Setting the Stage for Health Systems Strengthening: What We Have Learned from Doing Over 30 Health Systems Assessments
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Setting the Stage for Health Systems Strengthening: What We Have Learned from Doing Over 30 Health Systems Assessments



The HSA approach is an innovative tool designed to provide a rapid yet comprehensive assessment of a country’s health system. With experience in conducting HSAs in Asia, Africa, and the Caribbean, ...

The HSA approach is an innovative tool designed to provide a rapid yet comprehensive assessment of a country’s health system. With experience in conducting HSAs in Asia, Africa, and the Caribbean, presenters will highlight how HSA results are being used to strengthen health systems.

Presenter: Michael Rodriguez, Danielle Altman



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  • Version 1.75 incorporates lessons learned from last five years of conducting HSA What is the added value of the HSA approach? The tool began to be developed in 2005. An approach was needed that helps to: Diagnose health systems strengths and weaknesses Prioritize key constraints and areas for interventions Identify potential solutions for health systems strengthening Existing tools (in early 2005) did not offer comprehensive health systems assessment Some focused on profiles (PAHO, European Observatory) None allowed for integration across health systems functions and development of recommendations with a consistent set of indicators The framework is based on a WHO framework
  • Based on WHO building blocks Also discuss private sector as an assessment domain that penetrates all 6 building blocks.
  • MR – do we want to pick a few examples to show how HSA has been used, or just use the big table on the next three slides? Senegal - The HSA assessed the implementation of the ten-year national health strategy that was coming to a close at the time of the assessment. The HSA was tailored to provide input into the upcoming ten-year strategy the MOH was embarking on developing. The HSA approach was particularly suited to the needs of the MOH. At the time of the assessment, the MOH was already seeking a broad snapshot of what had been achieved and not achieved over the previous ten years, and what the bottlenecks were to health system performance. The MOH wanted and to use the results of such an assessment for developing the next ten-year strategy. The HSA was thus tailored to the needs of the MOH. The HSA addressed the following health system constraints: (1) Lack of technical coordination at the MOH; (2) weak planning unit at the MOH; (3) HRH shortages; (4) weak regional health districts; (5) segmentation of funds and responsibilities in the area of health financing; (6) lack of harmonized planning at district-level; and (7) weak planning around health insurance. The new ten-year health strategy responded to nearly every major recommendation in the HSA. The MOH is implementing all major HSA recommendations, including two that were not addressed directly in the ten-year health strategy. Bottlenecks 1 and 2 were addressed through the reorganization of the planning unit at the MOH (IR 2, Sub-IR 2.3, IR 3, Sub-IR 3.3). One issue in relation to bottleneck 3 was addressed by separating district health office management and district hospital management functions. Previously, one district health officer was in charge of managing both the district health office and the district hospital (Sub-IR 3.2). An Abt bilateral is currently implementing this intervention. Bottleneck 4 was addressed by delegating more power to regional health districts and strengthening their capacity (IR 2, Sub-IR 2.3, IR 3, Sub-IR 3.3).. Bottlenecks 5 and 7 are being addressed by the creation of one basket funding mechanism. The MOH is currently drafting the law that will enable the development of this new funding mechanism (IR 1, IR 3, Sub-IR 3.1). Bottleneck 6 is being addressed by improving coordination at the district-level (IR 2). At the time of the assessment, the MOH generally needed strengthened systems for governance and health financing. The MOH was also attempting to deal with the challenges of decentralization. The HSA proposed interventions to overcome major bottlenecks that affect every aspect of the health system (including weak planning at the MOH and fragmentation of health financing). The HSA also proposed smaller scale, easily actionable interventions (such as separating district health office and district hospital management) to relieve smaller scale constraints. In addition, by developing recommendations to resolve health system constraints at the national, regional, and district level, the HSA supported health system strengthening at all levels of the health system. Finally, by providing a comprehensive snapshot of health system performance against a previous ten-year national health strategy in order to inform the next ten year strategy, the HSA became a tool for USAID/Uganda to use in soliciting further health systems strengthening projects that were highly targeted, and in line with larger national health goals and plans. .
