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Health systems strengthening 19 jan mph

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  • This includes efforts to influence determinants of health as well as more direct health-improving activities:
    A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services.
    It includes for example a mother caring a sick child at home, private providers, behavior change programs, vector-control campaigns, health insurance organizations, occupational health and safety legislation.
    It includes intersectoral action by health staff: eg encouraging the ministry of education to promote female education, a well-known determinant of better health, and the ministry of transport to promote the use of safety belts to prevent severe injury to the driver and passengers of motor vehicles
  • Service delivery: preventive and curative personal health services; primary, secondary services and tertiary services (public/private/voluntary NGOs)
    Public health service; services for specific population groups such as children and women, or for specific conditions such as tobacco or alcohol problems
    Resources: trained staff, commodities, facilities and knowledge
    Financing: sources of funds such as user fees, insurance, tax,
  • The first step in improving responsiveness in to actually have health workers in place. In five countries of the Regions less than 50 per cent of births are attended by skilled attendants.
  • Social dialogue on the policy choices that will set the boundaries for strategic options
  • Transcript

    • 1. Health Systems Development and Strengthening Dr Nilar Tin
    • 2. What is a Health System? What are the Goals? What are the functions?
    • 3. What is a Health System? A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health
    • 4. Health Systems are thus defined as comprising • All Organizations & Institutions • People (health professionals both public/private) • Supplies • Information that are devoted to producing – Health Actions- whether personal health care or public health care or through intersectoral initiatives, primary purpose is to improve health- good health – World Health Report 2000 devoted entirely to Health Systems – WHO expands its traditional concern for people’s physical and mental well being to emphasize two other elements of good health; goodness and fairness Goodness: HS responding well to what people expect of it Fairness : HS responds equally well to everyone without discrimination
    • 5. Looking back to history: How Health Systems have evolved? • Health systems of some sort have existed for as long as people have tried to protect their health and treat disease (Traditional practices, spiritual healers, herbal– modern medicine) Looking back a century – organized HS barely existed • What the people at that time would suffer from? LE at birth • What kinds of health care were provided? Evolution • Founding of national health care systems • Extension of social health insurance schemes • Promotion of PHC approach--the goal of HFA
    • 6. PHC is an approach to health development “ essential health care based on practical, scientifically sound and socially acceptable methods and technology made universally accessible to individuals, and families in the community through their participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self determination. It forms an integral part of both the country’s health system, of which it is the central function and main focus, and the overall social and economic development of the community. It is the first level of contact of individuals, the family, and the community with the national health system bringing health care as close as possible to where people live and work and constitutes the first element of a continuing health care process”
    • 7. 1970s--1980s PHC actual application & Experiences 1. A package or a set of activities: 8 ELEMENTS of PHC; preventive and promotive more; emphasis more on public health rather than medical care 2. Level of care: Primary, Secondary and Tertiary levels of care. PHC goes further down to community-based care 3. An approach, which has been termed variously as the PHC principle -universal coverage (equity in health across all SE groups) -intersectoral collaboration (risk factors & Social determinants affecting health) -community participation (empowerment) -appropriate technology (not only resource-constrained countries but apply to all)
    • 8. 1980s Changes in economy: Oil crisis in middle east • • • • • SAPs- Structural Adjustment Policies Health Sector Reforms especially affecting African countries Players WB & IMF WB’s mandate: Promote sustainable economic growth & contribute to poverty alleviation Three pillars of WB’s poverty alleviation strategy – – – Sustained economic growth Productive use of labour Access to social service for the poor WB lends money to poor countries: Loans were there, but poor countries become poorer and rich countries become richer
    • 9. At the same time with economic changes Health Systems was being challenged with Demographic changes  Transitions where fertility and growth rate declined  Infant mortality has decreased and LE increased ---leading to increase in <15 years and elderly population  Process of rapid urbanization Epidemiologic changes  Migration and urban growth---led to resurgence of diseases that were once considered controlled such as cholera outbreaks + accidents, injuries, crime  AIDS pandemic  Still infectious diseases were giving problems
    • 10. Health Sector Reforms: – – – User financing (Rational drug use by donors- Bamoko Initiatives in 1987 in African countries) Selective Primary Health Care (GOBI for child survival) making priorities of elements of PHC Privatization (promoting hospital setting and sophisticated health measures) What were the results…….. – – – In Kenya introduction of user fee at STD clinic caused reduction in attendance & increased no: of untreated STDs in the population SAPs contributed to rapid spread of AIDS in Africa Many of 3 million deaths from TB in China during the 1980s might have been prevented if user fee was not introduced
    • 11. Socio-cultural transitions    Increased levels of education, improved communications---shrunk distances between countries Changes in life styles, nutritional, traditional, social and family structures, values and even expectations Led to ---social problems, adolescents problems, mental health problems--NCDs + CDs--double burden--increased demand of health care systems. Political changes   Political orientation and ideologies in many countries changed Changes in policies, management and services in all sectors.
