Hss lecture 2016 jan

1. Health Systems Strengthening
Dr Nilar Tin
Retired DDG (DOH)

2. What is a Health System?
What are the Goals?
What are the functions?

3. What is a Health System?
A health system
consists of all
organizations, people and actions
whose
primary intent is to
promote, restore or
maintain health

4. What is a Health System?
A health system
INGOs
Local
NGOs
VHWs

5. WHO expands its traditional concern for people’s physical and
mental well being to emphasize two other elements of good
health; goodness and fairness
• Goodness: HS responding well to what people expect of it
-the best attainable average level
• Fairness : HS responds equally well to everyone without
discrimination - the smallest feasible differences among
individuals and groups

6. How do we know whether a health system is performing as well
as it should?
• A minister of health defending the budget in parliament;
• A minister of finance attempting to balance multiple claims on the
public purse;
• A harassed hospital superintendent under pressure to find more
beds, more funds and more medicines;
• A health centre doctor or nurse who has just run out of antibiotics;
• A news editor looking for a story;
• A mother seeking treatment for her sick two-year old child;
• A pregnant woman with bleeding refusing to go to hospital;
• A midwife without sub-center for providing service;
• A pressure group lobbying for better services
-----All will have their own views for better health systems
-----Everything concerns with $$$$$$

7. Whatever standard we apply, it is evident that health systems
in some countries perform well, while others perform poorly.
Is it always due to differences in income or expenditure???
• Performance can vary markedly, even in countries with
very similar levels of health spending
• The way health systems are designed, managed and
financed affects people’s lives and livelihoods
• The difference between a well-performing health system
and one that is failing can be measured in -
– Death -MMR, IMR, U5MR
– Disability- PQLI, DALY, QALY
– Impoverishment –High OOP
– humiliation and despair- VAW, migrants, hard to reach

8. PHC is an approach to health development
• Primary Care: client’s first point of entry into the
health system when medical assistance is sought.
• Primary Health Care: a multidisciplinary approach
encompassing a continuum of care:
promotion, prevention, treatment, and rehabilitation
by addressing social, cultural, economic and
environmental factors that affect people’s health.
• A shift of attitude from
a focus of ill health a focus on communities
and hospitals & families controlling their
own health

9. 1970s--1980s PHC actual application & Experiences
1. A package or a set of activities to improve service cov:
8 ELEMENTS of PHC; preventive and promotive more;
emphasis more on public health rather than medical care
2. Level of care: Primary, Secondary and Tertiary levels of
care. PHC goes further down to community-based care
but also secondary & tertiary care is mandatory to
provide necessary back-up services in case of need.
3. PHC principles addresses:
 universal coverage -equity in health across all SE
groups (old wine in new bottle-UHC)
 inter-sectoral collaboration (risk factors & Social
determinants affecting health) (Beyond 2015 SDG,HiAP)
 community participation (health promotion &
empowerment)
 appropriate technology

10. • What do you mean when we refer to PHC in a
particular country????
PHC in a particular country is a health system that aims
at providing cost-effective, comprehensive, equitable
and quality care to the entire population including the
poor, the vulnerable and the marginalized.
• Why is PHC linked to a health system?????????
Because PHC is an approach for health development..
The health system is a vehicle for health development.
• What did the world commit itself with PHC ???
• 1978 --HFA 2000-----
• Year 2000---MDGs mission or objective of HFA till 2015
• Beyond 2015 unfinished agenda & SDGs : HiAP

11. Alma-Ata Declaration 1978-1990
Basic Comprehensive PHC to Selective PHC
MNCH Oral Rehydration is
invented
EPI modeled on
small pox
campaign
Safe motherhood
launched (1988) to
address 500,000
maternal deaths
Child Survival
Revolution
-UNICEF- GOBI
PHC National innovations-
China barefoot doctors
Some countries initiate major change
to PHC
NGOs innovations in
community actions
Training of TBA and CHW-major
strategy
WHO produce DHM tools
Global Health Small pox eradication HIV/AIDS
emerges
HIV/AIDs become
major issue
especially in
African countries

