forms a core health system function, it is also an outcome of the governance, financing and resource generation functions, with inputs including human resources, physical capital and consumables (Fig. 7.2) (Adams et al., 2003; WHO, 2010). This means that the performance of the service delivery function will reflect the performance of the governance, financing and resource generation functions.

Fig. 7.2. Health service provision (Adams et al).

Fig. 7.2

Health service provision (Adams et al). Source: Adams et al. (2003).

In its 2007 framework for action on health system strengthening, WHO expanded the conceptualization of service delivery to include consideration of the service production process and the ways in which the organization and management of inputs and services “ensure access, quality, safety and continuity of care across health conditions, across different locations and over time”. It later argued that increasing inputs would result in better service delivery and access to services, and that “ensuring availability of health services that meet a minimum quality standard and securing access to them are key functions of a health system” (WHO, 2010).

Service delivery is a broad concept and difficult to separate into sub-functions without considering a specific country context or service organization. Differentiation is further complicated in that the term “health service” can refer to both the organization that delivers care and the specific product being delivered (Van Olmen et al., 2010). Murray & Frenk (2000) differentiated provision as personal and non-personal health services. Personal health services were seen as those “consumed directly by an individual, whether they are preventive, diagnostic, therapeutic or rehabilitative, and whether they generate externalities or not”, whereas non-personal health services were defined as referring to “actions that are applied either to collectivities (for example, mass health education) or to the non-human components of the environment (for example, basic sanitation)”.

The World Health Report 2000 (WHO, 2000) built on the conceptualization of service delivery as proposed by Murray and Frenk, but it did not differentiate the service delivery function beyond personal and non-personal health service delivery. Instead, the report distinguished different organizational forms, such as hierarchical bureaucracy, long-term contractual arrangements and short-term market-based interactions; public or private ownership; and service delivery configurations that could be dispersed. These were defined as “competitive production by small producing units” (for example, primary care); concentrated (for example, hospital care, central public health laboratories), or hybrid (for example, programmes to control infectious diseases) (WHO, 2000).

Clearly, there are different conceptualizations, and the differentiations above also combine different perspectives. For the purpose of a generalized framework for health systems performance assessment, we distinguish public health, primary care and specialist care as three sub-functions of service delivery, which we will describe. However, it may first be helpful to separate out the notions embedded in various conceptualizations, either implicitly or explicitly, which distinguish service delivery according to:

  • the target population (for example, individual and collective health services)
  • the primary purpose of consumption (for example, preventive, curative, rehabilitative, long-term care)
  • the type of provider or delivery platforms (for example, primary health care unit, hospital)
  • the level of provision (for example, primary, secondary, tertiary)
  • the mode of provision (for example, inpatient, outpatient, day care, home care).

These conceptualizations provide a useful way to think about approaches to assessing service delivery performance, but they also show that there are multiple ways to differentiate the components of services. Appendix 7.1 provides a summary of these approaches to categorizing service delivery and discusses the challenges of each for HSPA.

7.3. Sub-functions

Having highlighted the various ways health service delivery may be classified and differentiated, and recognizing the need to enable performance assessment of areas within service delivery, we propose assessing service delivery in a way that allows for a degree of overlap between the various perspectives described above (target populations, purpose, platforms levels and modes), according to three broad sub-functions:

  • public health
  • primary care
  • specialist care.

There are some challenges associated with this differentiation, but it is commonly used and allows for flexibility to adjust for the organization and structure of health services in any given country.

7.3.1. Public health

Public health has been conceptualized using different disciplinary and professional perspectives, with a common thread – seeing it as a collective or societal approach aimed at “improving health, prolonging life and improving the quality of life among whole populations” (WHO, 1998). Public health covers the spectrum of health and well-being, from the eradication of particular diseases (World Health Organization Regional Office for Europe, 2020), to an increasing recognition of the political, commercial, economic, social and environmental determinants of health and social inequalities (Lomazzi, Jemkins & Borisch, 2016).

The practical application of this overarching understanding has remained complex, and globally there is considerable variation in terms of the essential functions assigned to public health (Martin-Moreno et al., 2016). Common elements of existing frameworks include surveillance, governance and financing, health promotion, health protection and legislation, human resources and research (WHO, 2018). However, there is greater variation around activities such as disease prevention, health care, emergency preparedness, social participation and communication within public health. This reflects, to a great extent, differences in perspectives on what constitutes public health – particularly in relation to UHC – and to what degree health care should be considered a public health operation. Similarly, the aims of defining essential public health functions vary and range from capacity-building exercises to strategies to improve the overall performance of health systems.

