A Senior Management Course for Health Managers in Kenya

Health Systems Management

2ND EDITION July 2014

Unit 1.2: Health Systems Concepts and WHO framework

Purpose

•This unit helps participants define concepts related to health systems thinking and approaches

•It introduces participants to building blocks of health systems in Kenya and their linkages to final outcomes and intermediate goals in the health sector

By the end of this unit, the participants should be able to: •Explain key health system concepts and their application in the context of Kenya’s health system•

•Discuss the systems thinking approach;

•Describe the framework and components of the health system;

Objectives

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This unit will cover the following topics:

•Basic concepts and application of health systems approach;

•WHO Framework and Components of the health systems;

•Systems thinking;

Overview

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Session 1.1:

Basic Concepts and their Application to Health Systems

Approach

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Activity 1.1: (10 minutes)

Participants brainstorm on definitions of the following concepts:

• Health systems vs. healthcare system;

• Health systems strengthening vs. health sector reforms.

• Systems thinking

(Copy this activity to TLA Unit 1.3.2 session 1.1.1).

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What is a system?What is a system?“A system is a group of interacting,

interrelated, or interdependent elements forming a complex whole”

(Heritage Dictionary, 4th ed., 2000 by Houghton Mifflin Company)

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Health System vs. Health Care System

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“A health system consists of all organisations, institutions, people and

actions whose primary intent is to promote, restore or maintain health.”

(WHO, 2007)

Health System

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Source: IDRC, 2003

Illustration of a Health System

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•People-centred - equity and fairness;•Results-oriented - quality management system for continual quality improvement;•Evidence-based - technocrats, academicians, politicians, community/local context and change;•Community-driven - leadership, governance accountability, transparency and sustainability;•Context-specific - in Sub-Saharan Africa, context is synonymous with resource-constrained environment;•Ethically sound – human rights and dignity, safety for the client, community and environment;•Systems thinking - holistic view of the health system.

Principles of a Health System

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A healthcare system is a means of organised social response to the health conditions of the population.

It is narrower than a health system and is often described in terms of the levels of healthcare and organisational structure of the Ministry responsible for health in most countries.

Definition of Healthcare System

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Health System Strengthening vs. Health

Sector Reforms

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•Health Systems Strengthening (HSS) is defined as building capacity in critical

components of health systems to achieve more equitable and sustained

improvements across health services and health outcomes (WHO).

Health System Strengthening

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•Refers to “sustained process of fundamental change in policy and institutional arrangements, guided by government, designed to improve the functions and performance of the health sector and ultimately the health status of the population.”

•Refers to totality of the health care system (preventive, curative and public health services; the public and private sectors; primary, secondary and tertiary care).

Health Sector Reforms

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•Uneven progress in health, and growing gaps:

-Focus on few programme areas, with others ignored / missed;

-Increase in gaps in health services, as focus is driven by priorities of donors.

•New challenges to health and health systems:

-New / re-emerging conditions, and health threats;

-Changing behaviour, leading to new risks – HIV, non communicable conditions, etc.

Why Health Systems Strengthening in Africa?

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•Persisting inequalities in access, use and financing of services:

-Poor, illiterate, and other disadvantaged groups still not accessing services.

•Rising expectations, and growing dissatisfaction:

-Globalisation, better information flows, meaning that persons are more aware of rights;

-Mismatch between expectations and performance.

Why Health Systems Strengthening in Africa? (Cont’d)

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•Renewed interest in basic principles in delivery of health services.

•Significant increase in funding for health: governments, donors, philanthropic agencies.

•Rapid increase in global health initiatives.

•Growing recognition, and political support for improving system performance under the two-tier government.

Opportunities for Strengthening the Health System

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• Aims to make most people live healthier and longer lives, whoever and wherever they are.

•The conceptual framework primarily focuses on determinants that will address the health outcomes.

•Focuses on the pillars or components of a health system.

Health Systems Approach

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Session 1.1.2:

Components of the Health System

•Health system goal: improving health and health equity, in ways that are responsive, financially fair, and make the best, or most efficient use of available resources.

•Health system objectives: definition of objectives being sought:

-Improve access, and quality of services;

-Achieve better coverage of services.

•Health system building blocks: seven investment areas:

-Investment in the building blocks aims to improve coverage of services through attaining desired access to interventions, without compromising quality and safety.

Conceptual Framework

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• The WHO framework refers to the building blocks of the health system. These are:

– service delivery;

– health workforce;

– information;

– medical products, vaccines and technologies;

– financing; and

– leadership and governance.

