Innovations for equity

Posts Tagged ‘health’

The scale and scope of private contributions to health systems

In Global Symposium on Health Systems Research, Health Markets on December 7, 2010 at 4:02 pm

BY HEALTHER KINLAW, GUEST BLOGGER FROM THE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO, GLOBAL HEALTH GROUP

The private sector provides more than half of the health services in Africa and Asia, measured both by source of financing for health services, and place of health service delivery.  While new data and better mapping of providers are improving the understanding of the scale of private healthcare services in low- and middle-income countries (LMICs), issues of dual public-private employment, undercounting of unregistered practitioners, and public sector distrust remain barriers to a full accounting of the size or the activities of the sector. To encourage filling this knowledge gap, in May 2010, the 63rd World Health Assembly passed a resolution called, “Strengthening the capacity of governments to constructively engage the private sector in providing essential health-care services,” which acknowledged that private providers are a major source of care in most countries, that private provision of services can lead to innovation as well as great challenges,  and that governments in LMICs can more effectively engage with and regulate private providers.

On November 17, 2010 researchers held a session entitled “The scale and scope of private contributions to health systems” as part of the First Global Symposium on Health Systems Research (HSR) – Science to Accelerate Universal Health Coverage hosted by the World Health Organization (WHO) and partners in Montreux, Switzerland to provide updates of current research on the private sector, highlight innovative financing mechanisms, and address future topics for research. The session was conducted as a “fishbowl conversation” to encourage audience participation; the design includes speaker chairs arranged in an inner circle that represents the fishbowl with one chair left empty for any member of the audience to occupy, at any time, at which point an existing member of the fishbowl must voluntarily leave to free a chair.  Speakers represented a growing group of researchers that have met regularly for the last five years to share findings and advances in research methods for studying the private sector from the perspective of public health, epidemiology, health economics, public policy, and management.  They included:

  • Sara Bennett,  Johns Hopkins Bloomberg School of Public Health (chair)
  • Ruth Berg, Abt Associates
  • Gerry Bloom, Institute of Development Studies
  • Tania Boler, Marie Stopes International
  • Kara Hanson, London School of Tropical Medicine and Hygiene
  • Birger Forsberg, Karolinska Instituet
  • Gina Lagomarsino, Results for Development Institute
  • Dominic Montagu, Global Health Group, University of California, San Francisco
  • Stefan Nachuk, Rockefeller Foundation
  • Gustavo Humberto Nigenda Lopez, National Institute of Public Health, Mexico

Speakers were asked to share their individual and institutional experience on innovative financing mechanisms which included: the Affordable Medicines Facility – malaria (AMFm), several national health insurance experiences, and public-private partnerships for regulation and otherwise.  Speakers also addressed communities of practice and other tool-sharing platforms that aim to make advances towards adoption of standardized methods for assessing private practitioners, their patients, and private funding flows using both secondary data sources and primary data collection, including: Social Franchising 4 Health (SF4Health.org), the Center for Health Market Innovation (healthmarketinnovations.org), Strengthening Health Outcomes through the Private Sector (shopsproject.org), The Alliance for Health Policy and Systems Research, Future Health Systems, Eldis on health systems, id21, and more by the World Bank and others.

Speakers and audience members suggested the following areas for future research: more anthropological studies around private provider behavior, motivations, and incentives; regulating counterfeit drugs within the private sector; consideration of the human resource aspects of the private sector, including recruitment and training, in their work; payment mechanisms and incentiving patients as well as providers; the increase of “payer” attention to the private sector, including governments; the role of purchasing (financial accounting, standards, etc.); the efficacy of various regulatory partnerships; quality of clinical service delivery; quality of chemical sellers (given that one longitudinal study by KEMRI found no significant difference between quality of chemical shops routinely inspected and those not).

Speakers reported on several upcoming literature reviews underway around the private sector: the Global Health Group at UCSF is conducting a Cochrane Review on health outcomes in publicly-vs-privately provided settings in LMICs and a review with Results for Development and the CHMI on informal providers.  At least one systematic review on voucher programs and health is also in progress.