7.3.2. Primary care

Definitions of what constitutes primary care also vary widely, although a common understanding is that primary care represents the first point of contact for unspecified and common health problems. Van Olmen et al. (2010) refer more broadly to “first line health services” – such as health centres, general practitioner practices or clinics – as the primary level of care because they are close to the people they serve, accessible to all, and able to address a wide range of health problems.

However, as indicated above, boundaries between what is referred to as primary care and public health at one end of the spectrum, and primary care and specialist care at the other end, are becoming increasingly blurred. As a result, many services that fulfil a wider public health function are provided in primary care settings (for example, vaccination, family planning), whereas in some countries primary care includes office-based specialists and fulfils a specialist care sub-function.

7.3.3. Specialist care

Specialist care is frequently distinguished into secondary and tertiary care. Secondary care is usually provided in local hospitals, whereas tertiary care comprises highly specialized care delivered in regional or national hospitals in order to concentrate expertise and complex, high-cost resources (Black & Gruen, 2005).

Again, boundaries between primary care and specialist care are becoming increasingly blurred. This is partly because, in some countries, specialists also work as office-based practitioners outside a hospital setting (Cacace & Nolte, 2011).

Perhaps more importantly, the delivery of health care services is changing. For example, new developments in medical technology, particularly telehealth and mobile technologies, make it possible to provide many services closer to the patient. This allows diagnostic or therapeutic interventions that previously required a hospital environment to be carried out in people’s homes or in ambulatory settings. In many countries there is also increasing recognition that the rising burden of chronic disease requires a different model of care, away from a dependence on hospital-based episodic delivery, towards one that offers some specialist care in the community. This is seen as a way to increase accessibility of services, enhance continuity of care and service responsiveness, and, potentially, reduce costs (WHO, 2016a).

7.3.4. Governance of service delivery

Governance is a core area within each health system function, providing the basis and structure for their operation. Given the dependence of service delivery on other health system functions, its governance is, in part, a task of those functions. For example, the overall regulation and organization of health services is a task of the overall governance function of the system; whereas the purchasing of services and aspects of health service coverage is governed by the financing function; and the planning and distribution of services is governed by the resource generation function. However, as Adams et al. (2003) pointed out, there are distinct areas of governance specific to service delivery – decision-making authority and service integration – to which we add quality assurance mechanisms. We will return to these below.

7.4. Assessing the performance of the service delivery function

As noted, a key feature of service delivery is that it is both a health system function and an outcome of the governance, financing and resource generation functions. As a result, service delivery links directly into intermediate objectives. In addition to this, we identify decision-making authority, service integration and quality assurance mechanisms as distinct elements of service delivery governance (Fig. 7.3).

Fig. 7.3. Assessing service delivery.

Fig. 7.3

Assessing service delivery. Source: Authors’ compilation.

Access and other identified assessment areas – effectiveness, safety, user experience, efficiency and equity of service delivery – are intermediate objectives of health system. Therefore, for consistency with the overarching framework, we refer to these assessment areas as intermediate objectives. They are also common to the assessment of the three service delivery sub-functions.

Regardless of the conceptualization of service delivery function in the HSA tools described in Chapter 2 (and, consequently, the country-specific HSA reports), this is the area that inevitably plays a key role in the HSA initiatives (Box 7.1).

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Box 7.1

Service delivery in the HSA tools.

7.4.1. Intermediate health system objectives as areas of assessment of service delivery

Quality is central to the performance of health service delivery. But, as highlighted in Chapter 2, there are many different ways to assess the quality of health services and systems. Most frameworks build on the seminal work by Donabedian, who argued that health services should be evaluated according to structure, process and outcome, as “good structure increases the likelihood of good process, and good process increases the likelihood of good outcome” (Donabedian, 1980, 1988). This approach was used widely in the study of health service quality, although a further dimension of outputs was added to capture the immediate results of health services carried out by health workers or institutions (Box 7.2).

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Box 7.2

Dimensions of health services and health systems.