12. 1990-2000 World Summit for Children goals set 1990
Cairo ICPD -Reproductive Health 1992
Millennium Development Goals set 2000
MNCH World Summit for
Children 26 goals
selective on measurable
interventions
Limited funding for
MCH even
immunization funding
reduced
Safe Motherhood
initiative –
WHO –SBA ; less
training TBA
PHC Limited global focus on PHC and community mobilization and
community based care
Some organizations NGOs persist s/a BRAC or international s/a
Save and CARE but mainly smaller scale interventions
Some countries persist with socialism
Global Health Health for all goals set Leadership vacuum for global health
particularly in UN system
World Bank-
implementation of user
fees in African countries
Structural adjustment hit African
countries by debt
HIV/AIDs globalization

13. 2000-2010
MNCH Lancet CS Series (2003)
calls for second CS
Revolution, refocusing on
selective interventions
Neonatal survival
series-shift of
MCH to MNCH to
save 4 million
neonatal deaths
(>15 yrs passed)
Lancet Maternal
survival series
(2006)
First Countdown to 2015
focussed on CS (2005)
SM initiative –
WHO –SBA ; less
training TBA
Second Countdown
to 2015 focus on
MNCH, RH and
continuum of care
PHC Statement regarding skilled
attendance for delivery and
discouraging training of
TBAs
Human Resource
Crisis (WHR 2006)
pay more attention
on CHW
Alma-Ata 30 yrs
celebration –
revisiting PHC
More focus on
Health systems
Strengthening esp
MCH
Global
Health
New funding for
HIV/AIDS, TB Malaria GF
GAVI -immunization
Partnership for
MNCH formed
Bird Flu
investments
Increasing
More global leaders
and personalities
giving attention &
funds for global H

14. PRIMARY HEALTH CARE
IN
SOUTH-EAST ASIA
Around 2008: 30 years after Alma Ata
Declaration on PHC

15. Experiences in Equity and
Universal Coverage
• CHCs and Conditional Cash Transfers –
Bangladesh
• 30 Baht Scheme – Thailand
• Community Health Security (Jamkesmas)
– Indonesia
• Integration of Traditional Medicine in
Health System – Bhutan
• Household Doctors – DPR Korea

16. Source: Health Situation in the South-East Asia Region, 2001 - 2007
Life Expectancy at Birth of selected countries in
WHO/SEARO
45.0
50.0
55.0
60.0
65.0
70.0
75.0
1990 1995 2000 2005 2010
Years
Lifeexpectancyatbirth(years)
BAN
BHU
IND
INO
MAL
NEP
THA
TIMOR
People are Living Longer
Has PHC Worked ?

17. 0
20
40
60
80
100
120
140
160
180
200
1965-70 1970 -75 1975-80 1980-85 1985-90 1990-95 1995-2000
InfantMortalityrate
Years
Infant Mortality in SEAR by country, 1965 - 2000
Bangladesh Bhutan DPR Korea India Indonesia
Maldives Myanmar Nepal Sri Lanka Thailand
Source: Health Situation in the South-East Asia Region, 2001 - 2007
Significant Decline in Child Mortality

18. Source: Progress on Sanitation and Drinking-water: 2010
update, WHO and UNICEF
Percentage of Access to Safe Drinking Water in
SEAR Countries from 1990-2008

19. Source: Progress on Sanitation and Drinking-water: 2010
update, WHO and UNICEF
Percentage of Access to Improved Sanitation Facilities
in SEAR Countries from 1990-2008

20. Source: WHO Vaccine preventable diseases: monitoring
system. 2009 summary
Annual Report of Measles Cases and Vaccination Coverage, South-East
Asia Region, 1980-2008
Significant Success in Controlling VPDs

