WHO South-East Asia Journal of Public Health
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 Table of Contents  
COMMENTARY
Year : 2021  |  Volume : 10  |  Issue : 3  |  Page : 30-32

Unpacking the service delivery function: COVID-19 provides an opportunity for some reverse thinking


1 World Health Organization, Geneva, Switzerland
2 Independent consultant, National Health Systems Resource Centre, New Delhi, India
3 National Health Systems Resource Centre, New Delhi, India
4 St. Michael’s Hospital, University of Toronto, Canada

Date of Web Publication26-Feb-2021

Correspondence Address:
Dr Ann-Lise Guisset
World Health Organization, Geneva
Switzerland
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DOI: 10.4103/2224-3151.309869

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How to cite this article:
Guisset AL, Travis P, Bagheri Nejad S, Ved R, Rouleau K. Unpacking the service delivery function: COVID-19 provides an opportunity for some reverse thinking. WHO South-East Asia J Public Health 2021;10, Suppl S1:30-2

How to cite this URL:
Guisset AL, Travis P, Bagheri Nejad S, Ved R, Rouleau K. Unpacking the service delivery function: COVID-19 provides an opportunity for some reverse thinking. WHO South-East Asia J Public Health [serial online] 2021 [cited 2021 Apr 18];10, Suppl S1:30-2. Available from: http://www.who-seajph.org/text.asp?2021/10/3/30/309869


  All forms of service delivery are being scrutinized during the COVID-19 pandemic Top


The rapid spread of coronavirus disease 2019 (COVID-19) has threatened to overwhelm health systems worldwide. In some countries, the COVID-19 crisis has shown the urgent need for more effective population-based services as well as personal care. Countries’ responses to COVID-19 have also shown that some health systems can be agile and develop innovative approaches, implementing strategic shifts[1] to respond to the pandemic effectively while maintaining other essential health services. The pandemic has accelerated changes in what health and social services are delivered where and how, such as with the use of telemedicine and through fostering partnerships between public and private care providers. However, COVID-19 has also exposed and exacerbated persistent inequalities in risks to health and health outcomes, despite decades of commitment to health for all. While we are still learning, many changes introduced as responses to the crisis deserve to be sustained as we aim for more equitable and resilient health systems. The COVID-19 crisis has firmly reinforced the need for health systems that are based on a primary health care (PHC) approach that includes robust community-based services and reinforced public health functions.

A PHC approach includes three components: meeting people’s health needs throughout their lives; addressing the broader determinants of health through multisectoral policy and action; and empowering individuals, families and communities to take charge of their own health. Health systems aim to improve health and health equity in ways that are responsive and financially fair. To achieve these goals, health systems must fulfil four core functions: service delivery, stewardship/governance, financing and generation of resources.[2] PHC is a policy mechanism for executing the four core health system functions in the most effective way. The pandemic has provided an impetus to revisit the service delivery function so that we can gain a clearer and more widely shared understanding of what it encompasses and its interactions with the other health system functions. This is not just a theoretical exercise; this understanding is required to optimize what services are delivered to communities and to individuals, and how.


  Unpack and optimize the service delivery function Top


Commonly described shortcomings in health systems point to specific failures in service delivery. These include but are not limited to patients feeling lost in the system as they try to find their way to and among health providers; people postponing care seeking, not completing their treatment, or not accessing services at all because of a range of informational, organizational, financial or cultural barriers; irrational use of medicines; professionals under stress due to congestion in some facilities while other facilities lie almost empty; and unnecessarily repeated diagnostic tests because results were not shared between providers.[3]

Health services can be classified in a multitude of ways. They can be described by their purpose, such as health promotion and prevention, resuscitation, curative care, rehabilitation or palliative care.[4] They can be categorized by place of delivery – in the community, at home, at a health centre, in a hospital or at a long-term care facility. Other classifications include by target, population versus personal services and whether the service delivery was by a public or private provider. These are all descriptions of the elements of service delivery. These elements require actions with regard to critical processes, including priority setting, planning, organization and quality of health services, and management of service delivery facilities.[4] Together, these processes constitute the function of service delivery, which is influenced by, but distinct from, the other health system functions.


  Make service delivery the cornerstone of action to strengthen a health system Top


Regardless of whether changes in health service provision are attempted at the facility (micro) level, the district/municipality (meso) level, or the national or state (macro) level, a process built on agreed models of care is essential to achieve desired changes. Models of care refer to a set of service principles that broadly define good practice in the way health services are delivered for an individual, a patient cohort or a population group.[5] A model of care aims to deliver the right care at the right time and in the right place. Models of care are not static or universal; they are adapted to local health care needs and systems. Existing services are constantly challenged by people’s evolving needs, preferences and assets; innovations in diagnostics and treatment; and the need to evolve within a maturing health system.

