Transcript dfg - World Bank

Role of Referral Hospitals
DCP2 workshop Tanzania 21-23 August
Max Price
Martin Hensher
Sarah Ademakoh
What are we talking about?
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Almost all levels are referral
Tertiary – Specialist, sub-specialist, high cost
Size – 300 to 1500+
Academic –
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Linked to Faculty of Health Sciences
Teaching
Research
Outreach
Support
Inconsistency in National Accounts
Debate: What value What resources?
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LESS
Consume too large a share of
budget
Benefit very few
Urban bias
Middle class bias
Don’t address major public
health problems
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MORE
Then why do we continue to
spend on RH?
 Politics? Power of Drs?
Or
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Rational basis
 Cost-benefit is positive
 Need referral system
 Training needs
 Indirect benefits
Cost-Benefit/Utility Analysis
approach to Resource Allocation
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Analyse QALYs for each intervention
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Other ways of valuing benefits
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Particularly favours childhood interventions, preventive
care, PHC
e.g. willingness-to-pay, human capital approach
Rank all interventions – most to least cost effective
Aggregate to budget limit
Therefore – minimal tertiary care!
Can Cost/QALY Analysis be applied
to referral hospitals?
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Complex economies of scope and scale
Multiple outputs – indirect contribution to QALYs
 Training health workers, specialists
 Referral and support to lower levels
 Research, piloting technologies and interventions
 Quality assurance throughout hospital system
 Countering brain drain from public sector and
country
Fails to capture critical dimension of utility and
social welfare
Theory of ‘Peace of Mind’
e.g. Kidney transplant service
 Actual no. of patients benefiting = few hundred a year
 High cost per QALY, low public health impact
 BUT, in principle, whole pop (millions) benefit
 Reassured that available if needed
 Willing to pay cf. insurance
 Social Welfare, aggregate utility high
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Paradox: The more expensive the intervention,
and the rarer the disease, the higher the
aggregate benefit-cost ratio
Indirect benefits
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Referral and support
Quality Assurance in hospitals
Training
Research
Emergency care
Public confidence in the health system
Foreign confidence – investors, tourism, 2010
 Economic benefits
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Question: Should this be left to Private Sector?
General Guidelines
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Linked to per capita GDP
Linked to level of Health Service Development
Availability of specialised personnel
Balance – will always need some referral and tertiary –
but how much?
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Population size, density, distance between main centres
Demographic and epidemiologic transition
Ensure adequate referral system and gatekeeping to
ensure equitable access – this usually means more
investment in Urban services!
Provide enough resources to do outreach, quality
assurance, support