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Inaugural KEYSTONE Course on Health Policy and Systems Research 2015

Health Systems and Health Policy Frameworks - 2

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Health Systems and Health Policy Frameworks - 2

Kabir Sheikh

23 February 2015 

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• HEALTH SYSTEMS STRENGTHENING• SOCIAL JUSTICE AND EQUITY

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HEALTH SYSTEM STRENGTHENING

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Chronology of Health Systems Frameworks

Focus on Health Systems Structure:

Primary Health Care(1) Comprehensive: Alma Ata 1979• Principles and Values• Level of Care: first contact• Elements: eight programs

(2) Selective PHC – UNICEF 1982• GOBIFF

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Shift to Health system function:

(3) Basic Health Care Packages: World Bank 1993• Public Health Programs• Essential Clinical Services

(4) World Health Report 2000: Health Systems, Improving Performance

• Goals and Functions• Six Building Blocks

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Engaging with health systems change

(5) Paris Declaration on Aid Effectiveness: 2005• Country Government Ownership• Use of Government Systems to deliver aid

(6) Health System Strengthening• Opportunities for Global Health Initiatives in the Health 

System Agenda WHO 2006• HSS: Everybody’s Business WHO 2007• Complexity and interaction  (Systems Thinking – AHPSR 2009)

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2000 move towards ‘HSS’ because

• ‘Effective interventions exist for many priority health problems in low income countries; prices are falling, and funds are increasing. However, progress towards agreed health goals remains slow. There is increasing consensus that stronger health systems are key to achieving improved health outcomes.’  (Travis et al., 2004)

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Constraint Disease-programme response

Health system response

Poorly motivated staff

Financial incentives to reward delivery of particular priority services

Institution of proper performance review systems Creating greater clarity of roles and expectations regarding performance of roles Review of salary structures and promotion procedures

Health system strengthening goes beyond dedicated disease/condition-specific programmes

Travis et al. 2004

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Vertical, Horizontal and Diagonal approaches

• Vertical programs: focus on delivery of intervention targeting specific disease or condition (eg immunisation)

• Horizontal program: focus on health system components with relatively less attention on delivery outcomes

• Diagonal approach: Addressing health systems bottlenecks to specific vertical programs  while achieving system-wide benefits

WHO Everybody’s business 2009

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SOCIAL JUSTICE AND EQUITY

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Utilitarianism

J Bentham and JS Mill

• “The greatest good for the greatest number of people”

• Focus on consequences

Jeremy Bentham

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Justice as Fairness

Justice as Fairness

1. Equality of opportunity for all

2. Difference principle – maximize benefit to the most disadvantaged members of society

John Rawls

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Types of Equity

• Horizontal equity Providing equal healthcare to those who are the same

• Vertical EquityReducing health inequities - treating people with different needs differently, proportionate to their needs 

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Niti vs. Nyaya• ‘The Idea of Justice’ 2009

• Principles of justice are anchored to arrangements and rules rather than directly to social realisations and human lives and freedoms

• Need to focus questions of justice on what actually happens and actual lives rather than merely looking for ideal institutions and arrangements

Amartya Sen

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Health as a Human Right

• WHO Constitution: "the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being…”

• Health is not cited as a constitutional right in India

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Relational Ethics

• Processes as important as outcomes

• How do we treat others - respect and trust

• Intentions are important (deontology)

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GROUPWORK

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Health System Problems1. The non-implementation of standard public health guidelines and 

protocols is a widely witnessed phenomenon and problem in India and other low and middle income countries, in both public and private health care services.  This is widely seen to be of concern since users of services may be denied standardized and evidence-based modes of care and treatment.

2. Health workers who are deployed in health care facilities are frequently irregular in reporting for their duties, and are sometimes entirely absent from their posts.

3. Routine health-related data collected through existing health information systems is often viewed to be unreliable, either overestimating or underestimating the actual quantum of the event or disease being measured. This causes problems in priority setting, responding and allocating resources. 

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4. Professional self regulation is a globally accepted approach in which health care professions are expected to establish and maintain standards of conduct and ethics, within the confines of the profession, by setting up relevant boards or councils.  However it is widely observed that professional self regulatory bodies (such as medical, nursing and pharmacy councils) do not play an optimal role in regulating the standards as laid out in their constitutions. 

5. In spite of widespread evidence and numerous policy pronouncements and expert statements on the primacy of primary health care in order to achieve health goals, current financial allocations tend to favour tertiary institutions in urban areas.

6. Globally, there is a widespread deficiency in resource allocation and innovation for development of new medicinces, vaccines and medical products for diseases that disproportionately affect developing countries and the poor.

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Groupwork plan• 15 min: Form 6 groups of 3-4 members each – one group for each health 

system problem. Groups to brainstorm the research questions they can ask in relation to the problem.  Keep in mind the following:– From whose perspective are we asking the question (policy planner / manager / 

service provider / user / someone else)?– Purpose of asking the question (to prove / evaluate / explain / explore / bring a 

change)?– What is the level of the analysis (“macro” – architecture and oversight of system / 

“meso” – functioning of organizations and interventions / “micro” – the individual in the system)

• 60 min: 10 minutes for each group to present their research questions in plenary, including moderated discussion on the “balance” of the questions

• 10 min: HSHP wrap up: scope of HPSR, research plan template, reading list

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Macro Meso Micro

Normative / evaluative

Explanatory / Exploratory

Emancipatory

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• What are the reasons behind the problem of irregular timing?

• Can you implement CBM to ensure doctors coming on time?

• Can we create colleges with reservation for local populations? 

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• What is the magnitude of unreliable data and factors influencing unreliable data  under the current HIMS?

• How can IT be leveraged for improving Health System related information?

• What is the scope of large scale surveys in incorporating Health System related information?

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