health systems strengthening 19 jan mph

Health Systems Development and Strengthening

Dr Nilar Tin

What is a Health System?

What are the Goals?

What are the functions?

What is a Health System?

A health system consists of all

organizations, people and actions whose

primary intent is to promote, restore or

maintain health

Health Systems are thus defined as comprising • All Organizations & Institutions• People (health professionals both public/private)• Supplies• Information that are devoted to producing

– Health Actions- whether personal health care or public health care or through intersectoral initiatives, primary purpose is to improve health- good health

– World Health Report 2000 devoted entirely to Health Systems

– WHO expands its traditional concern for people’s physical and mental well being to emphasize two other elements of good health; goodness and fairness

Goodness: HS responding well to what people expect of it Fairness : HS responds equally well to everyone without

discrimination

Looking back to history: How Health Systems have evolved?• Health systems of some sort have existed for as long as

people have tried to protect their health and treat disease (Traditional practices, spiritual healers, herbal– modern medicine)

Looking back a century – organized HS barely existed• What the people at that time would suffer from? LE at birth• What kinds of health care were provided?

Evolution• Founding of national health care systems

• Extension of social health insurance schemes

• Promotion of PHC approach--the goal of HFA

PHC is an approach to health development“ essential health care based on practical, scientifically

sound and socially acceptable methods and technology made universally accessible to individuals, and families in the community through their participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of self reliance and self determination.

It forms an integral part of both the country’s health system, of which it is the central function and main focus, and the overall social and economic development of the community.

It is the first level of contact of individuals, the family, and the community with the national health system bringing health care as close as possible to where people live and work and constitutes the first element of a continuing health care process”

1970s--1980s PHC actual application & Experiences1. A package or a set of activities:

8 ELEMENTS of PHC; preventive and promotive more; emphasis more on public health rather than medical care

2. Level of care: Primary, Secondary and Tertiary levels of care. PHC goes further down to community-based care

3. An approach, which has been termed variously as the PHC principle -universal coverage (equity in health across all SE groups)-intersectoral collaboration (risk factors & Social determinants affecting health)-community participation (empowerment)-appropriate technology (not only resource-constrained countries but apply to all)

1980s Changes in economy: Oil crisis in middle east

• SAPs- Structural Adjustment Policies • Health Sector Reforms especially affecting

African countries• Players WB & IMF• WB’s mandate: Promote sustainable economic

growth & contribute to poverty alleviation• Three pillars of WB’s poverty alleviation strategy

– Sustained economic growth – Productive use of labour – Access to social service for the poor

WB lends money to poor countries: Loans were there, but poor countries become poorer and rich countries become richer

At the same time with economic changes Health Systems was being challenged with

Demographic changes Transitions where fertility and growth rate

declined Infant mortality has decreased and LE

increased ---leading to increase in <15 years and elderly population

Process of rapid urbanization

Epidemiologic changes Migration and urban growth---led to resurgence

of diseases that were once considered controlled such as cholera outbreaks + accidents, injuries, crime

AIDS pandemic Still infectious diseases were giving problems

Health Sector Reforms: – User financing (Rational drug use by donors- Bamoko

Initiatives in 1987 in African countries)– Selective Primary Health Care (GOBI for child

survival) making priorities of elements of PHC– Privatization (promoting hospital setting and

sophisticated health measures)

What were the results…….. – In Kenya introduction of user fee at STD clinic caused

reduction in attendance & increased no: of untreated STDs in the population

– SAPs contributed to rapid spread of AIDS in Africa– Many of 3 million deaths from TB in China during the

1980s might have been prevented if user fee was not introduced

Socio-cultural transitions Increased levels of education, improved

communications---shrunk distances between countries

Changes in life styles, nutritional, traditional, social and family structures, values and even expectations

Led to ---social problems, adolescents problems, mental health problems--NCDs + CDs--double burden--increased demand of health care systems.

