Strengthening the health systems in SSA: the role of health policy and systems research & analysis (HPSR+A)

Prof BSC Uzochukwu (MBBS, MPH, FWACP)

3rd African Epidemiological Association Conference,

Yaoundé, Cameroon.

4 – 6 June, 2014

Introduction• Health outcomes are unacceptably low across much of SSA

• Rapid progress towards MDG targets and UHC is greatly hampered by weak, poorly functioning health systems

• Much of the burden of disease can be prevented or cured with known, affordable technologies, yet the gaps in health outcomes continue to widen

• The problem is getting these affordable technologies on time, reliably, in sufficient quantity and at reasonable cost – to those who need them

Introduction…

The reality is straightforward.

The power of existing interventions is not matched by the power of health systems to deliver them to those in greatest need, in a comprehensive way, and on an adequate scale.

What is a health system?

“all organizations, people and actionswhose primary intent is to promote,restore or maintain health”, includingefforts to address the determinants ofhealth, besides direct activities to improvehealth (WHO).

Health Systems…

• It’s more than the pyramid of publicly owned facilities that deliver personal health services.

• It includes, for example, a mother caring for a sick child at home, private providers, informal providers, behaviour change programmes, vector-control campaigns, health insurance organizations; inter-sectoral action etc.

The six building blocks of a health system

People

Governance

Information

Financing

Service delivery

Human resources

Medicines &

technology

Elements of health systems interact together to form a complex system, and the health system interacts with the wider context within which it is situated. These interactions

affect the achievement of goals for health systems.

A good health system delivers quality services to all people, when and where they need them

The Health System

Leadership,governance & accountability

Deliver effective, safe, quality health services Sufficient, fairly

distributed, competent,

responsive & productive health

workforce

Functioning health information system

Equitable access to essential medicine

and medical products

Raises adequate funds for health & avoids financial catastrophe

Community participation

People

People

Health systems are shaped by hardware and software elements

Health Systems Strengthening • There is increasing recognition that disease specific

interventions implemented in vertical silos are unsustainable, and growing interest in strengthening health systems

• “ We will not be successful in our efforts to end deaths from AIDS, malaria and tuberculosis unless we do more to improve health systems around the world…”

(President Obama, May 5, 2009).

“The responses of many health systems so far have been generally considered inadequate and naïve. . . . a system’s failure requires a system’s solution – not a temporary remedy.”

(WHO World Health Report, 2008).

Health Systems Strengthening…

• Involves improving the six health system building blocks and managing their interactions in ways that achieve more equitable and sustained improvements across health services and health outcomes.

• In recent years there have been some major new initiatives to support health system strengthening

• These developments have been accompanied by a growing recognition of the role of research in improving health systems and health care delivery

What is Health Policy and Systems Research & Analysis (HPSR+A) ?

• “an emerging field that seeks to understand and improve how societies organize themselves in achieving collective health goals, and how different actors interact in the policy and implementation processes to contribute to policy outcomes.”

• By nature, it is a multidisciplinary and inter-disciplinary field of research, a blend of economics, sociology, anthropology, political science, public health and epidemiology.

• Central to health systems strengthening because it tries to draw a comprehensive picture of how the health system and broader determinants of health can shape and be shaped by policies.

Recognising the diversity of HPSR+A

Epidemiology& ClinicalSciences

Policy & Practice

Social Sciences

HPSR+A

• Global Forum, Bamako, 2008

• First HSR symposium, Montreux, November 2010

• UK funders meeting, London, December 2011

• Second HSR symposium, Beijing, October 2012

• Third HSR symposium Cape Town Sept/Oct 2014: ‘The Science and Practice of People-centred Health Systems’

• Mills HPP 2011

• PLOS medicine papers 2011

• London meeting background document, Dec 2011

• Reader, February 2012

• WHO global health systems research strategy background document, March 2012

Lots of interest in HPSR+A!

The New Interest in HPSR+A

• Owes much to recognition of its importance for the success of health interventions and programmes, and the changing macroeconomic environment of international health.

