A Senior Management Course for Health Managers in Kenya Health Systems Management

1. A Senior Management Course for Health Managers in Kenya Health Systems Management 2ND EDITION July 2014

2. Unit 1.2: Health Systems Concepts and WHO framework

3. Purpose • This unit helps participants define concepts related to health systems thinking and approaches • It introduces participants to building blocks of health systems in Kenya and their linkages to final outcomes and intermediate goals in the health sector

4. Objectives • By the end of this unit, the participants should be able to: • Explain key health system concepts and their application in the context of Kenya’s health system • Discuss the systems thinking approach; • Describe the framework and components of the health system;

5. Overview • This unit will cover the following topics: • Basic concepts and application of health systems approach; • WHO Framework and Components of the health systems; • Systems thinking;

6. Session 1.1: Basic Concepts and their Application to Health Systems Approach

7. Activity 1.1: (10 minutes) • Participants brainstorm on definitions of the following concepts: • Health systems vs. healthcare system; • Health systems strengthening vs. health sector reforms. • Systems thinking • (Copy this activity to TLA Unit 1.3.2 session 1.1.1).

8. What is a system? “A system is a group of interacting, interrelated, or interdependent elements forming a complex whole” (Heritage Dictionary, 4th ed., 2000 by Houghton Mifflin Company)

9. Health System vs. Health Care System

10. Health System “A health system consists of all organisations, institutions, people and actions whose primary intent is to promote, restore or maintain health.” (WHO, 2007)

11. Illustration of a Health System Source: IDRC, 2003

12. Principles of a Health System • People-centred - equity and fairness; • Results-oriented - quality management system for continual quality improvement; • Evidence-based - technocrats, academicians, politicians, community/local context and change; • Community-driven - leadership, governance accountability, transparency and sustainability; • Context-specific - in Sub-Saharan Africa, context is synonymous with resource-constrained environment; • Ethically sound – human rights and dignity, safety for the client, community and environment; • Systems thinking - holistic view of the health system.

13. Definition of Healthcare System A healthcare system is a means of organised social response to the health conditions of the population. It is narrower than a health system and is often described in terms of the levels of healthcare and organisational structure of the Ministry responsible for health in most countries.

14. Health System Strengthening vs. Health Sector Reforms

15. Health System Strengthening • Health Systems Strengthening (HSS) is defined as building capacity in critical components of health systems to achieve more equitable and sustained improvements across health services and health outcomes (WHO).

16. Health Sector Reforms • Refers to “sustained process of fundamental change in policy and institutional arrangements, guided by government, designed to improve the functions and performance of the health sector and ultimately the health status of the population.” • Refers to totality of the health care system (preventive, curative and public health services; the public and private sectors; primary, secondary and tertiary care).

17. Why Health Systems Strengthening in Africa? • Uneven progress in health, and growing gaps: • Focus on few programme areas, with others ignored / missed; • Increase in gaps in health services, as focus is driven by priorities of donors. • New challenges to health and health systems: • New / re-emerging conditions, and health threats; • Changing behaviour, leading to new risks – HIV, non communicable conditions, etc.

18. Why Health Systems Strengthening in Africa? (Cont’d) • Persisting inequalities in access, use and financing of services: • Poor, illiterate, and other disadvantaged groups still not accessing services. • Rising expectations, and growing dissatisfaction: • Globalisation, better information flows, meaning that persons are more aware of rights; • Mismatch between expectations and performance.

19. Opportunities for Strengthening the Health System • Renewed interest in basic principles in delivery of health services. • Significant increase in funding for health: governments, donors, philanthropic agencies. • Rapid increase in global health initiatives. • Growing recognition, and political support for improving system performance under the two-tier government.

20. Health Systems Approach • Aims to make most people live healthier and longer lives, whoever and wherever they are. • The conceptual framework primarily focuses on determinants that will address the health outcomes. • Focuses on the pillars or components of a health system.

21. Session 1.1.2: Components of the Health System

22. Conceptual Framework • Health system goal: improving health and health equity, in ways that are responsive, financially fair, and make the best, or most efficient use of available resources. • Health system objectives: definition of objectives being sought: • Improve access, and quality of services; • Achieve better coverage of services. • Health system building blocks: seven investment areas: • Investment in the building blocks aims to improve coverage of services through attaining desired access to interventions, without compromising quality and safety.

23. Components / Pillars of Health System • The WHO framework refers to the building blocks of the health system. These are: • service delivery; • health workforce; • information; • medical products, vaccines and technologies; • financing; and • leadership and governance. • The building blocks need to be functioning well for the health system to produce the expected health outcomes.