• The building blocks need to be functioning well for the health system to produce the expected health outcomes.

Components / Pillars of Health System

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BUILDING BLOCKS GOALS / OUTCOMES

Responsiveness to legitimate needs

Responsiveness to legitimate needs

Social, and financial risk

protection

Social, and financial risk

protection

Improved health (level and equity)Improved health (level and equity)

Access

Coverage

Quality

Safety

SERVICE DELIVERYSERVICE DELIVERY

LEADERSHIP / GOVERNANCE

HEALTH WORKFORCEHEALTH WORKFORCE

INFORMATIONINFORMATION

MEDICAL PRODUCTS, VACCINES &

TECHNOLOGIES

MEDICAL PRODUCTS, VACCINES &

TECHNOLOGIES

FINANCINGFINANCINGImproved efficiencyImproved efficiency

Source: World Health Organisation. Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes—WHO’s Framework for Action. Geneva: WHO, 2007, page 3.

Health System Building Blocks / Components

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Activity 1.1.2.1: 15 minutes

Participants brainstorm in pairs on limitations of WHO’s building blocks framework.

List responses on flipchart in plenary.

(Copy to TLA unit 1.3.2 )

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1. Good health services are those which:

• Deliver effective, safe, quality personal and non-personal health interventions to those that need them, when and where needed, with minimum waste of resources;

• Demand for care, service delivery models and integrated packages, leadership and management, and infrastructure and logistics.

Expected Outcomes of Well Functioning Pillars

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2. A well-performing health workforce is one that:

• Works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed, they are competent, responsive and productive);

• Needs norms/standards that govern production of sufficient staff and ensure fair distribution (HRH must be competent, responsive and productive);

• HRH observatories are essential for facilitating HRH management.

Expected Health Outcomes of Well Functioning Pillars (Cont’d)

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3. A well-functioning health information system is one that:

• Ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status;

• Has standardised and integrated systems and tools;

• Enables linkages – local, national, regional and global.

Expected Health Outcomes of Well Functioning Pillars (Cont’d)

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4. A well-functioning health system ensures equitable access to essential medical products and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientific soundness and cost-effective use.• The medical products include medicine,

reagents, etc.;• Technologies include health

infrastructure (e.g. X-ray, lab, vaccines, etc.);

• Norms/standards and policy options on products and technologies are needed;

• Procurement processes, monitoring, innovation and patenting of new products are essential.

Expected Health Outcomes of Well Functioning Pillars (Cont’d)

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5. A good health financing system:

• Raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophes or impoverishment associated with having to pay for them;

• Provides incentives for providers and users to be efficient;

• Includes policies that support sustainable options/social protection, use of information, sound financial management/ dialogue.

Expected Health Outcomes of Well Functioning Pillars (Cont’d)

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6. Leadership and governance denotes:• Stewardship that involves ensuring

that strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system-design, transparency and accountability.

Expected Health Outcomes of Well Functioning Pillars (Cont’d)

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Building Block

Variables for Consideration

Service Delivery

• Supervision activities – (technical, integrated, emergency);

• Outreach activities;• Strategies to ensure patient safety;• Efforts to ensure quality of services; • Creation of demand for health services (community

demand creation);• Research in service delivery approaches.

Health Workforce

• Definition of norms and standards for investment in health workforce;

• Regular planning and review of use of applicable health workforce;

• Recruitment and deployment of required health workforce;

• Strategies to motivate existing workforce;• Monitoring, and review of health workforce distribution

and motivation.

Health Information

• Mechanisms to access, and use relevant facility based information;

• Mechanisms to access, and use relevant population based information;

• Mechanisms to access, and use relevant surveillance information.

Variables for Consideration for Health System Building Blocks

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Building Block

Variables for Consideration

Medical Products, Vaccines, Technologies

• Definition of norms, and standards for medical products;

• Definition of comprehensive procurement, and distribution plans;

• Quantities of medical products required:- Medicines (essential, and public health) and

related supplies required,- Vaccines and related supplies required,- Medical and hospital equipment and related

supplies required,- Physical infrastructure required, - Transport (medical, and utility) required,- ICT supplies and equipment required.

• Maintenance of medical products; • Monitoring, and review of medical products

procurement, distribution and functionality.

