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.