Throughout the session, speakers also emphasized the economic booms occurring in Asia, and the private health sector growth that has quickly followed and stressed that in many significant amounts of delivery and care are happening outside of the regulatory system, including a prominent informal sector in many countries.  Finally, speakers called for greater transparency around public-private partnerships to ensure efficacy and lesson sharing.

Blog round up

In Global Symposium on Health Systems Research on November 26, 2010 at 12:36 pm

BY KATE HAWKINS, INSTITUTE OF DEVELOPMENT STUDIES

We have all arrived home from the Global Symposium and I’ve had a little bit of time to browse web coverage to see what news and views filtered out from Montreux into the public realm. Given the conference organisers’ desire to archive learning from the meeting and reach out to a wide audience to prompt interest in this area of research it’s useful to see what areas captured people’s imagination.

Scidevnet have covered the symposium with regular updates from T V Padma their South Asia Regional Coordinator. Issues covered included:

  • The need to increase research capacity in developing countries and encourage collaborative learning and research into policy
  • Researching complex systems
  • Tackling TB and HIV in Ukraine and Russia through a system wide approach
  • The challenge of tackling health financing
  • Gaps in universal health coverage in Sub-Saharan Africa

Meanwhile in their news section Aisling Irwin covers the announcement made in the closing session of the creation of a new international entity under their headline, “Ailing Global Forum for Health Research joins COHRED.”

We are big fans of the BMJ and were happy to see our friend and colleague Tracey Koehlmoos of ICDDR,B was providing them with updates. She commented,

“In addition to the plethora of great plenary speakers and interesting sessions, is the real benefit of coming together with so many of my global colleagues. For many of us, we fight the war on poverty and disease from the frontlines in developing countries. Some groups work in relative isolation or grouped on the occasional multi-country study. We often only hear of one another or read one another’s research findings through publications.   After exercising early, I sat alone at breakfast the other morning, and within twenty minutes I was surrounded by a large group of South Asian colleagues most of whom had not met previously but we had all heard of one another and some of us had corresponded with one another via e-mail.  It was transformational to sit face to face and talk about our common challenges in the region.  I left the table feeling empowered —and pretty sure that we will figure out a way to work together in near future.”

If you see any other good news reporting on the symposium please do let us know…

See Sara on film talking in the plenary at the Global Symposium

In Global Symposium on Health Systems Research, Uncategorized on November 25, 2010 at 4:22 pm

It is now possible to see Sara Bennett’s plenary presentation on the web. You can also download her PowerPoint presentation from the Global Symposium site.

Exploring the spread and scale up of health interventions and service coverage

In Global Symposium on Health Systems Research on November 24, 2010 at 3:14 pm

BY KATE HAWKINS, INSTITUTE OF DEVELOPMENT STUDIES

The Future Health Systems Consortium has invested in a stream of work called, “Beyond Scaling Up: Pathways to universal access.” This research has looked at some of the challenges involved in rapid scale up and what can be learnt from successes in this area. Drawing on a background paper, co-authored with Peroline Ainsworth, Gerry Bloom opened a parallel session at the Global Symposium with an overview of learning in this area.

Gerry argued that there are many challenges that might impact upon the scaling up process. Recent years have seen many political commitments to increase access and an improved financing environment for health systems strengthening underpinned by new global organisations. There is a recognition that scaling up means managing change in a dynamic and complex context (where there has been a shift from absolute scarcity to problems with safety, quality and cost with changing patterns of inequality, the introduction of new technologies and institutional arrangements, the rise of patient and citizen movements and mixed systems). Unexpected outcomes and unintended consequences caused by the scaling up process point to the need for systematic knowledge and shared understandings amongst a range of actors.