  • 2008, A variety of factors contributed to the adoption of HSA recommendations into Senegal’s strategic plan: The assessment was requested by the Ministry to feed directly into their planning process; The short timeframe of the assessment allowed for the information to be readily available; Stakeholders were involved throughout the assessment to ensure that the findings were relevant to their needs. The HSA was used to guide the development of the ten-year strategic plan covering the period from 2009 to 2018
  • HSAs have been adapted in various ways to meet client needs and country context.
  • For example, findings from the HSAs in the Caribbean reveal a strong reliance on the private health sector as a first source of care, ranging from 23 percent in Dominica to over 40 percent in Antigua. Renewed focus on importance of health system functioning to achieve health goals Despite this, the private health sector–particularly the for-profit sector–tends to be overlooked in health systems strengthening initiatives that are traditionally focused on the public sector. A likely explanation for this is that the private health sector tends to be viewed in isolation and is not often conceptualized in a health systems framework.
  • Building on the WHO HSS building block framework, the 2012 HSA approach conceptualizes the private sector as an integral part of the health system. The manual presents a framework for incorporating the private sector into the building-block specific and cross-cutting analysis. Key private sector actors, organizations, contributions, and gaps are explored within and across each building block. Private sector stakeholders and engaged and interviewed throughout the HSA. [address Peter’s comments] Doesn’t prioritize which block is more important, and doesn’t show causal relationships First step, increasing awareness of who are key actors and what they are doing or could do HSoptimal way to identify the key actors in a specific country context, and ways that they are engaged or could be in HSS Let’s turn our attention to the different components of a health system and the range of private sector actors. This is diagram – which is on the wall as a reference as well as a handout in your packet – is based on the WHO six building blocks. The six building blocks are in the middle green circle. They include governance; information; financing; human resources and medicine and technology. The outer blue ring illustrates the breadth and scope of private sector providers. Private sector is a cross–cutting theme in each of health system building blocks LIST A FEW BY BUILDING BLOCK As you can note, there are a diverse range of private sector actors beyond private healthcare providers. As mentioned before, the diversity presents a challenge for public sector because the private health sector is often fragmented and not “organized”. The breadth of private sector actors also presents an opportunity, offering a greater range of PPP possibilities that can strengthen the health system. Another important observation is that many of the same private health sector actors are present in multiple building blocks. This signifies that when the public sector can effectively work with the private sector partners it not only helps strengthen one building block but in most cases, several health systems.
  • SVG and St. Lucia -- Missing private sector data; no population-based surveys; no sero-prevalence surveys. Need to capture statistics on health indicators across the whole population When developing recommendations with stakeholders, opportunities are identified for harnessing the private sector to support health systems strengthening and improve health outcomes. Figure above represents some major strategies to strengthen health systems through the private sector It illustrates the range of policy instruments and mechanisms to engage and partner with the private sector. As the figure illustrates, there are multiple tools and approaches to engage the private sector. Of course the mechanism depends on the element of the health system one is trying to strengthen. For example, MENTION A FEW. It is important to note that: The range of tools illustrated in this diagram reveal that there are many ways to engage the private sector above and beyond just PPPs That most private sector interventions touch/relate to more than one health system building block
  • Larger capacity building strategy across all HS2020 activities…. As part of a health systems strengthening strategy, once the methodology was solidified, the aim was to start institutionalizing the methodology. We have built MOH capacity in HSA approach, and regional capacity of African research institutions to conduct HSAs
  • HSPI has conducted two provincial level HSAs in Vietnam Makerere is conducting HSAs in Uganda and Ethiopia IRSP is conducting an HSA in Benin
  • Goal – build capacity of MOH to coordinate and monitor HSS activities Cote d’Ivoire: Multiple Stakeholder training workshops at the National level, by WB and HS 20/20. Technical work was conducted by national working groups who wrote 90% of the report. The exercise was country led. Bulk of the work was conducted by mid-level technical staff from gov’t agencies. High level decision makers attended a launch and will attend the dissemination country led process, consultative, participatory, results will be used to inform project development by WB and other partners, as well as partnership framework. Cost benefit, capacity built. time, challenges in sustaining momentum/involvement of MOH colleagues, no field level data collection
  • HSA stakeholder engagement guide – piloted in Guyana and adapted and used all 2010 – 2011 HSAs (17 HSAs in total) Steps in the approach – shaping assessment, launch workshop, key informant interviews, validation and prioritization workshop Emphasize broad range of stakeholders interviewed – government, dev partners, civil society, healthcare providers, and private businesses Wide range – 100+ key stakeholder interviews Regional and district-level site visits and interviews Goal is to enhance country ownership through Interviewing key informants at this scale and at this range requires a structured approach. It is not a standard assessment, in which a team flies in, writes the report, and then calls people together for the dissemination of findings. Stakeholders are engages up front to define objectives, agree on process, participate in data gathering and validation, and continue to be involved through the validation and prioritization process. In order to engage people at this range and scale in the most productive way, a standardized approach was needed.