• Realization that the Millennium Development Goal targets would not be achieved due to weak health systems despite increased funding for health during the period 2000–2008

Scope of HPSR+A

We seek to understand

• what health systems are & how they function

• what needs to be done to strengthen them

• how to influence policy agendas on health system development

• how to develop and implement policies in ways that strengthen health systems

The terrain of HPSR+A

Health Policy:

Contents & InstrumentsActors, Politics & Power

Health Systems:

Hardware: Structure; Organisation; Technology; Resourcing

Software: Values; Norms; Actors & Relationships

System functioning

&

Policy Change/System Strengthening

Global and national forces

What priorities in developing research & analysis?

• Balance in questions asked• not only what works (best)? but also why and how?

(interventions work, systems are now and change over time)

• Less description, more appropriate exploration and deeper analysis

• more careful thinking about study design & more understanding of range of alternatives

» case studies, mixed method studies, longitudinal work

• use of theory

• More understanding of how to ensure rigour

Key research approach and methods: Epidemiological studies vs. HPSR+A

Deductive:

Hypothesis & method-driven

Emphasis on measurement through surveys, data records & statistical

analysis;

some qualitative data

FIXED RESEARCH DESIGNS

Inductive: theory building & testing ; problem- or

question-driven

Emphasis on qualitative data collection approaches

&

Interpretive analysis

FLEXIBLE RESEARCH DESIGNS

Epidemiological studies HPSR+A

Positivist:Validity & reliability of data & analysis

Relativist:Trustworthiness of interpretive judgements

As epidemiologists, let’s think outside the box!!

• Despite benefits of disease-targeted programmes for improved outcomes for communicable diseases, evidence on optimum system designs is weak.

• Because epidemiological studies on their own cannot strengthen the health system, we need to think outside the box

• Think about what keeps a programme or service going…The underlying building blocks for that.

Health systems thinking approach

Addressing ill-health: programmatic vs. systems orientations

Constraint Disease-programme

thinking approach

Health system thinking

approach

Inappropriately skilled staff

Continuous education and training workshops to develop skills in focal diseases

Review of basic medical and nursing training curricula to ensure that appropriate skillsincluded in basic training

Poor TB data Introduction of TB register Improvement in health information systems

Physical inaccessibility: distance to facility

Outreach for focal diseases Capital investment and sitingof facilities

Financial inaccessibility:inability to pay, informal fees

Exemptions/reduced prices for focal diseases

Development of risk-pooling strategies- Health insurance

Some HPSR+A studies that have strengthened health systems

1. Rwashana AS, Williams DW, Neema S (2009). System dynamics approach to immunization healthcare issues in developing countries: a case study of Uganda. Health Informatics Journal, 15(2):95–107.

Systems analysis of an immunization programmecaptured and analyse complex interactions between behavioural, technical, policy and cultural issues. This enabled decision makers to focus on the root causes of shortcomings and not the symptoms alone

2. Sheikh K, Porter J (2010). Discursive gaps in the implementation of public health policy guidelines in India: The case of HIV testing. Social Science & Medicine, 71(11): 2005–2013.

Focused on actors’ decision-making

Recognising the deliberative nature of implementation, and strengthening discourse and communications between involved actors may be critical to the success of public health policies in Indian and comparable LMIC settings. Effective policy implementation in the long term also necessitates enhancing practitioners’ contributions to the policy process, and equipping country public health functionaries to actualize their policy leadership roles.

3. D Blaauw, E Erasmus, N Pagaiya, V Tangcharoensathein, K Mullei, S Mudhune, C Goodman, M English & M Lagarde

Policy interventions that attract nurses to rural areas: a multi country discrete choice experiment. Bull World Health Organ 2010;88:350–356 | doi:10.2471/BLT.09.072918

DCEs to help policy-makers choose more effective interventions to address staff shortages in rural areas. Intervention packages tailored to local conditions are more likely to be effective than standardized global approaches.

4. Martha Morrow, Quy A Nguyen, Sonia Caruana, Beverley A Biggs, Nhan H Doan and Tien T Nong

Pathways to malaria persistence in remote central Vietnam: a mixed-method study of health care and the community. BMC Public Health 2009, 9:85 doi:10.1186/1471-2458-9-85.

Malaria control cannot be achieved through community education alone in this region. Whilst appropriate awareness-raising is needed, it is most urgent to address weaknesses at systems level, including bed-net distribution, health provider staffing and skills, as well as equipment and supplies.

