STRENGTHENING HEALTH SYSTEMS

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STRENGTHENING HEALTH SYSTEMS

• Anne Mills
• DCPP Editor
• London School of Hygiene and
• Tropical Medicine

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BACKGROUND

• Core of DCP2 is evidence and analysis of burden
  of disease and cost-effectiveness
• Interventions usually delivered through a health
  system
• Cost-effectiveness data usually reflect a
  reasonable level of technical efficiency may
  not be readily achievable in real life
• Need to know how best to strengthen health
  systems so they are able to deliver interventions
  cost-effectively and at scale

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AIM OF PRESENTATION

• Summarise key messages from the wealth of
  evidence in the chapters of DCP2 concerned with
  strengthening national health systems

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STRENGTHENING HEALTH SYSTEMS

• Stewardship/regulation
• Organisational structures and their financing
• General management functions - human resources
  and quality assurance
• NB
• Lack of evidence
• Effectiveness of approaches depend on starting
  point

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STEWARDSHIP/REGULATION

• Strengthen accountability to communities and
  increase user voice (eg Burkina Faso Ceara)
• Enforce regulations (where capacity exists)
• Use approaches that work with the private sector

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ORGANISATIONAL STRUCTURES AND FINANCING

• Clarification of purchaser and provider roles
  within public health sector
• Decentralisation to hospitals and districts
• Vertical versus horizontal modes of organising
  and managing service provision
• Contracting out service provision

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Improved health care coverage rates
CONTRACTING EXPERIMENT IN CAMBODIA 1997-2001
(Swartz and Bushan 2004)
Poor benefited more than richer groups
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HOSPITAL CONTRACTS IN SOUTH AFRICA

• Contractors costs lower than public similar
  quality
• Cost advantage largely due to higher staff
  productivity
• Contract cost to government gt government cost of
  provision
• Study led to re-negotiation of contract terms

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CONTRACTS WITH GPs IN SOUTH AFRICA

• Formal aspects of contracts had little influence
  (eg design, monitoring, sanctions)
• Social and institutional factors important
• Contracts highly relational and context
  specific
• Policy implications emphasise cooperation,
  shared interests, professionalism

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HUMAN RESOURCES

• Use local cadres (not internationally mobile)
  give specific skills (eg Malawi caesarean
  section training to clinical officers)
• Use incentive payments if can be regulated and
  controlled
• Otherwise use broader performance management
  approach emphasising non financial rewards

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QUALITY ASSESSMENT/ASSURANCE

• Good quality possible even in highly resource
  constrained settings
• Evidence that two approaches can work

• Policies which directly affect individual and
  group practice (eg shopkeepers, Kilifi)

• Policies which change structural conditions and
  indirectly affect providers (eg contracting)

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TARGETING RESOURCES

• Systems level eg resource allocation formulae
  financial incentives to users
• Service level eg planning and budgeting
  frameworks consumer education and information

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THE TANZANIA ESSENTIAL HEALTH INTERVENTIONS
PROJECT (TEHIP) (de Savigny et al 2004)

• Provided tools for district level decision makers
  to influence resource allocation
• Linked burden of disease data with expenditure on
  interventions
• Showed improved match between disease burden and
  district budget

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THE CONTRIBUTION OF TEHIP TO IMPROVED HEALTH
OUTCOMES
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SELECTED KEY MESSAGES

• Keep the health of the system in mind whenever
  major new programmes are put in place - ensure
  disease-specific efforts contribute to system
  strengthening
• Reforms affecting organisational structures and
  human resource management more likely to be
  successfully implemented if they are incremental
  and gradual
• Successfully linking financial incentives to
  performance dependent on careful monitoring
  difficult in low income settings without
  continuing external involvement
• Capacity strengthening required at all levels

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SELECTED RESEARCH PRIORITIES

• Cost and effectiveness of approaches to
  strengthening system capacity
• Identification of delivery strategies that can
  maintain high coverage for specific interventions
  
• Identification of governance and institutional
  arrangements that will help achieve health
  improvements for the poorest

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RESEARCH CAPACITY STRENGTHENING (Source
Alliance for Health Policy and Systems Research
2004)

• Project funding for health systems research lt
  0.02 of annual developing country health
  expenditure
• More than half of research projects had budgets lt
  25,000
• A third of institutions engaged in health systems
  research had no doctoral level staff
• Only 5 percent of health systems research
  literature in Medline concerns developing
  countries
• Great need for strengthening capacity in health
  systems research