Bringing a Health Systems Perspective to Programming for HIV/AIDS and Health

System Strengthening

Peter BermanLead Economist, The World Bank

Adjunct Professor, Harvard School of Public Health Vienna, July 2010

Abandon the Antagonism Between Categorical Programs and Health System Strengthening

Lets put it away! Competition over resources…by other means Evidence is inconclusive – categorical programs can strengthen

wider systems or weaken them All health programs are means to improving outcomes Health systems perspective seeks to maximize outcomes

• There are synergies, but there are also real, and troubling, trade-offs across outcomes

• There are efficiencies in delivery, but there are also real, and troubling, inefficiencies in delivery

Allocative efficiency issues are not unique to HIV/AIDS, but there are some unique problems

“Do no harm” as minimum standard. “Seek out synergies” more proactive. (Essence of the “diagnonal approach”)

Ultimate Goals of Health SystemsHealth Status

RiskProtection

PublicSatisfaction

Level

Distribution

From Control Knobs to Outcomes

4

“Diagnosis and Therapy” of the Health System

Outcomes

Determinants of poor system performance(causal analysis/response to intervention)

Health systems control knobs

Reform interventions

Politics

CultureValues

HistoryD

iagnosisTh

erap

y

“Health System Analysis” – an analytical basis for programming for categorical programs and HSS Significant body of work across countries at all levels of income, e.g.

• National studies: Mexico, India• Health in Transition series• World Bank country studies, e.g. CSRs in Africa• USAID supported “health system assessments”

Distinction between description, analysis, prediction Review of 12 major World Bank studies (Bitran et al, 2010)

• Comprehensive reviews• Overall framework sound• Some key elements weak

• Organization and service delivery• Health systems analysis of categorical programs• Governance and institutional analysis• Linkage to policy process

More and better health system analysis needed to integrate categorical programs with national health strategies and their HSS elements

Typical HSA Structure

7

Health status assessment• Review of current health status in the country• Emphasis varies among countries depending on income level, but tends to be on infant, child, and maternal

mortality and morbidity, and HIV/AIDS• Review of inequalities among population groups• Review of trends over time• Comparison of country health status with other, similar countries

Analysis of health status determinants

Within the health sectorOutside of the health sector

Determinants of health status other than health care

• Nutrition• Education• Alcoholism• Fertility and demographics• Hygiene

Conclusions• Extent to which health

determinants outside of health sector influence health status

• Policy recommendations about what should be done in other sectors to improve health

Stewardship

Health care financing

Organization and delivery

Human resources

Pharmaceuticals

Recommendations

Recommendations

Recommendations

Recommendations

Recommendations

Costing (Turkey, Mozambique)

Phasing

Expl

anat

ory

appr

oach

From

out

com

es to

cau

ses:

“H

ow w

e go

t to

whe

re w

e ar

e”

Pred

ictiv

e a

ppro

ach

From

pro

cess

es to

out

com

es:

“How

cha

nge

will

impr

ove

perfo

rman

ce”

Programming from an HSS Perspective: Two Dimensions

From Inputs to Reform: More, Better, New ApproachesAddtn’l health system inputs: Reforms to health systemsHRH, drugs, bldgs, vehicles improving access, quality,

demand

More Better New(Inputs) (mainly govt) (mainly non-govt)

From Single Disease to Cross-Cutting Health System Elements

Single Disease Multiple diseases Cross-cuttingor interventions or intervention cluster elements not

disease specific

Different programming strategies combine these dimensions in different ways

More Better New(Inputs) (mainly govt) (mainly non-

govt)

Single Disease Multiple diseases Cross-cutting

or interventions or interventions cluster elements not disease

specific

Increase essential supplies, such as

LLINs

Introduce RBF contracts for govt

and non-govt providers

Strengthen regulation to improve quality of non-government providers, like private maternities

An Example: Strengthening HIV/AIDS Service Delivery

Objectives: Increase volume, access, quality, efficiencyRange of strategies possible – for example: Increase inputs – expand capacity: human resources, supplies, etc. Improve support systems to assure distribution/delivery of inputs “Integrate” related services at point of front-line delivery Share (“integrate”) support services (e.g. laboratory, information) Redesign service delivery tasks, e.g. task-shifting Incentivize organizations or health workers, e.g. PBF Redesign service delivery organization (platforms) – new types of facilities

and staffing patterns Engage new providers, e.g. public-private partnership, contracting

These strategies span MORE—BETTER—NEW; differ in degree they require cross-cutting action and change; and involve different actors in system

Strategy Focus Categorical or

Systemic?

Focus on which actor?

Increase inputs, expand capacity C Front-line Provider

Improve support systems C Facility/OrgManager

“Integrate” linked services at front-line C Front-line Provider

Share support resources C/S Facility/Org Manager

Redesign service delivery tasks C/S Facility/Org Manager

Incentive organizations and/or providers S Planner/Policy Maker

Redesign service delivery platforms S Planner/Policy Maker

Engage new providers S Planner/Policy Maker

Some take aways Strengthening HIV/AIDS service delivery to increase access, quality, and

efficiency can be addressed through a wide range of strategies Strategies can be selected which are more categorical (single or several

disease or problem focused) or more systemic (involve actions or changes which engage health systems more broadly). These characteristics are correlated with the actors more likely to be involved.

More “systemic” strategies are likely to require changes beyond categorical programs or with wider effects; several or all “control knobs”

Strategies should be chosen to achieve the objectives and based on an analysis of causes constraining that achievement. Need to fit the intervention to the causes…but feasibility is also an issue.

As HIV/AIDs programs scale up, they bump against system-related constraints or themselves affect the wider systems

The “do no harm” principle implies that responsible HIV/AIDS programmers consider these effects. Health system analysis can help.

More dialogue with health system planners and capacity building may also be needed.

Concluding Thoughts Health system is not a “black box”, we have concepts and

tools to analyze The tools have not been sufficiently applied to disease

control programs and HIV/AIDS Evidence base on HSS strategies is imperfect, but not

vacant. Aren’t there serious gaps in our knowledge about technical strategies for HIV/AIDS behavior change and case management? We can provide “conditional guidance”

More integrated programming is essential as programs mature