5. Rifat Atun, Diana E C Weil, Mao Tan Eang, David Mwakyusa. Health-system strengthening and tuberculosis control. Lancet 2010; 375: 2169–78

HPSR was used to resolve the bottlenecks to TB control: Bottlenecks in relation to governance, financing, supply chain management, human resources, health information systems, and service delivery in Bangladesh, Cambodia, India, Tanzania, Thailand, and Vietnam

6. Douglas Wilson, Victoria Howell, Christina Toppozini, Krista Dong, Michael Clark, and Rocio Hurtado. Against All Odds: Diagnosing Tuberculosis in South Africa. The Journal of Infectious Diseases 2011;204:S1102–9

Context-appropriate systems for the diagnosis of tuberculosis are entirely dependent on effective and responsive management of human resources and an uninterrupted supply of clinical materials.

7. Ben Rolfe, Sebalda Leshabari, Fredrik Rutta and Susan F Murray. The crisis in human resources for health care and the potential of a ‘retired’ workforce: case study of the independent midwifery sector in Tanzania.Health Policy and Planning 2008;23:137–149

Because of their location and emphasis on personalized care, small-scale independent practices run by retired midwives could potentially increase rates of skilled attendance at delivery at peripheral level.

8. Jennifer Bryce, Cesar G Victora, Jean-Pierre Habicht, Robert E Black and Robert W Scherpbier. Child survival: results of a multi-country evaluation of Integrated Management of Childhood Illness. Health Policy and Planning, 20 (supplement 1):i5–i17.

This analysis highlights the need for a shift if child survival efforts are to be successful. Delivery systems that rely solely on government health facilities must be expanded to include the full range of potential channels in a setting and strong community-based approaches.

9. Reham Khresheh and Lesley Barclay. Implementation of a new birth record in three hospitals in Jordan: a study of health system improvement. Health Policy and Planning 2008;23:76–82

Quantitative and qualitative audit data demonstrated improved clinical reporting, organizational development and sustained commitment to the new record from clinicians, managers and policy leaders.

10. Uzochukwu BSC, Onwujekwe OE, Soludo E, Ezuma N, Obikeze EN and Onoka CA (2010). Implementing Community Based Health Insurance in Anambra State, Nigeria. www.crehs.lshtm.ac.uk

Make efforts to secure widespread backing among groups (both within and outside the Ministry of Health), take into consideration power dynamics between local community actors when designing policies to be implemented at the local-level and ensure that policy guidelines are clearly communicated to those responsible for implementing the policy and to community members.

Problems with HPSR+A

• Funding for HPSR in developing countries and by developing country researchers is meagre.

– Evidence suggests that such funding is at most 0.02% of health expenditure

• A multidisciplinary and inter-disciplinary field of research, as such it lacks an obvious institutional home in universities and other research institutes

– The lack of a fixed home means poorly defined career structures for researchers in this field.

• Lack of capacity to do HPSR in Africa

End note• HPSR has much to contribute to our understanding of health systems and

policies and such knowledge can be applied to improve the health of the worst-off of SSA population

• The application of HPSR+A has contributed to problem resolution, and a widely applicable scientific body of knowledge is emerging.

• Its potential to achieve health system change hinges on it becoming more people-centred in how it is conceived, conducted, and utilized.

• Epidemiologists need to begin to think outside the box since epidemiological studies alone cannot produce evidence to strengthen the health systems

• But we need to build capacity for HPSR+A especially in Africa and epidemiologists are invited

ACKNOWLEGEMENT

CHEPSAA Consortium for Health Policy & Systems Analysis in Africa

Thank youCHEPSAA members:

• School of Public Health and Family Medicine, University of Cape Town, South Africa

• School of Public Health, University of Western Cape, South Africa

• Centre for Health Policy, University of Witwatersrand, South Africa

• Institute of Development Studies, University of Dar es Salaam, Tanzania

• School of Public Health, University of Ghana, Legon, Ghana

• Tropical Institute of Community Health, Great Lakes University of Kisumu, Kenya

• College of Medicine, University of Nigeria Enugu, Nigeria

• London School of Hygiene & Tropical Medicine, United Kingdom

• Nuffield Centre for International Health and Development, University of Leeds, United Kingdom

• Karolinska Institutet, Sweden

• Swiss Tropical and Public Health Institute, University of Basel, Switzerland