Translating System Thinking for Health Systems Strengthening and Development. 1. The journey from real world practice to systems thinking

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1 Translating System Thinking for Health Systems Strengthening and Development 1. The journey from real world practice to systems thinking Marcel Tanner & Don de Savigny Swiss Tropical & Public Health Institute SSPH+ Summer School Lugano, 20 August 2012

2 Content 1. Context and some history the past lies ahead of us 2. Challenges 3. From issues to information and systems 4. The paradigm change of systemic, focused approaches 20. August

3 20. August

4 Challenges for public and international health Climate change Environment pollution Diseases of poverty and neglected diseases Emerging diseases Demographic and epidemiological transition Urbanization - Migration Access - Equity Health care financing, rationalisation and rationing Global health initiatives Global versus international health Fragmentation of topics and systems Fragmentation of approaches and methodologies Risks but hardly risks in context and rarely context of risk 20. August

5

6 Millennium Development Goals 1. Eradicate extreme poverty and hunger 2. Achieve universal primary education 3. Promote gender equality & empower women 4. Reduce child mortality 5. Improve maternal health 6. Combat HIV/AIDS, TB, malaria 7. Ensure environmental sustainability 8. Develop global partnership for development All critical for health development But silent on systems to achieve targets 20. August

7 International and global health - Global understanding of fragments Or -Global sharing and comparing of determinants of health across different social, political and cultural systems Growth Sector Quality Distribution Integration Coverage, Access 20. August

8 1978 Alma Ata Comprehensive PHC HFA UNICEF Child Survival Revolution Selective PHC WB WDR 93 Minimum Essential Health Interventions 1993 UN Millennium Development Goals 2000 Commission on Macroeconomics and Health 2001 Global Fund for AIDS, TB, Malaria Million on ARVs by Strengthening Health Research Strengthening Health Systems Global strategies for health PHC Reform for Systems Systems Thinking August

9 20. August

10 Good health at low cost 20. August

11 Good health at low costs Historical Commitment 1. Early legislation, early medical systems Social Welfare 1. Prevention, food subsidy, education, land reforms Participatory Orientation 1. Community involvement, decentralization Equity concerns Equality of Coverage 1. Focus on risk groups (women, children, minorities ) 2. Differentials urban/rural Intersectoral linkages Mechanisms, incentives, training China, Costa Rica, Sri Lanka, Kerala State, Cuba 20. August

12 Towards Health Development Technocratic view Rank morbidity & mortality Assess available technology Choose Apply Software approach Address: Management Logistics Training Sustainability of Finances / Policy Diseases and technology less important 20. August

13 Combine software approach with technocratic view 20. August

14 3 X Strategy Values C-PHC S-PHC Reforms & Minimum Packages Scaling-up Equity, participation, multi-sector Efficiency, single-sector / disease Content Broad Narrow Focus Process Output Orientation Time Frame Actors System Support Horizontal Vertical Longer Shorter WHO UNICEF WB SWAp s PRSP s GFATM, GAVI, WHO Friendly Antagonistic System Dependence High Higher 20. August

15 Key challenges 1. Understanding health, social and environmental systems 2. Dynamics of people and systems 3. Priority setting and resources allocation within systems Surveillance Response Approaches 20. August

16 Needs in Health Planning Minimal Essential Information From Users and Providers Established Participatory Timely Adequate Precise Applicable - immediately 20/08/

17 Monitor indicators for change (HIS) Data Compile manage & analyze (HIS) Impact Implement decisions (System) Decisions Framework for evidence based decisions Information Integrate interpret & evaluate (HIS) Evidence Influence plans and decisions (Planners & policy makers) Knowledge Format for presentation to planners & stakeholders (HIS) 20/08/

18 Solutions and the way forward M&E and surveillance: critical activities to measure program performance, impact and achievement of goals M&E Framework - current focus is on tracking intervention coverage and morbidity and mortality, but very few HMIS focus on processes, behaviours and outcomes (not impact!) How much M&E and surveillance and how? 20/08/

19 Data Collected But Not Used Data rich but information poor No responses The process of obtaining the information is as important (particularly in view of subsequent and immediate public health action) as the Information itself 20/08/

20 From «classical M&E» to: «surveillance response» 20. August

21 Key areas for surveillance in any health systems 1. Risks (incl. behavior) and burden 2. Creative listening to needs, demand, solutions 3. Health systems and intervention decay analysis 4. Priority setting and resources allocation 5. Partnership/cooperation, roles and responsibilities WHO GMEP definition:...surveillance is.. aimed at discovery, investigation, and elimination of continuing transmission, the prevention and cure of infection and final substantiation of claimed eradication...surveillance is.. aimed at discovery, investigation, and control or elimination through prevention and cure of continuing health problems and systems barriers 20. August

22 Creative listening Needs demands Disease illness Perceptions and behaviors Mapping of: Potentials and solutions Who is at risk? Who is vulnerable and who is resilient? 20. August

23 Real time mhealth surveillance and response systems.. We have good drugs for malaria! But a continuing challenge of global, national and local responses to antimalarial drug procurement and supply chain system realities. Surveillance in place Modern Approaches M-Health with incentives but Action is lacking??? Training Understanding Management Current situation in 5,141 public health facilities in Tanzania on May 16th, % of health facilities have total stock out this week Red if a stock out this week Green if in stock this week Antimalarial stock outs! A continuing challenge of global, national and local drug procurement and supply chain systems. Situation in 5,141 public health facilities in Tanzania (15 May 2012): Total stock-out 24% Red if a stock-out this week Green if in-stock this week Source: SMS for Life Tanzania

24 Tools and approaches for decay analysis From Efficacy to Effectiveness Efficacy 80% X Access x 80% X Targeting Accuracy x 80% X Provider Compliance x 75% X Consumer Adherence X 75% = Effectiveness = 29% 20. August

25 Systems matter Systems factors major risk factors Understand determinants of health and disease Delay and quality of care Ensuring Access - equity Introduction of new tools Tailoring strategies and for achieving Equity effectiveness 20. August

26 Research for more effective health systems Tanzania Essential Health Interventions Project (TEHIP) Health expenditures: 4 (8) USD / capita TEHIP +1 USD / capita 20. August

27 And why was it rapidly scalable at national level? 63% reduction in 10 years since 2000 is primarily due to Health System change Target Source: Data from Tanzania DHS 2010

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