78
Brock, Leonard, Masatu, and Serneels
Broadly, the model shows that policy levers → health worker characteristics → service inputs → service attributes → performance outputs → health system outcomes. The schematic representation and the model of health worker performance are easiest to explain by starting with the key element of any health care system: the patient-health worker interaction. Thus, we begin our discussion in the middle, moving from service attributes through health system outcomes and then from service inputs back to policy levers. • Service attributes. Health workers provide health care to patients with at least four attributes: presence, performance, satisfaction, and expense. Presence represents the fact that if the patient chose to visit a particular provider, services would be provided (because the clinician is present). Performance is the medically assessed quality of the care, compared to some standard of care for a given condition. Satisfaction is how happy patients are with the services, including how the patient perceives quality, politeness, and responsiveness. Expense is the cost to the patient of the services provided. These attributes contribute to the demand for health care, in particular the demand for services at a given provider. The provision of health care also potentially generates revenue or income for the health worker, a feature which is not important to patients,6 but can be important to health workers. • Performance outputs. Whereas service attributes are measured at the level of the patient-health worker interaction, performance outputs are measured at the level of health worker, facility, or potentially the health system. We examine three types: the productivity of health workers, the quality of services provided, and the integrity of services provided. • Health system outcomes. Performance outputs are important because they improve health system outcomes in society. There are many possible outcomes, but some examples include the number of immunizations, number of assisted deliveries, and percentage of the population covered with quality services. • Service inputs. Provider effort and capacity are the service inputs, determining the attributes of a patient’s visit. Effort is both whether the health worker provides a given service and how hard he or she works to diagnose and treat the patient. Capacity is the ability of a health