Title: Striking Synergies between Global Health Initiatives and Health Systems: the research and learning i
1Striking Synergies between Global Health
Initiatives and Health Systems the research and
learning imperative
- Tim Evans
- Assistant Director General, Information Evidence
and Research Cluster, WHO - XVII International AIDS Conference,
- 4 August 2008, Mexico City
2Outline
-
- The Opportunity
- Three levels of "research"
- Clinical and community, the "coal face"
- Systems supports
- Comprehensive Evaluation.
- Scaling up research and learning
- A new science?
- Essential capacities
3A learning opportunity
- Its an opportunity!
- Beyond false dichotomies
- GHIs/national programs are part of the system
- Necessary but not sufficient conditions
- Universal Coverage for HIV or for ALL?
- Learning to strengthening performance of health
sector - faster
- And more equitably
- Can't afford to miss this opportunity!
- Enhance returns on investment
- Prevent adverse consequences.
4- "poor TB services" deemed the underlying reason
for emergence of XDR-TB. - Insufficient vehicles
- No TB satellite centres
- Inadequate supervision of patients beyond
hospital - Interruption in supply chains
- Unacceptable rates of "first line" 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)
5Striking synergies a three level approach to
research
- Community/Clinical
- the "coal face", delivery models
- Systems support
- pillars, building blocks, foundations
- Comprehensive assessment
- monitoring and evaluation
61. The coal face
7Evidences of Synergies
- Patients
- empowered, treated with respect by services,
vibrant support groups - Providers
- Improved CARE (Competencies, Availability,
Responsiveness, Efficiency) due to task
shifting, better pay, working conditions and
supervision - Information
- Electronic Medical Records, SMS alerts,
side-effect management, timely communication of
laboratory tests - Supplies
- improved procurement, distribution and inventory
management - Infrastructure
- new and better equipped facilities, promotes
confidentiality, appropriate privacy, clean and
safe - Financing
- largely free at point of service, lower indirect
costs savings from decreased hospitalization,
8Synergies leading to systems transformation
9Health systems building blocks for prevention and
control of Non-Communicable Diseases (NCDs)
and HIV
HIV STRATEGIES
NCD STRATEGIES
National Plans
National Plans
Surveillance
Surveillance
Commonalities between health priority strategies
and links to health systems building blocks
Healthy Lifestyles
Safe sex
Clinical prevention and treatment
Treatment
Continuing Care
Continuing Care
Strengthened health system platform to support
delivery and equity
Stewardship
Health financing
Human resources
Medicines, infrastructure and logistics
Health Information systems
Service delivery
10Fostering Innovation
112. Essential Systems Supports
12The building blocks of systems also require
dedicated attention
- Linkages or "integration" with other service
delivery priorities - HIV and non-communicable diseases
- Stewardship
- National governmental, Non state sector
- Global - Donor and multi-lateral behaviors
- Financing
- National and Global
- Workforce
13World Health Report 2006 Critical shortage of
health workers in 57 countries 4.3 million more
health workers needed to provide essential
interventions.
14A crisis in education
- Institutional Insufficiencies!
- numbers, location, type (providers/public health)
- Accreditation absent!
- Unregulated expansion of private sector training
opportunities - Faculty fleeing!
- poor pay, unsupported, poor career prospects
- Precarious pedagogy!
- Outdated curricular content, teaching methods and
materials - Students starving!
- Enrolments stagnating, high fees rates of
attrition, - Investment Inefficiency!
- capacity building is low yield, e.g. "Hotel
Training" - Spending more on "technical assistance" than
building in-country capacity
15A growth industry!the increasing share of
"technical assistance" as a percentage of
overseas development assistance
Figure 6. A growing mar.
163. Comprehensive Assessment
.
17Framework for monitoring performance and
evaluation of the scale-up for better health
Process
Inputs
Outputs
Outcomes
Impact
Funding Domestic sources International
sources Plan Coherent, prioritised and
funded Harmonization Aligned international
efforts with national plan Well coordinated and
harmonized support
Health system strengthened Governance, HR,
medical products, information
Increased service utilization and intervention
coverage Reduced inequity (e.g. gender,
socio-economic position) Responsiveness No
drop-off non-health sector interventions (e.g.
water sanitation)
Improved survival Child mortality Maternal
mortality Adult mortality due to infectious
diseases Improved nutrition Children Pregnant
women Reduced morbidity HIV, TB, malaria, repr.
health Improved equity Social and financial
risk protection Reduced impoverishment due to
health expenditures
Improved services
Access, safety, quality, efficiency
National plan implementation Systems
strengthening Priority interventions
scale-up Capacity building Programmes Institution
s People Accountability Performance
monitoring Results focus and evaluation Use for
better practices
M E action
Aid process monitoring Resource tracking
Implementation Monitoring
Health system monitoring
Coverage monitoring
Impact monitoring
Strengthen country health information systems
Evaluation process, health systems
strengthening, impact
18Comprehensive Assessment
- If gold standard evidence for clinical medicine
is the RCT, what is it for scaling up health
systems and striking synergies with GHIs? - Retrospective
- case studies of success and failure
- Prospective
- Four cell designs
- Real time experiments in implementation
- Innovative randomization
- New Approaches to research
- Complex adaptive systems
19Scaling up Research and Learning
- An emerging "field" of research
- beyond the RCT?
- science to illuminate the black box of delivery?
- Comparative analyses of high and low performers?
- savvy (vs serendipity) in striking systems
synergies? - Essential Research Capacities
- Information/evidentiary systems
- basic, real-time, e-systems
- Research workforce
- scope, teams, beyond investigator led, mentors
- Institutional integrity
- sustained support, independence, effective
twinning
20Scaling up Research and Learning
- Rapid growth in new initiatives
- Doris Duke Foundation "Africa Health
Initiative" - PEPFAR "Public Health Evaluation"
- Gates "Delivery"
- IHP "Common Monitoring and Evaluation
Framework" - GAVI "Health Systems Strengthening Window"
- Working together
- Director General, Task Force on "scaling up
research and learning for better health" - August 5, 2008 Joint WHO/WB Launch of GHI and
HSS - November 17-19 Bamako Ministerial Forum on
Research for Health.