![What is Health Systems Strengthening?
improving [the] six health system building
blocks and managing their interactions in
ways that achieve more equitable and
sustained improvements across health
services and health outcomes
Beyond a single disease
Beyond a single building block - harness the interactions
between the building blocks
Beyond the life of the intervention - sustained improvements
Country ownership](https://image.slidesharecdn.com/hsslecture2016jan-170626083508/85/Hss-lecture-2016-jan-69-320.jpg)
Hss lecture 2016 jan
- 1. Health Systems Strengthening Dr Nilar Tin Retired DDG (DOH)
- 2. What is a Health System? What are the Goals? What are the functions?
- 3. What is a Health System? A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health
- 4. What is a Health System? A health system INGOs Local NGOs VHWs
- 5. WHO expands its traditional concern for people’s physical and mental well being to emphasize two other elements of good health; goodness and fairness • Goodness: HS responding well to what people expect of it -the best attainable average level • Fairness : HS responds equally well to everyone without discrimination - the smallest feasible differences among individuals and groups
- 6. How do we know whether a health system is performing as well as it should? • A minister of health defending the budget in parliament; • A minister of finance attempting to balance multiple claims on the public purse; • A harassed hospital superintendent under pressure to find more beds, more funds and more medicines; • A health centre doctor or nurse who has just run out of antibiotics; • A news editor looking for a story; • A mother seeking treatment for her sick two-year old child; • A pregnant woman with bleeding refusing to go to hospital; • A midwife without sub-center for providing service; • A pressure group lobbying for better services -----All will have their own views for better health systems -----Everything concerns with $$$$$$
- 7. Whatever standard we apply, it is evident that health systems in some countries perform well, while others perform poorly. Is it always due to differences in income or expenditure??? • Performance can vary markedly, even in countries with very similar levels of health spending • The way health systems are designed, managed and financed affects people’s lives and livelihoods • The difference between a well-performing health system and one that is failing can be measured in - – Death -MMR, IMR, U5MR – Disability- PQLI, DALY, QALY – Impoverishment –High OOP – humiliation and despair- VAW, migrants, hard to reach
- 8. PHC is an approach to health development • Primary Care: client’s first point of entry into the health system when medical assistance is sought. • Primary Health Care: a multidisciplinary approach encompassing a continuum of care: promotion, prevention, treatment, and rehabilitation by addressing social, cultural, economic and environmental factors that affect people’s health. • A shift of attitude from a focus of ill health a focus on communities and hospitals & families controlling their own health
- 9. 1970s--1980s PHC actual application & Experiences 1. A package or a set of activities to improve service cov: 8 ELEMENTS of PHC; preventive and promotive more; emphasis more on public health rather than medical care 2. Level of care: Primary, Secondary and Tertiary levels of care. PHC goes further down to community-based care but also secondary & tertiary care is mandatory to provide necessary back-up services in case of need. 3. PHC principles addresses: universal coverage -equity in health across all SE groups (old wine in new bottle-UHC) inter-sectoral collaboration (risk factors & Social determinants affecting health) (Beyond 2015 SDG,HiAP) community participation (health promotion & empowerment) appropriate technology
- 10. • What do you mean when we refer to PHC in a particular country???? PHC in a particular country is a health system that aims at providing cost-effective, comprehensive, equitable and quality care to the entire population including the poor, the vulnerable and the marginalized. • Why is PHC linked to a health system????????? Because PHC is an approach for health development.. The health system is a vehicle for health development. • What did the world commit itself with PHC ??? • 1978 --HFA 2000----- • Year 2000---MDGs mission or objective of HFA till 2015 • Beyond 2015 unfinished agenda & SDGs : HiAP