    • 12. Impact of all these Trainsitions / Health Systems Challenges  Impact of ageing population with need of provision of chronic care/ social security  Threats of AI, H1N1-affecting more on poor countries and HR issues  Competition for resources between hospitals and between public and private sector  High tech in diagnosis and life long treatment could not protect people from catastrophic spending  Universal coverage, tax based funding, Social Health Insurance, Microcredit-- financing schemes need major demand on managerial capacity  Migration of health workforce had made the sender country to suffer more PHC,
    • 13. Impact of all these Trainsitions/HS Challenges • Where providers depend largely on out-of-pocket payments for their income, there is over-provision of services for people who can afford to pay, and lack of care for those who cannot pay. • • OPPORTUNITIES The global health landscape has been transformed in the last ten years with the emergence of multiple, billiondollar global health partnerships such as the Global Fund and the GAVI Alliance. • WHO- Health Metrics Network, Global Health Workforce Alliance, Commission for Social Determinants of Health,
    • 14. Health system challenges: a few facts and figures • Globally, health is a US$3.5 trillion industry, or equal to 8% of the world's GDP. • Large health inequalities persist: even within rich countries such as USA and Australia, life expectancy still varies across the population by over 20 years. • Recent essential medicines surveys in 39 mainly low- and low-middle-income countries found that, while there was wide variation, average availability was 20% in the public sector, and 56% in the private sector.
    • 15. Health system challenges: a few facts and figures • Each year, 100 million people are impoverished as a result of health spending. • Extreme shortages of health workers exist in 57 countries; 36 of these are in Africa. • In over 60 countries, less than a quarter of deaths are recorded by vital registration systems. • An estimated 50% of medical equipment in developing countries is not used, either because of a lack of spare parts or maintenance, or because health workers do not know how to use it.
    • 16. Health system challenges: a few facts and figures • Private providers are used by poor as well as rich people. For example, in Bangladesh, around ¾ of health service contacts are with non-public providers. • In 2000, less than 1% of publications on Medline were on health services and systems research. • Globally, about 20% of all health aid goes to support governments' overall programmes (i.e. is given as general budget or sector support), while an estimated 50% of health aid is off budget. • There has been a rapid increase in global health partnerships. More than 80 now exist, of which WHO houses over 30.
    • 17. Discussions for today In Two Groups (30 minutes) • Myanmar in the context of Health Systems Development… • What are the Health Systems Challenges? • What are the opportunities???? • Where are we now ?????
    • 18. Health system functions and goals Goals Good health outcomes Responsiveness Fairness in financing Functions Service delivery Resource generation: HWF, supplies, information Financing Governance and stewardship
    • 19. The six building blocks of a health system 1.Good health services are those which deliver.. • effective, • safe, • quality • personal and non-personal health interventions to those that need them; when and where needed; with minimum waste of resources. 2. A well-performing health workforce is one that works in ways that are.. responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed; they are competent, responsive and productive).
    • 20. The six building blocks of a health system 3. A well-functioning health information system is one that ensures.. • the production, • analysis, • dissemination and • use of reliable and timely information on health determinants, health system performance and health status. •4. A well-functioning health system ensures equitable access to.. • essential medical products, • vaccines and • technologies of • assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use.