24. Health System Building Blocks / Components BUILDING BLOCKS GOALS / OUTCOMES SERVICE DELIVERY Access Coverage Improved health (level and equity) HEALTH WORKFORCE Responsiveness to legitimate needs INFORMATION MEDICAL PRODUCTS, VACCINES & TECHNOLOGIES Social, and financial risk protection Quality Safety FINANCING Improved efficiency LEADERSHIP / GOVERNANCE Source: World Health Organisation. Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes—WHO’s Framework for Action. Geneva: WHO, 2007, page 3.

25. Activity 1.1.2.1: 15 minutes Participants brainstorm in pairs on limitations of WHO’s building blocks framework. List responses on flipchart in plenary. (Copy to TLA unit 1.3.2 )

26. Expected Outcomes of Well Functioning Pillars • Good health services are those which: • Deliver effective, safe, quality personal and non-personal health interventions to those that need them, when and where needed, with minimum waste of resources; • Demand for care, service delivery models and integrated packages, leadership and management, and infrastructure and logistics.

27. Expected Health Outcomes of Well Functioning Pillars (Cont’d) • A well-performing health workforce is one that: • Works in ways that are responsive, fair and efficient to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, fairly distributed, they are competent, responsive and productive); • Needs norms/standards that govern production of sufficient staff and ensure fair distribution (HRH must be competent, responsive and productive); • HRH observatories are essential for facilitating HRH management.

28. Expected Health Outcomes of Well Functioning Pillars (Cont’d) • A well-functioning health information system is one that: • Ensures the production, analysis, dissemination and use of reliable and timely information on health determinants, health system performance and health status; • Has standardised and integrated systems and tools; • Enables linkages – local, national, regional and global.

29. Expected Health Outcomes of Well Functioning Pillars (Cont’d) • A well-functioning health system ensures equitable access to essential medical products and technologies of assured quality, safety, efficacy and cost-effectiveness, and their scientific soundness and cost-effective use. • The medical products include medicine, reagents, etc.; • Technologies include health infrastructure (e.g. X-ray, lab, vaccines, etc.); • Norms/standards and policy options on products and technologies are needed; • Procurement processes, monitoring, innovation and patenting of new products are essential.

30. Expected Health Outcomes of Well Functioning Pillars (Cont’d) • A good health financing system: • Raises adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophes or impoverishment associated with having to pay for them; • Provides incentives for providers and users to be efficient; • Includes policies that support sustainable options/social protection, use of information, sound financial management/ dialogue.

31. Expected Health Outcomes of Well Functioning Pillars (Cont’d) • Leadership and governance denotes: • Stewardship that involves ensuring that strategic policy frameworks exist and are combined with effective oversight, coalition-building, regulation, attention to system-design, transparency and accountability.

32. Variables for Consideration for Health System Building Blocks

33. Variables for Consideration for Health System Building Blocks (Cont’d)

34. Variables for Consideration for Health System Building Blocks (Cont’d)

35. Activity 1.1.2.2: Video (30 minutes) • Participants watch ‘Baby Maya’ video -10 mins • Participants brainstorm in plenary to: • identify health systems components in the video -15 minutes; • identify opportunities for systems approach to strengthening the health systems in their respective contexts - 15 minutes.

36. Application of Health Systems Management Problem: Poorly motivated staff, not enough skilled staff, poor quality of care, stock-outs:

37. Health System Management: Reality Check! • Objective • Evidence-based • Context specific • Not prescriptive - tailored to the country • Long-term process • Few quick wins • Attribution difficult • Sustainable • Partnerships matter • Structures and governance • Principles of service delivery

38. The Dynamic Architecture and Interconnectedness of the Health System Building Blocks Source: WHO, 2009, Systems Thinking for Health System Strengthening, P.32 Fig 1.2

39. Session 1.1.3: Systems Thinking

40. What is systems thinking? • Systems thinking refers to: • Paradigm shift that emphasises a deeper understanding of dynamism, linkages, relationships, interactions and behaviours among the elements that constitute the entire system; • It focuses on holistic approach to designing, implementing and evaluating health interventions; • It is an approach to problem solving that views ‘problems’ as part of a wider dynamic system.

41. Systems Thinking Rationale • Systems thinking works to reveal the underlying characteristics and relationships of systems. • Every intervention, from the simplest to the most complex, has an effect on the overall system. The overall system also has an effect on every intervention. • It is a tool for diagnosing organisational issues and understanding change dynamics. • Work in the field of engineering, economics and ecology shows systems as constantly changing, with components that are tightly connected and highly sensitive to change occurring elsewhere.

42. Elements of Systems Thinking

43. Principles of Systems Thinking • The following five principles are considered core to an organisation’s learning and innovation: • Personal mastery; • Mental models; • Building shared vision; • Team learning; • Systems thinking. • (The Fifth Discipline, Doubleday, 1990, p. 7)

44. Skills in Systems Thinking