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Health system strengtheningA conceptual framework
Basile KeugoungMD, MPH, PhD
Regional workshop on HISHotel du Lac, Cotonou Bénin
16-18 Décembre 2015
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• Agenda of many organisations and Global HealthInitiatives (GHI)
• Huge resourcee are dedicated to HSS
• Major strategies of national health sector strategic
• Positive results of HSS interventions are published...
Health system strengthening (HSS)
HSS: Agenda of many organizations
HSS: Agenda of many organizations
HSS: Agenda of many organizations
RSS: Agenda des organisations
HSS: Agenda of many organizations
Increase investments in health systems
• GAVI: 524million USS$ committed to 44 countries and225 million US$ disbursed to 36 countries in 2012
• Global Fund: 22,4 billion US$ by mid-2011• GAVI HSS strategy:
– Strengthen the capacity of the health system toprovide immunization and other health services
– Target bottlenecks in the health system that impedeprogress in improving provision of and demand forimmunization and other child and maternal healthservices
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• Health systems remain weak santé
• All components are affected
• Many population needs are uncovered
• High preventable morbidity and mortality
• MDG: not achieved in most sub-Saharan Africancountries
General contex
One question ?
Where does money go?
• Indeed, official development assistance for health for theOECD: 13.3 billion US$ in 2006– Most of these funds were channeled through vertical
programs– HIV/AIDS, malaria and other communicable diseases
received nearly half (47%) in 2002-2006– HSS<10%
• GHI: focus on specific diseases
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WHO health system framework
Health Financing
Health information system
Leadership et governance
Human Resources
Health care delivery
Drugs, equipments and othermedical supplies
Health
Equity
ReactivityReeourcesgeneration
Stewardship
Financing
Health caredelivery
Components Functions Objectives
…Beyond Building blocks
But local health system
Public Health centresPrivate-for-profithealth Centres
Faith-based healthCentres
Tradiraticiens
Health DistrictManagement Teams
District hospital
Other supportServices
Local Government
Prestataires desanté individuels
CommunityCommunity health relaysIndividuals, households
Private Hospital
Traditional, politicaland religious leaders
NGO and civilsociety
Local services fromother Ministries
- Education- Water- Agriculture- …
Is made of many actors…
How do we manage information flux?
Local health system…
…is the implementation of rolesFor example for the District health management teams: 10 essentialfunctions1. Diagnostic and investigation of health problems and determinants2. Policy and development plans3. Resources management4. Health care delivery regulation5. Operational research6. Quality health care delivery7. Partner Mobilization (community, NGOs, funding agencies, …)8. Monitoring and evaluation9. Coordination10.Supervision
Local health system……Is a system : Intrants, Processes, Outputs, Impact
Intrants Legal and regulatory framework
o Directives, norms et standardso Policies
Resources : ICT equipment, drugs, funds…
Local health system…
Processes
Institutional arrangments Information flow management Platforms of management of fora Management procedures District health management teams functionality Redevability
Outputs Health care delivery
Impact Access , Quality, Efficiency, Service use
…Is a system : Intrants, Processes, Outputs, Impact
How can we strengthen localhealth systems?
Systemic capaciybuilding
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Potter & Brough (2004)Complexity
Intrants
Skills
Staff and infrastructure
Structures, systems and roles
Time
Support to the health system
HSS
Policy and regulationsOrganizational structureChangement de comportementInterrelations between compornentsHealth information system flowsStewardship
IntrantsperdiemsTrainingRehabilitation
Chee et al (2012)
Support vs HSS
Systemic capacity building and oursessions goals
• Intrants: Equipment : Smartphone 5A, 5B
• Human resources: 4C• Supervisory capacity: monitoring and evaluation systems:
6A, 6B
• Support services capacity: 8, 9
• Systemic capacity : 3; 6A, 6B• Structural capacity : 7B, 8• Role capacity: 6C, 7A
HIV/AIDS program and HSS in Cameroon?
Santé Publique 2015; 27(4): 547-556
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Specific training and supervision
HIV/AIDS therapeutic committeeCommunity relay enrolment
?
Reduced funding ofhospitalsFrequent out-of-stock
Parallel health information systemReduced ditrict health managementteams
Reduced motivation of staffHigh workload
Low implication of districthealth management teams
Laboratory equipment, HIVtests, Antiretroviral drugsMotobike, office equipment
Positiveeffects
Negativeeffects
Effets on pyramid of capacity
22Health system
District level
Regional level
Central level
International level
Why missed opportunities?
A vicious circle
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Missedopportunities
Individualfactors
Functionalfactors
Structuralfactors
Low implementation of HSSinterventions
Incitants
Increasedbottlenocks
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Opportunities
Stewards
HSSinterventions
Strong localhealth systems
Implementation of theStewardship componentsIncitative
measures
Detection andcorrection ofbottlenecks
Strengthenstewardship
Monitoring the healthsystem interventions
Strengthenstucturalcapacities
To strengthen health systems… transform the vicious circle into a vertuous circle
Conclusions
• We should optimize HSS interventions, need for
– A performant HIS
– A HIS leading to collective intelligence
– A learning organization
• We should regularly adapt our ICT technology to strengthenHIS
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Thank you
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