- 11. Alma-Ata Declaration 1978-1990 Basic Comprehensive PHC to Selective PHC MNCH Oral Rehydration is invented EPI modeled on small pox campaign Safe motherhood launched (1988) to address 500,000 maternal deaths Child Survival Revolution -UNICEF- GOBI PHC National innovations- China barefoot doctors Some countries initiate major change to PHC NGOs innovations in community actions Training of TBA and CHW-major strategy WHO produce DHM tools Global Health Small pox eradication HIV/AIDS emerges HIV/AIDs become major issue especially in African countries
- 12. 1990-2000 World Summit for Children goals set 1990 Cairo ICPD -Reproductive Health 1992 Millennium Development Goals set 2000 MNCH World Summit for Children 26 goals selective on measurable interventions Limited funding for MCH even immunization funding reduced Safe Motherhood initiative – WHO –SBA ; less training TBA PHC Limited global focus on PHC and community mobilization and community based care Some organizations NGOs persist s/a BRAC or international s/a Save and CARE but mainly smaller scale interventions Some countries persist with socialism Global Health Health for all goals set Leadership vacuum for global health particularly in UN system World Bank- implementation of user fees in African countries Structural adjustment hit African countries by debt HIV/AIDs globalization
- 13. 2000-2010 MNCH Lancet CS Series (2003) calls for second CS Revolution, refocusing on selective interventions Neonatal survival series-shift of MCH to MNCH to save 4 million neonatal deaths (>15 yrs passed) Lancet Maternal survival series (2006) First Countdown to 2015 focussed on CS (2005) SM initiative – WHO –SBA ; less training TBA Second Countdown to 2015 focus on MNCH, RH and continuum of care PHC Statement regarding skilled attendance for delivery and discouraging training of TBAs Human Resource Crisis (WHR 2006) pay more attention on CHW Alma-Ata 30 yrs celebration – revisiting PHC More focus on Health systems Strengthening esp MCH Global Health New funding for HIV/AIDS, TB Malaria GF GAVI -immunization Partnership for MNCH formed Bird Flu investments Increasing More global leaders and personalities giving attention & funds for global H
- 14. PRIMARY HEALTH CARE IN SOUTH-EAST ASIA Around 2008: 30 years after Alma Ata Declaration on PHC
- 15. Experiences in Equity and Universal Coverage • CHCs and Conditional Cash Transfers – Bangladesh • 30 Baht Scheme – Thailand • Community Health Security (Jamkesmas) – Indonesia • Integration of Traditional Medicine in Health System – Bhutan • Household Doctors – DPR Korea
- 16. Source: Health Situation in the South-East Asia Region, 2001 - 2007 Life Expectancy at Birth of selected countries in WHO/SEARO 45.0 50.0 55.0 60.0 65.0 70.0 75.0 1990 1995 2000 2005 2010 Years Lifeexpectancyatbirth(years) BAN BHU IND INO MAL NEP THA TIMOR People are Living Longer Has PHC Worked ?
- 17. 0 20 40 60 80 100 120 140 160 180 200 1965-70 1970 -75 1975-80 1980-85 1985-90 1990-95 1995-2000 InfantMortalityrate Years Infant Mortality in SEAR by country, 1965 - 2000 Bangladesh Bhutan DPR Korea India Indonesia Maldives Myanmar Nepal Sri Lanka Thailand Source: Health Situation in the South-East Asia Region, 2001 - 2007 Significant Decline in Child Mortality
- 18. Source: Progress on Sanitation and Drinking-water: 2010 update, WHO and UNICEF Percentage of Access to Safe Drinking Water in SEAR Countries from 1990-2008
- 19. Source: Progress on Sanitation and Drinking-water: 2010 update, WHO and UNICEF Percentage of Access to Improved Sanitation Facilities in SEAR Countries from 1990-2008
- 20. Source: WHO Vaccine preventable diseases: monitoring system. 2009 summary Annual Report of Measles Cases and Vaccination Coverage, South-East Asia Region, 1980-2008 Significant Success in Controlling VPDs
- 21. Then why it is necessary To revitalize PHC 30 years after Alma Ata in 2008?
