This presentation was given at the 'Beyond Scaling Up: Pathways to Universal Access' workshop which was held at the Institute of Development Studies, Brighton on the 24-25 May, 2010. This event was co-sponsored by the Future Health Systems Research Programme Consortium and the STEPS Centre. Peters presented on change in complex health systems.

1. 1 Beyond Scaling Up Management of Change in Complex Health SystemsMay 24, 2010David H PetersJohns Hopkins University

2. The Problems of Implementation in the Health Sector Many cost-effective solutions are known to save lives Why can’t health systems consistently deliver solutions at large scale?to vulnerable populations? 2

3. Understanding Change in Complex Health Systems Do we ask the right questions? Do we have the right models & assumptions? 3

4. 4 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

5. 5 What Do We Want to Know? Questions, Inferences, How To Investigate

6. Do We Have The Right Models? 6

7. The Conventional Pathway For Improving Health Outcomes Choose the right (cost-effective) health interventions Set ambitious, common targets Fund them adequately Implement interventions as designed

8. Do Countries Follow a Common Pathway for Delivering Immunizations? Trends in DPT3 Coverage (All LMICs) Multi-level models, each line represents one country

9. How Strategies are Implemented Matters: Odds of Success from Systematic Review * Pvalue<0.05; ** Pvalue<0.01

10. Literature on Models for Scaling Up Health Services: Two Views 10 Subramanian et al (2010). Under review

12. Pay attention to political, organizational, and functional scale up, and need to nurture local organizations

14. Coverage

15. Utilization

16. Quality

17. Equity

18. Cost

21. Disorganized markets

22. Narrow range of services

23. Unsustainable strategies

24. Crowding out key actors

26. Uganda Safe Deliveries Pilot Project Pregnant woman transported to Nkond Health Center Discussion with pregnant women in Kidera Village