    • 21. The six building blocks of a health system 5. A good health financing system raises adequate funds for health, in ways that ensure • people can use needed services, • and are protected from financial catastrophe or impoverishment associated with having to pay for them. • It provides incentives for providers and users to be efficient. 6. Leadership and governance involves ensuring • strategic policy frameworks exist • and are combined with effective oversight, • coalition building, • regulation, • attention to system-design and accountability.
    • 22. What is Health System Strengthening?
    • 23. Defining Health Systems Strengthening At its broadest, health system strengthening (HSS) can be defined as an array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvement in access, coverage, quality, or efficiency. (Health system Action Network)
    • 24. Health System Strengthening • Stewardship / governance / leadership : defining sector strategies, clarifying roles, managing competing demands • Health financing : ensuring fair and sustainable financing, including financial protection • Human resources : having a sufficient and productive workforce • Information and knowledge : ensuring the generation and use of information • Technology and infrastructure : ensuring adequate drugs, equipment, infrastructure • Service delivery : improving organization, management, and quality of services
    • 25. Health Service Delivery Integrated service delivery packages WHO will continue to produce and disseminate costeffectiveness data for prevention and treatment, and define service standards and measurement strategies for tracking trends and inequities in service availability, coverage and quality. It will help define integrated packages of services, and the roles of primary and other levels of care in delivering the agreed packages, as part of its health policy development support.
    • 26. Health Service Delivery Service delivery models WHO will consider the whole network of public and private providers in order to enhance equitable access, quality and safety. It will synthesize and share experience of the costs, benefits and conditions for success of strategies to improve service delivery. These may include -community health workers, -task shifting, outreach, contracting, -accreditation, -social marketing, -uses of new technologies such as telemedicine, -hospital service organization and management, -delegation to local health authorities, -other forms of decentralization, etc.
    • 27. Health Service Delivery Leadership and Management WHO will support Member States to improve management of health services, resources and partners by health authorities, as a means to expand coverage and quality. This will be done through: -promoting tools for analyzing barriers to care, and management weaknesses; -generating and sharing knowledge on strategies to improve management, often in the context of decentralization; -developing local resource institutions’ capacity to support local health managers; and -developing methods to monitor progress.
    • 28. Health Workforce International norms, standards and databases WHO will maintain and strengthen the Global Atlas on the health workforce. It will facilitate the generation and exchange of information on health workforce availability, distribution and performance by supporting regional workforce observatories. Realistic strategies WHO will increase its support for realistic national health workforce strategies and plans for workforce development. These will consider the range, skill-mix and gender balance of health workers (health service providers and management and support workers) needed to deliver the agreed package of services across priority programmes. They will address workforce education, recruitment, retention and performance and define regulatory options
    • 29. Health Workforce Costing WHO will generate knowledge about the financial costs of scaling-up and then maintaining the expanded health workforce, as well as ways to address financial sustainability, and use this in dialogue with international financing institutions. Training WHO will support the redesign of training programmes to produce the spectrum of health workers (service providers and management and support workers) to deliver health services. It will explore and document ways to maximize the use of priority programme training initiatives, and mechanisms such as accreditation to assure quality of training programs.
    • 30. Information National information systems Support improved population and facility-based information systems, so that they can generate, analyse and use reliable information from multiple data sources, in collaboration with partners (e.g. UN, other agencies, the Health Metrics Network partnership, the Institute of Health Metrics and Evaluation). Stronger national surveillance and response capacity Public health systems that are equipped with up-to-date technologies and dedicated personnel and are able to detect, investigate, communicate and contain threats to public health security, and be part of an unbroken international line of defence against such threats.
    • 31. Information Tracking performance Establish a set of core and additional health system metrics to track health system performance for use by countries and external agencies financing investments in health systems. Standards, methods and tools These include the International Classification of Diseases, Global Burden of Disease updates, MDG monitoring tools; development and measurement of Health System Metrics; and standards for electronic medical records. A key role will be played by expert groups, including the Advisory Committee for Health Monitoring and Statistics.