- 22. At the same time with economic changes, Health Systems was being challenged with………. Demographic changes Transitions where fertility and growth rate declined Infant mortality has decreased and LE increased ---leading to increase in <15 years and elderly population Process of rapid urbanization Epidemiologic changes Migration and urban growth---led to resurgence of diseases that were once considered controlled such as cholera outbreaks + accidents, injuries, crime AIDS pandemic Still infectious diseases were giving problems
- 23. Source: UN, World population prospects: The 2006 revision (http://esa.un.org/unpp). Population aged 65 years and older (%) 2009 - 2015, in selected countries 2 3 4 5 6 7 8 9 10 11 1990 1995 2000 2005 2010 2015 Percentage Bangladesh DPRK India Myanmar Sri Lanka Thailand World The Ageing Population – an emerging issue
- 25. Socio-cultural transitions Increased levels of education, improved communications---shrunk distances between countries Changes in life styles, nutritional, traditional, social and family structures, values and even expectations Lead to ---social problems, adolescents problems, mental health problems--NCDs + CDs--double burden--increased demand of health care systems… Political changes Political orientation and ideologies in many countries changed Changes in policies, management and services in all sectors.
- 26. Health Expenditure in South East Asia Countries, 2006 High Out-of-Pocket Expenditure on Health
- 27. Where are we now in Myanmar as regards MDG goals set in the year 2000? Targeting 1990-2015
- 28. MDG 1: Prevalence of underweight children <5 years of age Target: Halve between 1990 and 2015 (50% reduction)
- 29. MDG 4: Under-five mortality rate Target: Halve between 1990 and 2015 (50% reduction)
- 30. MDG 4: Infant mortality rate Target: Sub-indicator of U5MR to reduce by two thirds between 1990 and 2015
- 31. MDG 4: Proportion of 1-year-old children immunized against measles Target: Measles coverage >90% It is a sub-indicator of U5MR to reduce by two thirds between 1990 and 2015
- 32. MDG 5: Maternal mortality ratio Target: Reduce by three quarters between 1990 and 2015
- 33. MDG 5: Proportion of births attended by skilled health personnel Target: country-specific
- 34. MDG 5: Antenatal care coverage (at least one visit) Target: Achieve by 2015 universal access to reproductive health
- 35. MDG 6: HIV prevalence (%) in adults 15~49 years Target: Have halted by 2015 and begun to reverse the spread of HIV/AIDS
- 36. MDG 6: Proportion of population with advanced HIV infection with access to antiretroviral drugs: Target: Universal access (>80%) to treatment for HIV/AIDS for those who need it
- 37. MDG 6: Malaria incidence Target: Reduce the 1990 incidence rate by three quarters
- 38. MDG 6: Malaria mortality Target: Reduce the 1990 incidence rate by three quarters
- 39. MDG 6: Tuberculosis prevalence Target: 50% reduction from 1990 baseline
- 40. MDG 6: Tuberculosis mortality Target: 50% reduction from 1990 baseline
- 41. Why are we in this situation is a Q? GAPS in Myanmar Health Systems
- 42. Physical and human resources Capital stocks and investment -no: of Infrastructure (as of 2013) • Increase in the number of public hospitals • In total additional (140 ) from 2004-2005 to 2012-2013
- 43. Capital stocks and investment • Ayeyarwaddy Region has received the most (29.9%), • Followed by Sagaing Region (22.1%), NPT (22%) • No change in the number of hospitals in Chin State • The number of private hospitals increased but at a lower rate than public hospitals • During these years there was 17.4% increase in number of hospitals yet 12.6% increase in RHCs (70% of tot pop resides in rural) - ACCESS
- 44. Capital stocks and investment Standard Staff Positions of Government Hospitals Now there has been changes in the standard staff positions like Station Hospital’s staff increased from 17 to 19 (additional one PHS 1 and one radiology technician as X-ray machines distributed to SH level) – QUALITY of CARE Type of position Size of hospital (beds) 16 25 50 100 150 200 300 Doctors 2 6 8 29 29 106 107 Nurses 6 16 23 87 92 298 301 Technicians 2 8 17 22 29 55 74 Others (Clerical & Auxiliary staff) 7 25 33 63 87 135 162 Total 17 55 81 201 237 594 644