Variables for Consideration for Health System Building Blocks (Cont’d)

Building Block

Variables for Consideration

Health Financing

• Definition of resource mobilisation strategy;• Support to health financing management

system;• Monitoring, and review of health financing

status.

Leadership and Governance

• Definition of overall knowledge management approach;

• Support to planning process at national, and sub national levels;

• Performance monitoring process at national, and sub national levels;

• Coordination and partnership arrangements;• Strengthening of regulatory framework.

Variables for Consideration for Health System Building Blocks (Cont’d)

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Activity 1.1.2.2: Video (30 minutes)

• Participants watch ‘Baby Maya’ video -10 mins

• Participants brainstorm in plenary to:

- identify health systems components in the video -15 minutes;

- identify opportunities for systems approach to strengthening the health systems in their respective contexts - 15 minutes.

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Problem: Poorly motivated staff, not enough skilled staff, poor quality of care, stock-outs:

ProblemHealth System Management

• Health workers on fixed salaries paid by donors to deliver focal services

• Pay health workers for performance

• Hotel training • Integrate training into medical and nursing pre- and in-service education

• Parallel commodity logistics system

• E-procurement systems

Application of Health Systems Management

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•Objective

–Evidence-based

•Context specific

–Not prescriptive - tailored to the country

•Long-term process

–Few quick wins

–Attribution difficult

•Sustainable

–Partnerships matter

–Structures and governance

–Principles of service delivery

Health System Management: Reality Check!

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Source: WHO, 2009, Systems Thinking for Health System Strengthening, P.32 Fig 1.2

The Dynamic Architecture and Interconnectedness of the Health System

Building Blocks

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Session 1.1.3:

Systems Thinking

Systems thinking refers to:

•Paradigm shift that emphasises a deeper understanding of dynamism, linkages, relationships, interactions and behaviours among the elements that constitute the entire system;

•It focuses on holistic approach to designing, implementing and evaluating health interventions;

•It is an approach to problem solving that views ‘problems’ as part of a wider dynamic system.

What is systems thinking?

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•Systems thinking works to reveal the underlying characteristics and relationships of systems.

•Every intervention, from the simplest to the most complex, has an effect on the overall system. The overall system also has an effect on every intervention.

•It is a tool for diagnosing organisational issues and understanding change dynamics.

•Work in the field of engineering, economics and ecology shows systems as constantly changing, with components that are tightly connected and highly sensitive to change occurring elsewhere.

Systems Thinking Rationale

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System Organising

Managing and leading a system; the types of rules that govern the system and set direction through vision and leadership; set prohibitions through regulations and boundaries; and provide permissions through setting incentives or providing resources.

Systems Networks

Understanding and managing system stakeholders; the web of allstakeholders and actors - individual and institutional - in the system, through understanding and managing the networks.

Systems Dynamics

Conceptually modelling and understanding dynamic change; attempting to conceptualise, model and understand dynamic change through analysing organisational structure and how that influences behaviour of the system.

Systems knowledge

Managing content and infrastructure for explicit and tacit knowledge; the critical role of information flows in driving the system towards change, and using the feedback chains of data, information and evidence for guiding decisions.

Source: WHO, 2009 Systems Thinking for Health System Strengthening (p 45 Box 2.5)

Elements of Systems Thinking

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The following five principles are considered core to an organisation’s learning and innovation:

•Personal mastery;

•Mental models;

•Building shared vision;

•Team learning;

•Systems thinking. (The Fifth Discipline, Doubleday,

1990, p. 7)

Principles of Systems Thinking

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Conventional approach Systems thinking approach

Static thinkingFocusing on particular events

Dynamic thinkingFraming a problem in terms of a pattern of behaviour over time

Systems-as-effect thinkingViewing behaviour generated by a system as driven by external forces

System-as-cause thinkingPlacing responsibility for a behaviour on internal actors who manage the policies and "plumbing" of the system

Tree-by-tree thinkingBelieving that really knowing something means focusing on the details

Forest thinkingBelieving that to know something requiresunderstanding the context of relationships

Factors thinkingListing factors that influence or correlate with some result

Operational thinkingConcentrating on causality and understanding how a behaviour is generated

Straight-line thinkingViewing causality as running in one direction, ignoring (either deliberately or otherwise) the interdependence and interaction between and among the causes

Loop thinkingViewing causality as an on-going process, not a one-time event, with effect feeding back to influence the causes and the causes affecting each other

Source: WHO, 2009 Systems Thinking for Health system Strengthening, page 43-Table 2.1

Skills in Systems Thinking