  • Sample agendas, facilitation skill guidance,
  • Sample agendas, facilitation skill guidance,

Setting the Stage for Health Systems Strengthening: What We Have Learned from Doing Over 30 Health Systems Assessments Setting the Stage for Health Systems Strengthening: What We Have Learned from Doing Over 30 Health Systems Assessments Presentation Transcript

  • better systems, better healthSetting the Stage for Health SystemsStrengthening: What We Have Learned fromDoing Over 30 Health System Assessments Better Health Systems: Strategies that Work Presentation Series at the Global Health Council Michael Rodriguez, MA Danielle Altman, MA March 6, 2012Abt Associates Inc.  In collaboration with:I Aga Khan Foundation I Bitrán y AsociadosI BRAC University I Broad Branch AssociatesI Deloitte Consulting, LLP I Forum One CommunicationsI RTI International I Training Resources GroupI Tulane University’s School of Public Health
  • Global Attention toHealth Systems Strengthening
  • Health System Assessment ApproachBroad USAID’S Health Systemhealth Assessment Approachsystem ScopeFocused R A Pr A Pr D Pr ec ss na ec og io of om es ly is rit ra i le sm si io m iz m s s n- en at en m m io da in t ak n g tio in ns g Decision-Making Process
  • Objectives and Use of Health SystemAssessments HSA approach piloted in Angola, Benin, and Azerbaijan in 2005-2007 Rapid yet comprehensive/integrated approach Findings inform stakeholders of critical system strengths and constraints Recommendations developed that cut across the building blocks HSS interventions prioritized
  • Assessment Domains 5
  • Steps in the Health System AssessmentApproach Validation/prioritization workshop and final report 4 •Validate findings and prioritize recommendations at stakeholder workshop •Produce final report Analyze findings •Analyze findings by building block 3 •Develop cross-cutting findings and recommendations •Prepare preliminary report of key findings and recommendations Data collection and launch workshop 2 •Review background materials and compile data on quantitative indicators •HSA launch workshop for in-country stakeholders •Interview key informants Shape the assessment1 •Identify needs and priorities of client •Agree on scope and use of assessment •Choose indicators within each module to answer client’s priority questions
  • Documented Uses of HSA Results Ukraine: Inform health reform agenda Lesotho: Inform MOHSW Eastern Caribbean: Support health system activities implementation of US- through Millennium Challenge Caribbean Regional HIV and Account; USG PartnershipAIDS Partnership Framework in Framework; National Health 6 countries Policy and Strategic Plan
  • Documented Use of HSA in Senegal HSA Recommendation HSA Action ItemImprove technical coordination at MOH; Create department of planning, research, monitoring andstrengthen the planning unit evaluation at the MOHDevise strategies to relieve HRH Change health system at peripheral level, so that healthshortages district coordinators do not also head district health centers. Separate district health offices from health centersStrengthen regional health districts Change design of health system at intermediate level by transforming regional health offices to regional departments of health with more power over human resources management, financial management, and service deliveryImprove planning around health Draft a law to enable pooling of funds for free-careinsurance services and health insurance
  • Evolution of the HSA Approach 2005 - 2012 Incorporate assessment of private sector Build capacity in HSA methodology Standardize and strengthen stakeholder engagement approach
  • Evolution of the HSA Manual Version 1.75 25 countries Version 1.5 Tanzania, Uganda, Ukraine, Mozambique, Ethiopia, Benin, St. 13 countries Kitts and Nevis, Vietnam, Namibia, Antigua, St. Vincent Version 1.0 Nigeria, Senegal, Cote and the Grenadines, d’Ivoire, Lesotho, Grenada, Dominica, 3 pilot countries Zimbabwe, Angola, and St. Lucia Benin, Angola, Kenya, Guyana Azerbaijan2005 – 2007 2007 – 2010 2011 – 2012
