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Professor Rifat Atun Professor of International Health Management, Imperial College London & Director Strategy, Policy and Performance Cluster, The Global Fund to Fight AIDS, TB & Malaria. Positive Synergies between Global Health Initiatives. Key Research Questions.

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positive synergies between global health initiatives

Professor Rifat Atun

Professor of International Health Management, Imperial College London &

Director Strategy, Policy and Performance Cluster, The Global Fund to Fight AIDS, TB & Malaria

Positive Synergies between Global Health Initiatives

key research questions
Key Research Questions

What are the extent and nature of integration of GHIs (programmes they finance) and health systems to achieve synergies in varied contexts?

Which factors influence the extent and nature of integration?

How the varied health system designs and delivery structures influence outcomes?

key variables affecting the nature and extent of integration
Key variables affecting the nature and extent of integration

The Problem being addressed

The Intervention

The Adoption System

The Health System characteristics

The Broad Context

Atun, Ohiri, Adeyi, 2008

integrate or not to integrate framework for analysis
Integrate or not to integrate: framework for analysis

Broad Context

Health System Characteristics

Adoption

System

Intervention

Problem

Broad Context

the problem
The Problem

Necessity and Urgency

Burden

Economic and social

Perceived and real

Social Narrative

Transmission dynamics

the intervention
The Intervention

Complexity

Scalability

Simpler to more complex*

Replicability

* See next slide

intervention simple versus complex
Intervention: simple versus complex

Single episode

Less complex

Multiple

elements

Few

elements

More complex

Multiple episodes

Atun and Kyratsis 2007

intervention simple versus complex8
Intervention: simple versus complex

Few stakeholders

Less complex

Multiple

levels

Few

levels

More complex

Multiple stakeholders

Atun and Kyratsis 2007

intervention simple versus complex9
Intervention: simple versus complex

User engagement lower

Less complex

Behaviour

dominates

Technology

dominates

More complex

User engagement higher

Atun and Kyratsis 2007

the adoption system
The Adoption System

Receptivity

Individual & organisational

Political economy

Incentives

agency/provider/user incentive alignment

Legitimacy

Cognitive

Technical

Normative

Economic

health system characteristics
Health System Characteristics

Feasibility

Governance

Structure and organization

Financing

Provider payment methods

Resource availability

Service delivery

M&E system

the context
The Context

Sustainability

Attributability

Fiscal space

Overall and health sector specific

Frailty

Reporting needs

the context13
The Context

Opportunity

Desirability

Critical events

Visibility

Synergy

Technology / innovation

Political economy

Socio-cultural factors

integration into critical health system functions
Integration into Critical Health System Functions

Governance

Reporting

Accountability

Financing

Pooling

Provider payment

Planning

Needs assessment

Priority setting

Resource allocation

integration into critical health system functions16
Integration into Critical Health System Functions

Service Delivery

Structural

Human resources,

Shared infrastructure

Operational integration

Supply chain

Guidelines

Procurement

Monitoring and Evaluation

Data collection and analysis

Demand Generation

Financial incentives – e.g. CCT, insurance

Population interventions – e.g. education and promotion

intervention complexity
Intervention Complexity

Single

Dular - India

Onchocerciasis - Uganda

Nutrition - Peru, etc.

FP/MCH - Matlab, Bangladesh

STD - Mbofana

FP; STD - Lafort

Many

Few

FP/MCH - Pakistan - LHWP

FP/MCH - Nepal (Tuladhar)

Malaria - Colombia

Dengue - Cuba

Leprosy - India, Sri Lanka

Schistosomiasis - Brazil, Burundi, Cameroon, China, Saudi Arabia, Uganda

HIV/AIDS - Haiti

ICDS

IMCI

Mental health - Whetten

Substance abuse - Friedmann

Multiple

Intervention frequency/number of episodes

Intervention

elements

extent of integration success as documented in studies
Extent of integration & success as documented in studies

Fully integrated

Most to all outcomes

Partially integrated

Mixed outcomes

Few to no outcomes

Not integrated

?

?

Unknown

Unknown

extent of integration success as documented in studies21
Extent of integration & success as documented in studies

Governance

Service delivery

Monitoring & Evaluation

Success

Demand generation

Planning

Finance

Dengue

?

