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KEYSTONE / Module 1 / Slideshow 3 / Health System and Health Policy Frameworks - 2


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KEYSTONE HPSR Initiative // Module 1: Introducing Health Systems & Health Policy // Slideshow 3 Health Systems and Health Policy Frameworks - 2
This is the third slideshow of Module 1: Introducing Health Systems & Health Policy, of the KEYSTONE Teaching and Learning Resources for Health Policy and Systems Research

To access video sessions and slides for all modules copy and past the following link in your browser:

Module 1: Introducing Health Systems & Health Policy
This module introduces students to the KEYSTONE initiative, the objectives and design of the inaugural course, and the field of Health Policy and Systems Research. Common frameworks used to understand health systems and health policy are delineated, including the WHO building blocks framework, health systems hardware and software, systems thinking, social construction, and people-centred health systems.

There are 5 slideshows in this module.

Module 1: Introducing Health Systems & Health Policy
-Module 1 Slideshow 1: KEYSTONE Course: Getting Oriented
-Module 1 Slideshow 2: Health Systems and Health Policy Frameworks - 1
-Module 1 Slideshow 3: Health Systems and Health Policy Frameworks - 2
-Module 1 Slideshow 4: Health Systems and Health Policy: Wrap Up
-Module 1 Slideshow 5: Epistemological self-diagnosis

The other modules in this series are:
Module 2: Social justice, equity & gender
Module 3: System complexity
Module 4: Health Policy & Systems Research frameworks
Module 5: Economic analysis
Module 6: Policy analysis
Module 7: Realist evaluation
Module 8: Systems thinking
Module 9: Ethnography
Module 10: Implementation research
Module 11: Participatory action research
Module 12: Knowledge translation
Module 13: Research Plan Writing

KEYSTONE is a collective initiative of several Indian health policy and systems research (HPSR) organizations to strengthen national capacity in HPSR towards addressing critical needs of health systems and policy development. KEYSTONE is convened by the Public Health Foundation of India in its role as Nodal Institute of the Alliance for Health Policy and Systems Research (AHPSR).

The inaugural KEYSTONE short course was conducted in New Delhi from 23 February – 5 March 2015. In the process of delivering the inaugural course, a suite of teaching and learning materials were developed under Creative Commons license, and are being made available as open access resources. The KEYSTONE teaching and learning resources include 38 videos and 32 slide presentations organized into 13 modules. These materials cover foundational concepts, common approaches used in HPSR, and guidance for preparing a research plan.

These resources were created and are made available through support and funding from the Alliance for Health Policy & Systems Research (AHPSR), WHO for the KEYSTONE initiative.

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KEYSTONE / Module 1 / Slideshow 3 / Health System and Health Policy Frameworks - 2

