Service delivery

Service delivery configurations are focused on how health facilities, services, and health workers are organized to respond to the needs of communities. How services are delivered is important ensuring coverage, quality, financial protection and health outcomes.  

 

What is our focus?

  • Service Delivery Models

The WKC conducts research about how services are organized, delivered and financed that can help countries to leapfrog progress in achieving better coverage and financial protection, particularly in light of population ageing.

In doing so, research needs to be carried out in such a way to identify the elements that are replicable to other settings and other countries.

  • Sustainable Financing

As populations age, policy-makers are increasingly concerned about health care expenditures and how health services can be paid for. The WKC conducts research about health expenditure growth and revenue generation in light of population ageing. We also study policy choices to improve efficiency and quality, including how prices are set for health services.

  • Innovations

Innovations are designed to solve specific problems and vary by country context. Innovations include new methods and approaches – whether policy, systems, or technologies.  The WKC aims to document and evaluate country level innovations for delivering quality care, determine the conditions for scale-up within countries, and identify elements that can be generalized to other settings.

 

Why is this important?

As countries strive to attain UHC, better evidence is needed to make informed policy options.

Sustainable financing in the context of population ageing

Background

Given the population decline associated with ageing, countries are increasing concerned about how they will finance health and social systems with declining payroll contributions. Similarly, there is an interest in monitoring expenditures and service delivery models to address the increased demand for services that respond to the health needs of older adults.

Methods                                                                                                                                                                          

WHO WKC has partnered with the European Observatory on Health Systems and Policies and the WHO Health Financing Team to prepare briefs focusing on the impacts of shifting age demographics on health care expenditure trends and the ability to finance health systems. This research will result in two policy briefs that collate the most up-to-date data and information and provide policy options for countries. While data may only be available for high income countries, the policy briefs will discuss implications for low and middle-income settings that are rapidly ageing.

Results                                                                                                                                                                             

Early results demonstrate that a health system heavy reliant on contributions linked to the labor market is unsustainable as populations age. 

Conclusions       

Pending completion of study.

Price setting in health care and implications for Universal Health Coverage

Background

In implementing universal health coverage (UHC), policy makers should decide who is covered by public benefits, what services are covered, and how much will be paid. With increases in public spending towards UHC, countries are paying more attention to value for public spending, and the decisions about how to channel funding and organize services to respond to people’s needs. Pricing policies are closely linked with the decisions about the benefits package, how to pay health care providers, and how to harness resources from the private health care sector. However, the process of setting and negotiating prices is poorly understood.

Methods                                                                                                                                                                          

Nine country case studies were commissioned, representing a range of health care systems, experiences in purchasing and price setting, and the commitment to improve financing mechanisms to attain broader policy goals. Recognizing that no single model is applicable to all settings, the study aimed to generate best practices and identify areas for future research to support countries, particularly in low- and middle-income settings, to increase access and affordability and meet international commitments towards Universal Health Coverage.

Results                                                                                                                                                                             

The ways of calculating prices depend on the strength of data collection systems about expenditures, volumes, and outcomes. Unilateral price setting has generally performed better in controlling price levels, avoiding price discrimination, and providing incentives for quality. Pricing has been used to control volumes and promote quality, for example, through reductions in prices for repeated unplanned outpatient visits, hospital admissions, and sentinel events. Prices have also been adjusted to attain broader public health goals, by making price adjustments for rural and remote facilities and for facilities treating high numbers of low-income or high-cost patients.

Conclusions                                                                                                                                                                

The overall pricing framework should be set in a transparent way. Several countries have established independent institutions to oversee and manage this process. Investing in data infrastructure is critical. Systematic testing and evaluation is needed to inform policy. Lessons from other countries should be evaluated based on their feasibility to unique country contexts including the regulatory environment and institutional capacity.

