IAPB 9 th General Assembly Eye Health: Everyone’s Business Hyderabad, India September 17-20, 2012

1. IAPB 9th General AssemblyEye Health: Everyone’s BusinessHyderabad, IndiaSeptember 17-20, 2012 Scaling up: Perspectives for VISION 2020 Prof. Don de Savigny Health Systems Research Department of Epidemiology and Public Health d.desavigny@unibas.ch

2. “VISION 2020: The Right to Sight aim to eliminate avoidable blindness by 2020…. will not be achieved by eye care services acting in isolation.” • Karl Blanchet. Indian Journal of Ophthalmology 60: (2012)

3. “More authorities are becoming aware that campaigns for the control of diseases will have only temporary effects if they are not followed by the establishment of permanent health services to deal with day-to-day work in the control and prevention of disease and the promotion of health.” Annual Report of the Director-General, WHO Brock Chisholm 1951

4. Increasing fragmentation in Global Health Many Global Health Alliances, Partnerships, Consortia, and Initiatives Mobilizing substantial resources Most with a single disease or single intervention focus Huge potential to support or weaken fragile health systems No obvious Global Health architecture or leadership

5. Vision 2020 strategy • cost effective disease controlinterventions; • human resource development; and • infrastructure development • Guiding principles (ISSE): • Integrated into existing health care systems • Sustainable in terms of money and other resources • Equitable care and services available to all • Excellence – a high standard of care throughout • Objectives: • increase awareness • identify and secure the necessary resources • facilitate national programmes This requires a deliberate convergence of disease-specific programme managers with health system developers. Not so easy….

6. The problem of verticality & the difficulty of integration Ooms et al. BMC Globalization and health (2008)

7. Scaling up: a definition • ‘‘The ambition or process of expanding the effective coverage of health interventions through programmes, services or systems’’

8. Scaling up: Not just multiplication Real world system behaviour • Non-linear, not predictable, not controllable; • Highly heterogeneous actors and contexts; • Complex dynamics with unexpected feedback loops, delays and unintended consequences Scaling up assumptions • Linear, pre-planned process; • Simplistic, deterministic; • Standardized methods for predicting human and financial resources; • What works in small scale and specific contexts will easily replicate elsewhere Pilot Projects National Programmes Sustainable integration in health systems Where we usually stop; Where indicators stagnate and targets become elusive … New way of thinking required

9. Systems integration of Vision 2020 programmes: some perspectives Governance structure, leadership, policy dialogue, network analysis, stakeholder engagement, & ownership Going beyond programme “M&E” to routine information flows Quantification, procurement and supply chains that work Work at interfaces: E.g. Relate disease burden information to financing Recognize and respond to local contexts and emergent behaviours In national strategic plans, NHA and MTEF with performance management Standards of care from inter-professional teams Comprehensive, patient centered, effective coverage across a continuum of care Understand dynamic health system relationships & demand

10. India’s intervention targetable burdenin Shares of total DALYs

11. Success factors in scaling up… • strong leadership and governance with active stakeholder network analysis, management and ownership • choosing simple integrated packages widely agreed to be valuable, • active engagement of a range of implementers and of the target community, • flexibility in tailoring the scale-up approach to local contexts, and • incorporating research before and along with implementation. (Modified from Yamey. PLoSMed 2011) Lessons for integrating in systems • Scaling up is not predictable or controlled • Use theories of change to develop local organizational, functional & political capacities; • Identify constraints & complex pathways • Learn by doing • Apply systems thinking ………..

12. Paradigm shift?:Why engage with systems, and why now… “Systems Thinking” is the language, and “Systems Science” is the discipline for such a shift. Approaching 2020 will benefit from increasingly sophisticated approaches to tipping points in complex adaptive health systems. Vertical funding is often necessary at the beginning, but as health systems develop, separate mini-health systems for each disease and problem is wasteful and inefficient.

13. Thank you