  • Incorporating Private Sector into HSA Approach  Governments face constraints in delivering essential health services  Harnessing private sector can help relieve public sector constraints and can result in:  Increased efficiencies in management  Expanded health workforce and service delivery infrastructure  Additional resources  Increased responsiveness to consumer preferences  Broader market for health promotion messages  Better/more creative policymaking  Particularly critical to help sustain HIV response as countries face static or declining external aid for HIV/AIDSSource: International Finance Corporation 2007; Barnes et al. 2009 11
  • Recognizing Private Sector Role In Health Systems StrengtheningSource: Arur A. et al. 2010. Strengthening Health Systems by Engaging the Private Health Sector: Promising HIV/AIDS Partnerships. 12SHOPS Project, Abt Associates.
  • Strategies for Strengthening Health Systems Through Partnerships with Private SectorSource: Arur A. et al. 2010. Strengthening Health Systems by Engaging the Private Health Sector: Promising HIV/AIDSPartnerships. SHOPS Project, Abt Associates. 13
  • Building Capacity in the HSA Methodology Health Systems 20/20’s capacity building strategy aims to transition health system strengthening methodologies to regional partners Enhance country ownership of HSA process and recommendations
  • Developing Regional Capacity Health Systems 20/20 has trained HSPI (Vietnam), IRSP (Benin), and Makerere University (Uganda) in HSA approach Health Systems Assessment - Technical Skill Set Health systems knowledge in six building blocks Stakeholder engagement Qualitative data collection and analysis Technical writing These institutions will market their skills and use the HSA methodology without Health Systems 20/20 support
  • Building MOH Capacity in HSA Guyana  MOH staff shadowed Health Systems 20/20 assessment team and participated in collecting data for each module  Health Systems 20/20 wrote bulk of report  MOH will use the approach to monitor progress over time
  • Building HSA Capacity – LessonsLearned Participation of MOH staff on HSA enhances country ownership of HSA recommendations Intensive training needed, particularly in qualitative data collection and analysis Need for long-term strengthening of regional institutions Transferring HSA methodology is a long-term process
  • Strengthening and Standardizing HSA Stakeholder Engagement Methodology Engaging Stakeholders in Health System Assessments: A Guide for HSA Teams
  • Stakeholder Engagement Guide Guides HSA team in involving a wide range of health system stakeholders – government, nongovernmental and civil society groups, research and academia, and private sector – throughout all phases of the HSA Describes stakeholder engagement in greater detail than the HSA manual
  • Stakeholder Engagement Guide cont’d Provides user-friendly job aids, tools, and guidance:  During Planning Phase  Drafting potential list of key stakeholders  Planning and coordinating the HSA team participants  Conducting pre-assessment visits  Assessment Phase  Gathering data  Conducting in-country debriefing session on initial findings  Validation Phase  Validating findings with stakeholders  Prioritizing and action planning key proposed interventions
  • Summary Health system strengthening is not a result, it’s a process The HSA methodology sets the stage for health systems strengthening The HSA approach highlights linkages across the building blocks As HSAs have been completed, results have fed back into adaption and modification of the methodology
  • Version 1.5 of the HSAA Manual Available at the following URL: You can register on the site for updates as they are made
  • better systems, better health Thank you Thank you! www.HealthSystems2020.orgAbt Associates Inc.  In collaboration with:I Aga Khan Foundation I Bitrán y AsociadosI BRAC University I Broad Branch AssociatesI Deloitte Consulting, LLP I Forum One CommunicationsI RTI International I Training Resources GroupI Tulane University’s School of Public Health