Post on 30-Dec-2015
description
An Assessment of the Interactions between health systems and Global Health Initiatives
Tim EvansAssistant Director-General
Information, Evidence and ResearchWorld Health Organization
Common challenges to scale up services for HIV, TB, malaria, and immunization
HIV/UA assessment report
Global Plan to stop TB
World Malaria report
GAVI/Norad report
• Inadequate financing• HR crisis • Affordable commodities • Stigma, discrimination…• Accountability
• Partnership alignment • Inadequate financing • Laboratory capacity • HR crisis • Quality drugs
• Drug efficacy • Information system • Inadequate financing
• HRH and Community
services • M&E
• HR crisis • Inadequate financing • Leadership and
management • Inter-agency
coordination
World Health Report 2006
Critical shortage of health workers in 57 countries;
4.3 million more health workers needed to provide essential interventions.
"poor TB services" deemed the underlying reason for emergence of XDR-TB.
•Insufficient vehicles
•Inadequate supervision of patients beyond hospital
•Interruption in supply chains
•Unacceptable rates of "first line" treatment failure
•No response to evidence of "first line" failure
•Sloppy "second line" treatment practices
•Poor infection control in hospitals (over-crowding)
•Missing laboratory support structures (resistance monitoring)
Systems Performance Shortfalls
• Scale --- safe, proven and cheap interventions not reaching those in need
• Scope --- comprehensive services responding to needs and expectations are the exception
• Distribution --- those with unmet needs are disproportionately those with lesser means
• Protection/Safety --- too many are worse off through encounters with the health system
• Systems capabilities --- primitive frameworks and responses to dealing with complex challenges
2. Concepts and Methods
• Global Health Initiatives
• Country Health Systems
• Conceptual Framework
• Methods
Global Health Initiatives
• Address priority health problems of developing countries
• Focused on specific diseases, selected interventions, or commodities
• Generate substantial funding (billions!) for these priorities based on strong culture of results
• Transnational in organization and operations:• Invite proposals from countries for support• Independent technical review of proposals• Make direct investments in countries
• Dynamic, evolving…
Health Systems
The main goals are:– Improving health and health equity– Responsiveness, – Financial fairness
The intermediate goals are:– Greater access and coverage– Quality and safety
A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health
Methods
• Inputs: – Literature searches
• >250 studies from published and grey literatures, – Call for original data
• 15 new studies (Table 2)
• Analysis – review of evidence on interactions– more "association" than "causation"– may change with time– what is the point of comparison?
• No GHIs; Pre/Post-GHI?; between GHIs?
Assessing the nature of the interactions
Positive, synergistic
Equivocal, unclear, mixed
Negative, undesired
3. Findings
• Service delivery
• Governance
• Financing
• Health Workforce
• Supply management
• Information systems
Findings - service delivery
•Access
• Rapid expansion targeted services
•Expansion of non-targeted services e.g.
maternal health
•Supply-induced demand
•Equity
•Services free at point of service
•Focus on marginalized populations
•Quality
•Promoting universal standards of care
•Rush to meet targets compromising quality
•Planning and Coordination
•Demands of GHI planning processes
overwhelm national capacities
•GHIs responsive to country systems needs
through new funding windows
•Community Involvement
•GHIs have accelerated non-state sector/civil
society engagement in health sector
planning, delivery and accountability
Findings - governance
•Total Financing
•GHIs linked to recent surge in health ODA
•Unclear association between GHI and
domestic health financing
•Aid Effectiveness
•GHI funding more; "predictable";
"sustainable" e.g. Innovative Financing
mechanisms; "responsive" to global burden
of disease;
•GHI funds skew country priorities
•Out-of-pocket expenditures
• GHIs have promoted principle of free
services and subsidies but have not
invested in prepayment systems
Findings - financing
Findings - health workforce•Production and Strengthening
•Limited investment in expanding the workforce
through pre-service training
•Better productivity of existing workforce
through in-service training, task shifting,
supervision and material support
•Distribution
•Workforce drawn away from non-targeted
services
•Incentives get workers to remote areas
•Retention
•Brain drain from public to private sector due to
better pay
Findings - supply management systems
•Procurement and Distribution
•Rapid improvements in availability
and affordability of commodities
•Strong GHI-owned systems duplicate
and displace national supply chains
•Quality
•Improvements in quality through pre-
qualification and agreement on global
standards
Findings - health information systems
•Availability and Accuracy
•Disease surveillance and service coverage
data specific to GHIs is improving.
•Chronic weaknesses of information systems
largely ignored esp. vital statistics and
measures of health systems performance
•Use and Demand
•Dominance of stand-alone info systems is
inefficient and burdensome
•Growing demand and funding for more
comprehensive HIS
• Innovation
•Electronic records are improving efficiency
and quality of care
Piecing together the big picture
• There is ample evidence of:– "strong synergies"; – "serious shortfalls";– And "uncertainty"
• Actions need to be developed towards:– Amplifying synergies– Stemming shortfalls– Understanding uncertainty
Challenging the way we do business
• Beyond false dichotomies
• Necessary but not sufficient conditions:– Universal Access for HIV/AIDS– One M+E for HIV– Global financing mechanisms– Sustainable financing for TB
• No one size fits all
• Harnessing innovation systematically
Overarching Recommendations
1. High Profile Research Agenda
2. Engage decision-makers
3. Country leadership backed globally
4. Increase finance
Learning to do better