Striking Synergies between Global Health Initiatives and Health Systems: the research and learning i

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Striking 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

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Outline

• 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

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A 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.

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• "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)

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Striking 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

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1. The coal face
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Evidences 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,

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Synergies leading to systems transformation
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Health 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
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Fostering Innovation
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2. Essential Systems Supports
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The 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

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World Health Report 2006 Critical shortage of
health workers in 57 countries 4.3 million more
health workers needed to provide essential
interventions.
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A 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

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A growth industry!the increasing share of
"technical assistance" as a percentage of
overseas development assistance
Figure 6. A growing mar.

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3. Comprehensive Assessment
.
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Framework 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
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Comprehensive 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

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Scaling 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

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Scaling 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.