Evidence & Implementation of Strategies to Strengthen Health ServicesDavid H. Peters, Johns Hopkins University Beijing, IHEAJuly 13, 2009

The QuestTo find the “best evidence” to strengthen health services2

Health Interventions Are “Known” To Be Cost-Effective in Developing Countries3Laxminarayan, Chow, Shahid-Salles (2006). Intervention Cost-Effectiveness: Overview and Main Messages. DCPP II

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

Do Countries Follow a Common Pathway to Expanding Health Services? Trends in Skilled Birth AttendanceSource: Matsubayashi, Peters & Rahman (2009)Multi-level models, each line represents one country

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a Common Trajectory to Reach the MDG for Reducing Child Mortality Rates by Two-Thirds?Source: Matsubayashi & Peters (unpublished)Multi-level models, each line represents one country

What Evidence Do We Want About Strategies to Strengthen Health Services?Adapted from Habicht et al (1999)

8Evidence Before Economics or EpidemiologySutra of BuddhaAristotleConfuciusAdi ShankaraIbn RushdJS MillsDavid Hume

Systematic Reviews On What Works in Developing Countries9Peters, El-Saharty, Siadat et al (2009). Improving Health Service Delivery in Developing Countries: From Evidence to Action

Types of Strategies10

Types of Studies with “Adequate” Designs for Systematic ReviewRandomized controlled before-and-after trialsNon-randomized controlled before-and-after trialsRandomized controlled post-only trialsInterrupted time series designs with at least 3 data points before and after the interventionCase-control study with prospective data collection11

Improving Health Service Delivery: Common FindingsImplementation faults are very commonMany different types of strategies can succeed, but are not replicable in much detailStrategies with the same label do very different thingsStrategies produce many unintended consequences, not predictable in detailPolicy makers define strategies, but often have limited influence on how they are implementedInstitutions involved and how implementation occurs matter greatlyNot nearly enough attention has been paid to demonstrating how to improve services for the poor12

Characteristics of Strategies that Strengthen Services for the PoorIntention for benefits to reach the poorRegular measurement of impact on the poorOversight to ensure that the poor benefit13

Strengthening Health Services: Successful Approaches

Community Empowerment Strategies that Work90 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 servicesProviding training opportunities for local health workersHolding service providers, officials, and private organizations accountable15

Context Also Matters: Factors that Really Make Community Empowerment Strategies Work16

Main Limitations of Systematic Reviews on Health Systems StrategiesWeak ability to generalize findings because of:Pooling of data on widely different interventions (often with the same label or name) and on multiple outcomesMany very different and changing factors that influence outcomesUnsuitability of many large-scale strategies for controlled designsLittle information on HOW implementation occurredPlausibility and limited probability inferences onlyPublication bias17

Key Lessons for ImplementationThere is NO BLUEPRINT for successful implementationHow a strategy is implemented is at least as important as what strategy is pursuedInsufficient assessment of experience in involving poor in design, implementation, or assessment of resultsA “learning and doing” approach underlies successful implementation of many different strategies18

StrategiesInstitutional SupportCustomers & BeneficiariesProvider OrganizationsFlexible, Capable ManagementPublic Participation Iterative LearningStructured Learning & Doing: What’s Involved19

Implications for the FutureStop requirements for blueprints of what to doIdentify and engage key local institutionsApply “Learning & Doing” approaches: Ask difficult questions about leaders, laggards, and lessonsUse information intelligently: look for intended results, unintended consequences, explanations, connectionsMeasure and disclose how programs affect the poor20

Evidence to Support a Learning ApproachExplanatory and Plausibility/Probability Interferences: Mixed qualitative-quantitative designsLongitudinal tracking of:Quality and scale of implementationHow information is used, learning processesPerspectives and roles played by critical players Results for beneficiaries, stakeholders, organizationsComparison groups where possible21

Future Health Systems Example: Chakoria BangladeshLarge 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

Afghanistan: Using A Balanced Scorecard to Improve ServicesAnnual 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

A Bright Future for Health SystemsMany strategies workUse data and disclose informationInvolve all key stakeholdersFocus on needs of disadvantagedUse opportunities for learning24