Recognising the need for whole system change: towards PHC

renewal and universal coverage

ICHS 4

www.hpsa-africa.org

@hpsa_africa

www.slideshare.net/hpsa_africa

Introduction to Complex Health Systems

Contemporary system-

level intervention

s

Source: de Savigny and Adam (2009)

User fee removal

• Remove fees…. AND• Improve drug supply …. AND• Maintain/improve HW motivation …

AND• Improve supportive supervision ….

AND• Strengthen gatekeeping function of

primary care facilities & referral procedures and processes…. AND

Thinking through the inter-linkages of a system level intervention

Remove fees

Strengthen gatekeeping function & referral procedures

Sustain HW motivation

Ensure drug supply to facilities

Strengthen supportive supervision

Whole system change: achieving good health at low cost (Balabanova et al. 2011)

Good governance, effective institutions and bureaucracies,

planning and leadership Not always identified:

clear in Thai case

Fair and sustainable financing

Effective primary care as entry point to referral network

Not always identified:

clear in Thai case

New cadres, large numbers, new roles; payment mechanisms (values)

Drug supply, low cost technologies (ORS)

PHC

UHC

Service delivery

Process through which providers, health facilities, health programmes

and policies are coordinated and implemented so as to reach the

desired outcomes and goals of the health system

van Olmen et al., 2012

General issues in strengthening service delivery

Rules for the system: Unitary vs Plural? Integrated vs.

Fragmented?Managing health workers &

organisations

What are the challenges of implementation? Are we achieving intended

gains?

Funding levels and allocations

What package of services?

How provided: what organisations

& how manage?

Who should deliver

services? How ensure available to

deliver services?

How ensure good

performance?

Appropriate drugs &

technology

Preparing the workforce/Managing attrition/Enhancing performance

WHO 2006

Why PHC? Moving towards health for all requires

that health systems respond to the challenges of a changing world and

growing expectations for better performance. This involves substantial reorientation and reform of the ways

health systems operate in society today: those reforms constitute the

agenda of the renewal of PHC.(WHO 2008)

WHO, 2008

WHO, 2008

Why PHC?• PHC increases access to variety of services for

relatively deprived pop groups• Common health issues best treated by PHC physicians• PHC associated with improved disease and Illness

prevention• PHC manages health issues at early stage, before

conditions become serious and require more complex care

• PHC focuses on individual rather than ailment or disease

• PHC leads to avoidance of inappropriate or unnecessary care

Starfield et al. 2005

The goal of universal health coverage is to ensure that all

people obtain the health services they need without suffering financial hardship

when paying for them. http://www.who.int/universal_health_coverage/en/

index.htmlDG WHO http://www.who.int/universal_health_coverage/videos/en/index.html

PS Ghanahttp://www.who.int/universal_health_coverage/videos/en/index2.html

To achieve UHC need:Strong efficient well-run system; Working

with other sectors

What are the challenges of

implementation? Are we achieving

intended gains?

1) raising funds for health2) reducing financial barriers to access 3) allocating or using funds to promote efficiency and equity

Meeting priority health needs through

people-centred, integrated care

Sufficient, well-trained,

motivated health workers

to provide services to

meet patients’ needs based on the best available evidence

Access to essential

medicines and technologies to diagnose and treat medical

problems

Achieving universal coverage: reducing financial barriersWHO, 2008; see also WHO, 2010

Tackling the 20-40% waste problem (WHO 2010)

Critically assess what care is needed;

Eliminate waste & corruption

Improve hospital efficiency;

Reduce medical errors

Motivate health

workers

Medicines supply most important but also

technology

Settings & Sequence

Actions

Low-income countries and post-conflict settings, first steps

mobilize extra resources for health care 

All contexts (including post-conflict settings), subsequent steps

reduce out-of-pocket payments widen geographical access to comprehensive services re-allocate government resources geographically improve the acceptability and quality of public services enhance technical efficiency (especially in relation to

pharmaceuticals)

Also, in low-income countries consider:

work with non-state providers to extend access and improve quality?

test community-based health insurance?

Also, in middle-income countries, take action over time to:

expand pre-payment widen the benefit/service package provided, including to

poorer groups reduce fragmentation and segmentation strengthen purchasing strategies regulate private insurance

Different systems, different steps……

Governance & Leadership

Overseeing and guiding the whole health system, private as well as public, in order

to protect the public interest through:

Policy guidance & setting roles Intelligence & oversight

Collaboration & coalition buildingRegulation

System designAccountability

WHO 2007

Public policy reforms (WHO, 2008)

• Systems policies: cut across building blocks to support universal coverage and effective service delivery– e.g. Human resources, pharmaceuticals

• Public-health policies: to address priority health

problems through cross-cutting prevention and health promotion

• Policies in other sectors: contributions to health that can be made through inter-sectoral collaboration.

21

Health governance• Efficient, effective, and equitable service provision,

regulation, and management

• Leadership to address public health priorities• Responsiveness to public health needs and

clients’/citizens’ preferences• Inclusion of clients’/citizens’ voice• Transparency in policymaking, resource allocation,

and performance• Evidence-based policy and decision-making• Clear and enforceable accountability

Brinkerhoff & Bossert 2008

Leadership for PHC (WHO, 2008)

• Exercise authority through participation & negotiation, with fair & transparent procedures

• Use wide range of data & information in decision-making, including learning through doing

• Manage the political & implementation process actively, to secure support, resources & changes in organisational structure & culture

In order to bring about such reforms in the extraordinarily complex environment of the health sector, it will be necessary to reinvest in public leadership in a way that pursues collaborative models of policy dialogue with multiple stakeholders – because this is what people expect, and because this is what works best (WHO 2008 pxviii)

PHC and UHC demand multiple, interacting actions across the HS =

whole system change

Source: de Savigny and Adam (2009)

Copyright

Funding

You are free:To Share – to copy, distribute and transmit the work

To Remix – to adapt the work

Under the following conditions:Attribution You must attribute the work in the manner specified by the author or licensor (but not in any way that suggests that they endorse you or your use of the work).

Non-commercial You may not use this work for commercial purposes.

Share Alike If you alter, transform, or build upon this work, you may distribute the resulting work but only under the same or similar license to this one.

Other conditionsFor any reuse or distribution, you must make clear to others the license terms of this work.

Nothing in this license impairs or restricts the authors’ moral rights.

Nothing in this license impairs or restricts the rights of authors whose work is referenced in this document.

Cited works used in this document must be cited following usual academic conventions.

Citation of this work must follow normal academic conventions. Suggested citation:

Introduction to Complex Health Systems, Presentation 4. Copyright CHEPSAA (Consortium for Health Policy & Systems Analysis in Africa) 2014, www.hpsa-africa.org www.slideshare.net/hpsa_africa

This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no. 265482). The views expressed are not necessarily those of the EC.

The CHEPSAA partners

University of Dar Es SalaamInstitute of Development Studies

University of the WitwatersrandCentre for Health Policy

University of GhanaSchool of Public Health, Department of Health Policy, Planning and Management

University of LeedsNuffield Centre for International Health and Development

University of Nigeria Enugu Health Policy Research Group & the Department of Health Administration and Management

London School of Hygiene and Tropical MedicineHealth Economics and Systems Analysis Group, Depart of Global Health & Dev.

Great Lakes University of KisumuTropical Institute of Community Health and Development

Karolinska InstitutetHealth Systems and Policy Group, Department of Public Health Sciences

University of Cape TownHealth Policy and Systems Programme, Health Economics Unit

Swiss Tropical and Public Health InstituteHealth Systems Research Group

University of the Western CapeSchool of Public Health