Evidence on Improving Health Service Delivery in Developing Countries


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This presentation by David Peters of the Future Health Systems Consortium was given at the Global Symposium on Health Systems Research in November 2010.

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  • Note the change from intervention (simple and repeatable) to strategy, which is more complex, and can affect many interventions, and concerned with how to do itAll things that countries have been encouraged to do by international agencies, and things that many countries have tried
  • Evidence on Improving Health Service Delivery in Developing Countries

    1. 1. 1 Objectives and Evidence November 18, 2010 Evidence on Improving Health Service Delivery in Developing Countries
    2. 2. Session Objectives  Understand evidence of different strategies to improve delivery of health services  Recognize strengths and limitations of methods used for “evidence-based public health”, implications for future research and decision-making  Identify how institutions and incentives influence selection, implementation, and results of improvement strategies 2
    3. 3. Key Questions  Which strategies best improve the delivery of a range of health services in a given context?  Which factors help or hinder implementation?  Which strategies will ensure that the poor and disadvantaged will benefit?
    4. 4. The Conventional Pathway For Improving Health 1.Choose the right (cost-effective) health interventions 2.Set ambitious, common targets 3.Fund them adequately 4.Implement interventions as designed
    5. 5. Do Countries Follow a Common Pathway to Reducing Childhood Mortality According to Millennium Development Goals? Matsubayashi & Peters (under review) Multi-level models, each line represents one country
    6. 6. Purpose •Health Status (MDGs) •Financial protection •Trust in health system GOVERNMENT Governance (Leadership; Stewardship; Planning; Legislation; Regulation) Financing (Revenue; Pooling; Allocation; Payment) Information (Disclosure; Research; Evaluation) Health Services •Access •Coverage •Utilization •Efficiency •Quality PROVIDER ORGANIZATIONS Management Systems & Inputs Human Resources; Financial Management; Information Systems; Drugs and Medical Supplies (Logistics); Medical Technology; Maintenance & Buildings; Auxiliary Services PEOPLE Poor / Non-Poor Communities Advocacy groups Consumer protection groups MACRO ENVIRONMENT HEALTH SECTOR ENVIRONMENT Enabling & InhibitingEnabling & Inhibiting FactorsFactors STRATEGY to strengthen health services Health Services Strategies Analytic Framework
    7. 7. 7 Knowing What vs. How vs. Why  What works  “Evidence” for simple interventions  How does it work  Knowledge of context, actors, & implementation processes for complex change  Why do it  Beliefs and values for motivated and sustained action
    8. 8. 8 Thinkers on evidence for causation who didn’t need epidemiology or economics Confucius Aristotle Sutra of Buddha Adi Shankara Ibn Rushd JS MillsDavid Hume
    9. 9. 9 “Parachutes reduce the risk of injury after gravitational challenge, but their effectiveness has not been proved with randomized controlled trials” Smith & Pell (2003) BMJ
    10. 10. 10 What Do We Want to Know? Questions, Inferences, How To Investigate Primary question Inference Design Implications Is any measured health effect due to the implemented strategy? Probability Controlled (cluster randomized) trials; health strategy implemented in some areas and not in others Is any measured health effect likely due to the strategy rather than other influences? Plausibility Concurrent, non randomized clusters; strategy implemented in some areas and not in others; before-after or cross- sectional study in program recipients and non-recipients Are health indicators changing among beneficiaries of a strategy? Adequacy Before-after or time-series in program recipients only How did implementation of the strategy lead to effects on health behavior, services or status? Explanatory Mixed methods: Repeated measures of context, actors, depth and breadth of implementation across subunits + Qualitative methods: key informant interviews, focus groups, historical reviews, and triangulation of data sources
    11. 11. 11 Who wants to know? Which question is most important to:  Policy-makers  Managers  The public  Development partners  Funding agencies  Researchers
    12. 12. Systematic Reviews Chapter Main issues addressed 1. Strategies to strengthen health services What is the evidence of the effect of different approaches to strategies to strengthen health services? What are the main enabling and inhibiting factors influencing their effect? 2. Community empowerment strategies for health What is the evidence of the effect on health services or outcomes of different strategies to empower communities? 3. Strategies to improve health care provider performance What is the evidence of the effect on the performance of health workers of different strategies to improve that performance? 4. Strategies to strengthen the performance of health organizations What is the evidence of the effect of different strategies to improve the performance of health services organizations?
