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Improving Health Services &

Strengthening Health System; Adopting &

Implementing Innovative Strategies

Improving Health Services &

Strengthening Health System; Adopting &

Implementing Innovative Strategies

Journal Club Presentation

By

Dr. Arvind Dhotre

Junior Resident

Department of Hospital Administration,

P.G.I.M.E.R., Chandigarh. 1

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Why this Initiative?

The Making Health System Work working

paper series is designed to make current

thinking & actual experience on different

aspects of health systems available in a simple

& concise format for decision makers.

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Working Papers in this Series

1. Strengthening Management in Low-Income Countries

2. Working with the Non-state Sector to Achieve Public

Health Goals

3. Improving Health System Financing in Low-Income

Countries

4. Opportunities for global Health Initiatives in the Health

System Action Agenda

5. Improving Health Services & Strengthening Health

System; Adopting & Implementing Innovative Strategies

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C

urrent Topic

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An exploratory review in twelve countries By

Department of Health Policy, Development andServices

Evidence and Information for Policy, WHO

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Introduction

In recent years number of specific strategies for improving

health services and strengthening health systems have been

consistently advocated.

The 2003 & 2004 World health report proposed improving

rewards to health workers to improve productivity, along with

deploying community health workers and engaging

communities in their health care.

The world development report 2004 advocated Contracting,

Local government financing, Empowering communities, and

using Vouchers and other approaches to subsidize key health

services to the poor.5

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In addition to analyzing the role of selected strategies in

specific countries over the last 5 years, the study examined

the salient features and dynamics of each national health

system and broader context within which it operates, and

highlighted developments and events that are likely to have

had a bearing on decision made in the health sector.

The study considered both scale and scope so as to shed light

not only on the details of the strategies under review, but also

to explore factors enhancing or inhibiting the country-wide

implementation of the promising innovation.

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Study ApproachSelection Strategies: Was finalized at a meeting of WHO,

World Bank Staff and Consultants. Focusing on the delivery

mechanisms and management systems and mixed bag of

diverse strategies, final list was chosen and it comprised of

following innovative strategies:

1. Contracting2. Delegation of authority

3. User fee exemptions

4. Subsidies for the poor

5. Performance-related pay and incentives

6. Reorganizing the outreach workers

7. Social marketing

8. Community engagement

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Organization

& financing

Humanresource

management

Creating

demand &

accountability

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Selection of the study countries:

In all 12 countries were selected with a view to covering a

wide spectrum of situations, including 3 falling in the

categories of fragile states(according to the world banks

country policy and institutional assessment). The selected

indicators were:

1. Population

2. GNI per capita

3. Under 5 mortality

4. Total fertility rate

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Method:

1. Multiple IndicatorC

luster Surveys2. Data were gathered primarily by desk reviews

3. Literature search through PubMed

4. Searching for unpublished documents

5. Field visits: To explore in greater depth the factorsunderlying health service results and constraints to

country-wide implementation

Preliminary findings were further reviewed in key informantinterviews with selected WHO and World Bank staff.

Consultation were also held to review the findings and to

engage in a wide-range discussion of their implications for

WHO.9

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Context

There were divergent patterns of health services outputs

across each country, with each country demonstrating

improvements in some areas of health service delivery.

In nearly all countries, when there was progress in health

service outputs, the changes tended to be small and gradual,

rather than showing radical change.

Progress in the health service outputs tended to occur in one

or only a limited number of areas. Even where a particular

program is achieving some success in service delivery, there

was little positive effect on other program areas.

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Adaptation and Implementation

A framework was developed to assess how and to what extent the

individual strategies were developed, adopted and implemented.Three distinguished categories were identified i.e.

1. Development & adoption strategy

2. Plans for scaled-up implementation

3. Record of actual implementation.

These categories were further classified depending upon varying

degrees of adoption and implementation of strategies, taking into

account the pilot projects

1. Full-scale implementation from outset

2. Timeframe of implementation

3. Geographical coverage.

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Indicators of health service output

1. Antenatal coverage

2. Skilled birth attendance

3. Full immunization

4. HIV knowledge

5. Child bed net use

6. TB-case detection rate

7. TB successful treatment rate

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Findings and Discussion

Development & adoption of strategies:Ministries of health in each country are either

implementing or planning to implement at least 2 of the

strategies under study, confirming the relevance of these

strategies across a wide range of low-income countries.

Strategy development & adoption were categorized in to

1. No plan

2. Under review/development3. Adopted strategy/plan

4. Two distinct strategies pursued

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The data suggested that there may be a

relationship between openness to innovation

and ability to deliver services that allows

countries

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Implications for Hospital Administrator

Approaches to subsidize key health services for the poor and

their implementation (Contracting, local government

financing, empowering communities, and using vouchers etc.)

Improving health services and strengthening health system by

developing, adopting and implementing innovative strategies

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Thank you

6JCPM

;QW

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