    • 32. Medical Products, VACCINES AND TECHNOLOGIES Establish norms, standards and policy options Set, validate, monitor, promote and support implementation of international norms and standards to promote the quality of medical products, vaccines and technologies, and ethical, evidence-based policy options and advocacy. Procurement Encourage reliable procurement to combat counterfeit and substandard medical products, vaccines and technologies, and to promote good governance and transparency in procurement and medicine pricing.
    • 33. Sustainable Finanacing & Social Protection Health financing policy option Assess and disseminate information about what works and what does not work in health financing strategies; Facilitating the sharing of country experience in various types of health financing reforms; Sharing of key information required by country policy makers; and the development of tools, norms and standards including those required to assist countries to generate and use information in their own settings. Improve or develop pre-payment, risk pooling and other mechanisms to reduce the extent of financial catastrophe and impoverishment due to out-of-pocket payments, and to extend financial and social protection.
    • 34. Leadership and Governance Develop health sector policies and frameworks that fit with broader national development policies and resource frameworks, and are underpinned by commitments to human rights, equity and gender equality. Generate and interpret intelligence and research on policy options . At the international level, it will facilitate access to knowledge on approaches to policy and systems development: -by promoting a more systematic health systems research agenda; through the Alliance on Health Policy and Systems Research; -by building capacity in regional observatories or their equivalent; and -by increasing access to and use of new knowledge management technologies.
    • 35. Have the health system goals been achieved? SEAR countries
    • 36. Infant Mortality Rate 200 180 160 Infant deaths ( per 1000 live births) 140 1990 120 2005 100 88 HFA 2000 target of IMR < 50 80 61 60 51 50 35 40 22 20 0 61 60 22 14 12 DPR Korea Sri Lanka Thailand Maldives Indonesia Reference year of data for 2005 vary from 2000 to 2005 Source : Country reports on MDG Bhutan India Bangladesh Myanmar Nepal Timor-Leste
    • 37. Under-5 Mortality Rate (Reduce by two-thirds b/w 1990-2015) (UN MDG Goal-G4, T5, Deaths of under five years old children ( per 1000 live births) 200 180 160 1990 140 2005 2015 Target HFA 2000 target of U5MR < 70 120 100 80 60 40 20 0 Nepal Bangladesh Myanmar India Indonesia Bhutan Maldives Baseline data for 1990 for Timor-Leste is an estimate and 2015 is target set as MDG Reference year of data for 2005 vary from 2000 to 2005 Source : Country reports on MDG Thailand DPR Korea Sri Lanka Timor-Leste
    • 38. Deaths of childeren under-5 years of age (per 1000 live births) Trends in under-five m ortality in the SEA Region, by country, 1975 - 1999 250 Bhutan Bangladesh 200 Nepal India 150 Myanmar Indonesia Maldiv es SEAR W ORLD 100 HFA 2000 tar ge t of U5M R < 70 Thailand DPR Korea 50 Indonesia Sri Lanka 0 1975-79 1980-84 1985-89 1990-94 Ye ar Source: W HO Genev a, Bulletin of the W orld Health Organization, 2000, 78:1175-1191 1995-99
    • 39. 100 Proportion of 1 year-old children immunized for measles births attended by skilled health personnel 1990 90 80 Percentage 60 2003 72 67 56 94 88 97 99.7 95 85 80 77 75 70 99 80 75 69 71 65 57 Nepal Indonesia Bangladesh 60 57.5 50 40 30 20 10 0 India Source : Country reports on MDG Bhutan Myanmar Sri Lanka Thailand Maldives DPR Korea Timor-Leste
    • 40. How have health system been performing in SEAR? • Fairness in Financing Com posi t i on of t ot a l h ea l t h spen di n g i n SEA R 27% 3% 4% 66% OOPs soc ia l in su r a n c e pr iv a t e in su r a n c e tax
    • 41. Why have they failed to achieve the goals?
    • 42. What does this mean? Health Systems of SEA regional countries have failed to achieve the health system goals in relation to maternal and child health services, - in terms of disease burden, - fairness in financing and - responsiveness
    • 43. Why have they failed? • Political commitment even at the highest level MDGs • Lots of development work has taken place Many donor agencies have come forward • Lots of funds are available and being used • However health outcomes did not improve as expected WHY?
