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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
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)
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
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)
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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