21. Then why it is necessary
To revitalize PHC 30 years after Alma
Ata in 2008?

22. At the same time with economic changes, Health
Systems was being challenged with……….
Demographic changes
 Transitions where fertility and growth rate declined
 Infant mortality has decreased and LE increased
---leading to increase in <15 years and elderly
population
 Process of rapid urbanization
Epidemiologic changes
 Migration and urban growth---led to resurgence of
diseases that were once considered controlled such as
cholera outbreaks + accidents, injuries, crime
 AIDS pandemic
 Still infectious diseases were giving problems

23. Source: UN, World population prospects: The 2006
revision (http://esa.un.org/unpp).
Population aged 65 years and older (%) 2009 - 2015,
in selected countries
2
3
4
5
6
7
8
9
10
11
1990 1995 2000 2005 2010 2015
Percentage
Bangladesh DPRK India Myanmar
Sri Lanka Thailand World
The Ageing Population – an emerging issue

24. Changing epidemiological profile

25. Socio-cultural transitions
 Increased levels of education, improved
communications---shrunk distances between countries
 Changes in life styles, nutritional, traditional, social
and family structures, values and even expectations
 Lead to ---social problems, adolescents problems,
mental health problems--NCDs + CDs--double
burden--increased demand of health care systems…
Political changes
 Political orientation and ideologies in many countries
changed
 Changes in policies, management and services in all
sectors.

26. Health Expenditure in South East Asia Countries, 2006
High Out-of-Pocket Expenditure on Health

27. Where are we now in Myanmar
as regards MDG goals set in
the year 2000?
Targeting
1990-2015

28. MDG 1: Prevalence of underweight children <5 years of
age
Target: Halve between 1990 and 2015 (50% reduction)

29. MDG 4: Under-five mortality rate
Target: Halve between 1990 and 2015 (50% reduction)

30. MDG 4: Infant mortality rate
Target: Sub-indicator of U5MR to reduce by two thirds between 1990
and 2015

31. MDG 4: Proportion of 1-year-old children immunized against measles
Target: Measles coverage >90% It is a sub-indicator of U5MR to reduce by
two thirds between 1990 and 2015

32. MDG 5: Maternal mortality ratio
Target: Reduce by three quarters between 1990 and 2015

33. MDG 5: Proportion of births attended by skilled health
personnel
Target: country-specific

34. MDG 5: Antenatal care coverage (at least one visit)
Target: Achieve by 2015 universal access to reproductive health

35. MDG 6: HIV prevalence (%) in adults 15~49 years
Target: Have halted by 2015 and begun to reverse the spread
of HIV/AIDS

36. MDG 6: Proportion of population with advanced HIV infection
with access to antiretroviral drugs: Target: Universal access (>80%)
to treatment for HIV/AIDS for those who need it

37. MDG 6: Malaria incidence
Target: Reduce the 1990 incidence rate by three quarters

38. MDG 6: Malaria mortality
Target: Reduce the 1990 incidence rate by three quarters

39. MDG 6: Tuberculosis prevalence
Target: 50% reduction from 1990 baseline

40. MDG 6: Tuberculosis mortality
Target: 50% reduction from 1990 baseline

41. Why are we in this situation is a Q?
GAPS in Myanmar Health Systems

42. Physical and human resources
Capital stocks and investment -no: of Infrastructure (as of
2013)
• Increase in the number of public hospitals
• In total additional (140 ) from 2004-2005 to 2012-2013

43. Capital stocks and investment
• Ayeyarwaddy Region has
received the most
(29.9%),
• Followed by Sagaing
Region (22.1%), NPT
(22%)
• No change in the number
of hospitals in Chin State
• The number of private
hospitals increased but at
a lower rate than public
hospitals
• During these years there was
17.4% increase in number of
hospitals yet 12.6% increase in
RHCs (70% of tot pop resides
in rural) - ACCESS