Cuba (ToledoRomani2007)

Malaria

Colombia (Rojas2001)

extent of integration success as documented in studies22
Extent of integration & success as documented in studies

Governance

Service delivery

Success

Monitoring & Evaluation

Demand generation

Planning

Finance

Schistosomiasis control

?

?

?

Brazil (Filho1992)

?

?

?

?

Burundi (Engels1993,1995)

Cameroon (Bausch1995,Cline1996)

China (Sleigh1998)

?

Saudi Arabia (Ageel 1997)

?

?

Uganda (Kabatereine 2006)

?

extent of integration success as documented in studies23
Extent of integration & success as documented in studies

Stewardship/Governance

Service delivery

Success

Monitoring & Evaluation

Demand generation

Planning

Finance

Leprosy

India (Rao 2002, Thakar 2003)

?

?

Sri-Lanka (Kasturiaratchi 2002)

extent of integration success as documented in studies24
Extent of integration & success as documented in studies

Governance

Service delivery

Success

Monitoring & Evaluation

Demand generation

Planning

Finance

Nutrition

Peru

Bangladesh (Hossain2005)

?

?

Various (Deitchler2004)

?

extent of integration success as documented in studies25
Extent of integration & success as documented in studies

Governance

Service delivery

Success

Monitoring & Evaluation

Demand generation

Planning

Finance

Child health & development

IMCI*

ICDS - India

(Agarwal2000, Kapil1999)

?

?

?

Dular - India (Dubowitz2007)

extent of integration success as documented in studies26
Extent of integration & success as documented in studies

Governance

Service delivery

Success

Monitoring & Evaluation

Demand generation

Planning

Finance

Family Planning services

Bangladesh – FPHSP (Philips1984, de Graff 1986)

?

?

?

?

?

Pakistan – LHWP

(Douthwaite 2005)

?

?

?

?

Nepal (Tuladhar 1982)

extent of integration success as documented in studies27
Extent of integration & success as documented in studies

Stewardship/Governance

Service delivery

Success

Monitoring & Evaluation

Demand generation

Planning

Finance

HIV/AIDS & STD services

?

?

?

Haiti (Peck 2003)

conclusions
Conclusions

Extent and nature of integration varies

Context matters: complex adaptive systems at play

Reductionist approaches counterproductive: aim to ‘unpack’ what is meant by integration

case study approach
Case Study Approach

Exploratory

Descriptive

Explanatory

design
Design

Logic of design key

Russia TB

Estonia PHC

Africa HIV

Euro PHC

Tech adoption

Baltic PPP

Russia HIV

embedded units
Embedded units

HIV

TB

Malaria

NTDs

Regions

analytic vs statistical generalisation
Analytic vs. Statistical Generalisation

Cases not sampling units but each akin to an individual ‘experiment’

Analytic generalisation using theory developed a priori

Replication logic

n number of case studies support the same theory

n number of case studies do not support a rival theory

Statistical generalisation

Sampling logic

careful case selection
Careful case selection

Literal replication

Each predict similar results (n=4)

Theoretical replication

Predict contrasting results --- but for predictable reasons (n=4)

theoretical framework and propositions key
Theoretical framework and propositions key

State the conditions under which particular phenomena are likely to be found

Allows literal replication

State the conditions when particular phenomena are not likely to be found

Allows theoretical replication

closed vs flexible design
Closed vs. flexible design

Closed but with inductive analysis

Retain replication logic

Build theory as an output

Test ‘additional’ new/alternative propositions

Flexible and inductive

Risk of drift

one or two tail design
One or two tail design

Good outcome

Good and poor outcome

slide38
Data

Mixed methods

Multiple sources

Inductive

Iterative

Triangulation

process
Process

Construct validity

Reliability

Agree theory

Construct validity

Internal validity

Analytical tools

approach & d/base

Generate

propositions

Pilot cases

Refine tools

Rival propositions

Propositions

Case studies

Case studies

Literal replication

Theoretical replication

Explanatory theory & Evidence

Internal validity

External validity

cases
Cases

Africa

Tanzania

Ghana

SE Asia

Thailand

Viet Nam

Embedded units of analysis

NTDs + malaria + TB + HIV

NTDs + malaria + TB + HIV

Malaria, TB, HIV?

Malaria, TB, HIV?