The US Institute of Medicine described quality as “the degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current medical knowledge” (Institute of Medicine, 2001); and it identified six dimensions to evaluate this:

  • safety
  • effectiveness
  • patient-centredness
  • timeliness
  • efficiency
  • equity.

Other dimensions, including access, acceptability and continuity, have been added and there is a degree of overlap between dimensions (for an overview see Nolte et al., 2011).

A review of performance indicators which looked at eight high-income Organisation for Economic Cooperation and Development (OECD) countries found the most commonly used health system performance domains were effectiveness, access, safety and efficiency, and there was significant overlap of these domains (Braithwaite et al., 2017). We focus on the six most commonly used and widely considered core dimensions to measure the service delivery function of health systems. For the purposes of performance assessment, we use the definitions by Nolte et al. (2011) and the National Academies of Sciences and Medicine (2018):

  • Effectiveness: Extent to which a service achieves the desired results or outcomes, at the patient, population or organizational level.
  • Safety: Extent to which health care processes avoid, prevent and ameliorate adverse outcomes or injuries that stem from the processes of health care itself.
  • User experience: Extent to which the service user perspective and experience of health care is measured and valued as an outcome of service delivery.
  • Access: Extent to which services are available and accessible in a timely manner that does not undermine financial protection.
  • Equity: Extent to which the distribution of health care and its benefits among a population is fair; it implies that, in some circumstances, individuals will receive more care than others to reflect differences in their ability to benefit or in their particular needs.
  • Efficiency: Relationship between a specific product (output) of the health system and the resources (inputs) used to create the product (Palmer & Torgerson, 1999), distinguishing technical and allocative efficiency (see below).

Some dimensions describe the service delivery function specifically, in particular the quality domains of effectiveness, safety and user experience; whereas access, equity and efficiency reflect a broader interaction of all health system functions that ultimately work through service delivery. This approach is closest to the OECD framework for assessing the technical quality of health care, noting that quality in health care means that the care provided is effective, in that it achieves desirable outcomes based on need; safe, because it reduces harm caused in the delivery of health care processes; and person-centred (Kelley & Hurst, 2006).

Before exploring the assessment of sub-functions of service delivery – public health, primary care and specialist care – we briefly discuss the dimensions of access, equity and efficiency as cross-sectional areas related to service delivery that reflect broader aspects of health system performance. Access

Access has been conceptualized in numerous ways and is most frequently defined in relation to the use of services. However, Levesque, Harris & Russell (2013) developed a broader framework that brings together the different dimensions and determinants of access to health services. This distinguishes approachability, acceptability, availability, accommodation, affordability and appropriateness, alongside what they termed population “abilities”. These are defined as the ability to identify, seek, reach, pay for and engage with health services. Clearly, the factors that determine the different dimensions of access to services go beyond the service delivery function. Thus, access is determined, largely, by governance decisions about the organization of services and the population covered. This is driven by financing decisions about what is covered and the degree of financial protection provided; and also by resource generation decisions around investment in human and physical capital.

Indicators of access include a number of direct markers such as:

  • unmet need, instances where people need care but are unable to receive it
  • financial reasons such as the cost of care
  • geographical factors including distance and lack of transport
  • service availability, which might be reflected in waiting lists.

Indirect markers include the health consequences of not being able to access timely care – such as amputation rates among people with diabetes or reduced survival due to late diagnosis. Another marker is the level of service utilization, although indicators of overuse and underuse of services should be interpreted with caution (Elshaug et al., 2017). Indicators such as utilization and outcomes, which can be used to measure access on both the demand and supply sides, need to be examined alongside each other to avoid misinterpretation and to ensure that decision-making is adequately informed.

Boundaries are not clear-cut, as can be seen in hospital admissions for chronic conditions such as diabetes or heart failure. As these are potentially avoidable when managed appropriately in primary care, high rates of admissions can be viewed as an indicator of poor access to primary care, or a lack of coordination between primary and specialist care. This could be the result of failings in quality or efficiency, or, indeed, both (Gibson, Segal & McDermott, 2013) (see also Box 7.3).

