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Key issues in health
system development
ICHS 3
www.hpsa-africa.org
@hpsa_africa
www.slideshare.net/hpsa_africa
Introductio...
Outline
1. Dimensions of health system
performance
2. Understanding the Thai experience
STARTING POINTS: HEALTH
SYSTEM PERFORMANCE
WHO, 2007
4
Washington, among others [9–11]. organization. This framework is informed by extensive
Fig. 1. Framework for health system...
Access & coverage
Donabedian: “proof of
access is in use of service,
not presence of a facility”
Degree of fit between
bet...
From availability to effective
coverage
for whom
service
available
can use
service
who are
willing to use
services
who use...
Responsiveness
how people are treated and the
environment in which they are treated
when seeking health care
a particular ...
Health care responsiveness (percentage of respondents who responded either
“good” or “very good”) comparisons across count...
What is a health system’s
broader societal value?
The knowledge of a safety net for times of
vulnerability
‘Public value’
...
THE THAI EXPERIENCE
Health performance
• Achieved MDGs
early 2000s
• Over 40 years:
– LEB gone up, IMR
gone down, MMR
gone down, strong
annual...
Health care performance
• Cause specific mortality
decreases for
intervention-addressable
conditions (PyCare,
MCH, pub hea...
Factors explaining
experience
Health care performance gains over time
due to
Sustained action to address access barriers
o...
Sustained action to address access barriers over time:
Balabanova et al. 2011
Source: de Savigny and Adam (2009)
What building blocks were
addressed?
What building blocks were addressed?
Tackling access barriers
Hardware:
• Physical availability:
– provincial > district hospitals (phased imp)
– human resourc...
Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedica...
Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedica...
Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedica...
Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedica...
Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedica...
Note
• SYSTEM development matters!
– Action went beyond specific interventions,
services or programmes
– Intersectoral act...
Copyright
Funding
You are free:
To Share – to copy, distribute and transmit the work
To Remix – to adapt the work
Under th...
The CHEPSAA partners
University of Dar Es Salaam
Institute of Development Studies
University of the Witwatersrand
Centre f...
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Key issues in health system development

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Key issues in health system development