Political changes Political orientation and ideologies in many

countries changed Changes in policies, management and services

in all sectors.

Impact of all these Trainsitions / Health Systems Challenges

Impact of ageing population with need of provision of chronic care/ social security

Threats of AI, H1N1-affecting more on poor countries and HR issues

Competition for resources between hospitals and PHC, between public and private sector

High tech in diagnosis and life long treatment could not protect people from catastrophic spending

Universal coverage, tax based funding, Social Health Insurance, Microcredit-- financing schemes need major demand on managerial capacity

Migration of health workforce had made the sender country to suffer more

Impact of all these Trainsitions/HS Challenges

• Where providers depend largely on out-of-pocket payments for their income, there is over-provision of services for people who can afford to pay, and lack of care for those who cannot pay.

• OPPORTUNITIES• The global health landscape has been transformed in the

last ten years with the emergence of multiple, billion-dollar global health partnerships such as the Global Fund and the GAVI Alliance.

• WHO- Health Metrics Network, Global Health Workforce Alliance, Commission for Social Determinants of Health,

Health system challenges: a few facts and figures

• Globally, health is a US$3.5 trillion industry, or equal to 8% of the world's GDP.

• Large health inequalities persist: even within rich countries such as USA and Australia, life expectancy still varies across the population by over 20 years.

• Recent essential medicines surveys in 39 mainly low- and low-middle-income countries found that, while there was wide variation, average availability was 20% in the public sector, and 56% in the private sector.


• Each year, 100 million people are impoverished as a result of health spending.

• Extreme shortages of health workers exist in 57 countries; 36 of these are in Africa.

• In over 60 countries, less than a quarter of deaths are recorded by vital registration systems.

• An estimated 50% of medical equipment in developing countries is not used, either because of a lack of spare parts or maintenance, or because health workers do not know how to use it.


• Private providers are used by poor as well as rich people. For example, in Bangladesh, around ¾ of health service contacts are with non-public providers.

• In 2000, less than 1% of publications on Medline were on health services and systems research.

• Globally, about 20% of all health aid goes to support governments' overall programmes (i.e. is given as general budget or sector support), while an estimated 50% of health aid is off budget.

• There has been a rapid increase in global health partnerships. More than 80 now exist, of which WHO houses over 30.

Discussions for today

In Two Groups (30 minutes)

• Myanmar in the context of Health Systems Development…

• What are the Health Systems Challenges?

• What are the opportunities????• Where are we now ?????

Health system functions and goals

Functions

Service deliveryResource generation: HWF, supplies, informationFinancingGovernance and stewardship

Goals

Good health outcomesResponsivenessFairness in financing

1.Good health services are those which deliver.. • effective, • safe, • quality • personal and non-personal health interventionsto those that need them; when and where needed; with minimum waste of resources.

The six building blocks of a health system

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).

The six building blocks of a health system3. 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.

•4. A well-functioning health system ensures equitable access to.. • essential medical products, • vaccines and • technologies of • assured quality, safety, efficacy and cost-effectiveness, and their scientifically sound and cost-effective use.

The six building blocks of a health system

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 catastrophe or impoverishment associated with having to pay for them. • It provides incentives for providers and users to be efficient.

6. Leadership and governance involves ensuring • strategic policy frameworks exist • and are combined with effective oversight, • coalition building, • regulation, • attention to system-design and accountability.

What is Health System Strengthening?

Defining Health Systems Strengthening At its broadest, health system

strengthening (HSS) can be defined as an array of initiatives and strategies that improves one or more of the functions of the health system and

that leads to better health through improvement in access, coverage, quality, or efficiency.