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Box 7.3

Expanding access to primary care services in Brazil. Equity

Equity is a cross-sectional dimension of both the health system and its service delivery function because it encompasses fairness and equitable availability and distribution of health services, as well as resulting outcomes (see Chapter 3). In terms of service delivery, equity centres on the distributive effects of the quality and effectiveness of services delivered, and on the ability of different population groups to access those services. Equity has multiple strands, which are more, or less, relevant in each specific context. These could be geographical and include variation across countries or regional differences within countries; socioeconomic and span income and employment status; or demographic and vary by age, sex and ethnicity. Box 7.4 illustrates this issue using the example of antenatal care.

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Box 7.4

Equity in antenatal care quality. Efficiency

Efficiency is also a cross-sectional dimension of both service delivery and health system performance (Chapter 3), but there are different ways of thinking about efficiency in the context of service delivery.

Technical efficiency covers operational performance (Cylus, Papanicolas & Smith, 2017). Measures to enhance technical efficiency in service delivery include those aimed at reducing the duplication of services; limits on the use of expensive or unnecessary inputs through measures such as reduced prescribing of branded drugs and using nurses rather than physicians to provide services when appropriate; or reducing errors and adverse events at system, organizational and patient levels (Bentley et al., 2008).

Allocative efficiency relates to choices of inputs or outputs, and measures to enhance allocative efficiency include re-balancing services across the health system. This could include moving care into the community, co-ordinating care more effectively, or strengthening preventive care with measures such as incentives at the provider and system levels. Efficiency of service delivery is influenced by governance decisions including:

  • uptake of cost-effective technologies and treatments
  • wider quality assurance frameworks including national standards and guidelines
  • financing decisions around the incentivization and reimbursement of service providers
  • resource generation decisions about investment and the appropriate mix of skills, competencies and infrastructure needed to deliver the right care to the right people in the right place.

Additionally, there is an explicit service delivery assessment component relating to how well services use conditions set by the wider governance and financing framework (see Box 7.5).

Box Icon

Box 7.5

Measuring efficiency in service delivery: antibiotic use.

7.4.2. Assessing the performance of sub-functions of service delivery

It is important to remember that the boundaries between delivery sub-functions are often poorly defined because their scope and breadth is determined, to a large extent, by the specific regional and country contexts within which these functions are organized and financed. For this reason, we propose a set of indicative measures aimed at a global assessment of effectiveness, safety, user experience, access, equity and efficiency, which draw on existing sources when these are available. By global we mean these indicators should be applicable to, and available for, countries at all stages of economic development. The proposed indicators are presented in Tables 7.1 to 7.3, and are organized into structure, process and outcome indicators.

Table 7.1

Table 7.1

Indicative measures for public health

Table 7.2

Table 7.2

Indicative measures for primary care

Table 7.3

Table 7.3

Indicative measures for specialist care Assessing public health

What constitutes good performance of public health as a sub-function may vary. This is reflected in the assessment tools for different frameworks, which vary in scope and depth (WHO, 2018). Available tools use country self-assessments, questionnaires and case studies to evaluate the performance of a given public health function. However, there is no overarching framework for the assessment of public health services that includes real-world indicators (Williams & Nolte, 2018). A review of strategies to ensure the quality of public health services in a range of European countries (Rechel et al., 2018) found that existing approaches focused on selected indicators of health protection such as vaccination rates; the notification and incidence rates of a range of infections; and indicators of disease prevention and health improvement, such as the use of tobacco and alcohol (Williams & Nolte, 2018). Existing approaches often include indicators of early diagnosis such as cancer screening, but there can be considerable overlap with the primary care function, particularly if screening is not population-based. Globally, several of the targets and indicators of the health-related Sustainable Development Goals capture the core public health domains of health protection, health promotion and disease prevention. In Table 7.1, we propose a selection of these, or related indicators, along with the overarching indicator of preventable mortality – which we define as premature death from causes that can be avoided, or reduced, through public health policies, or policies in other sectors that impact public health (Nolte & McKee, 2004). Assessing primary care

Primary care is central to the achievement of sustainable development (Pettigrew et al., 2015) and, in particular, UHC. The 2018 Astana Declaration reaffirmed the values and principles of the Declaration of Alma Ata seeing primary health care as the foundation of a sustainable health system (Global Conference on Primary Health Care, 2018). Against this background, the development of measures to assess the performance of primary health care systems globally has become increasingly important. Key initiatives include the Primary Health Care Performance Initiative (PHCPI), launched in 2015, which focuses on primary care improvements in low- and middle-income countries (PHCPI, 2018); and the European Commission prioritizing the assessment of the performance of primary care systems (European Commission, 2018). In line with the Astana Declaration, the WHO and UNICEF continue to assess and measure primary health care (WHO and UNICEF, 2018).

