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Health systems concepts and health systems research Barbara McPake, Institute for International Health and Development, Queen Margaret University, Edinburgh

Mar 31, 2015

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Health systems concepts and health systems research Barbara McPake, Institute for International Health and Development, Queen Margaret University, Edinburgh Slide 2 What is a health system? A health system consists of all the organizations, institutions, resources and people whose primary purpose is to improve health (WHO, 2000) www.qmu.ac.uk/iihd Slide 3 Slide 4 Useful starting point but presents a static framework, emphasises components rather than relationships, and fails to identify what is systemic about this system (the interconnectedness of its elements) Has implications for how health systems strengthening (being used by global health initiatives) has been conceptualised and is being implemented. www.qmu.ac.uk/iihd Slide 5 Marchal, Cavalli and Kegels (2009) find that these GHIs are doing 3 kinds of things: Providing inputs or resources Reinforcing capacities that are directly related to disease control programmes Integrating programme activities into general health services Slide 6 (These) HSS strategies are essentially a means to deliver targeted interventions more efficiently, rather than being strategic and directed towards the root causes of health system weaknesses. Most current HSS strategies are in fact selective, disease-specific interventions, and their effects may undermine progress towards the long-term goal of an effective, high-quality, inclusive health system. www.qmu.ac.uk/iihd Slide 7 The effect of the global fund on the drug distribution system in Uganda Kyagonza, P. and McPake, B. (2007; unpublished) Increased investment in procurement of ART drugs has not been followed by a proportionate increase in investment in strengthening drug supply systems. Scaling up ART has affected the mainstream supply chain for essential drugs and medical supplies through the creation of a parallel supply chain for ART drugs, and the precedence given to management of ART drugs over that of other essential drugs and medical supplies. www.qmu.ac.uk/iihd Slide 8 So, not only do the building blocks seem to lack something quite important in terms of how they describe a health system, but this seems to be reflected in how things are actually being done and what investments are being made, with negative practical implications www.qmu.ac.uk/iihd Slide 9 Health system = system whose output is access to effective (preventative and treatment) health interventions (or activities whose primary purpose is to promote, restore or maintain health) www.qmu.ac.uk/iihd Slide 10 Dynamic responses model of the health system www.qmu.ac.uk/iihd Dynamic responses: How people (users and providers) react and interact in response to formal structures and rules De facto system: Services as experienced by (poor) people For example: access; quality De jure system: Organisational structures Intended incentives Management procedures Training courses Slide 11 The exclusion of the poor from health interventions is systematic some examples www.qmu.ac.uk/iihd Worrall et al. (2005) reported differentials in the uptake of malaria control interventions through a global literature review preventive measures (coils, sprays etc.), ownership and use of bed nets choice of healthcare provider for treatment All used less by the poorest (measured through a variety of indicators). The poorest were more likely to opt for self-treatment and less likely to use private or higher level public providers. (Compiled by Riquelme and Thiede) Slide 12 Chinas 2003 National Household Health Survey revealed that both breadth and depth of TB services were comparatively low in poorer rural areas; both receipt of care and affordability of TB services declined with socio-economic position (Zhang et al., 2007). A study conducted in Malawi found that direct costs associated with TB service (e.g. food and transport) as well as indirect costs (e.g. work days lost), were particularly significant for women and the poor (Kemp et al., 2007). A study on access to Indias TB control programme revealed that poor and socially marginalised patients systematically received worse services (Singh et al., 2002) www.qmu.ac.uk/iihd Socio-economic conditions impact on access to TB care (Compiled by Riquelme and Thiede) Slide 13 Systematic factors underpinning the exclusion of the poor www.qmu.ac.uk/iihd There are costs of accessing care, even when free the poor have more difficulty in covering these Non-financial resources including social capital can also be involved in securing access to services the poor have more limited access to these Public health services constitute a significant resource people with power use it to capture an unfair share As the de jure features of systems are changed to try to counteract these forces, people use their money, social capital and power to reassert the status quo Slide 14 Examples