    • 44. What are the health systems factors that affect MCH service delivery • • • • Health workforce Organization and management of services Governance stewardship Essential drugs and medicine, logistics, infrastructure • Health information • Health Financing
    • 45. System wide barrier study 2004 • Identified key barriers / bottlenecks to increasing sustained coverage which were beyond the control of the immunization system: – human resource numbers and motivation – transport to reach the hard to reach (especially for outreach) – Fund flow issues especially to district level – Peripheral level management, logistics and monitoring – Coordination with and between partners
    • 46. Does Health workforce shortages affect health outcomes?
    • 47. Health workers save lives … but we need enough of them High Probability of survival Maternal Survival Child Survival Infant Survival Low Low Proportion of health workers per population High Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization
    • 48. Proportion of births attended by skilled health personnel 100 90 1990 80 86 2005 85 99 85 68 68 70 Percentage 97 95 60 51 48 50 42 40 36 32 30 20 20 10 24 22 14 24 15 7 0 Nepal Bangladesh Bhutan Timor-Leste India Reference year of data for 2005 vary from 2000 to 2005 Source : Country reports on MDG Myanmar Indonesia Maldives Thailand Sri Lanka DPR Korea
    • 49. Relationship between Coverage of deliveries by skilled birth attendants and Maternal Mortality, 2005 (Countries with higher level of coverage of deliveries by skilled birth attendants tend to have lower maternal mortality )* Thailand 98 DPR Korea 98 Sri Lanka 97 Maldives 14 97 47 87 72 Indonesia 72 Myanmar 68 India 307 380 54 301 Timor-Leste 32 Bhutan 32 Bangladesh 30 Nepal 20 Deliveries attended by skilled health personnel (%) 660 225 380 281 MMR (maternal deaths per 100,000 live births) * Not a univariate relation as there are other determinants of it Notes : Reference year of data vary from 200 to 2005 Source : :Country reports on MDG
    • 50. Is there a critical level of health workers needed to achieve essential health interventions? • To have 80% coverage in skilled births and measles vaccination there should be a minimum threshold of 2.5 (Docs + Nur + Midwives) / 1000 population - JLI • To have 80% coverage in skilled births there should be a minimum threshold of 2.28 (Docs+ Nur + Midwives) / 1000 population - WHO
    • 51. Where are we in relation to this population norm? Number of (Doctors + Nurses + Midwives) per 1,000 population 8.000 7.000 6.000 5.000 4.000 3.000 Threshhold 2.28 2.000 1.000 0.000 BAN BHU DPRK IND INO MAV MMR NEP SRL THA TLS
    • 52. How to move forward?
    • 53. 1. Identify key barriers / bottlenecks to increase sustained coverage which are beyond the control of the immunization system HRH shortages, distribution, quality, motivation etc. transport to reach the ‘hard to reach’ (especially for outreach) affordability and fund flow issues especially to district level infrastructure at periphery, logistics management monitoring & supervision coordination with and between partners 2. Identify what caused lead to these problems problem analysis 3. Identify how to overcome them formulate your objectives identify interventions
    • 54. At what level are the performance constraints & bottlenecks? SYSTEM LEVEL Policy & sector analysis: NHSS, PRSP, MDGS PROGRAM LEVEL Strategy analysis: RED, MPA, demand vs. supply driven OPERATIONAL LEVEL Needs analysis HR: skills, skills mix, retention Capital: stores, equipment, vehicles
    • 55. Goals and Objectives Goals SMART Objectives Expected outcome, outputs Activities Resources / Budget Monitoring and Evaluation
    • 56. Strengthening interventions ISS ISS ISS Drug Supply & Quality Logistics Service delivery Surveillance ISS Advocacy & Communication ISS
    • 57. Strengthening Systems MoF, World Bank, HIPC Gov’T, UNDP, MoP HSS Drug Supply & Quality Logistics HSS Service delivery Surveillance HSS UNICEF PRSP Advocacy & Communication SWAp
    • 58. Policy space ACCESS EQUITY Drug Supply & Quality Logistics Service delivery Surveillance STEWARDSHIP Advocacy & Communication PRO-POOR
    • 59. Thank you