Health systems concepts and health systems research

The critical role of pro-poor health systems in maternal, child and newborn health

Health systems concepts and health systems researchBarbara McPake,Institute for International Health and Development, Queen Margaret University, EdinburghWhat 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/iihdStrain you patience by starting with a definition.

I would add and their relationships with each other2www.qmu.ac.uk/iihd

Key points service delivery only one component (something I dont think works very well seems to be dependent on all the other blocks) but does emphasise that service delivery and health system are not the same concept sometimes confused.Leadership/governance looks like concept that over-arches the others.In other words, the building blocks dont really look like the same kinds of things; and it follows that3Useful 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/iihd4www.qmu.ac.uk/iihd

Marchal, Cavalli and Kegels (2009) find that these GHIs are doing 3 kinds of things:Providing inputs or resourcesReinforcing capacities that are directly related to disease control programmesIntegrating programme activities into general health servicesInputs or resources: drugs; perhaps support to information systemsCapacities: specialist training for particular diseasesIntegration: for example moving from separate HIV or TB clinics to HIV or TB patients attending general OPD; 5(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.

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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Kyagonza, P. and McPake, B. (2007; unpublished) Increased investment in procurement of ART drugs has not been followed by a proportionate increase in investment in strengthening drug supply systems.Scaling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/iihd7So, 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/iihdSo, not only do the prevalent definitions and conceptualisations seem to lack something quite important in terms of how they describe a health system, but this is reflected in how things are actually being done and what investments are being made, with negative practical implications. 8Health 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/iihdTrying to move towards a more useful modelKey ideas: 9Dynamic responses model of the health systemwww.qmu.ac.uk/iihdDynamic responses:How people (users and providers) react and interact in response to formal structures and rules

De facto system:Services as experienced by (poor) peopleFor example: access; quality De jure system:Organisational structuresIntended incentivesManagement proceduresTraining coursesKey ideas very simple, but ignored in much health systems thinking:De jure system the one that is legislated, mandated, accords to regulations. The only place we can intervene.No direct link to de facto system.Everything mediated through people.For example, in the de jure system, user fees are removed users may react my using the services to a greater extent; providers may react by charging for increasingly scarce drugs; users may then react by sourcing cheaper drugs from peddlars out of all these interactions comes the de facto system what its really possible to access; and thinking about pro-poor health systems by poor people.The model drawn like a closed system, but what is not drawn are the external pressures on it from social and economic change; natural disasters, changes in disease conditions for example in reality it is an open system10The exclusion of the poor from health interventions is systematic some exampleswww.qmu.ac.uk/iihdWorrall 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 treatmentAll 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)11Chinas 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/iihdSocio-economic conditions impact on access to TB care(Compiled by Riquelme and Thiede)12Systematic factors underpinning the exclusion of the poorwww.qmu.ac.uk/iihdThere are costs of accessing care, even when free the poor have more difficulty in covering theseNon-financial resources including social capital can also be involved in securing access to services the poor have more limited access to thesePublic health services constitute a significant resource people with power use it to capture an unfair shareAs 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

