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

An Assessment of the Interactions between
health systems and Global Health Initiatives
Tim Evans
Assistant Director-General
Information, Evidence and Research
World Health Organization
Overview
1.
2.
3.
4.
Rationale
Concepts and Methods
Findings
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
• Inadequate financing
• HR crisis
• Affordable commodities
• Stigma, discrimination…
• Accountability
• Partnership alignment
• Inadequate financing
• Laboratory capacity
• HR crisis
• Quality drugs
World Malaria
report
• Drug efficacy
• Information system
• Inadequate financing
• HRH and Community
services
• M&E
GAVI/Norad
report
• 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
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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
A health system consists of all organizations, people and actions whose primary intent is
to promote, restore or maintain health
The main goals are:
– Improving health and health equity
– Responsiveness,
– Financial fairness
The intermediate goals are:
– Greater access and coverage
– Quality and safety
Conceptual Framework
Methods
• Inputs:
– Literature searches
• >250 studies from published and grey literatures,
– Call for original data
• 15 new studies (Table 2)
• Analysis
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–
–
–
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
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•
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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
Findings - governance
•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 - financing
•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 - 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 prequalification 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
Learning to do better
Overarching
Recommendations
1. High Profile Research
Agenda
2. Engage decision-makers
3. Country leadership backed
globally
4. Increase finance
Thank you