  1. 1. Building the HPSR CommunityBuilding HPSR Capacity KEYSTONE Inaugural KEYSTONE Course on Health Policy and Systems Research 2015 Health Systems and Health Policy Frameworks - 2
  2. 2. 14-03-2016 KEYSTONE Health Systems and Health Policy Frameworks - 2 Kabir Sheikh 23 February 2015
  5. 5. 14-03-2016 KEYSTONE Chronology of Health Systems Frameworks Focus on Health Systems Structure: Primary Health Care (1) Comprehensive: Alma Ata 1979 • Principles and Values • Level of Care: first contact • Elements: eight programs (2) Selective PHC – UNICEF 1982 • GOBIFF
  6. 6. 14-03-2016 KEYSTONE Shift to Health system function: (3) Basic Health Care Packages: World Bank 1993 • Public Health Programs • Essential Clinical Services (4) World Health Report 2000: Health Systems, Improving Performance • Goals and Functions • Six Building Blocks
  7. 7. 14-03-2016 KEYSTONE Engaging with health systems change (5) Paris Declaration on Aid Effectiveness: 2005 • Country Government Ownership • Use of Government Systems to deliver aid (6) Health System Strengthening • Opportunities for Global Health Initiatives in the Health System Agenda WHO 2006 • HSS: Everybody’s Business WHO 2007 • Complexity and interaction (Systems Thinking – AHPSR 2009)
  8. 8. 14-03-2016 KEYSTONE 2000 move towards ‘HSS’ because • ‘Effective interventions exist for many priority health problems in low income countries; prices are falling, and funds are increasing. However, progress towards agreed health goals remains slow. There is increasing consensus that stronger health systems are key to achieving improved health outcomes.’ (Travis et al., 2004)
  9. 9. 14-03-2016 KEYSTONE Constraint Disease-programme response Health system response Poorly motivated staff Financial incentives to reward delivery of particular priority services Institution of proper performance review systems Creating greater clarity of roles and expectations regarding performance of roles Review of salary structures and promotion procedures Health system strengthening goes beyond dedicated disease/condition-specific programmes Travis et al. 2004
  10. 10. 14-03-2016 KEYSTONE
  11. 11. 14-03-2016 KEYSTONE Vertical, Horizontal and Diagonal approaches • Vertical programs: focus on delivery of intervention targeting specific disease or condition (eg immunisation) • Horizontal program: focus on health system components with relatively less attention on delivery outcomes • Diagonal approach: Addressing health systems bottlenecks to specific vertical programs while achieving system-wide benefits WHO Everybody’s business 2009
  13. 13. 14-03-2016 KEYSTONE Utilitarianism J Bentham and JS Mill • “The greatest good for the greatest number of people” • Focus on consequences Jeremy Bentham
  14. 14. 14-03-2016 KEYSTONE Justice as Fairness Justice as Fairness 1. Equality of opportunity for all 2. Difference principle – maximize benefit to the most disadvantaged members of society John Rawls
  15. 15. 14-03-2016 KEYSTONE Types of Equity • Horizontal equity Providing equal healthcare to those who are the same • Vertical Equity Reducing health inequities - treating people with different needs differently, proportionate to their needs
  16. 16. 14-03-2016 KEYSTONE Niti vs. Nyaya • ‘The Idea of Justice’ 2009 • Principles of justice are anchored to arrangements and rules rather than directly to social realisations and human lives and freedoms • Need to focus questions of justice on what actually happens and actual lives rather than merely looking for ideal institutions and arrangements Amartya Sen
  17. 17. 14-03-2016 KEYSTONE Health as a Human Right • WHO Constitution: "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being…” • Health is not cited as a constitutional right in India
  18. 18. 14-03-2016 KEYSTONE Relational Ethics • Processes as important as outcomes • How do we treat others - respect and trust • Intentions are important (deontology)
  19. 19. 14-03-2016 KEYSTONE GROUPWORK
  20. 20. 14-03-2016 KEYSTONE Health System Problems 1. The non-implementation of standard public health guidelines and protocols is a widely witnessed phenomenon and problem in India and other low and middle income countries, in both public and private health care services. This is widely seen to be of concern since users of services may be denied standardized and evidence- based modes of care and treatment. 2. Health workers who are deployed in health care facilities are frequently irregular in reporting for their duties, and are sometimes entirely absent from their posts. 3. Routine health-related data collected through existing health information systems is often viewed to be unreliable, either overestimating or underestimating the actual quantum of the event or disease being measured. This causes problems in priority setting, responding and allocating resources.
  21. 21. 14-03-2016 KEYSTONE 4. Professional self regulation is a globally accepted approach in which health care professions are expected to establish and maintain standards of conduct and ethics, within the confines of the profession, by setting up relevant boards or councils. However it is widely observed that professional self regulatory bodies (such as medical, nursing and pharmacy councils) do not play an optimal role in regulating the standards as laid out in their constitutions. 5. In spite of widespread evidence and numerous policy pronouncements and expert statements on the primacy of primary health care in order to achieve health goals, current financial allocations tend to favour tertiary institutions in urban areas. 6. Globally, there is a widespread deficiency in resource allocation and innovation for development of new medicinces, vaccines and medical products for diseases that disproportionately affect developing countries and the poor.
  22. 22. 14-03-2016 KEYSTONE Groupwork plan • 15 min: Form 6 groups of 3-4 members each – one group for each health system problem. Groups to brainstorm the research questions they can ask in relation to the problem. Keep in mind the following: – From whose perspective are we asking the question (policy planner / manager / service provider / user / someone else)? – Purpose of asking the question (to prove / evaluate / explain / explore / bring a change)? – What is the level of the analysis (“macro” – architecture and oversight of system / “meso” – functioning of organizations and interventions / “micro” – the individual in the system) • 60 min: 10 minutes for each group to present their research questions in plenary, including moderated discussion on the “balance” of the questions • 10 min: HSHP wrap up: scope of HPSR, research plan template, reading list
  23. 23. 14-03-2016 KEYSTONE Macro Meso Micro Normative / evaluative Explanatory / Exploratory Emancipatory
  24. 24. 14-03-2016 KEYSTONE • What are the reasons behind the problem of irregular timing? • Can you implement CBM to ensure doctors coming on time? • Can we create colleges with reservation for local populations?
  25. 25. 14-03-2016 KEYSTONE • What is the magnitude of unreliable data and factors influencing unreliable data under the current HIMS? • How can IT be leveraged for improving Health System related information? • What is the scope of large scale surveys in incorporating Health System related information?
  26. 26. 14-03-2016 KEYSTONE
  27. 27. Open Access Policy KEYSTONE commits itself to the principle of open access to knowledge. In keeping with this, we strongly support open access and use of materials that we created for the course. While some of the material is in fact original, we have drawn from the large body of knowledge already available under open licenses that promote sharing and dissemination. In keeping with this spirit, we hereby provide all our materials (wherever they are already not copyrighted elsewhere as indicated) under Creative Commons Attribution-NonCommercial 4.0 International License. To view a copy of this license visit This work is ‘Open Access,’ published under a creative commons license which means that you are free to copy, distribute, display, and use the materials as long as you clearly attribute the work to the KEYSTONE course (suggested attribution: Copyright KEYSTONE Health Policy & Systems Research Initiative, Public Health Foundation of India and KEYSTONE Partners, 2015), that you do not use this work for any commercial gain in any form and that you in no way alter, transform or build on the work outside of its use in normal academic scholarship without express permission of the author and the publisher of this volume. Furthermore, for any reuse or distribution, you must make clear to others the license terms of this work. This means that you can: read and store this document free of charge distribute it for personal use free of charge print sections of the work for personal use read or use parts or whole of the work in a context where no financial transactions take place gain financially from the work in anyway sell the work or seek monies in relation to the distribution of the work use the work in any commercial activity of any kind distribute in or through a commercial body (with the exception of academic usage within educational institutions such as schools and universities However, you cannot: