Lecture - Recognising the need for whole system change: Towards PHC renewal and universal coverage

1. Recognising the need
for whole system
change: towards PHC
renewal and universal
coverage
ICHS 4
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Introduction to Complex Health
Systems

2. Contemporary
system-level
interventions
Source: de Savigny and Adam (2009)

3. User fee removal
• Remove fees…. AND
• Improve drug supply …. AND
• Maintain/improve HW motivation … AND
• Improve supportive supervision …. AND
• Strengthen gatekeeping function of
primary care facilities & referral
procedures and processes…. AND

4. Thinking through the inter-linkages of a
system level intervention
Remove fees
Strengthen
gatekeeping
function &
referral
procedures
Sustain HW
motivation
Ensure drug
supply to facilities
Strengthen
supportive
supervision

5. Whole system change: achieving good health at
low cost (Balabanova et al. 2011)
Good governance, effective institutions
and bureaucracies, planning and
leadership Not always
identified: clear
in Thai case
Fair and
sustainable
financing
Effective primary
care as entry
point to referral
network
Not always
identified: clear in
Thai case
New cadres, large
numbers, new roles;
payment
mechanisms
(values)
Drug supply, low
cost technologies
(ORS)
PHC
UHC

7. Service delivery
Process through which providers, health
facilities, health programmes and policies
are coordinated and implemented so as to
reach the desired outcomes and goals of
the health system
van Olmen et al., 2012

8. General issues in strengthening service
delivery
Rules for the system:
Unitary vs Plural? Integrated vs. Fragmented?
Managing health workers & organisations
What are the
challenges of
implementation?
Are we achieving
intended gains?
Funding
levels and
allocations
What package of
services?
How provided: what
organisations & how
manage?
Who should
deliver
services? How
ensure
available to
deliver
services?
How ensure
good
performance?
Appropriate
drugs &
technology
Preparing the
workforce/Managing
attrition/Enhancing
performance
WHO 2006

9. Why PHC?
Moving towards health for all requires that
health systems respond to the challenges of
a changing world and growing expectations
for better performance. This involves
substantial reorientation and reform of the
ways health systems operate in society
today: those reforms constitute the agenda
of the renewal of PHC.
(WHO 2008)

10. WHO, 2008

11. WHO, 2008

12. Why PHC?
• PHC increases access to variety of services for
relatively deprived pop groups
• Common health issues best treated by PHC
physicians
• PHC associated with improved disease and Illness
prevention
• PHC manages health issues at early stage, before
conditions become serious and require more complex
care
• PHC focuses on individual rather than ailment or
disease
• PHC leads to avoidance of inappropriate or
unnecessary care
Starfield et al. 2005

13. The goal of universal health
coverage is to ensure that all
people obtain the health services
they need without suffering financial
hardship when paying for them.
http://www.who.int/universal_health_coverage/e
n/index.html
DG WHO
http://www.who.int/universal_health_covera
ge/videos/en/index.html
PS Ghana
http://www.who.int/universal_health_covera
ge/videos/en/index2.html

14. To achieve UHC need:
Strong efficient well-run
system; Working with
other sectors
What are the
challenges of
implementation?
Are we achieving
intended gains?
1) raising funds for
health
2) reducing financial
barriers to access
3) allocating or
using funds to
promote efficiency
and equity
Meeting priority health
needs through people-
centred, integrated care
Sufficient, well-
trained,
motivated health
workers to
provide services
to meet patients’
needs based on
the best available
evidence
Access to
essential
medicines and
technologies to
diagnose and treat
medical problems

15. Achieving universal coverage: reducing
financial barriers
WHO, 2008; see also WHO, 2010

16. Tackling the 20-40% waste problem
(WHO 2010)
Critically assess what
care is needed;
Eliminate waste &
corruption
Improve hospital efficiency;
Reduce medical errors
Motivate health
workers
Medicines supply most
important but also
technology

17. Settings & Sequence Actions
Low-income countries and
post-conflict settings, first
steps
 mobilize extra resources for health care
All contexts (including post-
conflict settings),
subsequent steps
 reduce out-of-pocket payments
 widen geographical access to comprehensive services
 re-allocate government resources geographically
 improve the acceptability and quality of public services
 enhance technical efficiency (especially in relation to
pharmaceuticals)
Also, in low-income
countries consider:
 work with non-state providers to extend access and
improve quality?
 test community-based health insurance?
Also, in middle-income
countries, take action over
time to:
 expand pre-payment
 widen the benefit/service package provided, including to
poorer groups
 reduce fragmentation and segmentation
 strengthen purchasing strategies
 regulate private insurance
Different systems, different steps……

19. Governance & Leadership
Overseeing and guiding the whole health
system, private as well as public, in order to
protect the public interest through:
Policy guidance & setting roles
Intelligence & oversight
Collaboration & coalition building
Regulation
System design
Accountability
WHO 2007

20. Public policy reforms
(WHO, 2008)
• Systems policies: cut across building blocks to support
universal coverage and effective service delivery
– e.g. Human resources, pharmaceuticals
• Public-health policies: to address priority health problems
through cross-cutting prevention and health promotion
• Policies in other sectors: contributions to health that can
be made through inter-sectoral collaboration.

21. 21
Health governance
• Efficient, effective, and equitable service provision,
regulation, and management
• Leadership to address public health priorities
• Responsiveness to public health needs and
clients’/citizens’ preferences
• Inclusion of clients’/citizens’ voice
• Transparency in policymaking, resource allocation, and
performance
• Evidence-based policy and decision-making
• Clear and enforceable accountability
Brinkerhoff & Bossert 2008

22. Leadership for PHC
(WHO, 2008)
• Exercise authority through participation &
negotiation, with fair & transparent
procedures
• Use wide range of data & information in
decision-making, including learning
through doing
• Manage the political & implementation
process actively, to secure support,
resources & changes in organisational
structure & culture

23. In order to bring about such reforms in the
extraordinarily complex environment of
the health sector, it will be necessary to
reinvest in public leadership in a way that
pursues collaborative models of policy
dialogue with multiple stakeholders –
because this is what people expect, and
because this is what works best (WHO
2008 pxviii)

24. PHC and UHC demand multiple, interacting
actions across the HS = whole system
change
Source: de Savigny and Adam (2009)

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26. The CHEPSAA partners
University of Dar Es Salaam
Institute of Development Studies
University of the Witwatersrand
Centre for Health Policy
University of Ghana
School of Public Health, Department of
Health Policy, Planning and Management
University of Leeds
Nuffield Centre for International Health and
Development
University of Nigeria Enugu
Health Policy Research Group & the
Department of Health Administration and
Management
London School of Hygiene and
Tropical Medicine
Health Economics and Systems Analysis
Group, Depart of Global Health & Dev.
Great Lakes University of Kisumu
Tropical Institute of Community Health and
Development
Karolinska Institutet
Health Systems and Policy Group,
Department of Public Health Sciences
University of Cape Town
Health Policy and Systems Programme,
Health Economics Unit
Swiss Tropical and Public Health
Institute
Health Systems Research Group
University of the Western Cape
School of Public Health