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Health Systems Development for Equity Ritu Sadana, MSPH, DS Senior Scientist and Policy Analyst

6 December 2005 Bellagio, Italy. Health Systems Development for Equity Ritu Sadana, MSPH, DS Senior Scientist and Policy Analyst Office of the Assistant Director General Evidence and Information for Policy WHO, Geneva.

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Health Systems Development for Equity Ritu Sadana, MSPH, DS Senior Scientist and Policy Analyst

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  1. 6 December 2005 Bellagio, Italy Health Systems Development for Equity Ritu Sadana, MSPH, DS Senior Scientist and Policy Analyst Office of the Assistant Director General Evidence and Information for Policy WHO, Geneva WHO

  2. Take a systems perspective • Context and policies matter • Monitor good intentions - for equity WHO

  3. What makes up a health system? • Social Values • Context • People's needs • Responsibility - accountability • Boundaries • Goals • Functions • Inputs WHO

  4. SOCIAL GOALS AND SYSTEMS SOCIAL SYSTEMS SOCIAL GOALS Economic Education Health Political Cultural Other Education Health Consumption Democratic participation Knowledge Other Responsiveness Fair financing WHO

  5. Main Social Goals to Which Health Systems Contribute LEVEL DISTRIBUTION Health x x Responsiveness Efficiency x x Financial Contribution x Quality Equity WHO

  6. Goals of health systems • Improving health status • Reducing health inequalities • Enhancing responsiveness of systems • Protecting people equitably from financial loss associated with ill health WHO

  7. WHO

  8. Goals of health systems • Improving health status • Reducing health inequalities • Enhancing responsiveness of systems • Protecting people equitably from financial loss associated with ill health WHO

  9. Respect for persons Dignity Confidentiality Autonomy Communication Client Orientation Prompt attention Access to social support networks Quality of basic amenities Choice of provider Components of Responsiveness WHO

  10. Goals of health systems • Improving health status • Reducing health inequalities • Enhancing responsiveness • Protecting people equitably from financial loss due to ill health WHO

  11. Number of People with Catastrophic Expenditure and Impoverishment Due to Health Spending, Annually WHO

  12. Stewardship (oversight) Responsiveness Resource development Service delivery (provision) Health Financing (collecting, pooling and purchasing) Functions and Goals of Health System GOALS / OUTCOMES OF THE SYSTEM FUNCTIONS THE SYSTEM PERFORMS I N P U T S Quality Coverage Fairness in financial contribution Efficiency WHO

  13. WHO

  14. Distribution of health workers, urban versus rural, Australia Source: Australia's Health Workforce. Productivity Commission Position Paper. Canberra, 2005. WHO

  15. % of people not using any service when reporting illness, 13 countries, asset Qs WHO

  16. Poorer Richer Inequities in access to drugs 35 30 % children in rural areas with probable pneumonia who received an appropriate antibiotic, 2000 25 20 15 10 5 None Source: Schellenberg et al. THE LANCET • Vol 361 • February 15, 2003 0 Low 2nd 3rd 4th Highest SES quintiles WHO

  17. Universal coverage – effective services to all those in need Effective Coverage Identification and implementation to "scale up" each type of coverage Contact Coverage Acceptability Coverage Accessibility Coverage Availability Coverage Tanahashi 1978 Total or Target Population WHO

  18. Inter-country variations in levels of mortality in 67 developing countries explained by indicators of care and context 100 Unexplained variation 90 Variation explained by financial inputs and responsiveness 80 70 Variation explained by human resource density 60 % of variation explained 50 40 Variation explained by interaction between care and context 30 20 Variation explained by contextual factors 10 0 Infant Mortality Postneonatal Mortality Neonatal Mortality Maternal Mortality Fuente: World Health Report 2005, pg 83, WHO

  19. Functions and Goals of Health System FUNCTIONS GOALS / OUTCOMES THE SYSTEM PERFORMS OF THE SYSTEM } { ? Stewa r dship I Health C r eating r esou r ces (level and equity) N (investment and training) P Responsiveness Service delivery (to people ’ s non-medical (personal and population- expectations) U based) Financial p r otection T Financing (and fair distribution of burden of (collecting, pooling and funding) purchasing) WHO