Notwithstanding the value and importance of these initiatives, they look at primary care systems in isolation, not as part of the wider health system. For example, the PHCPI framework describes governance, financing and resource generation functions, which focus on primary care, but are difficult to disentangle from aspects of the wider system level, such as financial coverage (PHCPI, 2018). Similarly, the proposed framework for assessing primary care within the European context considers 10 domains (Kringos et al., 2019) and includes functions or sub-functions, such as financing and purchasing and resource generation, in the form of infrastructure and human resources. This approach strengthens primary care generally and is valuable for assessments that focus on the performance of the primary care function in order to guide primary care reforms and investments in low- and middle-income countries (Veillard et al., 2017). However, performance assessments that focus on health systems as a whole need an overall assessment framework that incorporates a range of relevant measures. Drawing on existing primary care performance assessment frameworks, Table 7.2 proposes a selection of indicators that focus specifically on the primary care sub-function. Assessing specialist care

Compared with public health and primary care, the performance of specialist – or more specifically, secondary and tertiary care – services has been measured more closely (Cacace et al., 2011; Rechel et al., 2016). Much of this has taken place in high-income countries, in the form of performance data of selected hospital services that are publicly reported in an effort to promote high quality, efficiently delivered specialist care. The OECD Health Care Quality and Outcomes programme – previously known as the Health Care Quality Indicators (HCQI) Project – has been developing internationally comparable indicators to assess what it refers to as acute care. In 2019, these indicators, along with selected indicators for primary care, mental health care and cancer care, involved almost 40 countries, and included non-OECD members including Singapore, Costa Rica and Malta (OECD, 2020). Many of these indicators rely on fairly advanced hospital-based data collection systems, which may not always be available in the majority of low- and middle-income countries.

Here, existing data on the quality of care are often generated within vertical programmes and focus only on specific areas of the health system. These are frequently maternal and child health, or HIV and tuberculosis, with an emphasis on inputs to health services (Kruk et al., 2018a). Table 7.3 proposes a selection of performance indicators for specialist care.

7.4.3. Assessing the governance of service delivery: decision-making authority, service integration and quality assurance mechanisms

Building on the conceptualization by Murray & Frenk (2000), Adams et al. (2003) suggested assessing the performance of the service delivery function by examining three key themes (Fig. 7.4):

  • health system inputs, that is, financial, physical and human resources
  • organizational structure and processes, which they defined as autonomy, integration and incentives
  • outputs, that is the quantity and quality of health services as they relate to the health needs of the population.
Fig. 7.4. Service provision assessment framework (Adams et al).

Fig. 7.4

Service provision assessment framework (Adams et al). Source: Adams et al. (2003).

The areas of health system inputs as conceptualized by Adams et al., are covered in the governance, financing and resource generation function chapters of this volume. Here, we focus on what Adams et al., described as organizational structure and processes, in particular autonomy and integration. We extend the concept of autonomy to consider decision-making authority more widely, and include quality assurance as a separate dimension of health service governance. Decision-making authority

In conceptualizing the organizational structure of health services, Adams et al. (2003) highlight “the degree to which decision-making is delegated to semi-autonomous agencies such as hospitals or provider networks”, thus focusing on facilities providing specialist health services. Existing research has centred on the hospital sector and provider autonomy and, from the 1990s, this has occurred within the context of efforts to enhance hospital performance and a belief that the financial and administrative autonomy of public hospitals is key to improving health outcomes (Saltman et al., 2011; Chabrol, Albert & Ridde, 2019). Policies designed to achieve this autonomy have ranged from establishing quasi-independent organizations, which have some autonomy about decision-making but retain public ownership and government accountability, to fully independent organizations where direct lines of accountability to government have been replaced by other forms of public sector oversight (Ravaghi et al., 2018; Rechel, Duran & Saltman, 2018).

