Transcript Health Systems Unit Department of Epidemiology and Public

IAPB 9th General Assembly
Eye Health: Everyone’s Business
Hyderabad, India
September 17-20, 2012
Scaling up:
Perspectives for VISION 2020
Prof. Don de Savigny
Health Systems Research
Department of Epidemiology and Public Health
[email protected]
“VISION 2020: The Right to Sight aim to eliminate
avoidable blindness by 2020…. will not be achieved by
eye care services acting in isolation.”
Karl Blanchet. Indian Journal of Ophthalmology 60: (2012)
“More authorities are becoming aware that
campaigns for the control of diseases will have
only temporary effects if they are not followed by
the establishment of permanent health services
to deal with day-to-day work in the control and
prevention of disease and the promotion of
health.”
Annual Report of the Director-General, WHO
Brock Chisholm
1951
Increasing fragmentation in Global Health
Many Global Health Alliances, Partnerships, Consortia,
and Initiatives
Mobilizing substantial resources
Most with a single disease or single intervention focus
Huge potential to support or weaken fragile health
systems
No obvious Global Health architecture or leadership
Vision 2020 strategy
 cost effective disease control interventions;
 human resource development; and
 infrastructure development
Guiding principles (ISSE):
Integrated into existing health care systems
Sustainable in terms of money and other resources
Equitable care and services available to all
Excellence – a high standard of care throughout
Objectives:
 increase awareness
 identify and secure the necessary resources
 facilitate national programmes
This requires a
deliberate convergence
of disease-specific
programme managers
with health system
developers.
Not so easy….
The problem of verticality & the difficulty of integration
Ooms et al. BMC Globalization and health (2008)
Scaling up: a definition
‘‘The ambition or process of expanding
the effective coverage of health interventions
through programmes, services or systems’’
Scaling up: Not just multiplication
Scaling up assumptions
Real world system behaviour
 Linear, pre-planned process;
 Non-linear, not predictable, not
controllable;
 Simplistic, deterministic;
 Standardized methods for predicting
human and financial resources;
 What works in small scale and specific
contexts will easily replicate elsewhere
Pilot
Projects
National
Programmes
Where we usually stop;
Where indicators stagnate
and targets become elusive …
 Highly heterogeneous actors and
contexts;
 Complex dynamics with unexpected
feedback loops, delays and unintended
consequences
Sustainable integration
in health systems
New way of thinking required
Systems integration of Vision 2020 programmes: some perspectives
Governance structure, leadership, policy
dialogue, network analysis, stakeholder
engagement, & ownership
Quantification,
procurement and supply
chains that work
Recognize and respond
to local contexts and
emergent behaviours
Going beyond programme
“M&E” to routine
information flows
Work at interfaces: E.g.
Relate disease burden
information to financing
In national strategic plans,
NHA and MTEF with
performance management
Standards of care
from interprofessional teams
Understand dynamic health
system relationships &
demand
Comprehensive, patient
centered, effective coverage
across a continuum of care
India’s intervention targetable burden
in Shares of total DALYs
Success factors in scaling up…
 strong leadership and governance with active stakeholder network analysis,
management and ownership
 choosing simple integrated packages widely agreed to be valuable,
 active engagement of a range of implementers and of the target community,
 flexibility in tailoring the scale-up approach to local contexts, and
 incorporating research before and along with implementation.
(Modified from Yamey. PLoSMed 2011)
Lessons for integrating in systems
 Scaling up is not predictable or controlled
 Use theories of change to develop local organizational, functional & political
capacities;
 Identify constraints & complex pathways
 Learn by doing
 Apply systems thinking ………..
Paradigm shift?:
Why engage with systems, and why now…
Vertical funding is often necessary at the beginning, but as health
systems develop, separate mini-health systems for each disease and
problem is wasteful and inefficient.
“Systems Thinking” is the language, and
“Systems Science” is the discipline for such a shift.
Approaching 2020 will benefit from increasingly
sophisticated approaches to tipping points in complex
adaptive health systems.
Thank you