Assistive technologies to enhance quality of life of older people

Sustained activities of daily living (ADL) and quality of life (QOL) are vital issues for the older people. New technology that assists in the maintenance and improvement of physical functions is desired to achieve this goal. Falls (as a consequence of sarcopenia) are one of the most well-known factors that compromise ADL and QOL of older persons. This research project will contribute to the development
of a new strategy that maintains or improves ADL and QOL by utilizing several new assistive technologies to identify and reduce the risk of sarcopenia and falls.

Research objectives and methodology

The research consists of three parts.
Part I (led by Wakayama Medical University): A new algorithm to assess the amount of physical activity from electromyogram (EMG) signals of the femoral muscles will be developed from a pilot study involving 20 healthy volunteers over 20 years old. The developed algorithm will be applied to 20 inpatients over 65 years to assess the minimum amount of physical activity required to maintain ADL and walking function.

Part II (led by Osaka Medical College): Using a newly developed wearable accelerometer, 50 healthy people over 65 years old will be monitored for fall and accelerated motions in their daily life. The patterns of their falls and associated motions will be analysed to identify the risks of specific physical activities or postures that affect the frequency of falls.

Part III (led by Nara Medical University): 20 adult patients over 20 years old undergoing rehabilitation therapy for 6 different types of conditions at a university hospital will be monitored for their physical activities over 7 days from the starting date of inpatient rehabilitation using a wearable device with acceleration sensors. The activity levels of the patients will be stratified for the type of disease along with the disease progression and clinical outcome of the patients. The data will be utilized as a baseline to define the ideal activity level of inpatients for better outcomes of rehabilitation therapy.

Expected outcomes

1. A simple, new algorithm to assess physical activities from EMG signals of the femoral muscles that can be applied for broader use.
2. Fundamental information on the minimum amount of physical activity required to maintain the ADL of patients, which will be utilized to improve QOL.
3. Fundamental information on the relationship between specific postures and physical activities that affect the frequency of falls, which will contribute to fall prevention.
4. Baseline data about activity levels of patients and clinical outcomes to estimate ideal activity levels for better outcomes of rehabilitation therapy.
5. Through all three parts of the study, a new remote data collection system that can monitor physical activities and provide timely and effective advice to prevent falls and improve ADL and QOL.

Team members

Lead Institution: Wakayama Medical University
Fumihiro Tajima (PI), Professor, Department of Rehabilitation Medicine, Wakayama Medical University
Yoshiichiro Kamijo, Associate Professor, Department of Rehabilitation, Wakayama Medical University
Ryuichi Saura, Director and Professor, Department of Physical and Rehabilitation Medicine, Division of Comprehensive Medicine, Osaka Medical College
Akira Kido, Professor and Director, Department of Rehabilitation Medicine, Nara Medical University Hospital
Yasuo Mikami, Clinical Professor, Department of Rehabilitation Medicine, Graduate School of Medical Sciences, Kyoto Prefectural University of Medicine
Kanji Fukuda, Director and Professor, Department of Rehabilitation Medicine, Faculty of Medicine, Kindai University

 

ICF-based assessment tool development for care skill training in Japanese long-term care system

An increasing number of countries are facing the problem of population ageing, which is putting continuous stress on long-term care. The situation is particularly alarming in East Asia, where the demand for care workers is expected to at least double by 2050. Thus, a training system for long-term care staffs that supports universal health coverage is needed. To address shortages in long-term care workers, Japan has developed a “Technical Intern Training Programme”. This is the first training programme directed to foreigners who wish to work in the long-term care field. In order to achieve the objectives of the programme, tools that objectively measure whether the skills have been
transferred are essential. Furthermore, tools that can be applied internationally are preferred.

Study Goals and objectives

This study focuses on the Technical Intern Training Programme, and aims to develop tools to evaluate the process of transferring care skills to foreign trainees. The study will also examine the possibility of utilizing the International Classification of Functioning, Disability and Health (ICF) to apply existing tools to other countries.
The objective of the research is 1) to develop new evaluation tools using the ICF concept on the basis of current assessment tools that have been created for the Technical Intern Training Programme in Japan and 2) to validate the developed tools by conducting surveys and in-depth interviews at Japanese facilities providing care-training internships.