  1. 1. Key issues in health system development ICHS 3 www.hpsa-africa.org @hpsa_africa www.slideshare.net/hpsa_africa Introduction to Complex Health Systems
  2. 2. Outline 1. Dimensions of health system performance 2. Understanding the Thai experience
  3. 3. STARTING POINTS: HEALTH SYSTEM PERFORMANCE
  4. 4. WHO, 2007 4
  5. 5. Washington, among others [9–11]. organization. This framework is informed by extensive Fig. 1. Framework for health systems performance measures. Kruk and Freedman, 2008 Improved health Social & financial risk protection
  6. 6. Access & coverage Donabedian: “proof of access is in use of service, not presence of a facility” Degree of fit between between the health system and the population it serves A vailability A cceptability A ffordability
  7. 7. From availability to effective coverage for whom service available can use service who are willing to use services who use service who receive ‘effective’ care People: Shrinking proportion >>>
  8. 8. Responsiveness how people are treated and the environment in which they are treated when seeking health care a particular focus on inequitable treatment associated with social status www.who.int/responsiveness/en
  9. 9. Health care responsiveness (percentage of respondents who responded either “good” or “very good”) comparisons across countries Outpatient experiences Inpatient experiences S Africa Brazil Israel Euro* S Africa Brazil Israel Euro* Time 58 65 69 72 66 69 77 81 Dignity 71 93 92 90 74 90 90 89 Communication 69 81 87 87 67 76 87 82 Autonomy 60 70 80 83 61 66 79 72 Confidentiality 74 90 88 89 73 80 83 82 Quality of basic amenities 68 80 90 91 70 80 60 87 Support 68 70 91 92 Summary 67 80 83 87 68 76 81 83 *European countries included were: Austria, Belgium, Denmark, Finland, France, Germany, Greece, Ireland, Italy, Luxemburg, Netherlands, Portugal, Sweden, and United Kingdom World Health Survey data, 2003 (Pelzer, 2009 BMC Health Services Research) 2352 participants (1116 men and 1236 women)
  10. 10. What is a health system’s broader societal value? The knowledge of a safety net for times of vulnerability ‘Public value’ • producing things of value to groups of citizens • operating in fair, efficient & accountable ways
  11. 11. THE THAI EXPERIENCE
  12. 12. Health performance • Achieved MDGs early 2000s • Over 40 years: – LEB gone up, IMR gone down, MMR gone down, strong annual reduction in ChMR over 20yrs • Reduction in IMR and ChMR inequalities Value for money: Relatively low IMR for relatively low per capita health expenditure (compared to other countries)
  13. 13. Health care performance • Cause specific mortality decreases for intervention-addressable conditions (PyCare, MCH, pub health), except for peri-natal care • High coverage with many interventions critical for child survival • ‘Satisfactory’ essential obstetric care (no policy on unsafe abortions) • Equity in utilisation • Low out of pocket payments with low levels of catastrophic health expenditure
  14. 14. Factors explaining experience Health care performance gains over time due to Sustained action to address access barriers over time
  15. 15. Sustained action to address access barriers over time: Balabanova et al. 2011
  16. 16. Source: de Savigny and Adam (2009) What building blocks were addressed?
  17. 17. What building blocks were addressed?
  18. 18. Tackling access barriers Hardware: • Physical availability: – provincial > district hospitals (phased imp) – human resources: • Bonding to rural areas for doctors and nurses, plus • Expansion of nurse training & intro of less qualified cadres with career paths by MOPH (not MoEd) (some provincial EDLs) • Financial risk protection – Piecemeal & gradual extension to 70% of population by 2001 – Universal coverage 2002 – Increased government spending over time Software: • ‘Pro-rural’ values • Dedicated and committed health professionals across the system • Social recognition of health professionals
  19. 19. Sustained action over time: why and how? Hardware interventions to tackle access barriers Software: values-driven & dedicated health professionals How and why? Health system
  20. 20. Sustained action over time: why and how? Hardware interventions to tackle access barriers Software: values-driven & dedicated health professionals How and why? 1) Decision-making processes that have ensured consistent vision and persistent development towards goals How and why? 1. Values-based and charismatic political leadership 2. Elite and interest groups support 3. Competent, values- based and distributed technical leadership 4. Generation and use of evidence in decision-making 5. Decentralised authority 6. Flexible implementation 7. Communication and feedback, learning through doing Pro-poor, pro- rural ideologyHealth system
  21. 21. Sustained action over time: why and how? Hardware interventions to tackle access barriers Software: values-driven & dedicated health professionals How and why? 2) HC features: 1. public sector strengthened 2. integrated service provision 3. limited reliance on external resources How and why? Pro-poor ideology; Use of evidence; Economic context Health system
  22. 22. Sustained action over time: why and how? Hardware interventions to tackle access barriers Software: values-driven & dedicated health professionals How and why? 3) Community factors: 1. community awareness & acceptance of health programmes 2. public trust & confidence in DHS 3. public status of health professionals How and why? Socio-cultural values; positive experiences Health system
  23. 23. Sustained action over time: why and how? Hardware interventions to tackle access barriers Software: values-driven & dedicated health professionals How and why? 1) Decision-making processes that have ensured consistent vision and persistent development towards goals How and why? 2) HS features: 1. public sector strengthened 2. integrated service provision 3. limited reliance on external resources 1. Values-based and charismatic political leadership 2. Elite and interest groups support 3. Competent, values- based and distributed technical leadership 4. Generation and use of evidence in decision-making 5. Decentralised authority 6. Flexible implementation 7. Communication and feedback, learning through doing 3) Community factors: 1. community awareness & acceptance of health programmes 2. public trust & confidence in DHS 3. public status of health professionals How and why? Socio-cultural values; positive experiences Pro-poor, pro- rural ideology How and why? Pro-poor ideology; Use of evidence; Economic context Health system
  24. 24. Note • SYSTEM development matters! – Action went beyond specific interventions, services or programmes – Intersectoral actions • New challenges to be addressed
  25. 25. Copyright Funding You are free: To Share – to copy, distribute and transmit the work To Remix – to adapt the work Under the following conditions: Attribution You must attribute the work in the manner specified by the author or licensor (but not in any way that suggests that they endorse you or your use of the work). Non-commercial You may not use this work for commercial purposes. Share Alike If you alter, transform, or build upon this work, you may distribute the resulting work but only under the same or similar license to this one. Other conditions For any reuse or distribution, you must make clear to others the license terms of this work. Nothing in this license impairs or restricts the authors’ moral rights. Nothing in this license impairs or restricts the rights of authors whose work is referenced in this document. Cited works used in this document must be cited following usual academic conventions. Citation of this work must follow normal academic conventions. Suggested citation: Introduction to Complex Health Systems, Presentation 3. Copyright CHEPSAA (Consortium for Health Policy & Systems Analysis in Africa) 2014, www.hpsa-africa.org www.slideshare.net/hpsa_africa This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no. 265482). The views expressed are not necessarily those of the EC.
  26. 26. The CHEPSAA partners University of Dar Es Salaam Institute of Development Studies University of the Witwatersrand Centre for Health Policy University of Ghana School of Public Health, Department of Health Policy, Planning and Management University of Leeds Nuffield Centre for International Health and Development University of Nigeria Enugu Health Policy Research Group & the Department of Health Administration and Management London School of Hygiene and Tropical Medicine Health Economics and Systems Analysis Group, Depart of Global Health & Dev. Great Lakes University of Kisumu Tropical Institute of Community Health and Development Karolinska Institutet Health Systems and Policy Group, Department of Public Health Sciences University of Cape Town Health Policy and Systems Programme, Health Economics Unit Swiss Tropical and Public Health Institute Health Systems Research Group University of the Western Cape School of Public Health

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