- 45. Construction of health facilities/age/conditions CWH since 1897 • Old buildings were over 100 years • Majority over 50 years of age • need a lot of refurbishment everywhere • government expenditure on health used more on extension of building and renovation Actual need- upgrading township hospitals & SH according to standard for catering efficient services – in addition????? RGH in the early 1900s
- 46. Construction of Rural health facilities/age/conditions • Co investment by the local community in building RHCs and sub RHCs -widely practiced • No infrastructure at sub RHCs • Supported by UNDP, JICA and some development partners • Current health budget used for construction of Sub RHC with housing for BHS Still far more to fill- non monetary incentives &
- 47. Infrastructure- Hospital beds • Myanmar had 0.6 hospital beds per 1000 population in 2010 (World Bank, 2011) • Covers inpatients for both acute and chronic care available in public and private, general and specialized hospitals including rehabilitation centers • Sanctioned beds of MOH hospitals = 44,120 • MOD + Other Ministries’ hospitals = 11,185 • Private hospitals = 5,092 -AREAS of Improvement in Quality and not Quantity -Public Private Partnership -Continuous Professional Development (Skill)
- 48. Distribution of health facilities and beds across the country- inequities are evident
- 49. Gaps in HRH Population coverage ( Std) 1MW : 4000 pop 1MW : 5 V Actual 1 MW : >5000 pop 1 MW : > 10 V Still rely on AMW/TBA for delivery in the rural remote areas Delivery by Skilled Birth Attendants 58- 64% D,N,MW per 1000 pop is 1.49 (2010- 2011) Maternal Mortality 200/100,000 LB Skill Mix Issues -Midwives: PHS 2 still 10:1 which has to be 1:1 Midwives lack financial support MDG Goals Tot MW nearly10,000 tot villages >60,000
- 50. Where are we in relation to this population norm for HRH? 0.000 1.000 2.000 3.000 4.000 5.000 6.000 7.000 8.000 BAN BHU DPRK IND INO MAV MMR NEP SRL THA TLS Threshhold 2.28 Number of (Doctors + Nurses + Midwives) per 1,000 population
- 51. Training of Health workers –Others few?
- 52. Health workforce density • underproduction of dental surgeons (5 dentists per 100,000 population) • Under production of pharmacists and technicians as compared to doctors and nurses. • Under production of Basic Health Staff, HA &PHS 1 & 2 • a Human Resource for Health Master Plan was prepared in 2012 for the next 20–30 years • Others few-Audiometrist, Orthotist, Physicist, Clinical Engineer, Biomedical engineers, Statisticians, Medical Recording, ICT
- 53. Have to rely on Voluntary Health workers in rurals • Voluntary health workers have been recruited and trained since the 1980s. • Some attrition is there • Motivated by -training and assigning community health workers (CHWs) on special jobs by vertical programmes, more AMWs at villages • Providing social recognition, moral support and incentives • Need to train more locals in hard-to-reach areas, equipped with basic medicines & ORS • Think of Task Shifting as big picture- who else???????
- 54. Medicines & Medical equipment • Hospital Equipment is usually provided by the government budget • MOH’s share of government expenditure was increased four-fold in 2012 • Increase in procurement of medicines % X-Ray machines, CT, MRI etc. • Need to strengthen in this area of procurement & distribution of medicines • Regular maintenance mechanism of medical devices at the hospitals
- 55. Three pillars can be applicable for Myanmar for the next decade – Increased investment in: Township health system (network of hospitals, TH, Station Hospital, RHC, subRHC) as a key strategic hub • Integrated plans: infrastructure + medical equipments + HW team for comprehensive package of service – Education strategies: increased production + rural recruitment + home town placement more nurses, midwives and PHS than doctors – Rural retention strategies • Financial incentives • Non-financial incentives
- 56. Gaps in Health Information System
- 57. Information Technology • Improved ICT- increase in internet access and use • The existing HMIS needs to be strengthened- medical recording system & private sector information • More technical & financial support required • An e-health care system developed from primary level to tertiary hospitals.
