Maximizing Positive Synergies
Between Health Systems and
Global Health Initiatives
A Mixed Methods Approach
Dr. Jim Yong Kim
Harvard Medical School
Harvard School of Public Health
October 2, 2008
Positive Synergies
“How can global health initiatives and national
health systems optimize their interactions to
capitalize on positive synergies and minimize
negative impacts, thereby achieving their
common goal of improving health outcomes?”
What are the best methods to answer this
question and lead to the desired outcomes?
What are the Desired Outcomes?
• Healthier People/Equity/Social Justice
• Highly functioning health systems that are responsive to
everyone and deliver across the priorities
• Better policies that shape donor behavior, health system
design and health service delivery
• Evidence-based implementation and delivery by
systems and practitioners at all levels
• Evidence that links system design, implementation
strategy, management structure, degree and nature of
integration of services, civil society involvement, health
system architecture etc. – to health outcomes
• Methodologies and researchers that fit the task
Choosing the right methods
• What kind of data/information exists and does it
point the way to further studies?
• What is the state of framework and theory
development around the problem?
• Are researchers who represent “unusual”
disciplines working on the problem?
• Are civil society actors and affected communities
involved at every step?
• Will the methods used and research done be
helpful to practitioners at the country level and
lead to real health improvements for people?
Proposed Methodological Approach
• Cross-country Quantitative Analysis
• Country-level Mixed Methods Analysis
• Provider Unit-Level Analysis
Research Questions
1. How do GHI-funded programmes interact with
health systems in varied country contexts?
–
What positive synergies or negative interactions
emerge when GHI funded programmes interact with
local health systems?
2. In various contexts, which factors influence the
extent and nature of interaction between GHIfunded programmes and local health systems?
Research Questions
3. What are the specific system designs
and delivery strategies funded by the
GHI’s that have lead to the most positive
impacts on health systems?
a. How do these designs and delivery
structures influence the coverage of targeted
and non-targeted interventions and health
outcomes?
Conceptual Framework
Epidemiological
Demographic
Political
Governance
GHI investment
GovernanceD
Financing
E
Government
expenditure
Social
Health workforce
Health Outcomes
L
Fairness of
I
Health Systems
Infrastructure/Hardware
Monitoring
and
Financing
Private
expenditure
Other external
expenditure
Evaluation
Health
Technologies
Communities/Civil
Society
Legal
V
E
R
Responsiveness
Y
Economic
Technological
Environmental
Adapted from: WHO six building
blocks and RA Atun et al, 2006
Levels of Analysis
Cross-country
Identifying
quantitative
relationships
analysis
Country-level
Understanding
mixed relationships
methods analysis
Provider-unit
Understanding
level
theanalysis
impact
Mixed Methods Approach
• Appropriate for complex systems and
relationships
• Either quantitative or qualitative methods
alone are insufficient
• Employs multi-disciplinary teams
• Allows for triangulation with different types
of data
Cross-country quantitative study
Government health
expenditure
Coverage of immunization
GHI investments
Coverage of skilledattendance at delivery
Child mortality
Country-level mixed methods
analysis
• Case study library
• Level 1 – National level analysis of GHIHealth System Interaction
• Level 2 – Regional, district, and provider
unit level analysis of systems design and
local impact
Country Selection
• Develop sampling matrix in consultation
with partners:
– Geographical representation
– GHI investment as a percentage of total
health expenditure
– High burden of GHI-targeted disease
– Existing connections with partner institutions
GHI investment/
Total health expenditure
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
Burundi
Rwanda
Zambia
Somalia
Liberia
Guyana
Uganda
Gambia
Ethiopia
Tanzania
Malawi
Haiti
Mozambique
Kenya
Swaziland
GFATM, PEPFAR, GAVI disbursements through 2005
HIV Prevalence
1. Swaziland
2. Botswana
3. Lesotho
4. Zimbabwe
5. Namibia
6. South Africa
7. Zambia
8. Mozambique
9. Malawi
10. Central African Republic
11. Gabon
12. Cote d'Ivoire
13. Uganda
14. Kenya
15. United Republic of Tanzania
WHO Statistical Information System (WHOSIS), Accessed: July 2008
TB Incidence
1. Swaziland
2. South Africa
3. Djibouti
4. Namibia
5. Lesotho
6. Zimbabwe
7. Timor-Leste
8. Zambia
9. Botswana
10. Sierra Leone
11. Cambodia
12. Mozambique
13. Cote d'Ivoire
14. Congo
15. Rwanda
WHO Statistical Information System (WHOSIS), Accessed: July 2008
Proposed countries
Country
GHI/total
expenditure
Rwanda
2
Lesotho
HIV
3
Kenya
14
14
Tanzania
10
15
Mozambique
13
8
Ethiopia
9
TB
Partner
involvement
15

5


12


Proposed countries
Country
GHI/total
expenditure
South Africa
HIV
TB
Partner
involvement
6
2