Methodology

This project consists of three parts:
a) Development of new evaluation tools using the ICF concept and current assessment tools that have been created for the Technical Intern Training Programme in Japan.
b) Quantitative validation of the new tools by collecting and analysing additional data through self-reported questionnaires.
c) Additional qualitative examination of the new tools through in-depth interviews.

Expected outcomes

The project will contribute to the development of training systems for long-term care workers in Japan that can also be extended eventually for training in other countries. If the care training system can be applied to many countries, it could potentially contribute to reducing the shortage of care providers globally.

Team members

Lead institution: University of Hyogo
Takako Tsutsui (PI), Professor, Graduate school of Business, University of Hyogo
Masaaki Otaga, Researcher, Department of Social Services and Public Health, National Institute of Public Health, Japan
Sadanori Higashino, Assistant Professor, School of Management and Information, University of Shizuoka
Yasuhiko Haraguchi, Professor, Graduate School of Social Sciences, Hiroshima University

 

Technology and social innovations for an ageing Asia

In March 2016, the WHO Kobe Centre was invited to participate in a workshop on Comparative Ageing Policies in Asia at the Lee Kuan Yew School of Public Policy, National University of Singapore. There, participants developed the outline for a book, entitled “Ageing in Asia”, to be published in 2018. This book will offer an overview of how ageing influences policies throughout Asia, and cover social, economic and demographic trends, health and social issues relevant to the health of older people, and the role of technology and social innovations.

Objectives

The WHO Kobe Centre prepared the chapter “Technological and social innovations for an ageing Asia”. The chapter comprised of (a) a review of social innovations that support the re-alignment of health and social policies in response to population ageing; and (b) a review of innovative technologies and the role of Health Technology Assessments in health and social care for ageing populations.

Results

The review of (a) focused on three policy domains: pension and financial security, universal health coverage, and community-based approaches.

Experiences in Japan and the Republic of Korea have demonstrated that improving pension systems have yielded significant benefits in providing safety nets for older people, including protection from catastrophic health expenditure. Other parts of Asia would benefit from innovations in pension schemes to provide financial security for demographics with limited pension entitlements. Policies relying on family caregiving also need to be addressed.

The adoption of universal health insurance in Japan in 1961 has contributed greatly toward the achievement of universal health coverage. Even in countries with universal health insurance, however, out-of-pocket expenditures and health care costs are problematic for older persons on a low or fixed budget. High out-of-pocket costs also increase inequities in access to health technologies. Countries such as China will have to address growing shortages of health workers. Social innovations will support universal health coverage in Asia by addressing gaps in health systems and policies.  

Social innovations that supplement services offered by state institutions have had a largely positive impact throughout Asia. Successful community-based interventions in Viet Nam and Japan have empowered older people to retain their well-being even in the face of disease, disability, and health decline.

The review of (b) revealed low-cost, disease-specific products, such as smartphone applications in India to manage physical disabilities after a stroke, to more costly ones with broader application, such as exoskeletons used by older workers in Japan. Assistive health technologies that maintain function at older age is a particularly active area for innovation. Wider adoption of telemedicine and remote monitoring systems has the potential to make home-based care safer and accessible, especially in remote areas. Mobile health (mHealth) technology services can improve monitoring of chronic conditions and function in older people, as demonstrated in China with older diabetics and their family caregivers. Further research is needed, however, to ensure that mHealth technologies are appropriately designed and targeted to the end-users’ needs.

Health technology assessments (HTA) have been implemented in several countries to support decision-making processes and health reforms, especially with regards to facilitating market entry, providing insurance coverage, and ensuring accessibility of technologies for older adults. Asia has been a leader in developing HTA. Most HTA agencies in the region are now part of the HTA Asia Link Network as well as the International Network of Agencies for Health Technology Assessment (INAHTA). To realize the full potential of technological innovations, strategic partnerships between industry, NGOs, and governments are needed for policies and regulations that create accessible, affordable, and appropriate innovations that deliver impact at scale.

