Health systems concepts and health systems research

1. Health systems concepts and health systems research Barbara McPake, Institute for International Health and Development, Queen Margaret University, Edinburgh

2. What is a health system? • A health system consists of all the organizations, institutions, resources and people whose primary purpose is to improve health (WHO, 2000) www.qmu.ac.uk/iihd

3. www.qmu.ac.uk/iihd

4. Useful starting point but presents a static framework, emphasises components rather than relationships, and fails to identify what is ‘systemic’ about this system (the interconnectedness of its elements) • Has implications for how ‘health systems strengthening’ (being used by global health initiatives) has been conceptualised and is being implemented. www.qmu.ac.uk/iihd

5. Marchal, Cavalli and Kegels (2009) find that these GHIs are doing 3 kinds of things: • Providing inputs or resources • Reinforcing capacities that are directly related to disease control programmes • Integrating programme activities into general health services www.qmu.ac.uk/iihd

6. ‘(These) HSS strategies are essentially a means to deliver targeted interventions more efficiently, rather than being strategic and directed towards the root causes of health system weaknesses. • ‘Most current HSS strategies are in fact selective, disease-specific interventions, and their effects may undermine progress towards the long-term goal of an effective, high-quality, inclusive health system.’ www.qmu.ac.uk/iihd

7. The effect of the global fund on the drug distribution system in UgandaKyagonza, P. and McPake, B. (2007; unpublished) • Increased investment in procurement of ART drugs has not been followed by a proportionate increase in investment in strengthening drug supply systems. • Scaling up ART has affected the mainstream supply chain for essential drugs and medical supplies through the creation of a parallel supply chain for ART drugs, and the precedence given to management of ART drugs over that of other essential drugs and medical supplies. www.qmu.ac.uk/iihd

8. So, not only do the building blocks seem to lack something quite important in terms of how they describe a health system, but this seems to be reflected in how things are actually being done and what investments are being made, with negative practical implications www.qmu.ac.uk/iihd

9. Health system = system whose output is access to effective (preventative and treatment) health interventions (or activities whose primary purpose is to promote, restore or maintain health) www.qmu.ac.uk/iihd

10. Dynamic responses: How people (‘users’ and ‘providers’) react and interact in response to formal structures and rules De facto system: Services as experienced by (poor) people For example: access; quality Dejure system: Organisational structures Intended incentives Management procedures Training courses Dynamic responses model of the health system www.qmu.ac.uk/iihd

11. The exclusion of the poor from health interventions is systematic – some examples • Worrall et al. (2005) reported differentials in the uptake of malaria control interventions through a global literature review • preventive measures (coils, sprays etc.), • ownership and use of bed nets • choice of healthcare provider for treatment • All used less by the poorest (measured through a variety of indicators). • The poorest were more likely to opt for self-treatment and less likely to use private or higher level public providers. (Compiled by Riquelme and Thiede) www.qmu.ac.uk/iihd

12. Socio-economic conditions impact on access to TB care • China’s 2003 National Household Health Survey revealed that both breadth and depth of TB services were comparatively low in poorer rural areas; both receipt of care and affordability of TB services declined with socio-economic position (Zhang et al., 2007). • A study conducted in Malawi found that direct costs associated with TB service (e.g. food and transport) as well as indirect costs (e.g. work days lost), were particularly significant for women and the poor (Kemp et al., 2007). • A study on access to India’s TB control programme revealed that poor and socially marginalised patients systematically received worse services (Singh et al., 2002) www.qmu.ac.uk/iihd (Compiled by Riquelme and Thiede)

13. Systematic factors underpinning the exclusion of the poor • There are costs of accessing care, even when ‘free’ – the poor have more difficulty in covering these • Non-financial resources including social capital can also be involved in securing access to services – the poor have more limited access to these • Public health services constitute a significant resource – people with power use it to capture an unfair share • As the de jure features of systems are changed to try to counteract these forces, people use their money, social capital and power to reassert the status quo www.qmu.ac.uk/iihd

14. Examples of systemic factors in maternal health www.qmu.ac.uk/iihd

15. The posting system • Almost everywhere there is a serious imbalance of staffing between rural and urban areas that excludes poor rural dwellers from accessing services • Failure of system that directs staff to posts is understood • But alternatives are rarely developed and piecemeal • In Kenya, ‘emergency hire’ programme recruited staff to specific roles in rural areas – but intends to regularise these new staff as public servants - the same strategies that allow staff to relocate to urban areas will become available to them • The posting system entrenches interests that are more powerful than the stated policy objective of equitable access to health services www.qmu.ac.uk/iihd

16. Constraints on migration • In the early 2000s, staff were haemorrhaging from low-income country health systems, especially to the UK • In Ghana nurse migration was constrained by a bond (increased from C2m to C200m in 2005), payable by anyone seeking a qualification verification statement • No similar measure taken to constrain doctor migration which was higher in proportionate terms www.qmu.ac.uk/iihd