13Examples of systemic factors in maternal healthwww.qmu.ac.uk/iihd

14The posting systemwww.qmu.ac.uk/iihdAlmost everywhere there is a serious imbalance of staffing between rural and urban areas that excludes poor rural dwellers from accessing servicesFailure of system that directs staff to posts is understoodBut alternatives are rarely developed and piecemealIn 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 themThe posting system entrenches interests that are more powerful than the stated policy objective of equitable access to health services Rational changes to the de jure system are constrained by vested interests in the status quo15Constraints on migrationIn the early 2000s, staff were haemorrhaging from low-income country health systems, especially to the UKIn Ghana nurse migration was constrained by a bond (increased from C2m to C200m in 2005), payable by anyone seeking a qualification verification statementNo similar measure taken to constrain doctor migration which was higher in proportionate termswww.qmu.ac.uk/iihdRational changes to the de jure system are constrained by vested interests in the status quo16Divide between family planning and MNC health servicesCommon for these to be in separate Ministries or branches of Ministries in South AsiaRecognition that this causes overlapping responsibilities for populations, duplication of effort in some areas, gaps in service provision in othersAttempts to integrate the functions founder on the conflicts of interest between the different branchesFamily planning creates a stronger power base because its outcomes are more measurable and it is usually better funded externally, than maternal healthwww.qmu.ac.uk/iihdChanges to the de jure system are legislated; but their intentions are frustrated by the dynamic responses that relate to incentives and vested interests.17An ethnography of two labour wards in South AfricaPolicies implemented nominally but their intentions ignoredClinical guidelinesName badges for nursing staffSuggestion boxesMore 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/iihdChanges to the de jure system are made (in this case through planning and management mechanisms rather than legislated) but their intentions are frustrated by the force of inertia it needs more to promote the dynamic responses that are needed for these policies to work.18Rural allowances for staff in South AfricaOnly professional nurses and not lower grades of staff received the allowanceHigh levels of tension in maternity wardsDemotivated staff who did not get the allowance but also demotivated staff that did who felt guilty, embarrassed or awkwardYou get the allowance, you do the workwww.qmu.ac.uk/iihdThe change to the de jure system is made and implemented; but the dynamic responses it promotes produce an outcome counter to its intention.19Attempts by bilaterals and multilaterals in last decade to construct aid as a contract: system of rewards and penalties for good and bad performanceSWAp in Uganda funding to be provided in response to delivery of agreed undertakingsThe 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

Changes to the de jure system are made and implemented, dynamic responses in this case rooted in geo-politics prevent them operating as intended.20Dynamic responses model of the health systemwww.qmu.ac.uk/iihdDynamic responses:How people (users and providers) react and interact in response to formal structures and rules

De facto system:Services as experienced by (poor) peopleFor example: access; quality De jure system:Organisational structuresIntended incentivesManagement proceduresTraining coursesAdd some points to earlier discussion especially reverse direction arrows and feedback loops how the de jure system is constrained itself by what policy is acceptable given dynamic responses box.21It 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 researchwww.qmu.ac.uk/iihd22No solutions changes to the de jure system have less than fully predictable impacts on the de facto system context is criticalSystem 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/iihd23Why performance-based contracting failed in Uganda Freddie Ssengooba , Barbara McPake and Natasha Palmerwww.qmu.ac.uk/iihdWorld Bank and MoH implemented a bonus system for PNFP providers and undertook a controlled trial to evaluate it24The World Bank evaluation: a black boxwww.qmu.ac.uk/iihdIntervention

Performance25Their 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/iihdIndicates that PFP doesnt work? Not a result the Bank has put on the front of its website (Deaton).26Our evaluationwww.qmu.ac.uk/iihdWho 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 featuresImplementation featuresPerformanceWhat has been measured? What has not?27Key findings2-3 members of the hospital management team given a few hours in a one day meeting to choose service targetsImplementers changed the rules; refused to allow managers to change the targets for the second yearThe reliability of measured output volumes compromised by ad hoc adjustments to programmeStaff in hospitals that received bonuses frustrated when managers didnt use them in an agreed, transparent mannerFurious control group: YYY hospital got 10 million and yet zzz hospital is doing far much better. Its frustrating and lost meaning done better but no bonus'

www.qmu.ac.uk/iihd28Insight into the development of strategyPay attention to processMonitor, manage, adaptSweeping conclusions PFP good or bad cannot be arrived at on the basis of one or a few case studies. PFP is never the same thing in two placesSee PFP as a tool, learn, improve, adapt, and compare to alternative tools aiming at the same outcomeswww.qmu.ac.uk/iihdInsight into health systems researchAvoid the black box dont know what the intervention is or why outcomesAsk the right questions avoid questions that demand sweeping conclusions from a limited evidence baseUse research to support monitoring, managing, adapting to contextOver time, build sufficient case study evidence for a picture of which tools most promising in which kinds of contextwww.qmu.ac.uk/iihdConclusionsCurrent health systems strengthening investments may be misdirected in part because they mis-conceptualise the health systemEffective interventions will tackle the systemic causes of the exclusion of the poor by tackling incentives and attempts to manipulate incentives; challenging distribution of control over resources; not just by making inputs availableEffective health systems strategies and health systems research will use and test interventions as tools rather than implement or reject as solutions in their own right. www.qmu.ac.uk/iihd