Demographic And Health Analysis: Country Report & Analysis Overview
David H. Peters, MD, MPH, DrPH, FACPM Johns Hopkins University
Understanding Health Systems
Today’s Class
How do you understand health systems?
How do you use systems thinking?
How do you effect change in a health system?
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An Introduction to Understanding Health Systems
Section A
Ceci N’est Pas Une Pipe
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Ceci N’est Pas Une Pipe
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Not an Epidemic
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Common View of Health Systems in International Health
Inputs: Training Materials Buildings Salaries
Cross-cutting issues: Communications Health management information
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Building Blocks to Meet Health Systems Goals
Source: WHO (2007). Everybody’s business: Strengthening health systems to improve health outcomes.
System building blocks Overall goals/outcomes
Service delivery
Information Medical products, technologies
Health workforce
Financing
Leadership/governance
Improved health (level and equity)
Responsiveness
Financial risk protection
Improved efficiency
Access coverage
Quality safety
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What Is a Health System?
A health system is … “The combination of resources, organization, financing, and
management that culminate in the delivery of health services to the population” Roemer (1991)
“All the activities whose primary purpose is to promote, restore, or maintain health” WHO (2000)
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What Is a Health System? (continued)
A health system is … “The combination of resources, organization, financing, and
management that culminate in the delivery of health services to the population” Roemer (1991)
“All the activities whose primary purpose is to promote, restore, or maintain health” WHO (2000)
Any system that has a purpose related to health DHP (undated)
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What Is a System?
An interaction of parts and their interconnections that come together for a purpose
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Health System Actors, Functions, and Outcomes
People
Financing Revenue generation
Risk pooling Allocation and purchasing
Input management Human resources Knowledge Pharmaceuticals Technology Consumables Capital
Providers public/private
informal
Health status
Protection from health impoverishment
Oversight Policy setting Information, disclosure, and advocacy Regulation Strategic partnerships and incentives
The State politicians
policy-makers
Trust/satisfaction in system
Service delivery Public health services
Ambulatory care Inpatient care
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Health Systems Purposes
1. Reducing mortality, morbidity, disability, malnutrition, unwanted fertility; improving quality of life
2. Reducing poverty due to illness or health care payments
3. Improving trust and satisfaction with health system
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Measures of Purpose in a Health System
Level and distribution of … Health status Financial risk protection Trust
Importance of average levels vs. exceptions vs. variance
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Source: World Development Indicators. (2009).
Child Mortality Across the World
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50
100
150
200
250
300
1960 1965 1970 1975 1980 1985 1990 1995 2000 2005
U n d e r
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m o rt
al it
y ra
te (p
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World
East Asia and Pacific
East Europe and Central Asia
Middle East and North Africa
Sub-Saharan Africa
South Asia
Western Europe
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Common Pathway
Do countries follow a common pathway to reducing childhood mortality according to millennium development goals?
Source: Subramanian, Naimoli, Matsubayashi, and Peters (2011). Do we have the right models for scaling up health services to achieve the Millennium Development Goals? BMC Health Services Research. 16
Poor Financial Protection: Out-of-Pocket Payments for Health
0
10
20
30
40
50
60
70
80
90
100
0 10000 20000 30000 40000 50000 60000 70000
GDP Per Capita ($Int PPP) 2005
O ut
-O f-
P oc
ke t A
s P
er ce
nt o
f T ot
al H
ea lth
E
xp en
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re
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Trust in a Health System
What are the right measurements to capture … Trust in the providers and organizations patient satisfaction
with services Dignity and respect for public Responsiveness of health system Protection of rights
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MEASURING EQUALITY: THE CONCENTRATION INDEX
Measuring Equality: The Concentration Index
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Measuring Health Inequalities
Source: Data from Victora et al.’s study of MCH program in Ceara, Brazil.
CI = 2 x area between 45° line and concentration curve
CI < 0 when variable is higher amongst poor
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Who Captures the Benefits of Different Health Services in India?
Source: Mahal et al. (2001). The poor and health service use in India. 21
Public Financing of Health “Benefit Incidence”
Pro-rich distribution
Pro-poor distribution
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Health System Actors
People
Providers public/private
informal
The State politicians
policy-makers
Oversight and
compacts
Client power
Political voice
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Who Produces Health?
