How big is the the problem?

Providing a description of how big a problem is requires a consideration of which indicators would describe the size of the problem best, of the consequences of the problem, of what comparisons should be used to clarify the size and consequences of the problem, and where to find relevant data. Box 3.2 below illustrates an example of these considerations:

Box 3.2 Recruitment and retention of health professionals in rural areas: which indicators and comparisons can be used to describe the size of a problem

The problem (indicators and comparisons)

(Compared to goals or other problems over time, within the country, and within other countries)

Numbers of doctors, nurses and medical technicians in remote areas

Compared to targets in the National Plan
Compared to international (WHO) standards
Compared to other countries
Changes over time/turnover/length of stay
Remote areas compared to non-remote areas

Numbers of doctors, nurses and medical technicians registered in remote areas but not located there

Consequences of the problem (indicators and comparisons)

(Compared to goals or other problems, over time, within the country, and within other countries)

Utilisation of services, health status, quality of service, attitudes towards health services in remote areas

Compared to non-remote areas

Implicit or explicit comparisons are needed to establish the size of a problem. The following types of explicit comparisons may be helpful:

Comparisons with goals – e.g. the Millennium Development Goals (MDGs) for maternal or child mortality
Comparisons with other problems – e.g. with other priorities
Comparisons over time – e.g. an increase in treatment failures or in the prevalence of a disease or risk factor
Comparisons across areas within a country – e.g. variations in access to or utilisation of services
Comparisons with other countries – e.g. with mortality or prevalence rates in comparable countries or changes in these over time in those countries

Different indicators may be relevant when estimating the size of a problem. This may depend on whether the problem is described in terms of:

A risk factor or disease
Coverage, quality of care, cost of care, or equitable access to care
Delivery, financial or governance arrangements (see Table 3.2 below)
The implementation of agreed policies or programmes

Sources of data for risk factors and the burden of disease include epidemiological surveys and routinely collected data ². Sources of health services utilisation data also include routinely collected data, as well as studies of access to care, of the utilisation of care, of the quality of care, of health care expenditures and of health inequities. The availability of data describing health system arrangements and the implementation of policies and programmes is highly variable and such data may be difficult to find. Sources include government documents (often unpublished), data collected by the government or other agencies on their behalf (e.g. regarding expenditures or health workers), and studies that describe or analyse health system arrangements or policy implementation. A SUPPORT Tool providing guidance on how to find and use evidence about local conditions together with a worksheet, workshop materials and a presentation are provided in the ‘Additional resources’ of this guide. Strategies for finding unpublished studies and grey literature are also described in the ‘Additional resources’ section.

Table 3.2 Health system arrangements
Health system organisation can be categorised in different ways. The taxonomy illustrated below was developed by Lavis and colleagues and divides health system arrangements into three main types. Strategies for realising change do not form part of this taxonomy, but include those for changing health behaviours, professional practice, and organisational change.
Delivery arrangements	Financial arrangements	Governance arrangements
Including problems with:	Including problems with:	Including problems with:
To whom care is provided and the efforts made to reach them (such as culturally inappropriate care)	Financing – e.g. how revenue is raised for programmes and services	Policy authority – who makes policy decisions (such as specific types of decisions being centralised rather than decentralised)
By whom care is provided (such as providers working autonomously rather than as part of multidisciplinary teams)	Funding – e.g. how clinics are paid for the programmes and services they provide	Organisational authority – e.g. who owns and manages clinics (such as private for-profit clinics)
Where care is provided – e.g. care delivered at inaccessible health facilities	Remuneration – e.g. how providers are remunerated	Commercial authority – e.g. who can sell and dispense drugs and how they are regulated
What information and communication technology is used to provide care – e.g. record systems may not be conducive to providing continuity of care	Financial incentives – e.g. financial disincentives for patients or a lack of incentives for health workers	Professional authority – e.g. who is licensed to deliver services; how their scope of practice is determined; and how they are accredited
How the quality and safety of care is monitored – e.g. not having quality-monitoring systems in place	Resource allocation – e.g. providing insurance coverage for inefficient or ineffective services	Consumer and stakeholder involvement – who from outside government is invited to participate in policymaking processes and how their views are taken into consideration

How big is the the problem?

Box 3.2 Recruitment and retention of health professionals in rural areas: which indicators and comparisons can be used to describe the size of a problem

Table 3.2 Health system arrangements

This page was last updated November 2011.