of systemic factors in maternal health www.qmu.ac.uk/iihd Slide 15 The posting system www.qmu.ac.uk/iihd Almost everywhere there is a serious imbalance of staffing between rural and urban areas that excludes poor rural dwellers from accessing services Failure of system that directs staff to posts is understood But alternatives are rarely developed and piecemeal In Kenya, emergency hire programme recruited staff to specific roles in rural areas but intends to regularise these new staff as public servants - the same strategies that allow staff to relocate to urban areas will become available to them The posting system entrenches interests that are more powerful than the stated policy objective of equitable access to health services Slide 16 Constraints on migration In the early 2000s, staff were haemorrhaging from low-income country health systems, especially to the UK In Ghana nurse migration was constrained by a bond (increased from C2m to C200m in 2005), payable by anyone seeking a qualification verification statement No similar measure taken to constrain doctor migration which was higher in proportionate terms www.qmu.ac.uk/iihd Slide 17 Divide between family planning and MNC health services Common for these to be in separate Ministries or branches of Ministries in South Asia Recognition that this causes overlapping responsibilities for populations, duplication of effort in some areas, gaps in service provision in others Attempts to integrate the functions founder on the conflicts of interest between the different branches Family planning creates a stronger power base because its outcomes are more measurable and it is usually better funded externally, than maternal health www.qmu.ac.uk/iihd Slide 18 An ethnography of two labour wards in South Africa Policies implemented nominally but their intentions ignored Clinical guidelines Name badges for nursing staff Suggestion boxes More complex or difficult changes, particularly if they impacted on the culture of the facility or challenged existing power dynamics were ignored. www.qmu.ac.uk/iihd Slide 19 Rural allowances for staff in South Africa Only professional nurses and not lower grades of staff received the allowance High levels of tension in maternity wards Demotivated staff who did not get the allowance but also demotivated staff that did who felt guilty, embarrassed or awkward You get the allowance, you do the work www.qmu.ac.uk/iihd Slide 20 Attempts by bilaterals and multilaterals in last decade to construct aid as a contract: system of rewards and penalties for good and bad performance SWAp in Uganda funding to be provided in response to delivery of agreed undertakings The achievement of a satisfactory performance rating was facilitated by the agreeing of undertakings that were under-demanding, vaguely formulated and lacking quantitative benchmarks against which progress could be measured. However, even when poor performance was readily observable, penalties failed to be applied by donors. www.qmu.ac.uk/iihd Slide 21 Dynamic responses model of the health system www.qmu.ac.uk/iihd Dynamic responses: How people (users and providers) react and interact in response to formal structures and rules De facto system: Services as experienced by (poor) people For example: access; quality De jure system: Organisational structures Intended incentives Management procedures Training courses Slide 22 It is also possible to use the model to better understand how to develop strategies to tackle health system problems; and to better understand the role of health systems research www.qmu.ac.uk/iihd Slide 23 No solutions changes to the de jure system have less than fully predictable impacts on the de facto system context is critical System interventions are normally better understood as tools than solutions in themselves. Tools have to be appropriate to the task in hand and can be refined as the fit between tool and task is better understood. They also have to be applied well, requiring capacities of the user and benefiting from the user learning as the task progresses. www.qmu.ac.uk/iihd Slide 24 Why performance-based contracting failed in Uganda Freddie Ssengooba, Barbara McPake and Natasha Palmer www.qmu.ac.uk/iihd World Bank and MoH implemented a bonus system for PNFP providers and undertook a controlled trial to evaluate it Slide 25 The World Bank evaluation: a black box www.qmu.ac.uk/iihd Intervention Performance Slide 26 Their conclusion: ..assignment to the performance-based bonus scheme has not had a systematic or discernible impact on the production of health care services provided by PNFP facilities. www.qmu.ac.uk/iihd Slide 27 Our evaluation www.qmu.ac.uk/iihd Who came into contact with the intervention? How did they react? How did they influence others? What chains of effects were initiated and how was hospital performance affected? Intervention What did it really consist of? Design features Implementation features Performance What has been measured? What has not? Slide 28 Key findings 2-3 members of the hospital management team given a few hours in a one day me