- 58. Other Health Systems Challenges in Myanmar • Emergency epidemics SARS,H5N1, H1N1---Ebola • Natural Disasters (Nargis, Giri, Earthquakes) • Vaccines ?? Shortage of DPT3/HepB; new Penta V • Food security – WHAT ELSE??????
- 59. Reflecting unfinished agenda in post 2015 •GM surveillance, vitamin supplement nutrient package, HE, cooking demonstration, school meal program, school milk program, CNU, HNU, village food bank……not Health Sector alone but More inter-sector coordination More multi sector collaboration • Strengthen health systems to have UHC • Develop social protection systems •community empowerment Post 2015 development agenda Unfinished MDG agenda + • inclusive economic growth •Promoting job • Protecting environmental • inclusive social development (including health & education) • peace & security • Human rights • Equality • Equity
- 60. The number of under-five deaths worldwide has decreased from nearly 12 million in 1990 to 6.9 million in 2011. Globally U5MR reduced by 41% from 1990 to 2011. HH surveys data analysis South Asia U5MR reduced by 48% from 1990 to 2011 Gains in Medical Technology Improvement in education Child Protection Respect to Human Rights New ways of delivering services Global Progress in Child Survival Social Determinants on Health Poverty Rural poor Mother denied of education Violence Conflict & Fragility Intra/Inter sectoral coordination in child survival
- 61. CONCEPTUAL FRAMEWORK Health in All Policies to achieve UHC and HFA FRAGMENTED HEALTH SYSTEMS - Vertical approach/ selective PHC - Focus on medical care/ secondary/ tertiary care - Non responsive to community needs - Weak governance - Out of pocket expenditure → catastrophic health expenditure PHC + HFA 2000 Alma Ata 1978 - Equity - Intersectoral collaboration - Community participation - Appropriate technology REVITALIZATION/ RENEWAL OF PHC - Horizontal approach/comprehensive PHC → UHC - Focus on public health/primary care - People-centred care - Healthy Public Policy/ Health in All Policies (HiAP) - Leadership: to improve governance HEALTH SYSTEMS BASED ON PHC - Equitable access to quality and affordable care for all: SDH - Focus on public health with good referral backup - Social protection: pre-payment & risk pooling to prevent catastrophic expenditure and spiraling cost UNIVERSAL HEALTH COVERAGE/ HEALTH FOR ALL - Better equity in health - Better quality of life DETERMINANTS OF HEALTH SDH + physical environment ↓ Equitable access to quality and affordable care for all: SDH ↓ HiAP
- 62. Health Systems Challenges in Myanmar • Social Determinants of health- accomplishment??? -poverty, environmental hazards, education, gender • Mobilization collaboration with other sector – regulations • Demand side: social protection for the poor –Government responsibility to provide subsidized premium for Universal Coverage Insurance Scheme • Supply side: Access of health services to the poor –Capacity of PHC to perform outreach services to reach the poor and remote areas both CD & NCD –High operating cost (more NCD sufferers need facilities)
- 63. Where are we now? • Organizations, people & actions – Working harmoniously/less harmoniously under MOH? – Linking research papers to action-service delivery??? – Using HMIS data for performance appraisal/not? – Utilization of services as regards public vs private urban vs rural – Budget balancing between curative vs preventive and promotive ----many many many more others
- 64. Where are we now? Availability of services –Medicines and vaccines (including TM) -in terms of sufficiency, equity, efficiency, quality and safety? Govt-4 fold rise in budget –flushing EM to hospitals/RHCs –Balance between production and deployment of HWF? No more 2/3 rule in appointing health staff –Presence of HWF at HC –contract out system with PPP Accessibility –Service delivery-in terms of coverage, access (equity), reaching HTR?, migrant workers? –Physical barriers –Economic Barriers –Social Barriers from the user side
- 65. Where are we now? Utilization –Even at the presence of staff & medicines, utilization can be poor, why????? –Responsiveness?????? –High charges for transport and other cost- economic barrier –Quality of service –competent, skill? Quality of service –Skilled health professional –Safe methods and materials –Good working conditions/team work and good leader –Supportive supervision and monitoring –
- 66. Health system functions and goals What it should be --------- Functions Service delivery Resource generation: HWF, supplies, information Financing Governance and stewardship Goals Good health outcomes Responsiveness Fairness in financing
- 67. WHO Health System Framework Source: World Health Organization. Everybody’s Business: Strengthening health systems to improve health outcomes— WHO’s Framework for Action. Geneva: WHO, 2007, page 3.