    13. 13. Studies on How Health Services Change Occurs Chapter Main issues addressed Methodology 5. Cross-country changes in health services What are the trends over time of specific health service outputs across LMICs? How do changes in one priority health service affect changes in other health services? What are the contextual factors that most influence health service outputs at national level? Longitudinal statistical analysis of cross-country data on health services and contextual factors 6. Evaluation of changes in health services, financing, and health status in World Bank-assisted health projects How well do World Bank-assisted project evaluations measure changes in health services, financing, and health status? What are the main factors associated with measuring changes? Documentation analysis using standardized definitions and cross-sectional statistical analysis 7. Institutional context of health services What are the main institutional factors influencing the delivery of health services in LMICs? Literature review 8. Seven country case studies Describe the strategies of significant scale for strengthening health services delivery in the real-life context in which they occurred. What are the presumed causal links between the strategies and their effects? What are the lessons learned? Mixed methods case studies (data and documentation review, key informant interviews)
    14. 14. Some Systematic Reviews on What Works Systematic review Number of studies screened Number of studies with adequate designs 1. Health services strengthening strategies in LMICs 208 150 2. Community empowerment in health strategies in LMICs 27,000 156 3. Improving health worker performance in LMICs >105,000 223 (ongoing) 4. Improving the performance of health services organizations in LMICs 127,000 88 14
    15. 15. Strategies to Improve Implementation of Health Services Strategy Type Examples Public Oversight Policy Reviews; Regulations; Contracting; Supporting Consumer Organizations Provider Based Quality Improvement Programs; Training; Human Resource Management; Logistics Systems; Decentralization of Public Services Community Based Community Development Programs; Demand Creation Health Financing Provider Payment System Change; Subsidies; Health Insurance 1 5
    16. 16. Study Details 16
    17. 17. Conclusions & A Way Forward 17
    18. 18. Some Over-Arching 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  Institutions involved and how implementation occurs matter greatly  Policy makers define strategies, but often have limited influence on how they are implemented  Strategies produce many unintended consequences, not predictable in detail  Not nearly enough attention has been paid to demonstrating how to improve services for the poor 18
    19. 19. How Strategies are Implemented Matters: Odds of Success from Systematic Review Randomized Controlled Trials All “Adequate” Studies Odds ratio Odds ratio Community coordination and organization .. 4.6** Local adaptation of the intervention 9.3 4.3 * Broad-based support of various stakeholders .. 3.9 * Consultation and engagement of powerful interest groups 2.8 3.8** Flexibility and modification through stakeholder feedback .. 3.4 * Representation from powerful interest groups 2.4 3.0 * Constraints reduction plans 6.7 2.7 * * Pvalue<0.05; ** Pvalue<0.01 1 9
    20. 20. Practical Lessons from Implementation Experience  There is NO BLUEPRINT, NO MAGIC BULLET for successful implementation  How a strategy is implemented is at least as important as what strategy is pursued  Improvement for the poor involves planning for benefits to reach the poor, ensuring regular measurement of impact on the poor, and providing oversight to ensure the poor benefit  A “learning and doing” approach underlies successful implementation of many different strategies 2 0
    21. 21. What “Learning & Doing” Means  Asking difficult questions about leaders, laggards, and lessons  Using information intelligently:  intended results,  unintended consequences  explanations, connections  Involving key stakeholders and institutions  Revise implementation plans, authorities, accountabilities, incentives as you learn 21
    22. 22. Structured Learning & Doing Approaches Customers & Beneficiaries Provider Organizations Institutional Support Public Participation Iterative Learning Flexible, Capable Management Strategies 22
    23. 23. 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 23