UHC Leadership Programme

Countries that have or will soon experience rapid population ageing have not fully understood the implications nor potential impact of the needs of population ageing on their health and social delivery systems.  Planning for health systems strengthening towards UHC offers a major opportunity to transform systems and to appropriately plan for their future.  Working across sectors and engaging communities are essential strategies, as is the need to ensure equity.

Given that countries are still at the early stage of addressing population ageing, this effort is  a  step to assist them develop trajectories (or roadmaps) for health system design, service delivery and financing in their contexts.  The Leadership programme  is helping to advance and accelerate their UHC agenda by supporting the country counterparts (as individuals and as country teams) with leadership training, coalition building support and results-oriented collective action initiatives.  A key focus is to help define the “how to” for navigating and shaping the political economy in each country for the ageing and UHC agenda.

This UHC Leadership Programme is one of the opportunities to share evidence, data, information and case models for future policy options to the UHC leader in low and middle income countries.  This programme is implemented in collaboration with Kanagawa Prefecture, Japan.

 

The objectives of the programs were to:

1. Share national/local decision making to lead, advocate, advance, design and implement reforms and programmes to transform health/social service delivery systems for ageing populations to attain UHC.

2. Share lessons and insights from Japan and among Asian countries for systems to respond to the needs of ageing population.

3. Share information and experience among countries to enable countries to develop initial trajectories (or roadmaps) for pursuing actions in their countries.

4. Provide lessons and examples from leading countries (e.g., Japan, Singapore) and from WHO synthesized knowledge for major components of health and social service systems design to support ageing populations:  a) identifying a wide set of potential required services (coverage) b) models of delivery systems (and tailoring to each country needs); c) financing strategies d) health workforce implications e) use of technology and f) related enabling governance strategies.

 

Service delivery models to maximise quality of life for older people at the end-of-life: a rapid review

In this unprecedented era of increased human ageing, there is a global priority to realign health and social services toward older populations by supporting the dual priorities of living as well as possible whilst adapting to gradual functional decline. We aimed to provide a comprehensive synthesis of available evidence on service delivery models that optimise quality of life (QoL) for older people at end-of-life. Our remit included health, social and welfare services across all countries, with attention to low- and middle-income countries.

Methods                                                                                                                                                                              

This study was a rapid systematic scoping review of systematic reviews. We searched MEDLINE, CINAHL, EMBASE and the Cochrane Database of Systematic Reviews from 2000-2017, supplemented by reference searching. We selected reviews that reported the effectiveness of service models that aim to optimise QoL for older people, where>50% of the population was aged >60 years and in the last 1 or 2 years of life. Search results were independently screened, and the selected reviews’ were quality assessed using AMSTAR. Data were described and synthesised narratively.

Results                                                                                                                                                                                               

Of the 2238 reviews identified, 72 (including nine Cochrane) were retained, encompassing 784,983 individuals. Most reviews reported studies from America (52/72) and/or Europe (46/72). We identified two overarching classifications of service models intending to improve QoL, but with differing outcomes: 1) Integrated Geriatric Care, which targeted physical function, and 2) Integrated Palliative Care, which focused on symptoms and concerns (Figure 1). Areas of synergy included care centred on the person; education for service users and providers; and the multi-professional workforce. The reviews assessed 117 separate outcomes, with the 21% used in meta-analysis demonstrating effectiveness for QoL (4/4 reviews) and individual symptoms (5/5 reviews). Economic analysis was poorly considered overall.

Conclusions                                                                                                                                                                

Although they targeted different outcomes, service models classified as Integrated Geriatric Care or Integrated Palliative Care demonstrated effectiveness at improving QoL and symptoms for older people nearing end-of-life. The areas of synergy between these approaches highlights the imperative of their integration across the care continuum with service use triggered by patient need and intended outcomes. To inform scalability, we encourage economic analyses that span health and social care and an examination of all sources of finance to understand contextual inequalities.

Figure 1. Overarching service delivery models and processes to maximise quality of life for older people in their last years of life