  20. Stewardship (oversight) Responsiveness Resource development Service delivery (provision) Health Financing (collecting, pooling and purchasing) Functions and Goals of Health System GOALS / OUTCOMES OF THE SYSTEM FUNCTIONS THE SYSTEM PERFORMS How will functions reach objectives? What should be strengthened? How coordinated? How sequenced? How to account for each context? How to align/shape with political agenda? With global influences? With competing priorities? etc. I N P U T S Quality Coverage Fairness in financial contribution Efficiency WHO

  21. Take a systems perspective • Context and policies matter • Monitor good intentions - for equity WHO

  22. Related national objectives Generic goal Intermediate objectives Increased vaccination coverage Improved quality of antenatal and delivery care Reduced IMR, MMR Improved access to safe delivery services Improve health status Improved maternal and infant nutrition Improved quality of primary prevention and outpatient management of hypertension Reduced morbidity and mortality related to hypertension Increased patient ability to reduce risk factors From generic goals to specific objectives: an example WHO

  23. Possible reform Function Re-organize PHC Service Delivery Evidence-based clinical guidelines New GP and family nursing curricula Resource Creation Renovate and equip maternity services Geographic redistribution formula Financing Incentive payments for coverage targets Monitor compliance with new guidelines Stewardship Promote production of iron-enriched food Identify reforms that link to objectives Intermediate objectives National objective Increased vaccination coverage Improved quality of antenatal and delivery care Reduced IMR, MMR Improved access to safe delivery services Improved maternal and infant nutrition WHO

  24. Possible reform Function Service Delivery Resource Creation Financing Stewardship TB objectives & system reforms Intermediate objectives National objective Increased vaccination coverage ? Improved case detection Reduced TB Improved access to quality services Increased cure rates among poor WHO

  25. "Problem of TB in EURO countries exists principally not because health ministries don’t know about DOTS or that more training is needed – the main obstacles to effective implementation of interventions are systemicand require a coordinated, multi-functional response" Regional Committee Meeting presentation on health systems strengthening, EURO, Sept 05 WHO

  26. Components of stewardship, governance, leadership Pre requisites to …… Exercise…… High quality information setting strategic policy direction ensuring available intelligence Level autonomy from global processes Within health sector Mechanisms exist for Accountability / transparency coalition building 'tools and rules' Beyond health sector Social participation and empowerment Structure fits strategy Right mechanisms to steer the Health System WHO

  27. Availability of cause of death data from vital registration systems (192 countries) WHO

  28. WHO

  29. Key challenges WHO

  30. Areas for Support & Action – responding to problems and challenges WHO

  31. Example: support to better integrate "vertical" programs Nat'l TB P Nat'l AIDS CP Managerial functions of NTP • Planning • Resource allocation • Logistics • Monitoring • Supervision • Training National level National level Intermediate level Intermediate level CollaborativeInterventions Managerial functions of NACP • Planning • Resource allocation • Logistics • Monitoring • Supervision • Training Districtlevel Districtlevel Service Delivery Functions (NTP) • Detecting suspects • Diagnosing cases • Treating cases Primary Care Services level Service Delivery Functions (NACP) • Counselling & testing • Detecting sick people • Treating them • Promotion & prevention Community level WHO World Health Organization

  32. Take a systems perspective • Context and policies matter • Monitor good intentions – for equity WHO

  33. Universal coverage – effective services to all those in need Effective Coverage Identification and implementation to "scale up" each type of coverage Contact Coverage Acceptability Coverage Accessibility Coverage Availability Coverage Tanahashi 1978 Total or Target Population WHO

  34. Recent studies from child health • … Moser et al., BMJ, 2005: examined changes in inequities in 22 countries over 10 year period, using DHS • Mortality highest in poorest vs. least poorest quintile across all countries • 4 countries improved average levels, yet 7 countries increase ratio between poorest and least poor WHO

  35. Recent studies from child health • … Victora et al., Lancet, 2005: examined clustering of preventive interventions in 9 countries, using DHS • Inequities were inversely related to coverage …"raises the possibility that introduction of new technologies might primarily benefit children who are already covered by existing interventions" WHO

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