Ligia PainaLigia Paina and David Peters, Johns Hopkins School of Public Health, suggested that we might be using the wrong models for scaling up – that blue print, linear, one size fits all models are misaligned with the reality of health systems in practice. She explained how health systems are characterised by dynamic change which is rooted in local context. Complex adaptive systems thinking might help us to better understand a failure to scale up. It may explain why we cannot control the behaviour of communities and providers.

Emmanuel SokpoEmmanuel Sokpo and Jeff Mecaskey presented on the experiences of the Partnership for Reviving Routine Immunization in Northern Nigeria (PRRINN) project in northern Nigeria. Their work was rooted in an understanding of the social, political and economic history and context and included a political economy assessment. This assessment:

  • Deepened understanding of the positions of major stakeholders in the state with respect to the socio-political, institutional, structural and historical context as they pertain to the health sector
  • Identified issues which, in a general sense, appear to provide good opportunities for creating ‘coalitions of interest’ and for levering desired institutional changes
  • Provided input into the prioritisation of key interest groups and/or organisations that can be developed as a ‘coalition of interests’ to drive change

They found that political competition was largely occurring within the elite and was structured around the power struggles of individuals, and inter-familial tensions played out within the camps of political parties. There are few alternative centres of power and little check on executive power overall, making the programme highly reliant on key individuals. State power and resource control is in the hands of the state government, while those who still retain some influence over ideology are also under the financial influence of the government. In their opinion the link between policy, strategy , planning and implementation of health interventions was broken with more focus on capital inputs than on health outcomes. Finally they discovered that a fragmented primary health care system is convenient arrangement for States and LGAs to share health resources without accountability. This knowledge was invaluable to the successful scale up of their programme.

Wang YunPingZhenzhong Zhang and Wang YunPing, of the China Health Development Research Centre, a government think tank, provided an assessment of the rapid scale up of health insurance in China. She concluded that the success of the schemes rested on:

  • Political commitment and a change in values toward social and economic development. Health used to be a means to economic growth now it is one of the goals.
  • Learning by doing. The schemes were launched incrementally in a gradual move toward reaching the whole population. Work within the Health 8 and other health sector programmes provided a solid foundation of research which helped the Chinese Government move forward. They experimented with pilots which then spread and bridged the gap between research and policy.
  • The scheme was centralised and relatively decentralised. Central Government provided general principles but left space for local policy makers to think about the detail. They employed cross-ministry cooperation.
  • Changing role of communities. Rural residents are no longer passive recipients. Their needs and interests are the concern of the local officers. The government promoted the schemes with positive incentives and information about how they may benefit.

Vera at the SymposiumVera Schattan Coelho, Brazilian Centre for Anaysis and Planning,  reflected on the success of the SUS in Brazil. She explained how it reflected the aspirations of a movement that believed in health for all and was a process where local, federal and national levels worked together for change with the Support of social movements, public health practitioners and left wing parties. Vera explained that when the SUS began the institutions that we needed were not there. At the end of the 1970s the old system really wasn’t working and so state innovations started to take place, for example, the Family Health Programme. There was a complete change in the relation between the national and the municipal level and clear contracts were established where the federal state was responsible for the policy but transferred the money to the municipalities and they were responsible for implementing. This happened by degrees not all at once so there was a gradual building of institutional capacity. The social movement, “the health movement”, was involved in policy decision making through Councils that included civil society, health providers and Government. When it was discovered that health indicators for indigenous people were much poorer than for the general population minority groups pushed for new programmes targeted at. The indigenous health system was established in 1999. You can read more about this in our briefing. The lesson from this is that within scaling up processes there is a need to balance universalism and also the need for tailored services for some.

 

Learning by doing and applying our learning: What are the strategies and institutional options?

