Key HST research projects and health policy: a reflection

1. Key HST research projects and health policy: a reflection Dr René English HST 20th Anniversary 3 May 2012

2. Overview of presentation • The changing health policy context • Research Focus Areas • Key studies • Lessons learnt • Conclusion • Acknowledgements

3. The changing policy context

4. Changes in the policy landscape in South Africa – early 1990s • End of apartheid • Planning for health sector reform • Philosophy of Primary Health Care considered solution to fragmented, hospicentric, curative healthcare 1990 1994 2000 2009 2012

5. Changes in the policy landscape in South Africa – 1994 to 1999 • Advent of democracy • Key health policies introduced: • National Health Plan • White Paper for the Transformation of the Health System in South Africa • Decentralisation, redress, equity – focal areas 1990 1994 2000 2009 2012

6. Changes in the policy landscape in South Africa – 2000 to 2009 • HIV and AIDS take centre stage. • Decentralisation – post local government elections. • Consideration of broader development context. • National Health Act, 2003 • Introduction of PMTCT, antiretroviral therapy. • Task-shifting, community health care and mid-level workers 1990 1994 2000 2009 2012

7. Changes in the policy landscape in South Africa – 2009 to 2012 • Negotiated Service Delivery Agreement signed • Maternal and child health • Strengthening health systems effectiveness • PHC re-engineering • National Health Insurance • Focus on improving quality 1990 1994 2000 2009 2012 Source: http://www.woodburnsolutions.com/services.php

8. HST’s Research Priority Areas

9. HST • Vision • Health systems supporting health for all in southern Africa • Mission • To contribute to building comprehensive, effective, efficient and equitable national health systems by supporting the implementation of functionalhealth districts in South Africa and the southern African Region.

10. HST Research • Health Systems Research was core focus since inception. • Some outputs • National Health Systems Research Directory • Annual Health System Conferences

11. Research – 1993 to 2011 Primarily commissioned research In-house research

12. Research themes

13. Research Focus – 1993 to 2012 Developing policy Supporting decentralisation and establishment of the DHS, and equity Supporting priorityprogrammes; strengthening the DHS, equity Strengthening health systems effectiveness 1990 1994 2000 2009 2012

14. Pre-1994 - Developing policy • Health Care financing • Financing options • User fees policies • Purchasing options • Private sector role • National Health Insurance • Resource Allocation • Costing PHC • Allocation options • Cost-effectiveness (CHW’s) • Organisation of services • Integration • Technical efficiency • Information systems • NHIS/SA (National Health Information System of South Africa) • Surveillance (Agincourt) • Management indicators • Health information systems development • Geographic Information Systems (national, provincial) • Improving efficiency and quality of services • Tuberculosis • Women and child health • Legislation

15. 1994 to 1999 – Decentralisation, DHS, equity • Equity focus • ISDS – setting up health information systems • District Health Expenditure Reviews • Equity Gauge • Free health care assessments • District Health System Development • Assisting with decentralisation process (situation analysis) • Essential Drugs List implementation • Drug management • Pharmaceuticals procurement and distribution • Quality of Care • District quality of care assessment • Programmes • Mental health • Nutrition assessment

16. 2000 to 2009 – Priority programmes, HSS, equity • Equity focus • National Primary Health Care Facilities Survey (1997, 1998, 2000, 2003) • ISDS - ongoing work on the DHERs • District Health Barometer • District Health System Development • Home-based care and community-based care projects • Transport policies • Quality of Care • Client satisfaction survey tool • District Sexually Transmitted Disease Quality of Care Assessment (STI’s) tool • Clinic supervisory manual • Programmes • PMTCT, infant feeding and VCT • Strengthening TB control • Adolescent friendly clinics • Reproductive Health Care • Mapping the resource and funding flows for HIV and AIDS services at SD level • Mental health services

17. 2009 to 2012 – strengthening health systems effectiveness • Equity focus and quality of care • Baseline National Facilities Audit (2011) • District Health Barometer • Health System Development • PHC re-engineering • Health Information Systems • Health management • Community health workers • District hospital performance • Documenting good practices • Programmes • Tuberculosis • Reproductive health • Maternal and child health, vulnerable groups • HIV and AIDS • Occupational health • Social determinants of health • MDGs

18. Some key research activities and outputs over time • ISDS (Initiative for sub-district support) • Quality of Care initiatives • PMTCT and infant feeding • District Health Barometer • Current studies

19. Initiative for Sub-District Support • Aim • To improving quality of care by providing support to sub-districts. • How? • Develop practical ways to improve health care delivery at local level. • Research (equity, access, efficiency, effectiveness) • Evaluation • Communication • Technical support • Information • Facilitation • Your own input

20. Quality of Care and equity initiatives • District Health Expenditure Reviews • Quantify financial gap between existing services and proposed minimum services. • Monitors equity. • STI Initiatives - District Sexually Transmitted Disease Quality of Care Assessment (DISCA) tool • Inspection of facility, interviewing staff, reviewing records • Client satisfaction survey • Client satisfaction tool is aimed at measuring the perceptions of patients attending district hospitals and PHC facilities. • Taken over by NDOH; used in many provinces.

21. Quality of care initiatives • Norms and standards for environmental health and occupational hygiene at district hospitals • Application of total quality management techniques at hospitals – pharmaceutical services. • Saving babies: a perinatal survey of SA

22. Prevention of Mother-to-Child Transmission (PMTCT) and Infant Feeding • Aim • Monitoring and evaluation of 18 PMTCT pilot sites • Cohort study – to measure effectiveness of PMTCT • Evaluation of PMTCT training • Randomised controlled studies – counselling on PMTCT and infant feeding • Findings • PMTCT effective in real-life settings • Mixed infant feeding practices disadvantageous • Breastfeeding should be promoted • Ongoing strengthening of health system required

23. District Health Barometer • Aim • Contributes to improved quality and access to primary health care information. • How? • Analysis of a carefully selected range of health indicators. • Facilitates identification of areas of poor quality requiring appropriate corrective measures.

24. Ongoing work… • National Baseline Health Facilities Audit • Primary Health Care facility managers’ competencies assessment • Strengthening HIS • Analysis of key District Hospital indicators • Sub-district barometer • Supporting Provincial Health Research committees • PHC re-engineering

25. Lessons Learnt

26. Framework for Health Systems Research Sub-individual level Individual level Societal level Biomedical Research Clinical and Behavioural Research Population Health Research Health Policy Research Health Systems Research Micro Health Services Research Meso Macro Source: http://www.who.int/alliance-hpsr/alliancehpsr_backgroundpaperhsrstrat1.pdf

27. Review of key concepts relating to the HST Sub-individual level Individual level Societal level Biomedical Research Clinical and Behavioural Research Population Health Research Delivery science Improvement science Micro Micro Operations Research • Health Systems Research Health Services Research Implementation science Meso Management Science Macro Macro Source: http://www.who.int/alliance-hpsr/alliancehpsr_backgroundpaperhsrstrat1.pdf

28. Lessons • Partnership • Alignment • Relevance • Continuity • Futuristic and visionary • Innovation and translating policy into practice • Investment in developing research capacity • Reflection

29. Conclusion “Life can only be understood backwards; but it must be lived forwards.” ― Søren Kierkegaard

30. Acknowledgements • Catherine Ogunmefun • Jeanette Hunter • Peter Barron • Candy Day • Fiorenza Monticelli • Ashnie Padarath

31. THANK YOU Dr René English rene.english@hst.org.za http://www.hst.org.za