(Health system Action Network)

Health System Strengthening• Stewardship / governance / leadership : defining sector strategies, clarifying roles, managing competing demands • Health financing : ensuring fair and sustainable financing, including financial protection • Human resources : having a sufficient and productive workforce • Information and knowledge : ensuring the generation and use of information • Technology and infrastructure : ensuring adequate drugs, equipment, infrastructure • Service delivery : improving organization, management, and quality of services

Integrated service delivery packagesWHO will continue to produce and disseminate cost-effectiveness data for prevention and treatment, and define service standards and measurement strategies for tracking trends and inequities in service availability, coverage and quality.

It will help define integrated packages of services, and the roles of primary and other levels of care in delivering the agreed packages, as part of its health policy development support.

Health Service Delivery

Service delivery modelsWHO will consider the whole network of public and private providers in order to enhance equitable access, quality andsafety.

It will synthesize and share experience of the costs, benefits and conditions for success of strategies to improve service delivery. These may include

-community health workers, -task shifting, outreach, contracting, -accreditation, -social marketing, -uses of new technologies such as telemedicine, -hospital service organization and management, -delegation to local health authorities, -other forms of decentralization, etc.


Leadership and ManagementWHO will support Member States to improve management of health services, resources and partners by health authorities, as a means to expand coverage and quality.

This will be done through: -promoting tools for analyzing barriers to care, and

management weaknesses;-generating and sharing knowledge on strategies to

improve management, often in the context of decentralization;

-developing local resource institutions’ capacity to support local health managers; and

-developing methods to monitor progress.


International norms, standards and databasesWHO will maintain and strengthen the Global Atlas on the health workforce. It will facilitate the generation and exchange of information on health workforce availability, distribution and performance by supporting regional workforce observatories.

Health Workforce

Realistic strategiesWHO will increase its support for realistic national health workforce strategies and plans for workforce development. These will consider the range, skill-mix and gender balance ofhealth workers (health service providers and management and support workers) needed to deliver the agreed package of services across priority programmes. They will address workforce education, recruitment, retention and performance and define regulatory options

CostingWHO will generate knowledge about the financial costs of scaling-up and then maintaining the expanded health workforce, as well as ways to address financial sustainability, and use this in dialogue with international financing institutions.

Health Workforce

TrainingWHO will support the redesign of training programmes to produce the spectrum of health workers (service providers and management and support workers) to deliver healthservices.

It will explore and document ways to maximize the use of priority programme training initiatives, and mechanisms such as accreditation to assure quality of training programs.

National information systemsSupport improved population and facility-based information systems, so that they can generate, analyse and use reliable information from multiple data sources, in collaborationwith partners (e.g. UN, other agencies, the Health Metrics Network partnership, the Institute of Health Metrics and Evaluation).

Information

Stronger national surveillance and response capacityPublic health systems that are equipped with up-to-date technologies and dedicated personnel and are able to detect, investigate, communicate and contain threats to public health security, and be part of an unbroken international line of defence against such threats.

Tracking performanceEstablish a set of core and additional health system metrics to track health system performance for use by countries and external agencies financing investments in health systems.

Information

Standards, methods and toolsThese include the International Classification of Diseases, Global Burden of Disease updates, MDG monitoring tools; development and measurement of Health System Metrics; and standards for electronic medical records.

A key role will be played by expert groups, includingthe Advisory Committee for Health Monitoring and Statistics.

Establish norms, standards and policy optionsSet, validate, monitor, promote and support implementation of international norms and standards to promote the quality of medical products, vaccines and technologies, andethical, evidence-based policy options and advocacy.

Medical Products, VACCINES AND TECHNOLOGIES

ProcurementEncourage reliable procurement to combat counterfeit and substandard medical products, vaccines and technologies, and to promote good governance and transparency in procurement and medicine pricing.

Health financing policy optionAssess and disseminate information about what works and what does not work in health financing strategies;

Facilitating the sharing of country experience in various types of health financing reforms;

Sharing of key information required by country policy makers; and the development of tools, norms and standards including those required to assist countries to generate and use information in their own settings.

