Download strengthening health systems

STRENGTHENING HEALTH SYSTEMS
Anne Mills
DCPP Editor
London School of Hygiene and
Tropical Medicine
BACKGROUND
• Core of DCP2 is evidence and analysis of
burden of disease and cost-effectiveness
• Interventions usually delivered through a
health system
• Cost-effectiveness data usually reflect a
reasonable level of technical efficiency – may
not be readily achievable in real life
• Need to know how best to strengthen health
systems so they are able to deliver
interventions cost-effectively and at scale
AIM OF PRESENTATION
Summarise key messages from
the wealth of evidence in the
chapters of DCP2 concerned
with strengthening national
health systems
STRENGTHENING HEALTH SYSTEMS
•
Stewardship/regulation
•
Organisational structures and their
financing
•
General management functions human resources and quality assurance
NB:
1. Lack of evidence
2. Effectiveness of approaches depend on
starting point
STEWARDSHIP/REGULATION
• Strengthen accountability to communities and increase
user voice (eg Burkina Faso; Ceara)
• Enforce regulations (where capacity exists)
• Use approaches that work with the private sector
ORGANISATIONAL STRUCTURES
AND FINANCING
• Clarification of purchaser and provider
roles within public health sector
• Decentralisation to hospitals and ‘districts’
• Vertical versus horizontal modes of
organising and managing service provision
• Contracting out service provision
CONTRACTING
EXPERIMENT IN
CAMBODIA 19972001 (Swartz and Bushan 2004)
Improved health care
coverage rates
Poor benefited more than
richer groups
HOSPITAL CONTRACTS IN SOUTH AFRICA
• Contractors’
costs lower than
public; similar
quality
• Cost advantage
largely due to
higher staff
productivity
• Contract cost to
government >
government
cost of provision
• Study led to renegotiation of
contract terms
CONTRACTS WITH GPs IN
SOUTH AFRICA
• Formal aspects of contracts had little
influence (eg design, monitoring, sanctions)
• Social and institutional factors important
• Contracts highly ‘relational’ and context
specific
• Policy implications: emphasise cooperation,
shared interests, professionalism
HUMAN RESOURCES
• Use local cadres (not internationally mobile);
give specific skills (eg Malawi: caesarean
section training to clinical officers)
• Use incentive payments if can be regulated
and controlled
• Otherwise use broader performance
management approach emphasising non
financial rewards
QUALITY
ASSESSMENT/ASSURANCE
• Good quality possible even in highly resource
constrained settings
• Evidence that two approaches can work:
 Policies which
change structural
conditions and
indirectly affect
providers (eg
contracting)
 Policies which directly affect individual
and group practice (eg shopkeepers,
Kilifi)
TARGETING RESOURCES
• Systems level – eg resource
allocation formulae; financial
incentives to users
• Service level – eg planning and
budgeting frameworks; consumer
education and information
THE TANZANIA ESSENTIAL
HEALTH INTERVENTIONS
PROJECT (TEHIP)
(de Savigny et al 2004)
• Provided tools for district
level decision makers to
influence resource
allocation
• Linked burden of disease
data with expenditure on
interventions
• Showed improved match
between disease burden
and district budget
THE CONTRIBUTION OF TEHIP TO IMPROVED
HEALTH OUTCOMES
SELECTED KEY MESSAGES
1.
Keep the health of the system in mind whenever
major new programmes are put in place - ensure
disease-specific efforts contribute to system
strengthening
2.
Reforms affecting organisational structures and
human resource management more likely to be
successfully implemented if they are incremental and
gradual
3.
Successfully linking financial incentives to
performance dependent on careful monitoring;
difficult in low income settings without continuing
external involvement
4.
Capacity strengthening required at all levels
SELECTED RESEARCH PRIORITIES
• Cost and effectiveness of approaches to
strengthening system capacity
• Identification of delivery strategies that can
maintain high coverage for specific
interventions
• Identification of governance and
institutional arrangements that will help
achieve health improvements for the
poorest
RESEARCH CAPACITY
STRENGTHENING
(Source: Alliance for Health Policy and Systems Research 2004)
• Project funding for health systems research < 0.02%
of annual developing country health expenditure
• More than half of research projects had budgets <
$25,000
• A third of institutions engaged in health systems
research had no doctoral level staff
• Only 5 percent of health systems research literature
in Medline concerns developing countries
Great need for strengthening capacity in health
systems research