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After Households, Health Services Are Provided By …
Shopkeepers and vendors
Quacks
Traditional practitioners
Private providers—formal sector
Public sector providers
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Other Health Systems Actors?
Local and national governments
Financing and insurance organizations
Regulatory agencies
Pharmaceuticals manufacturers, wholesalers, retailers
Medical equipment suppliers
Health and medical information systems organizations
Faith-based and philanthropic organisations
Citizen and community groups
International organisations (financing, advocacy, technical, regulatory)
Academics 26
Key Functions
Service delivery
Financing
Managing inputs
Oversight
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Health Services Can Be Organized According to …
Service delivery point (clinics, hospitals)
Government administrative area (district)
Management unit
Profession
Community organization
Priority program/disease
Patient-centered
Prevention; promotion; cure; rehabilitation
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Health Financing: Key Functions
Raising revenues
Pooling resources
Allocating and purchasing
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Oversight
To keep watch over the health sector
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HOW DOES A GOVERNMENT PROVIDE OVERSIGHT IN THE HEALTH SECTOR?
How Does a Government Provide Oversight in the Health Sector?
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Traditional Regulation
The instruments by which governments place requirements on enterprises, citizens, and government itself, including laws, orders, and other rules issued by all levels of government and by bodies to which governments have delegated regulatory powers Economic regulation intervenes directly in enterprise and market
decisions such as pricing, competition, market entry, or exit Social regulation protects values such as health, safety, the
environment, and social cohesion Administrative regulation concerns government formalities and
paperwork, so-called “red tape” Regulatory reform aims at improving regulatory quality, be it the
revision of a single regulation; of regulatory institutions; or improved processes for making regulations and managing reform
Deregulation is a subset of regulatory reform and refers to complete or partial elimination of regulation in a sector
Source: OECD. (1997). 32
Oversight Approaches in the Health Sector
Policy-making
Establish and enforce laws and regulations
Public disclosure
Professional self-regulation
Consumer advocates
Independent media
Independent monitors
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Effective Regulation in the Health Sector
Informal and formal “rules of the game” (incentives) can greatly influence performance
Local institutions beyond government can be effective: consumer’s groups, professional organizations, media
Co-production-regulation may be more effective than government enforcement of rules
Source: Peters & Muraleedharan. (2008). Regulating India’s health sector: To what end? What future? Social Sciences & Medicine. 34
The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.
Systems Thinking
Section B
Systems and Non-Systems
Systems Parts are connected Changing one part or
connection affects other elements of the system
Parts operate toward a purpose
Non-systems Parts are independent Changing one part does
not necessarily affect other elements
No explicit purpose
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Systematic Thinking
Methodical, deliberate
“According to a system” (OED)
Requires using a model and/or theoretical basis for analysis or action
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Systems Thinking
The process of understanding how things influence each other in a system
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Changes in Country Characteristics and Coverage of Health Services
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DPT3 SBA TB Dx TB Tx
Governance 0.51* 0.47* 0.27* 0.04
U5MR -0.71* -0.74* -0.24* -0.30*
Fertility -0.64* -0.72* -0.18* -0.27*
Literacy rate 0.61* 0.79* 0.22* 0.24*
GNI per capita 0.41* 0.56* 0.11* 0.11*
Health expenditure 0.36* 0.50* 0.18* 0.06
ODA 0.05* 0.13* 0.17* 0.16*
Population (1990) -0.02 -0.06 -0.15* 0.12*
Pair-wise correlation coefficients (* p < 0.05)
Source: Matsubayashi, Peters, & Rahman. (2009). Analysis of cross-country changes in health services. In Improving Health Service Delivery.
