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Health system assessments

Health system assessments. Has DOTS expansion reached its limits through existing health systems?. Christy Hanson WHO Geneva. Health system assessments. Aims : Enhance DOTS expansion efforts by tapping into underutilized strengths of the existing health system

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Health system assessments

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  1. Health system assessments Has DOTS expansion reached its limits through existing health systems? Christy Hanson WHO Geneva

  2. Health system assessments Aims: • Enhance DOTS expansion efforts by tapping into underutilized strengths of the existing health system • Recognizing and addressing limitations of the health system in supporting DOTS expansion • Enhancing the contribution of DOTS expansion to the aims of health systems strengthening • Promote complementarity Application: • Planning within NTP • Global lessons learned • Partners Forum

  3. System aspects explored • Infrastructure • Coverage of health facilities by type / capacity • Public and private sectors • Human resources • Distribution • Activities by cadre • Training • Monitoring mechanisms • Supplies / logistics • Funding • Planning

  4. Measuring DOTS coverage

  5. Ethiopia DOTS coverage within limited PHC • 45% of rural population within walking distance from PHC facility • 85% of pop. lives in rural • Wide regional variance in facilities per population • 33% have access to safe water • 45% live on <US$1 / day • 30% of existing facilities implementing DOTS

  6. Vietnam DOTS Coverage within strong PHC • 11% of population in areas with limited geographical access to PHC • North / south variance: human resources • Hospital use: • 36% of users from highest income quintile • 8% from lowest income quintile

  7. Kenya Where patients go vs. Where the system provides DOTS

  8. Private sector • Overall: limited awareness of the role or magnitude of private sector, limited engagement in TB control • Ethiopia:limited but exists, pharmacies, hospitals • Kenya: almost equal use of public and private providers as entry point • Pakistan: 40% of health care provided by private sector • 79% of TB patients seek care initially in private sector • Vietnam: 60% of outpatient visits with private clinics

  9. Kenya Human resources 300 trained clinical officers unemployed

  10. Ethiopia Human resources: distribution

  11. Nigeria Human resources: distribution

  12. Human Resources: Training • Vietnam: systematic training for TB • 10,000 general health workers / year • Training not integrated in other general health training • No examples of TB integrated within pre-service training • No examples of NTP involvement in general PHC in-service training • Kenya: TB training of clinical officers stopped • Nigeria: States responsible for training own staff in PHC • NTP supports state training of 60 workers / year • Pakistan: training lady health workers for TB • Ethiopia: New cadre of health workers to be trained / deployed at most decentralized level (PHC)

  13. Vietnam Human resources involved in TB control Total: 15,772 staff involved in TB control

  14. Decentralization issues • Increased decision-making and budget authority at decentralized levels • Variable levels of political commitment to TB • Variable resources to invest in TB • Shifting of resources (human, financial) • Ethiopia: process • Nigeria: release of funds, planning • Vietnam: poor provinces, less to invest in health • Pakistan:

  15. High costs for patients • Nigeria: 70% of health expenditures private, mostly out-of-pocket • Kenya: cost-recovery in 68% of public facilities • Vietnam: 80% of health expenditures - direct household spending • Per capita household spending US$20 • Documented wealth inequalities in utilization of services: Kenya, Vietnam

  16. TB compared to other disease control programmes • Coverage • Kenya: immunization services in 80% of public facilities, reproductive health in 75% of facilities • TB control in 30% of public facilities • Ethiopia: leprosy has broader coverage than TB • Drug supplies: TB supplies generally more stable than other essential drugs

  17. Summary • Has DOTS Expansion reached its limits through existing health systems? • Strengths • Integrated lab networks • Stable drug supplies • Challenges • Political commitment at decentralized levels • Utilizing and building capacity of PHC • Recognizing types of facilities and workers, tailoring NTP • Engaging private sector and pharmacies • Training • Limited coverage of PHC in some countries

  18. Discussion • Any messages that would be useful to bring to Partners Forum?

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