Evidence & Implementation of Strategies to Strengthen Health Services

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    Notes on slide 1

    Where a country starts influences its rate of change and prospects for reaching MDG targets

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    Evidence & Implementation of Strategies to Strengthen Health Services - Presentation Transcript

    1. Evidence & Implementation of Strategies to Strengthen Health Services
      David H. Peters, Johns Hopkins University
      Beijing, IHEA
      July 13, 2009
    2. The Quest
      To find the “best evidence” to strengthen health services
      2
    3. Health Interventions Are “Known” To Be Cost-Effective in Developing Countries
      3
      Laxminarayan, Chow, Shahid-Salles (2006). Intervention Cost-Effectiveness: Overview and Main Messages. DCPP II
    4. But Implementation is Variable: Country-Specific Changes in DPT3 Coverage (All LMICs)
      Source: Matsubayashi, Peters & Rahman (2009)
      Multi-level models, each line represents one country
    5. Do Countries Follow a Common Pathway to Expanding Health Services? Trends in Skilled Birth Attendance
      Source: Matsubayashi, Peters & Rahman (2009)
      Multi-level models, each line represents one country
    6. Do Countries Follow a Common Trajectory to Reach the MDG for Reducing Child Mortality Rates by Two-Thirds?
      Source: Matsubayashi & Peters (unpublished)
      Multi-level models, each line represents one country
    7. What Evidence Do We Want About Strategies to Strengthen Health Services?
      Adapted from Habicht et al (1999)
    8. 8
      Evidence Before Economics or Epidemiology
      Sutra of Buddha
      Aristotle
      Confucius
      Adi Shankara
      Ibn Rushd
      JS Mills
      David Hume
    9. Systematic Reviews On What Works in Developing Countries
      9
      Peters, El-Saharty, Siadat et al (2009). Improving Health Service Delivery in Developing Countries: From Evidence to Action
    10. Types of Strategies
      10
    11. Types of Studies with “Adequate” Designs for Systematic Review
      Randomized controlled before-and-after trials
      Non-randomized controlled before-and-after trials
      Randomized controlled post-only trials
      Interrupted time series designs with at least 3 data points before and after the intervention
      Case-control study with prospective data collection
      11
    12. Improving Health Service Delivery: Common Findings
      Implementation faults are very common
      Many different types of strategies can succeed, but are not replicable in much detail
      Strategies with the same label do very different things
      Strategies produce many unintended consequences, not predictable in detail
      Policy makers define strategies, but often have limited influence on how they are implemented
      Institutions involved and how implementation occurs matter greatly
      Not nearly enough attention has been paid to demonstrating how to improve services for the poor
      12
    13. Characteristics of Strategies that Strengthen Services for the Poor
      Intention for benefits to reach the poor
      Regular measurement of impact on the poor
      Oversight to ensure that the poor benefit
      13
    14. Strengthening Health Services: Successful Approaches
    15. Community Empowerment Strategies that Work
      90 percent of all studies using community empowerment approaches had a positive primary outcome:
      Promoting communication and collective action by communities
      Supporting community ownership and management of services
      Providing training opportunities for local health workers
      Holding service providers, officials, and private organizations accountable
      15
    16. Context Also Matters: Factors that Really Make Community Empowerment Strategies Work
      16
    17. Main Limitations of Systematic Reviews on Health Systems Strategies
      Weak ability to generalize findings because of:
      Pooling of data on widely different interventions (often with the same label or name) and on multiple outcomes
      Many very different and changing factors that influence outcomes
      Unsuitability of many large-scale strategies for controlled designs
      Little information on HOW implementation occurred
      Plausibility and limited probability inferences only
      Publication bias
      17
    18. Key Lessons for Implementation
      There is NO BLUEPRINT for successful implementation
      How a strategy is implemented is at least as important as what strategy is pursued
      Insufficient assessment of experience in involving poor in design, implementation, or assessment of results
      A “learning and doing” approach underlies successful implementation of many different strategies
      18
    19. Strategies
      Institutional Support
      Customers & Beneficiaries
      Provider Organizations
      Flexible, Capable Management
      Public Participation
      Iterative Learning
      Structured Learning & Doing: What’s Involved
      19
    20. Implications for the Future
      Stop requirements for blueprints of what to do
      Identify and engage key local institutions
      Apply “Learning & Doing” approaches:
      Ask difficult questions about leaders, laggards, and lessons
      Use information intelligently: look for intended results, unintended consequences, explanations, connections
      Measure and disclose how programs affect the poor
      20
    21. Evidence to Support a Learning Approach
      Explanatory and Plausibility/Probability Interferences: Mixed qualitative-quantitative designs
      Longitudinal tracking of:
      Quality and scale of implementation
      How information is used, learning processes
      Perspectives and roles played by critical players
      Results for beneficiaries, stakeholders, organizations
      Comparison groups where possible
      21
    22. Future Health Systems Example: Chakoria Bangladesh
      Large informal markets and provider organizations are found to be the main source of outpatient care for the poor. But quality of medical practice often poor or dangerous.
      Information was used to support new partnerships (with public, private, beneficiaries, and research organizations) and innovations in services service delivery by informal providers.
      Integrated management of childhood illness (IMCI) protocols used to train informal providers, disclose performance, use local “Health Watch”, and reform payment systems (subsidies for services to poor).
      Results: increased coverage of safe deliveries linked to incentives, reduced use of inappropriate drugs, ongoing need shown for supportive institutions to back up training and education of public.
      22
    23. Afghanistan: Using A Balanced Scorecard to Improve Services
      Annual nation-wide assessment of health services by 3rd party used to support national policy to promote basic health package and benefits to the poor through service contracts with NGOs and government.
      The demonstration of improved coverage and quality of health services, and falling infant and child mortality, has helped strengthen management, policy-making (e.g. user fees policy determined by partner’s research), accountability, and new institutions in a post-conflict state.
      23
    24. A Bright Future for Health Systems
      Many strategies work
      Use data and disclose information
      Involve all key stakeholders
      Focus on needs of disadvantaged
      Use opportunities for learning
      24

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