44. Capital stocks and investment
Standard Staff Positions of Government
Hospitals
Now there has been changes in the standard staff positions like
Station Hospital’s staff increased from 17 to 19 (additional one
PHS 1 and one radiology technician as X-ray machines
distributed to SH level) – QUALITY of CARE
Type of position Size of hospital (beds)
16 25 50 100 150 200 300
Doctors 2 6 8 29 29 106 107
Nurses 6 16 23 87 92 298 301
Technicians 2 8 17 22 29 55 74
Others (Clerical & Auxiliary staff) 7 25 33 63 87 135 162
Total 17 55 81 201 237 594 644

45. Construction of health facilities/age/conditions
CWH
since
1897
• Old buildings were over 100
years
• Majority over 50 years of age
• need a lot of refurbishment
everywhere
• government expenditure on
health used more on extension
of building and renovation
Actual need- upgrading township
hospitals & SH according to
standard for catering efficient
services – in addition?????
RGH in the early 1900s

46. Construction of Rural health
facilities/age/conditions
• Co investment by the local
community in building RHCs
and sub RHCs -widely
practiced
• No infrastructure at sub RHCs
• Supported by UNDP, JICA and
some development partners
• Current health budget used for
construction of Sub RHC with
housing for BHS
Still far more to fill- non
monetary incentives &

47. Infrastructure- Hospital beds
• Myanmar had 0.6 hospital beds per 1000 population in
2010 (World Bank, 2011)
• Covers inpatients for both acute and chronic care
available in public and private, general and specialized
hospitals including rehabilitation centers
• Sanctioned beds of MOH hospitals = 44,120
• MOD + Other Ministries’ hospitals = 11,185
• Private hospitals = 5,092
-AREAS of Improvement in Quality and not Quantity
-Public Private Partnership
-Continuous Professional Development (Skill)

48. Distribution of health facilities and beds across the country-
inequities are evident

49. Gaps in HRH
Population
coverage ( Std)
1MW : 4000 pop
1MW : 5 V
Actual
1 MW : >5000
pop
1 MW : > 10 V
Still rely on
AMW/TBA for
delivery in the
rural remote
areas
Delivery by
Skilled Birth
Attendants 58-
64%
D,N,MW per 1000
pop is 1.49 (2010-
2011)
Maternal Mortality 200/100,000 LB
Skill Mix Issues
-Midwives: PHS
2 still 10:1 which
has to be 1:1
Midwives lack
financial
support
MDG
Goals
Tot MW
nearly10,000
tot villages
>60,000

50. Where are we in relation to this population norm for HRH?
0.000
1.000
2.000
3.000
4.000
5.000
6.000
7.000
8.000
BAN BHU DPRK IND INO MAV MMR NEP SRL THA TLS
Threshhold 2.28
Number of (Doctors + Nurses + Midwives) per 1,000 population

51. Training of Health workers –Others few?

52. Health workforce density
• underproduction of dental surgeons (5 dentists per
100,000 population)
• Under production of pharmacists and technicians as
compared to doctors and nurses.
• Under production of Basic Health Staff, HA &PHS 1 & 2
• a Human Resource for Health Master Plan was prepared in
2012 for the next 20–30 years
• Others few-Audiometrist, Orthotist, Physicist, Clinical
Engineer, Biomedical engineers, Statisticians, Medical
Recording, ICT

53. Have to rely on Voluntary Health workers in rurals
• Voluntary health workers have
been recruited and trained
since the 1980s.
• Some attrition is there
• Motivated by -training and
assigning community health
workers (CHWs) on special jobs
by vertical programmes, more
AMWs at villages
• Providing social recognition,
moral support and incentives
• Need to train more locals in
hard-to-reach areas, equipped
with basic medicines & ORS
• Think of Task Shifting as big
picture- who else???????