However, there is no clear evidence that increasing hospital autonomy has improved their performance, and, by implication, health system performance. In fact, the opposite may be true, as Ravaghi et al. (2018) have shown in a recent review of hospital autonomy reforms in low-resource settings. They found that these policies have not led to the desired outcomes in terms of improving quality, efficiency and accountability; and in some cases such reforms have led to increased hospital costs and out-of-pocket payments. There are a number of reasons for this including incomplete implementation of related policies with, for example, the central level not fully committing to moving responsibilities to the local institutional level (De Geyndt, 2017); or lack of scrutiny by the public sector and hospitals using public interest to increase their income by concentrating on more profitable services (Mills, 2014). Hence, any assessment of institutional autonomy needs to take account of wider governance arrangements for hospitals, such as hospital mandates on service quality; the integration of hospital and outpatient health care; and appropriate mechanisms to strengthen clinical governance (Bloom & Nolte, 2019). In addition, broader systems governance needs to be considered more generally, especially overall accountability mechanisms in place.

Discussions around autonomy have focused on hospitals as individual organizations and their performance, rather than the relationship of individual organizational performance to wider system performance. There is little systematic work considering autonomy with regard to public health and primary care institutions, or formal or informal provider networks. Here, the most relevant level of assessment is that of regional-tier administrations, such as local government or local health authorities, that oversee the organization and delivery of these services, and the degree of autonomy or decision-making authority they are granted. Service integration

Integration as conceptualized by Adams et al. (2003), refers to “the extent to which different inputs, organization, management and service functions are brought together”. More broadly, interest in service integration reflects increasing concern about the continued focus of health systems on acute, episodic illness and dependence on hospital-based service delivery (Nolte, 2017). Apart from the high cost of these services, the changing disease burden and rising number of people with multiple chronic health problems, raises questions about the suitability and efficiency of this approach (Nguyen et al., 2019). Health services have developed in ways that have tended to fragment delivery. Typically, people receive care from many different providers, often in different settings or institutions and with little coordination between them. Failure to improve the coordination of services along the care continuum may result in adverse events, such as preventable hospitalizations and medication errors (Vogeli et al., 2007; Hajat & Stein, 2018).

It is against this background that health systems globally are exploring new approaches to service delivery that better link the different professions, providers and institutions along the care pathway in order to provide better support for people with long-standing health and care needs (Nolte & McKee, 2008a; Nolte, Knai & Saltman, 2014; WHO, 2015a). Integration efforts often occur alongside wider moves to strengthen primary care as a hub to coordinate care (WHO, 2008; Global Conference on Primary Health Care, 2018). This may include introducing and strengthening referral pathways between different providers and levels of care, or taking specialist services into the community to increase the effectiveness, efficiency and sustainability of service delivery – and so improve health system responsiveness generally (Winpenny et al., 2016).

Any effort to integrate services will have to be embedded in the wider governance of health systems. This should include the development of an appropriate regulatory framework and performance and monitoring systems, and place equal importance on the financing and resource generation functions to guarantee the financial, physical and human resources required to create more integrated service delivery systems (Nolte & McKee, 2008b). Furthermore, as health systems globally are at different stages of integrating services, approaches to their assessment will differ. So, too, will the range of potential indicators to monitor and understand the performance of integrated care available to decision-makers and practitioners (European Commission, 2017). Published reviews point to a wide range of potential indicators – particularly process and outcome – to assess service integration across different domains (WHO, 2015b; European Commission, 2017; Suter et al., 2017; Kelly et al., 2020). However, many of these indicators, particularly outcome measures, assess the performance of service delivery and systems more widely, so are not specific to integrated care. Examples include outcome measures such as mortality or self-reported health, or process measures such as length of hospital stay (European Commission, 2017; Suter et al., 2017). There is a need for indicators that specifically assess the performance of integrated service delivery, in particular indicators of structure. More widely, a common set of measures is needed to enable the comparative assessment of integration across systems and over time. Quality assurance mechanisms

The quality of service delivery is largely determined by the overarching governance and regulatory framework at system level, which should define fundamental standards of care that service users and the wider population will receive. Quality assurance mechanisms include regulations and processes embedded in health system governance that define quality standards for health service provision and we therefore include quality assurance mechanisms as a distinct dimension of the governance of health service delivery.

