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Evaluating the system-wide effects of HIV scale-up: methodological gaps, challenges and recommendations . David Hotchkiss Health Systems 20/20/Tulane University. Introduction. Wide agreement that further evidence is needed on how GHIs have influenced health systems

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Evaluating the system-wide effects of HIV scale-up: methodological gaps, challenges and recommendations

David HotchkissHealth Systems 20/20/Tulane University

introduction
Introduction
  • Wide agreement that further evidence is needed on how GHIs have influenced health systems
  • Research in this area has been characterized as serendipitous rather than systematic
  • Black box between inputs and outcomes, and intended and unintended effects, still needs illumination
overview
Overview
  • What type of evidence is needed?
  • What are the obstacles to evaluation?
  • What are the available M&E approaches?
  • Where do we go from here?
what type of evidence is needed
What type of evidence is needed?
  • Routine monitoring
    • Monitoring of global goals and GHIs
    • Country-level health system and program monitoring focused on inputs, processes and outputs
  • Special purpose evaluations of the impact of health systems strengthening initiatives
  • All these aspects are overlapping and require an integrated approach at the country and global levels
what are the obstacles to evaluation
What are the obstacles to evaluation?
  • Evaluations require collective action
    • Systems research traditionally has not received adequate financial support
    • High quality studies “do get done, but not in the numbers or with the quality that are justified by the global benefits” (CGD 2006)
  • Arrangements for prospective HSS assessments typically not built in from the beginning
    • Too little investment in baseline survey data
    • No treatment and control groups to assess counterfactual
what are the obstacles to evaluation 2
What are the obstacles to evaluation? (2)
  • Routine tracking data should provide much of the data required for evaluation, but unfortunately, RHIS data are often incomplete and of poor quality
  • Attribution is challenging from a technical perspective
    • Systems strengthening a long-term, complex process
    • GHIs are also extremely complex and dynamic
    • Difficulty in attributing impact to any one GHI
  • Other factors, including concern about possible unfavorable results and limited capacity
what approaches and methods are available for monitoring
What approaches and methods are available for monitoring?
  • National Health Accounts and Sub-Accounts, a tool for tracking sources and uses of funds
    • Comparison of NHA data over time can yield useful insights on system-wide effects
  • Health Systems Assessment Approach: A How-To Manual (Health Systems 20/20)
    • Provides indicators and sources of data by WHO’s health system functions
what approaches and methods are available for evaluation
What approaches and methods are available for evaluation?
  • Retrospective
    • Global cross-country comparative analysis
    • Country-level mixed methods analysis (quantitative and qualitative, including case studies)
  • Prospective
    • Experimental designs assessing impact of interventions; economic evaluations of costs and benefits
  • Consider intervention-specific approaches
    • For some types of interventions, such as financing, service delivery, rigorous methods are available
    • For others, such as RHIS, more work is needed
where do we go from here
Where do we go from here?
  • Great opportunity exists to invest in systems research
    • GFATM and GAVI increasing systems funding
    • G8 placing more emphasis on systems strengthening
    • IHP+ has developed a common evaluation approach
  • Develop “a new field of science for health outcomes and systems research among a constituency that has been fragmented in the past” (MPS 2008)
what does this involve
What does this involve?
  • Advocate rigorous M&E as a key component of the health systems strengthening agenda
  • In establishing HSS objectives of GHIs, establish systems to monitor and evaluate process
    • Align health systems M&E with implementation, country planning cycles and mechanisms
  • Continue to develop frameworks, metrics and methods
    • Invest in RHIS to strengthen data quality and use
    • Develop intervention-specific frameworks and methods
    • Continue to develop mixed-methods approaches
    • Look for opportunities for prospective evaluations
selected references
Selected references

Atun RA, Bennett S, Duran A. When do Vertical (Stand-Alone) Programmes Have a Place in Health Systems? Policy Brief, WHO European Ministerial Conference on Health Systems, 25-27 June, 2008, Tallinn, Estonia.

Banteyerga, H, Kidanu, A, Stillman, K. (2006). The Systemwide Effects of the Global Fund in Ethiopia: Final Study Report. Bethesda, MD: PHRplus. Abt Associates Inc.

Global HIV/AIDS Initiative Network (GHIN) (2006). A Generic Guide to Research Practice: Following discussion at Lilongwe workshop of GHIN African teams.

International Health Partnership (2008) Monitoring Performance and Evaluating Progress in the Scale Up for Better Health: A Proposed Common Framework. M&E Working Group.

Kruck ME, Freedman LP (2008) Assessing Health System Performance in Developing Countries: A Review of the Literature. Health Policy 85.

Rockefeller Foundation (2008) Leveraging HIV Scale-up to Strengthen Health Systems. Report of high-level meeting in Bellagio, Italy, 2-5 September

WHO (2007) Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes. WHO, 2007.

selected references 2
Selected references (2)

WHO (2008) Maximizing Positive Synergies Between Health Systems and Global Health Initiatives. Report on the 3rd expert consultation, WHO, Geneva, 2-3 October.

WHO Maximizing Positive Synergies Collaborative Group (2009) An Assessment of Interactions Between Global Health Initiatives and Country Health Systems. The Lancet (373) June 20.