54. Medicines & Medical
equipment
• Hospital Equipment is
usually provided by the
government budget
• MOH’s share of
government
expenditure was
increased four-fold in
2012
• Increase in
procurement of
medicines % X-Ray
machines, CT, MRI etc.
• Need to strengthen in this area
of procurement & distribution
of medicines
• Regular maintenance
mechanism of medical devices
at the hospitals

55. Three pillars can be applicable for Myanmar for the
next decade
– Increased investment in:
Township health system (network of hospitals, TH,
Station Hospital, RHC, subRHC) as a key strategic hub
• Integrated plans: infrastructure + medical equipments +
HW team for comprehensive package of service
– Education strategies:
increased production + rural recruitment + home town
placement
more nurses, midwives and PHS than doctors
– Rural retention strategies
• Financial incentives
• Non-financial incentives

56. Gaps in Health Information System

57. Information Technology
• Improved ICT- increase in internet access and use
• The existing HMIS needs to be strengthened-
medical recording system & private sector
information
• More technical & financial support required
• An e-health care system developed from primary
level to tertiary hospitals.

58. Other Health Systems Challenges in Myanmar
• Emergency epidemics SARS,H5N1, H1N1---Ebola
• Natural Disasters (Nargis, Giri, Earthquakes)
• Vaccines ?? Shortage of DPT3/HepB; new Penta V
• Food security
– WHAT ELSE??????

59. Reflecting unfinished agenda in post 2015
•GM surveillance,
vitamin supplement
nutrient package,
HE, cooking
demonstration,
school meal
program, school milk
program, CNU,
HNU, village food
bank……not Health
Sector alone but
More inter-sector
coordination
More multi sector
collaboration
• Strengthen health
systems to have
UHC
• Develop social
protection systems
•community
empowerment
Post 2015
development
agenda
Unfinished MDG
agenda +
• inclusive
economic growth
•Promoting job
• Protecting
environmental
• inclusive social
development
(including health
& education)
• peace & security
• Human rights
• Equality
• Equity

60. The number of under-five deaths worldwide has decreased
from nearly 12 million in 1990 to 6.9 million in 2011.
Globally U5MR reduced by 41% from 1990 to 2011.
HH surveys
data analysis South Asia
U5MR reduced
by 48% from
1990 to 2011
Gains in Medical
Technology
Improvement in
education
Child Protection
Respect to Human
Rights
New ways of
delivering services
Global Progress in Child Survival Social Determinants on Health
Poverty
Rural poor
Mother denied of
education
Violence
Conflict &
Fragility
Intra/Inter sectoral
coordination in child survival

61. CONCEPTUAL FRAMEWORK
Health in All Policies to achieve UHC and HFA
FRAGMENTED HEALTH SYSTEMS
- Vertical approach/ selective
PHC
- Focus on medical care/
secondary/ tertiary care
- Non responsive to community
needs
- Weak governance
- Out of pocket expenditure →
catastrophic health
expenditure
PHC + HFA 2000
Alma Ata 1978
- Equity
- Intersectoral collaboration
- Community participation
- Appropriate technology
REVITALIZATION/ RENEWAL OF PHC
- Horizontal approach/comprehensive
PHC → UHC
- Focus on public health/primary care
- People-centred care
- Healthy Public Policy/ Health in All
Policies (HiAP)
- Leadership: to improve governance
HEALTH SYSTEMS BASED ON PHC
- Equitable access to quality and
affordable care for all: SDH
- Focus on public health with good
referral backup
- Social protection: pre-payment &
risk pooling to prevent catastrophic
expenditure and spiraling cost
UNIVERSAL HEALTH
COVERAGE/ HEALTH FOR ALL
- Better equity in health
- Better quality of life
DETERMINANTS
OF HEALTH
SDH + physical environment
↓
Equitable access to quality
and affordable care for all:
SDH
↓
HiAP