Sustainable Finanacing & Social Protection

Improve or develop pre-payment, risk poolingand other mechanisms to reduce the extent of financial catastrophe and impoverishment due to out-of-pocket payments, and to extend financial and social protection.

Develop health sector policies and frameworksthat fit with broader national development policies and resource frameworks, and are underpinned by commitments to human rights, equity and gender equality.

Leadership and Governance

Generate and interpret intelligence and research on policy options . At the international level, it will facilitate access to knowledge on approaches to policy and systems development:

-by promoting a more systematic health systems research agenda; through the Alliance on Health Policy and Systems Research;

-by building capacity in regional observatories or their equivalent; and

-by increasing access to and use of new knowledge management technologies.

Have the health system goals been achieved?

SEAR countries

22

12

2214

35

61 60

51 50

61

88

0

20

40

60

80

100

120

140

160

180

200

DPR Korea Sri Lanka Thailand Maldives Indonesia Bhutan India Bangladesh Myanmar Nepal Timor-Leste

Infa

nt

dea

ths

( p

er 1

000

live

bir

ths)

1990 2005

Infant Mortality Rate

Source : Country reports on MDG

Reference year of data for 2005 vary from 2000 to 2005

HFA 2000 target of IMR < 50

0

20

40

60

80

100

120

140

160

180

200

Nepal Bangladesh Myanmar India Indonesia Bhutan Maldives Thailand DPR Korea Sri Lanka Timor-Leste

Dea

ths

of

un

der

fiv

e ye

ars

old

ch

ild

ren

( p

er 1

000

live

bir

ths)

1990 2005 2015 Target

Under-5 Mortality Rate (Reduce by two-thirds b/w 1990-2015) (UN MDG Goal-G4, T5,

Baseline data for 1990 for Timor-Leste is an estimate and 2015 is target set as MDG



HFA 2000 target of U5MR < 70

0

50

100

150

200

250

1975-79 1980-84 1985-89 1990-94 1995-99

Death

s o

f ch

ild

eren

un

der-5

years o

f ag

e (

per 1

000 l

ive b

irth

s)

Year

Source: WHO Geneva, Bulletin of the World Health Organization, 2000, 78:1175-1191

Trends in under-five mortality in the SEA Region, by country, 1975 - 1999

Bhutan

Bangladesh

Nepal

India

Myanmar

SEAR

Indonesia

Maldives

WORLD

Thailand

DPR Korea

Sri Lanka

HFA 2000 target of U5MR < 70

Indonesia

6569

71

80 80

85

72

77

88

75

57.5

99.7

56 57

99

67

75

60

94 97 95

0

10

20

30

40

50

60

70

80

90

100

India Nepal Indonesia Bangladesh Bhutan Myanmar Sri Lanka Thailand Maldives DPR Korea Timor-Leste

Per

cen

tag

e

1990 2003

Proportion of 1 year-old children immunized for measles births attended by skilled health personnel


How have health system been performing in SEAR?

• Fairness in Financing

Composition of total health spending in SEAR

66%4%3%

27%

OOPs social insurance priv ate insurance tax

Why have they failed to achieve the goals?

What does this mean?

Health Systems of SEA regional countries have failed to achieve the health system goals in relation to maternal and child health services,

- in terms of disease burden,

- fairness in financing and

- responsiveness

Why have they failed?

• Political commitment even at the highest level MDGs

• Lots of development work has taken place Many donor agencies have come forward

• Lots of funds are available and being used

• However health outcomes did not improve as expected

WHY?

What are the health systems factors that affect MCH service delivery

• Health workforce

• Organization and management of services

• Governance stewardship

• Essential drugs and medicine, logistics, infrastructure

• Health information

• Health Financing

System wide barrier study 2004

• Identified key barriers / bottlenecks to increasing sustained coverage which were beyond the control of the immunization system:– human resource numbers and motivation– transport to reach the hard to reach (especially for

outreach)– Fund flow issues especially to district level– Peripheral level management, logistics and monitoring– Coordination with and between partners

Does Health workforce shortages affect health outcomes?

