An Assessment of the Interactions between health systems and Global Health Initiatives Tim Evans Assistant Director-General Information, Evidence and Research.

An Assessment of the Interactions between health systems and Global Health Initiatives

Tim EvansAssistant Director-General

Information, Evidence and ResearchWorld Health Organization

Overview

1. Rationale

2. Concepts and Methods

3. Findings

4. Learning to do better

Common challenges to scale up services for HIV, TB, malaria, and immunization

HIV/UA assessment report

Global Plan to stop TB

World Malaria report

GAVI/Norad report

• Inadequate financing• HR crisis • Affordable commodities • Stigma, discrimination…• Accountability

• Partnership alignment • Inadequate financing • Laboratory capacity • HR crisis • Quality drugs

• Drug efficacy • Information system • Inadequate financing

• HRH and Community

services • M&E

• HR crisis • Inadequate financing • Leadership and

management • Inter-agency

coordination

World Health Report 2006

Critical shortage of health workers in 57 countries;

4.3 million more health workers needed to provide essential interventions.

"poor TB services" deemed the underlying reason for emergence of XDR-TB.

•Insufficient vehicles

•Inadequate supervision of patients beyond hospital

•Interruption in supply chains

•Unacceptable rates of "first line" treatment failure

•No response to evidence of "first line" failure

•Sloppy "second line" treatment practices

•Poor infection control in hospitals (over-crowding)

•Missing laboratory support structures (resistance monitoring)

Systems Performance Shortfalls

• Scale --- safe, proven and cheap interventions not reaching those in need

• Scope --- comprehensive services responding to needs and expectations are the exception

• Distribution --- those with unmet needs are disproportionately those with lesser means

• Protection/Safety --- too many are worse off through encounters with the health system

• Systems capabilities --- primitive frameworks and responses to dealing with complex challenges

2. Concepts and Methods

• Global Health Initiatives

• Country Health Systems

• Conceptual Framework

• Methods

Global Health Initiatives

• Address priority health problems of developing countries

• Focused on specific diseases, selected interventions, or commodities

• Generate substantial funding (billions!) for these priorities based on strong culture of results

• Transnational in organization and operations:• Invite proposals from countries for support• Independent technical review of proposals• Make direct investments in countries

• Dynamic, evolving…

Health Systems

The main goals are:– Improving health and health equity– Responsiveness, – Financial fairness

The intermediate goals are:– Greater access and coverage– Quality and safety

A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health

Conceptual Framework

Methods

• Inputs: – Literature searches

• >250 studies from published and grey literatures, – Call for original data

• 15 new studies (Table 2)

• Analysis – review of evidence on interactions– more "association" than "causation"– may change with time– what is the point of comparison?

• No GHIs; Pre/Post-GHI?; between GHIs?

Assessing the nature of the interactions

Positive, synergistic

Equivocal, unclear, mixed

Negative, undesired

3. Findings

• Service delivery

• Governance

• Financing

• Health Workforce

• Supply management

• Information systems

Findings - service delivery

•Access

• Rapid expansion targeted services

•Expansion of non-targeted services e.g.

maternal health

•Supply-induced demand

•Equity

•Services free at point of service

•Focus on marginalized populations

•Quality

•Promoting universal standards of care

•Rush to meet targets compromising quality

•Planning and Coordination

•Demands of GHI planning processes

overwhelm national capacities

•GHIs responsive to country systems needs

through new funding windows

•Community Involvement

•GHIs have accelerated non-state sector/civil

society engagement in health sector

planning, delivery and accountability

Findings - governance

•Total Financing

•GHIs linked to recent surge in health ODA

•Unclear association between GHI and

domestic health financing

•Aid Effectiveness

•GHI funding more; "predictable";

"sustainable" e.g. Innovative Financing

mechanisms; "responsive" to global burden

of disease;

•GHI funds skew country priorities

•Out-of-pocket expenditures

• GHIs have promoted principle of free

services and subsidies but have not

invested in prepayment systems

Findings - financing

Findings - health workforce•Production and Strengthening

•Limited investment in expanding the workforce

through pre-service training

•Better productivity of existing workforce

through in-service training, task shifting,

supervision and material support

•Distribution

•Workforce drawn away from non-targeted

services

•Incentives get workers to remote areas

•Retention

•Brain drain from public to private sector due to

better pay

Findings - supply management systems

•Procurement and Distribution

•Rapid improvements in availability

and affordability of commodities

•Strong GHI-owned systems duplicate

and displace national supply chains

•Quality

•Improvements in quality through pre-

qualification and agreement on global

standards

Findings - health information systems

•Availability and Accuracy

•Disease surveillance and service coverage

data specific to GHIs is improving.

•Chronic weaknesses of information systems

largely ignored esp. vital statistics and

measures of health systems performance

•Use and Demand

•Dominance of stand-alone info systems is

inefficient and burdensome

•Growing demand and funding for more

comprehensive HIS

• Innovation

•Electronic records are improving efficiency

and quality of care

Synergies leading to systems transformation

Piecing together the big picture

• There is ample evidence of:– "strong synergies"; – "serious shortfalls";– And "uncertainty"

• Actions need to be developed towards:– Amplifying synergies– Stemming shortfalls– Understanding uncertainty

Challenging the way we do business

• Beyond false dichotomies

• Necessary but not sufficient conditions:– Universal Access for HIV/AIDS– One M+E for HIV– Global financing mechanisms– Sustainable financing for TB

• No one size fits all

• Harnessing innovation systematically

Overarching Recommendations

1. High Profile Research Agenda

2. Engage decision-makers

3. Country leadership backed globally

4. Increase finance

Learning to do better

Thank you