62. Health Systems Challenges in Myanmar
• Social Determinants of health- accomplishment???
-poverty, environmental hazards, education,
gender
• Mobilization collaboration with other sector
– regulations
• Demand side: social protection for the poor
–Government responsibility to provide subsidized
premium for Universal Coverage Insurance Scheme
• Supply side: Access of health services to the poor
–Capacity of PHC to perform outreach services to reach
the poor and remote areas both CD & NCD
–High operating cost (more NCD sufferers need facilities)

63. Where are we now?
• Organizations, people & actions
– Working harmoniously/less harmoniously under MOH?
– Linking research papers to action-service delivery???
– Using HMIS data for performance appraisal/not?
– Utilization of services as regards
public vs private
urban vs rural
– Budget balancing between
curative vs preventive and promotive
----many many many more others

64. Where are we now?
Availability of services
–Medicines and vaccines (including TM) -in terms of
sufficiency, equity, efficiency, quality and safety? Govt-4
fold rise in budget –flushing EM to hospitals/RHCs
–Balance between production and deployment of HWF?
No more 2/3 rule in appointing health staff
–Presence of HWF at HC –contract out system with PPP
Accessibility
–Service delivery-in terms of coverage, access (equity),
reaching HTR?, migrant workers?
–Physical barriers
–Economic Barriers
–Social Barriers from the user side

65. Where are we now?
Utilization
–Even at the presence of staff & medicines, utilization can
be poor, why?????
–Responsiveness??????
–High charges for transport and other cost- economic
barrier
–Quality of service –competent, skill?
Quality of service
–Skilled health professional
–Safe methods and materials
–Good working conditions/team work and good leader
–Supportive supervision and monitoring
–

66. Health system functions and goals
What it should be ---------
Functions
Service delivery
Resource generation: HWF, supplies, information
Financing
Governance and stewardship
Goals
Good health outcomes
Responsiveness
Fairness in financing

67. WHO Health System Framework
Source: World Health Organization. Everybody’s Business:
Strengthening health systems to improve health outcomes—
WHO’s Framework for Action. Geneva: WHO, 2007, page 3.

68. The 7th
Building Block – People
Individuals, households,
and communities as:
• Civil society
• Consumers
• Patients
• Payers
• Producers of health
through knowledge,
attitudes, behaviors,
and practices
Graphic: Bob Emrey, USAID

69. What is Health Systems Strengthening?
improving [the] six health system building
blocks and managing their interactions in
ways that achieve more equitable and
sustained improvements across health
services and health outcomes
 Beyond a single disease
 Beyond a single building block - harness the interactions
between the building blocks
 Beyond the life of the intervention - sustained improvements
 Country ownership

70. Health Systems Strengthening
• Interactions and linkages
• Partnerships
• Coordination of Inputs
• Steering and Regulations
• Efficiency, Equity and Effectiveness
• Links of Health Systems to Socio Economic Systems

71. Evolution of Health systems Management
Biomedical Relationship---------
Patient Doctors/Nurses
Treatment Diagnosis
Illness
Service
Deliveries
Health
Systems
Management
Social
Determinants
Of Health
D & N
HS
managers

72. Social Transformation
Transformative learning
Access Coverage Effective Social
coverage impact
Informative Formative Performative Transformative
Creative thinking –most important
Knowledge
I know malaria
Competency
I can treat
malaria
Outcome
I can cure
malaria
Transformation
I can promote no
malaria society

73. Creative Thinking among HRH signifies a process of
transformative learning for health systems in achieving UHC
• The unique Leadership and management training program
articulates health management teams’ mindset changed
as follows;
• (1) From Education to----- Learning
• (2) From Knowledge to------ Competency
• (3) From Individual to---------- Organization
• (4) From Pedagogy to ------------Andragogy
• (5) From Logic to --------------------Whole Systems
• (6) From Discussion to -------------------Dialogue

74. End of lecture
• What have we learnt from today's lecture?
• Write down three sentences
• Think about today's lecture
• Did you analyze well of the existing HS?
• Three things that you remember

75. Thank you