Quality assurance mechanisms at system level include mandatory mechanisms, such as professional licences (including licence revocation or suspension), medical malpractice legislation, mandatory continuous improvement including quality reporting, mandated incident reporting, external audit and inspection. In addition, there are a range of market-based mechanisms, including incentive payments, governance by contracting, and provider benchmarking and performance league tables (Schweppenstedde et al., 2014) (see also Chapter 5 on resource generation). However, there is considerable overlap with existing mechanisms at an organizational level, particularly voluntary mechanisms such as voluntary facility accreditation and quality improvement initiatives, as well as clinical protocols and organization-level quality and safety monitoring where there is no nationally or regionally mandated system in place.

Some organization-level indicators are included in the indicative measures for performance assessment of the health service delivery functions (shown in Tables 7.1 to 7.3). These tend to focus on inputs, such as the availability of appropriate staff and equipment in low-income settings, which can be found in existing resources, including the WHO Service Availability and Readiness Assessment tool (WHO, 2020a). Indicators that more comprehensively capture quality assurance mechanisms at operational level are needed. Such indicators should show the degree to which facilities and providers engage in the formulation and implementation of care standards locally and identify mechanisms for continued monitoring and reporting. This would enhance effectiveness, protect patient safety and ensure accountability. Indicative measure for assessing governance of service delivery

As noted above, there is often a lack of clarity on specific indicators that reflect performance of governance of service delivery. Table 7.4 lists some indicative measures proposed by WHO (2021).

Table 7.4

Table 7.4

Indicative measures for governance of service delivery

7.5. Conclusions

This chapter sets out a proposed conceptualization of the service delivery function and sub-functions within a health system, along with suggestions for assessing the performance of service delivery, both as a product of the governance, financing and resource generation functions and as a means though which most health system goals are being achieved. We show that there are many possible ways to conceptualize and assess the health services function, and there remains a need for a generalizable framework for assessing this function in the context of overall health systems performance assessment. We propose a set of assessment areas – effectiveness, safety, user experience, access, equity and efficiency – for each sub-function of service delivery, along with decision-making authority, service integration and quality assurance to capture broader governance aspects of the service delivery functions.

Overall, there remains a degree of ambiguity and overlap between the core health system functions, which is particularly evident for service delivery. We have tried to minimize this overlap and duplication by attributing specified assessment areas to each function (see also Chapter 3). Given that governance, financing and resource generation impact largely on the service delivery function, it is difficult to assess service delivery independently from the other functions. Furthermore, as discussed in this chapter and Appendix 7.1, service delivery can be conceptualized in many ways. We have chosen the sub-functions of public health, primary care and specialist care as this reflects the way service delivery is organized in most countries. This approach accommodates individual country settings in performance assessment and allows for countries to explore specific service areas – such as primary care, or the level of integration between primary and specialist care – in more detail.

In proposing indicative measures for the assessment of sub-functions we drew on indicators where data are available globally or for different regions, although this is subject to data quality, comparability and completeness. The measures we have proposed are not an exhaustive inventory of those available, but rather a selection of those we consider most useful. Where available, they can form the basis for, or complement more in-depth contextual and qualitative appraisal, which forms the core of most HSAs. Countries may elect to expand on these measures to better reflect their own service delivery organization and structure. Importantly, some areas are less well represented, in particular the governance of service delivery. There is a need for the development of suitable indicators that better capture these functions.


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Appendix 7.1 A brief overview of approaches to categorizing service delivery

Target population

One broad categorization of the service delivery function is that of individual, person-based health services and collective, population-based health services, as proposed by Murray & Frenk (2000). A similar conceptualization was brought forward in the development of the System of Health Accounts, a framework for the systematic description of the financial flows related to health care (OECD, EUROSTAT & WHO, 2011). It distinguishes personal and collective health care services, with the latter comprising prevention and public health services, as well as health administration and health insurance (Fig. 7.A1).

Fig. 7.A1. Categorization of service delivery according to the purpose of health care goods and services.

Fig. 7.A1

Categorization of service delivery according to the purpose of health care goods and services. Source: OECD, EUROSTAT & WHO (2011).

While providing a useful broad classification of health services, this conceptualization has the disadvantage of cutting across the range of services that can be directed at both individuals – screening or vaccination services, for example; and populations – for example, sanitation or health campaigns. Furthermore, services directed at groups of individuals, such as families or communities, will be difficult to categorize within this conceptualization of individual versus collective services.