Health workers save lives … but we need enough of them

Proportion of health workers per population

Pro

bab

ility

of

surv

ival

Low High

Low

High

Maternal Survival

Child Survival

Infant Survival

Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization

15

36

51

32

48

85 85

24 24

42

68 68

7

14

2022

99

86

95 97

0

10

20

30

40

50

60

70

80

90

100

Nepal Bangladesh Bhutan Timor-Leste India Myanmar Indonesia Maldives Thailand Sri Lanka DPR Korea

Per

cen

tag

e

1990 2005

Proportion of births attended by skilled health personnel



281

380

225

660

301

380

307

72

47

97

14

20

30

32

32

54

68

72

87

97

98

98

Nepal

Bangladesh

Bhutan

Timor-Leste

India

Myanmar

Indonesia

Maldives

Sri Lanka

DPR Korea

Thailand

(Countries with higher level of coverage of deliveries by skilled birth attendants tend to have

lower maternal mortality )*

Source : :Country reports on MDG

Deliveries attended byskilled health personnel (%)

MMR (maternal deaths per 100,000 live births)

Relationship between Coverage of deliveries by skilled birth attendants and Maternal Mortality, 2005

Notes : Reference year of data vary from 200 to 2005

* Not a univariate relation as there are other determinants of it

Is there a critical level of health workers needed to achieve

essential health interventions?

• To have 80% coverage in skilled births and measles vaccination there should be a minimum threshold of 2.5 (Docs + Nur + Midwives) / 1000 population - JLI

• To have 80% coverage in skilled births there should be a minimum threshold of 2.28 (Docs+ Nur + Midwives) / 1000 population - WHO

Where are we in relation to this population norm?

0 .0 0 0

1.0 0 0

2 .0 0 0

3 .0 0 0

4 .0 0 0

5 .0 0 0

6 .0 0 0

7 .0 0 0

8 .0 0 0

B A N B H U D P R K I N D I N O M A V M M R N E P S R L T H A T L S

T h r e s h h o l d 2 . 2 8

Number of (Doctors + Nurses + Midwives) per 1,000 population

How to move forward?

1. Identify key barriers / bottlenecks to increase sustained coverage which are beyond the control of the immunization system

HRH shortages, distribution, quality, motivation etc.transport to reach the ‘hard to reach’ (especially for

outreach)affordability and fund flow issues especially to district levelinfrastructure at periphery, logisticsmanagement monitoring & supervision coordination with and between partners

2. Identify what caused lead to these problems

problem analysis

3. Identify how to overcome them formulate your objectivesidentify interventions

At what level are the performance constraints & bottlenecks?

OPERATIONAL LEVEL

PROGRAM LEVEL

SYSTEM LEVEL

Policy & sector analysis: NHSS, PRSP, MDGS

Strategy analysis: RED, MPA, demand vs. supply driven

Needs analysisHR: skills, skills mix, retentionCapital: stores, equipment, vehicles

Goals

SMART Objectives

Expected outcome, outputs

Activities

Resources / Budget

Monitoring and Evaluation

Goals and Objectives

Strengthening interventions

Service deliveryService delivery

Drug Drug Supply & Supply & QualityQuality

LogisticsLogistics

Advocacy &Advocacy &CommunicationCommunication

SurveillanceSurveillance

ISS

ISS

ISS ISS

ISS

Strengthening Systems


Drug Supply & Drug Supply & QualityQuality

LogisticsLogistics



MoF, World Bank, HIPC

Gov’T, UNDP,MoP

HSS

HSS

HSS

SWAp

UNICEFPRSP

Policy space


Drug Supply & Drug Supply & QualityQuality

LogisticsLogistics



EQUITY

STEWARDSHIP

ACCESS

PRO-POOR

Thank you

health systems strengthening 19 jan mph

Health & Medicine