8

Zambia
3
7
Malawi
11
9

Uganda
7
13

Haiti
12
DRC

14
Other Likely Candidates
•
•
•
•
•
•
•
Cameroon
Senegal
Ghana
Viet Nam
Philippines
India
China
Data – Cross-country
•
•
•
•
•
Time series cross sectional data
GFATM, PEPFAR, GAVI disbursements
National Health Accounts
OECD’s Credit Reporting System
DHS, MICS, administrative data, data
from UN or WHO
Data – National and Regional
• Document review
• Semi-structured interviews with key
informants
• Collection and analysis of appropriate,
available quantitative information
• All data collected in cooperation with
Ministries of Health
Data – Provider Unit-Level
•
•
•
•
•
•
•
•
System Design – Implementation Strategies
Available Services
Laboratory Services
Essential Medicines
Human Resources
Infrastructure
Targeted Outcomes (HIV, TB)
Coverage of non-targeted interventions
Expected Outcomes
• Global cross-country analysis
• Case study library of more than 10 countries –
detailed information on health system design,
implementation strategy etc.
• Provider unit-level analysis in select countries
• Literature review
• Identification of knowledge gaps for further study
• Improved methodology
• Input for WHO policy recommendations
Timeline
• Late October: Finalized methodology with
partners
• Early November: Begin in-country data
collection
• November 17-19: Bamako Ministerial meeting
• January – March: Continued data collection
and analysis
• March – April: Preparation of results and
reports
Academic Partners
Rifat Atun
Imperial College, London/Global Fund
Ruairi Brugha
Royal College of Surgeons in Ireland
Eric Buch
Alex Coutinho
University of Pretoria
Makerere University, Uganda
Peter GodfreyFaussett
Alan Greenberg
London School of Hygiene & Tropical Medicine
Gorik Ooms
Institute of Tropical Medicine, Antwerp
Peter Ndumbe
University of Buea, Cameroon
K. Srinath Reddy
Papa Salif Sow
Public Health Foundation of India
University of Dakar, Senegal
David Sanders
University of Western Cape, Cape Town
George Washington University
Conclusions
• April is tomorrow
• Much very important work has already been done
• Must be clear about the question we are trying to
answer
• We must look to “unusual” methods and “unusual”
partners
• This effort is just the beginning of a much larger
effort – lead to the development of a “science” of
health care delivery?
• This has to be a team effort with collaborations in
all directions – a “community of practice”
Selected References
Atun, RA, Turcan, L, Berdega, V et. al. (2005). Review of Experience of Family Medicine
in Europe and Central Asia. (In five volumes) Volume V: Moldova Case Study. World
Bank Report No. 32354-ECA. Human Development Sector Unit, Europe and Central
Asia Region. Washington, DC: The World Bank.
Atun RA, Menabde N, Saluvere K et al. Introducing a Complex Health Innovation –
Primary Health Care Reforms in Estonia (Mulitmethods Evaluation). Health Policy 79
(2006) 79-91.
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.
Daniels N, Flores W, Pannrunoathai S (2005). An Evidence-Based Approach to
Benchmarking the Fairness of Health Reform in Developing Countries. Bulletin of the
World Health Organization. 83: 534-40.
Frontiers Development and Research Group. Global HIV/AIDS Initiatives in Zambia:
Issues of Scale Up and Health Systems Capacity: Interim District Report. (2008).
Global HIV/AIDS Initiative Network. OSI.
GAVIAlliance. Accessed July 2, 2008 at:
http://www.gavialliance.org/about/in_partnership/index.php.
Selected References
Global HIV/AIDS Initiative Network (GHIN). (2006). A Generic Guide to Research
Practice: Following discussion at Lilongwe workshop of GHIN African teams.
Global HIV/AIDS Initiative Network (GHIN). (2006). GHIN African District Studies:
Detailed Research Questions and Methods.
Gbangbadthoré, S, Hounsa, A, Franco, LM. (2006). Systemwide Effects of the Global
Fund in Benin: Final Report. Bethesda, MD: Health Systems 20/20. Abt Associates
Inc.
Loevinsohn, B, Aylward, B, Steinglass, R et. al. (2002). Impact of Targeted Programs on
Health Systems: A Case Study of the Polio Eradication Initiative. American Journal of
Public Health; 92(1):19-23.
Mtonya, B, Chizimbi, S. (2006). Systemwide Effects of the Global Fund in Malawi: Final
Report. Bethesda, MD: PHRplus. Abt Associates Inc.
Murray CJL, Evans DB, eds. Health systems performance assessment: debates,
methods and empiricism. Geneva: World Health Organization, 2003.
Semigina, T, Griga, I, Bogdan, D, Schevchenko, I, Bondar, V, Fuks, K, Spicer, N. (2008).
Tracking Global HIV/AIDS Initiatives and their Impact on the Health System in
Ukraine: Interim Report. Global HIV/AIDS Initiative Network. OSI.
Selected References
WHO. Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes. WHO,
2007.
WHO. The Global Fund Strategic Approach to Health Systems Strengthening. Report from WHO to
the Global Fund Secretariat, September, 2007.
WHO. Maximizing Positive Synergies Between Health Systems and Global Health Initiatives. Report
on the expert consultation, WHO, Geneva, 29-30 May 2008.
WHO. Opportunities for Global Health Initiatives in the Health System Action Agenda. WHO
Department of Health Policy, Development and Services, Evidence and Information for Policy,
2006.
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