IAPB 9th General AssemblyEye Health: Everyone’s BusinessHyderabad, IndiaSeptember 17-20, 2012

Scaling up:

Perspectives for VISION 2020

Prof. Don de SavignyHealth Systems ResearchDepartment of Epidemiology and Public Healthd.desavigny@unibas.ch

“VISION 2020: The Right to Sight aim to eliminate avoidable blindness by 2020…. will not be achieved by

eye care services acting in isolation.”

Karl Blanchet. Indian Journal of Ophthalmology 60: (2012)

“More authorities are becoming aware that campaigns for the control of diseases will have only temporary effects if they are not followed by the establishment of permanent health services to deal with day-to-day work in the control and prevention of disease and the promotion of health.”

Annual Report of the Director-General, WHO

Brock Chisholm

1951

Increasing fragmentation in Global Health

Many Global Health Alliances, Partnerships, Consortia, and Initiatives

Mobilizing substantial resources

Most with a single disease or single intervention focus

Huge potential to support or weaken fragile health systems

No obvious Global Health architecture or leadership

Vision 2020 strategy

cost effective disease control interventions; human resource development; and infrastructure development

Guiding principles (ISSE):

Integrated into existing health care systems

Sustainable in terms of money and other resources

Equitable care and services available to all

Excellence – a high standard of care throughout

Objectives:

increase awareness  identify and secure the necessary resources facilitate national programmes

This requires a deliberate convergence of disease-specific programme managers with health system developers.

Not so easy….

Ooms et al. BMC Globalization and health (2008)

The problem of verticality & the difficulty of integration

Scaling up: a definition

‘‘The ambition or process of expanding the effective coverage of health interventions

through programmes, services or systems’’

Scaling up: Not just multiplication

Pilot Projects

National Programmes

Sustainable integration in health systems

Where we usually stop;

Where indicators stagnate and targets become elusive …

New way of thinking required

Scaling up assumptions Linear, pre-planned process;

Simplistic, deterministic;

Standardized methods for predicting human and financial resources;

What works in small scale and specific contexts will easily replicate elsewhere

Real world system behaviour Non-linear, not predictable, not

controllable;

Highly heterogeneous actors and contexts;

Complex dynamics with unexpected feedback loops, delays and unintended consequences

Systems integration of Vision 2020 programmes: some perspectives

Governance structure, leadership, policy dialogue, network analysis, stakeholder

engagement, & ownership

Going beyond programme “M&E” to routine information flows

In national strategic plans, NHA and MTEF with

performance management

Comprehensive, patient centered, effective coverage across a continuum of care

Recognize and respond to local contexts and emergent behaviours

Standards of care from inter-

professional teams

Quantification, procurement and supply

chains that work

Work at interfaces: E.g. Relate disease burden

information to financing

Understand dynamic health system relationships &

demand

India’s intervention targetable burden

in Shares of total DALYs

Success factors in scaling up…

strong leadership and governance with active stakeholder network analysis, management and ownership

choosing simple integrated packages widely agreed to be valuable,

active engagement of a range of implementers and of the target community,

flexibility in tailoring the scale-up approach to local contexts, and

incorporating research before and along with implementation.

Scaling up is not predictable or controlled Use theories of change to develop local organizational, functional & political

capacities; Identify constraints & complex pathways Learn by doing Apply systems thinking ………..

Lessons for integrating in systems

(Modified from Yamey. PLoSMed 2011)

Paradigm shift?:Why engage with systems, and why now…

“Systems Thinking” is the language, and

“Systems Science” is the discipline for such a shift.

Approaching 2020 will benefit from increasingly sophisticated approaches to tipping points in complex adaptive health systems.

Vertical funding is often necessary at the beginning, but as health systems develop, separate mini-health systems for each disease and problem is wasteful and inefficient.

Thank you