Systems Thinking: Key Concepts
Parts of a system are interdependent
Actions have multiple-order consequences
Optimizing one part can lead to poor system performance
Organizational structures drive behavior
Mental models influence actions
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Systems Thinking Means Less Focus on …
Blueprints and roadmaps
Finding the “right” financing or organization
No “magic bullets” to find
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Many Cost-Effective Interventions Address MDGs Four and Five …
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Lancet child survival series (2003)
Lancet newborn series (2005)
Lancet maternal survival series (2006)
Lancet nutrition series (2008)
Evidence base
Comprehensive reviews
Community-based interventions review
Literature and program review
Few RCTs
Literature and program review
RCTs and observational studies
Focus Under-five child survival
Newborn deaths Maternal deaths and morbidity
Child and adult outcomes
Included 23 interventions reviewed
16 newborn interventions
120 interventions considered
45 interventions
Implementation challenge is a systems problem
Systems Thinking Means More Focus on …
Understand initiating conditions (context)
Identify binding constraints in health systems
Look outside health sector—changing behavior is beyond health services
Look for unintended consequences
Use learning processes to guide change
Understand how organizational structure influences behavior
Use data to guide decisions
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Systems Thinking Focuses on Results
Common to most strategies to improve implementation
Measure the right things, disclose results, and manage according to results
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The material in this video is subject to the copyright of the owners of the material and is being provided for educational purposes under rules of fair use for registered students in this course only. No additional copies of the copyrighted work may be made or distributed.
Effecting Change in a Health System
Section C
Values: Do They Matter?
Working in health systems requires more than technical expertise It depends on values and ethics
Values and ethics drive behavior in any human system
Ethical perspective helps define problems
Ethics help clarify assumptions and implications
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Influential Ethical Perspectives
Utilitarianism—maximize greatest good for the greatest number Who protects the minority?
Liberalism—individuals have rights to choose for themselves Whose rights prevail when they conflict?
Communitarianism—societies raise members with good character to create the good society Who decides what is the good society?
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The “Control Knobs” of Public Intervention in Health Systems
1. Oversight—how you regulate and use information to change behavior of key actors
2. Organization—who delivers services and manages health systems inputs and how they are delivered
3. Financing—how to raise money, pool funds, allocate and pay for health care With effective, technically sound services and behaviors
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Strategies to Improve Implementation in a Health System
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Strategy type Examples
Public oversight
Policy reviews; regulations; contracting; empowering community oversight, supporting consumer organizations
Organizational change: provider based
Quality improvement programs; training; human resource management; logistics systems; decentralization of public services
Organizational change: community based
Community development programs; demand creation
Health financing Provider payment system change; subsidies; health insurance
What Works in Improving Health Service Delivery in Developing Countries
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Number of studies screened
Number of studies with adequate designs
1. Health services strengthening strategies
208 150
2. Community empowerment in health strategies
27,000 156
3. Improving health worker performance
40,000 127
4. Improving performance in health services organizations
127,000 88
Health Service Implementation: Common Findings
Implementation faults are very common
Many different types of strategies can succeed but are not replicable in much detail
Strategies produce many unintended consequences, not predictable in detail
Policy makers define strategies but often have limited influence on how they are implemented
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How Strategies Are Implemented Matters
Odds of success from systematic review
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Randomized controlled trials
All “adequate” studies
Odds ratio Odds ratio
Community coordination and organization .. 4.6**
Local adaptation of the intervention 9.3 4.3 *
Broad-based support of various stakeholders .. 3.9 *
Consultation and engagement of powerful interest groups
2.8 3.8**
Flexibility and modification through stakeholder feedback
.. 3.4 *
Representation from powerful interest groups 2.4 3.0 *
Constraints reduction plans 6.7 2.7 *
* P-value < 0.05; ** P-value < 0.01
Successful Implementation Factors
Identifying and minimizing systemic constraints
Stakeholder involvement and consultation
Mobilization of adequate resources
The initial and continuous adaptation of the strategy to the local context is associated with more complete strategy implementation, and adaptation is easier in small-scale interventions
Strategies to strengthen disease-specific programs that are effective in one area can be successfully scaled up nationally
Multiple component strategies are more effective than single strategies, but risk of failure is greater
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What Are the Uses of Health Systems Models?
Identify policy choices and select options
Describe a system (e.g., at national level)
How to strengthen or “reform” a health system
Understand causation of changes in a health system
Plan, monitor, evaluate strategies for implementation and scaling up
Develop theories about health issues
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Summary
Improving health systems involves its own set of skills and knowledge base, including the ability to … Understand health systems—actors, connections, principles,
purpose Know where and how to intervene Use systems thinking
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Lecture Evaluation
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