Primary purpose of consumption

The System of Health Accounts framework mentioned above further differentiates the health service function according to the primary purpose of consumption, such as preventive, curative, rehabilitative or long-term care. This considers prevention and public health services as preventive, and rehabilitative or long-term care as curative, but include individual and collective goods and services (OECD, EUROSTAT & WHO, 2011). Here, prevention encompasses both primary and secondary prevention, whereas tertiary prevention is considered in the context of curative and rehabilitative care, with its primary aim being to reduce disease-related complications. Curative care is further broken down into general and specialized services.

Types of provider or delivery platforms

Van Olmen et al. (2010) emphasized that the provision of health services involves a range of services, delivery modes and providers. In relation to health care processes and structures, they use the term delivery platforms or channels (Table 7.A1).

Table 7.A1

Table 7.A1

Example of delivery platforms for certain health services

Table 7.A1 shows that not all health services are provided by all providers or delivery platforms but, rather, a number of services are provided by several platforms. Notably, households are also recognized as a platform through which health services can be delivered. This is in line with the WHO framework for action for health system strengthening (2007), which identified the locations of service delivery and included people’s own homes, the community, the workplace and health facilities (WHO, 2007).

Similarly, Watkins et al. (2017) suggested a classification of five delivery platforms in low- and middle-income countries:

  • population-based health interventions, including all non-personal or population-based health services
  • community services, including health outreach and campaigns, schools and community health workers
  • health centres, including higher and lower capacity health facilities
  • first-level hospitals
  • referral and specialized (second- and third-level) hospitals.

This approach was further refined by Kruk et al. (2018a), who distinguished community outreach, primary and hospital care, and the links between them through referral systems and emergency medical services.

The notion of different types of provider or delivery platforms is attractive to policy-makers because health care organizations can be steered, and held to account on health outcomes, through the appropriate governance and financing instruments. However, health care providers frequently deliver a wide range of overlapping services, and health outcomes, including complications or death, often occur at the end of a complex chain of events involving different types of provider. This makes it difficult to attribute accountability for outcomes to single organizations (Nolte & McKee, 2004). Similarly, with the rise of chronic and multiple conditions, population health needs are becoming increasingly complex. This requires different providers and organizations to work together, in an integrated manner, to enhance outcomes (Nolte, 2017). Inevitably, this will increasingly be at odds with the notion of attributing accountability to individual providers, and will require greater focus on the agency or agencies overseeing the integration of services.

Levels and modes of provision

A commonly used approach to classifying health services is by level or mode of provision, typically delineating the levels of primary, secondary and tertiary care or the modes of inpatient care, outpatient care, day care and home-based care. Primary care has been defined as “the first port of call for the sick” (Porter, 1997) for individuals, the family and the community. It “constitutes the first element of a continuing health care process” (International Conference on Primary Health Care, 1978); and it is general rather than specialized, as it focuses on the initial response to unspecified and common health problems. Secondary care refers to specialist care that is usually provided in local hospitals or in outpatient care settings, while tertiary care comprises highly specialized services that are usually provided in regional or national hospitals (Black & Gruen, 2005), in order to concentrate expertise and complex and high-cost resources.

The aforementioned System of Health Accounts framework does not specifically distinguish levels of care, but categorizes provision into different modes of care. These are characterized by whether a patient is formally admitted to a health care facility (inpatient and day care) or not (outpatient and home-based care), whether this involves an overnight stay (inpatient care) or not (day care), as well as the location of service provision. For example, outpatient care is delivered from the health care providers’ premises, whereas home-based care is provided at the patient’s home (OECD, EUROSTAT & WHO, 2011).

Although this classification is useful, as it differentiates levels of complexity and specialization along with the mode of service delivery, boundaries are not always clear-cut. For example, hospitals may provide primary, preventive, rehabilitative or long-term care, while primary care centres in some countries are increasingly providing specialized services through, for example, specialist clinics for diabetes or other chronic conditions (Winpenny et al., 2016). Importantly, levels of care can vary across types of provider and differentiating between levels and modes of provision will be increasingly challenging as countries move to more integrated systems of service delivery and continue to blur these boundaries.

© World Health Organization 2022 (acting as the host organization for, and secretariat of, the European Observatory on Health Systems and Policies)
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