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: http://bit.ly/25vVVp1 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.

1. https://twitter.com/KeystoneHPSR
Building the HPSR CommunityBuilding HPSR Capacity
KEYSTONE
Inaugural KEYSTONE Course on Health Policy and Systems Research 2015
Health Systems and Health Policy Frameworks - 2

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Health Systems and Health
Policy Frameworks - 2
Kabir Sheikh
23 February 2015

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• HEALTH SYSTEMS STRENGTHENING
• SOCIAL JUSTICE AND EQUITY

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HEALTH SYSTEM STRENGTHENING

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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

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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

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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)

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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)

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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

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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

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SOCIAL JUSTICE AND EQUITY

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Utilitarianism
J Bentham and JS Mill
• “The greatest good for
the greatest number of
people”
• Focus on consequences
Jeremy Bentham

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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

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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

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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

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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

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Relational Ethics
• Processes as important as outcomes
• How do we treat others - respect and trust
• Intentions are important (deontology)

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GROUPWORK

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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.

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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.

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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

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Macro Meso Micro
Normative /
evaluative
Explanatory /
Exploratory
Emancipatory

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• 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?

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• 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?

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