An Assessment of the Interactions between health systems and Global Health Initiatives

1. An Assessment of the Interactions between health systems and Global Health Initiatives Tim Evans Assistant Director-General Information, Evidence and Research World Health Organization

2. Rationale Concepts and Methods Findings Learning to do better Overview

3. Common challenges to scale up services for HIV, TB, malaria, and immunization HIV/UA assessment report Global Plan to stop TB World Malaria report GAVI/Norad report • Inadequate financing • HR crisis • Affordable commodities • Stigma, discrimination… • Accountability • Partnership alignment • Inadequate financing • Laboratory capacity • HR crisis • Quality drugs • HR crisis • Inadequate financing • Leadership and • management • Inter-agency • coordination • Drug efficacy • Information system • Inadequate financing • HRH and Community services • M&E

4. World Health Report 2006 Critical shortage of health workers in 57 countries; 4.3 million more health workers needed to provide essential interventions.

5. "poor TB services" deemed the underlying reason for emergence of XDR-TB. • Insufficient vehicles • Inadequate supervision of patients beyond hospital • Interruption in supply chains • Unacceptable rates of "first line" treatment failure • No response to evidence of "first line" failure • Sloppy "second line" treatment practices • Poor infection control in hospitals (over-crowding) • Missing laboratory support structures (resistance monitoring)

6. Scale --- safe, proven and cheap interventions not reaching those in need Scope --- comprehensive services responding to needs and expectations are the exception Distribution --- those with unmet needs are disproportionately those with lesser means Protection/Safety --- too many are worse off through encounters with the health system Systems capabilities --- primitive frameworks and responses to dealing with complex challenges Systems Performance Shortfalls

7. Global Health Initiatives Country Health Systems Conceptual Framework Methods 2. Concepts and Methods

8. Address priority health problems of developing countries Focused on specific diseases, selected interventions, or commodities Generate substantial funding (billions!) for these priorities based on strong culture of results Transnational in organization and operations: Invite proposals from countries for support Independent technical review of proposals Make direct investments in countries Dynamic, evolving… Global Health Initiatives

9. Health Systems A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health The main goals are: • Improving health and health equity • Responsiveness, • Financial fairness The intermediate goals are: • Greater access and coverage • Quality and safety

10. Conceptual Framework

11. Inputs: Literature searches >250 studies from published and grey literatures, Call for original data 15 new studies (Table 2) Analysis review of evidence on interactions more "association" than "causation" may change with time what is the point of comparison? No GHIs; Pre/Post-GHI?; between GHIs? Methods

12. Assessing the nature of the interactions Positive, synergistic Equivocal, unclear, mixed Negative, undesired

13. Service delivery Governance Financing Health Workforce Supply management Information systems 3. Findings

14. Findings - service delivery • Access • Rapid expansion targeted services • Expansion of non-targeted services e.g. maternal health • Supply-induced demand • Equity • Services free at point of service • Focus on marginalized populations • Quality • Promoting universal standards of care • Rush to meet targets compromising quality

15. Findings - governance • Planning and Coordination • Demands of GHI planning processes overwhelm national capacities • GHIs responsive to country systems needs through new funding windows • Community Involvement • GHIs have accelerated non-state sector/civil society engagement in health sector planning, delivery and accountability

16. Findings - financing • Total Financing • GHIs linked to recent surge in health ODA • Unclear association between GHI and domestic health financing • Aid Effectiveness • GHI funding more; "predictable"; "sustainable" e.g. Innovative Financing mechanisms; "responsive" to global burden of disease; • GHI funds skew country priorities • Out-of-pocket expenditures • GHIs have promoted principle of free services and subsidies but have not invested in prepayment systems

17. Findings - health workforce • Production and Strengthening • Limited investment in expanding the workforce through pre-service training • Better productivity of existing workforce through in-service training, task shifting, supervision and material support • Distribution • Workforce drawn away from non-targeted services • Incentives get workers to remote areas • Retention • Brain drain from public to private sector due to better pay

18. Findings - supply management systems • Procurement and Distribution • Rapid improvements in availability and affordability of commodities • Strong GHI-owned systems duplicate and displace national supply chains • Quality • Improvements in quality through pre-qualification and agreement on global standards

19. Findings - health information systems • Availability and Accuracy • Disease surveillance and service coverage data specific to GHIs is improving. • Chronic weaknesses of information systems largely ignored esp. vital statistics and measures of health systems performance • Use and Demand • Dominance of stand-alone info systems is inefficient and burdensome • Growing demand and funding for more comprehensive HIS • Innovation • Electronic records are improving efficiency and quality of care

20. Synergies leading to systems transformation

21. There is ample evidence of: "strong synergies"; "serious shortfalls"; And "uncertainty" Actions need to be developed towards: Amplifying synergies Stemming shortfalls Understanding uncertainty Piecing together the big picture

22. Beyond false dichotomies Necessary but not sufficient conditions: Universal Access for HIV/AIDS One M+E for HIV Global financing mechanisms Sustainable financing for TB No one size fits all Harnessing innovation systematically Challenging the way we do business

23. Learning to do better • Overarching Recommendations • High Profile Research Agenda • Engage decision-makers • Country leadership backed globally • Increase finance

24. Thank you