Health system reforms have often focused on changes in financing or governance functions, and for good reason. Sometimes, however, the reform becomes an end in and of itself, rather than a means to an end, and we can lose sight of the fact that the reform’s contribution to improved health is ultimately through strengthened service provision. Service delivery can be usefully positioned as the cornerstone of action to strengthen all four functions of health systems. For example, reforms designed to produce more doctors but not more nurses, or focused on increasing hospital productivity, should be critically examined for their effects on the level at which most people seek and receive services: primary care. Asking the right question – whether the proposed reform helps or hinders the goal of reaching people in need – also helps make the required links for successful service delivery reforms. For example, fostering team-based care requires not just the creation of teams but also the redesign of processes such as task sharing or task shifting, new competencies for individual health care workers, including implications for pre- service training, and new payment methods with incentives for team-based care.

These observations call for us to do some reverse thinking about strengthening health systems – to see that service delivery is not a passive consequence of governance and financing arrangements or the production of health workers. Service delivery is an integral component in shaping other health system functions.


  A paradigm shift: reverse thinking places people at the heart of service delivery Top


Service delivery is the confluence where health care users and providers interact most directly.[2] More reverse thinking can increase awareness of the dynamic roles individuals play in shaping health service provision and use across different levels of the health system. Looking through a service delivery lens highlights the processes and nuances of people-centred care: co-creation of a personal care plan; interactions between facility managers and staff in shaping organizational processes and culture; local health authorities engaging local communities and health care providers to prioritize services and supervise implementation; and decision-makers at national, state or district level exercising stewardship of these processes. Experience shows that the definition and revision of models of care require safe spaces for community engagement, along with reliable information on communities’ needs and assets, and assessment of service access, coverage and quality. A service-delivery- anchored approach to the design of PHC-oriented health systems further reinforces the importance of empowering people to engage in shaping service delivery processes, strengthening the quality of services and increasing their use as a result.


  Conclusion Top


The COVID-19 pandemic has highlighted the need for a coherent approach to strengthening the delivery of high-quality individual and population-based health services through a range of delivery platforms. The dual challenge of responding to the emergency while protecting other essential services, as well as considering future prevention and response, has put the spotlight back onto primary care. The three components of PHC are widely recognized as the foundation of successful efforts towards universal health coverage and health security.[6] It is time to recognize that the service delivery function is not simply an inevitable consequence of the performance of the other three functions or a passive stepping stone towards improved personal and population health; rather, it can and must be actively and directly managed to ensure impact. Service delivery has its own distinct processes involving the planning, organization and management of services. It will also be useful if more of us – policy-makers, programme implementers and policy analysts – can reverse our thinking about strengthening health systems and view health system dynamics through a service delivery lens, keeping the implications for service delivery squarely in our analysis as we work to strengthen any of the four interconnected health system functions. Country endorsement of service principles and models of care that are aligned to PHC will further bolster successful outcomes of reverse thinking.

Disclaimer: The views expressed in this article are the authors’ own and not an official position of their institutions or funders.

Source of support: None.

Conflict of interest: None declared.

Authorship: All authors contributed to the conceptualization of the paper. ALG and PT wrote the paper. All authors reviewed the manuscript.

 
  References Top

1.
COVID-19: operational guidance for maintaining essential health services during an outbreak – interim guidance. Geneva: World Health Organization; 25 March 2020 (https://apps.who.int/iris/ handle/10665/331561, accessed 8 January 2020).  Back to cited text no. 1
    
2.
The world health report 2000 – health systems: improving performance. Geneva: World Health Organization; 2000 (https://www. who.int/whr/2000/en/, accessed 24 December 2020).  Back to cited text no. 2
    
3.
People-centred and integrated health services: an overview of the evidence – interim report. Geneva: World Health Organization; 2015 (https://apps.who.int/iris/bitstream/handle/10665/155004/WHO_HIS_SDS_2015.7_eng.pdf?sequence=1, accessed 8 January 2020).  Back to cited text no. 3
    
4.
Tello J, Barbazza E. Health services delivery: a concept note. Copenhagen: World Health Organization Regional Office for Europe; 2015 (https://www.euro.who.int/_data/assets/pdf_file/0020/291611/Health-Services-Delivery-A-concept-note-301015.pdf?ua=1, accessed 24 December 2020).  Back to cited text no. 4
    
5.
WA Health Networks. Model of care overview and guidelines. Perth, Australia: Department of Health, Government of Western Australia; 2014 (http://cedd.org.au/wordpress/wp-content/uploads/2014/04/ Model-of-Care-Overview-and-Guidelines-WA-Health-Networks.pdf, accessed 24 December 2020).  Back to cited text no. 5
    
6.
A vision for primary health care in the 21st century: towards universal health coverage and the Sustainable Development Goals. Geneva: World Health Organization and the United Nations Children’s Fund (UNICEF); 2018 (https://apps.who.int/ iris/bitstream/handle/10665/328065/WHO-HIS-SDS-2018.15-eng. pdf?sequence=1&isAllowed=y, accessed 24 December 2020).  Back to cited text no. 6
    




 

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