17. Divide between family planning and MNC health services • Common for these to be in separate Ministries or branches of Ministries in South Asia • Recognition that this causes overlapping responsibilities for populations, duplication of effort in some areas, gaps in service provision in others • Attempts to integrate the functions founder on the conflicts of interest between the different branches • Family planning creates a stronger power base because its outcomes are more measurable and it is usually better funded externally, than maternal health www.qmu.ac.uk/iihd

18. An ethnography of two labour wards in South Africa • Policies implemented nominally but their intentions ignored • Clinical guidelines • Name badges for nursing staff • Suggestion boxes • More complex or difficult changes, particularly if they impacted on the culture of the facility or challenged existing power dynamics were ignored. www.qmu.ac.uk/iihd

19. ‘Rural allowances’ for staff in South Africa • Only professional nurses and not lower grades of staff received the allowance • High levels of tension in maternity wards • Demotivated staff who did not get the allowance but also demotivated staff that did who felt guilty, embarrassed or awkward • ‘You get the allowance, you do the work’ www.qmu.ac.uk/iihd

20. Attempts by bilaterals and multilaterals in last decade to construct aid as a contract: system of rewards and penalties for good and bad performance • SWAp in Uganda – funding to be provided in response to delivery of agreed undertakings • The achievement of a satisfactory performance rating was facilitated by the agreeing of undertakings that were under-demanding, vaguely formulated and lacking quantitative benchmarks against which progress could be measured. • However, even when poor performance was readily observable, penalties failed to be applied by donors. www.qmu.ac.uk/iihd

21. Dynamic responses: How people (‘users’ and ‘providers’) react and interact in response to formal structures and rules Defacto system: Services as experienced by (poor) people For example: access; quality Dejure system: Organisational structures Intended incentives Management procedures Training courses Dynamic responses model of the health system www.qmu.ac.uk/iihd

22. It is also possible to use the model to better understand how to develop strategies to tackle health system problems; and to better understand the role of health systems research www.qmu.ac.uk/iihd

23. No ‘solutions’ – changes to the de jure system have less than fully predictable impacts on the de facto system – context is critical • System interventions are normally better understood as ‘tools’ than solutions in themselves. • Tools have to be appropriate to the task in hand and can be refined as the fit between tool and task is better understood. • They also have to be applied well, requiring capacities of the user and benefiting from the user learning as the task progresses. www.qmu.ac.uk/iihd

24. Why performance-based contracting failed in Uganda Freddie Ssengooba , Barbara McPake and Natasha Palmer • World Bank and MoH implemented a bonus system for PNFP providers and undertook a controlled trial to evaluate it www.qmu.ac.uk/iihd

25. The World Bank evaluation: a ‘black box’ ‘Intervention’ ‘Performance’ www.qmu.ac.uk/iihd

26. Their conclusion: • ‘..assignment to the performance-based bonus scheme has not had a systematic or discernible impact on the production of health care services provided by PNFP facilities.’ www.qmu.ac.uk/iihd

27. Our evaluation ‘Intervention’ What did it really consist of? Design features Implementation features Who came into contact with the intervention? How did they react? How did they influence others? What chains of effects were initiated and how was hospital performance affected? ‘Performance’ What has been measured? What has not? www.qmu.ac.uk/iihd

28. Key findings • 2-3 members of the hospital management team given a few hours in a one day meeting to choose service targets • Implementers changed the rules; refused to allow managers to change the targets for the second year • The reliability of measured output volumes compromised by ad hoc adjustments to programme • Staff in hospitals that received bonuses frustrated when managers didn’t use them in an agreed, transparent manner • Furious control group: ‘YYY hospital got 10 million and yet zzz hospital is doing far much better. It’s frustrating and lost meaning – done better but no bonus' www.qmu.ac.uk/iihd

29. Insight into the development of strategy • Pay attention to process • Monitor, manage, adapt • Sweeping conclusions – PFP ‘good’ or ‘bad’ cannot be arrived at on the basis of one or a few case studies. PFP is never the same thing in two places • See PFP as a tool, learn, improve, adapt, and compare to alternative tools aiming at the same outcomes www.qmu.ac.uk/iihd

30. Insight into health systems research • Avoid the black box – don’t know what the intervention is or why outcomes • Ask the right questions – avoid questions that demand sweeping conclusions from a limited evidence base • Use research to support monitoring, managing, adapting to context • Over time, build sufficient case study evidence for a picture of which tools most promising in which kinds of context www.qmu.ac.uk/iihd

31. Conclusions • Current ‘health systems strengthening’ investments may be misdirected – in part because they mis-conceptualise the health system • Effective interventions will tackle the systemic causes of the exclusion of the poor – by tackling incentives and attempts to manipulate incentives; challenging distribution of control over resources; not just by making inputs available • Effective health systems strategies and health systems research will use and test interventions as tools rather than implement or reject as solutions in their own right. www.qmu.ac.uk/iihd