- 68. The 7th Building Block – People Individuals, households, and communities as: • Civil society • Consumers • Patients • Payers • Producers of health through knowledge, attitudes, behaviors, and practices Graphic: Bob Emrey, USAID
- 69. What is Health Systems Strengthening? improving [the] six health system building blocks and managing their interactions in ways that achieve more equitable and sustained improvements across health services and health outcomes Beyond a single disease Beyond a single building block - harness the interactions between the building blocks Beyond the life of the intervention - sustained improvements Country ownership
- 70. Health Systems Strengthening • Interactions and linkages • Partnerships • Coordination of Inputs • Steering and Regulations • Efficiency, Equity and Effectiveness • Links of Health Systems to Socio Economic Systems
- 71. Evolution of Health systems Management Biomedical Relationship--------- Patient Doctors/Nurses Treatment Diagnosis Illness Service Deliveries Health Systems Management Social Determinants Of Health D & N HS managers
- 72. Social Transformation Transformative learning Access Coverage Effective Social coverage impact Informative Formative Performative Transformative Creative thinking –most important Knowledge I know malaria Competency I can treat malaria Outcome I can cure malaria Transformation I can promote no malaria society
- 73. Creative Thinking among HRH signifies a process of transformative learning for health systems in achieving UHC • The unique Leadership and management training program articulates health management teams’ mindset changed as follows; • (1) From Education to----- Learning • (2) From Knowledge to------ Competency • (3) From Individual to---------- Organization • (4) From Pedagogy to ------------Andragogy • (5) From Logic to --------------------Whole Systems • (6) From Discussion to -------------------Dialogue
- 74. End of lecture • What have we learnt from today's lecture? • Write down three sentences • Think about today's lecture • Did you analyze well of the existing HS? • Three things that you remember
- 75. Thank you
Editor's Notes
- #4: This includes efforts to influence determinants of health as well as more direct health-improving activities: A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services. It includes for example a mother caring a sick child at home, private providers, behavior change programs, vector-control campaigns, health insurance organizations, occupational health and safety legislation. It includes intersectoral action by health staff: eg encouraging the ministry of education to promote female education, a well-known determinant of better health, and the ministry of transport to promote the use of safety belts to prevent severe injury to the driver and passengers of motor vehicles
- #5: This includes efforts to influence determinants of health as well as more direct health-improving activities: A health system is therefore more than the pyramid of publicly owned facilities that deliver personal health services. It includes for example a mother caring a sick child at home, private providers, behavior change programs, vector-control campaigns, health insurance organizations, occupational health and safety legislation. It includes intersectoral action by health staff: eg encouraging the ministry of education to promote female education, a well-known determinant of better health, and the ministry of transport to promote the use of safety belts to prevent severe injury to the driver and passengers of motor vehicles