In Global Symposium on Health Systems Research, Uncategorized on November 23, 2010 at 2:39 pm

BY KATE HAWKINS, INSTITUTE OF DEVELOPMENT STUIDES
BASED ON NOTES BY LIGIA PAINA, JOHNS HOPKINS SCHOOL OF PUBLIC HEALTH

Learning by doing sounds a nebulous concept but actually it is crucial in health systems development. If we can’t understand the process of intervening in the system and the positive and negative outcomes of our actions how can we improve the work that we are doing? The last decade has seen a rapid increase in the number of institutions such as learning platforms, health observatories, and think tanks. But at the same time, there is a lack of clarity in the difference between them, as well as their pros and cons.

This Future Health Systems Consortium session at the Global Symposium included presentations from the Asian Observatory on Health Systems, The Zambian Forum for Health Research, Health Intervention and Technical Assessment Program (HITAP) Thailand and The China National Health Development Research Center. It tried to better understand the work that they are doing as well as the challenges that they face. Read the rest of this entry »

Blogs we like: The Center for Health Market Innovations

In Global Symposium on Health Systems Research on November 23, 2010 at 8:12 am

KATE HAWKINS, INSTITUTE OF DEVELOPMENT STUDIES

Sitting in the Global Symposium marketplace is a good way of finding more about other projects and the people that make them tick. We were lucky to have the Center for Health Market Innovations as our neighbour. Rose, their Program Officer, has been kind enough to link to our blog. You should check them out, this is what they say about their blog:

The Center for Health Market Innovations (CHMI) blog features news about promising new programs, innovative collaborations, relevant resource articles, and editorial pieces authored by members of the CHMI community. These editorial pieces are intended to further conversations about health market trends, national health policies, and improving health care for the poor. We encourage you to participate in this dialogue in the comments section or suggesting a post to rreis at resultsfordevelopment.org.

New Consortium launched at the Symposium: REBUILD

In Global Symposium on Health Systems Research, Uncategorized on November 22, 2010 at 4:24 pm

BY TIM  MARTINEAU, GUEST BLOGGER FROM LIVERPOOL SCHOOL OF TROPICAL MEDICINE

Tim explaining the soft launchIn countries affected by political and social conflict, health systems often break down and emergency assistance provided by humanitarian organisations often constitutes the main source of care. As recovery begins, so should the process of rebuilding health systems but little is known about how effective different approaches are in practice. Health systems research has tended to neglect these contexts, because it may be more difficult to carry out studies in unstable environments and relevant capacity is often weak. Read the rest of this entry »

New Directions in Health-Environment Research: Implications for Health Systems

In Global Symposium on Health Systems Research on November 22, 2010 at 2:27 pm

BY MICHAEL LOEVINSOHN, GUEST BLOGGER FROM THE STEPS CENTRE

Michael chairing the sessionI chair a session on New Directions in Health-Environment Research: Implications for Health Systems. A bit off the beam of the Global Symposium’s thrust: one of 13 concurrent sessions, perhaps 20 people attend.

Setting the stage, I describe the methodological challenges researchers are tackling to uncover how environmental change, of different kinds, is creating health risks; in identifying developmental processes that are loosening structures of risk and in clarifying how health and other sectors can collaborate to realize these opportunities.    

The first case describes an “unnatural experiment”, the 2001-03 famine and its impact on the evolution of HIV in Malawi. Using existing data, I show how hunger profoundly affected the distribution of HIV and of people by pushing people into survival sex and distress migration. The data also show that hunger was less severe, maize price less volatile and migration and change in HIV prevalence less marked where people had access to robust crops like cassava, alongside the maize staple. Cassava appears to be providing a “prevention dividend”. Read the rest of this entry »

From Montreux – the First Global Symposium on Health Systems Research

In Global Symposium on Health Systems Research, Uncategorized on November 21, 2010 at 2:21 pm

BY MICHAEL LOEVINSOHN, GUEST BLOGGER FROM THE STEPS CENTRE

You know you’re a discipline or a significant sub-discipline when you can organize and find funding for a global symposium. Twelve hundred participants from umpteen countries also testify to the self-awareness that marks a field. And the Symposium’s theme is fittingly ambitious: Science to Accelerate Universal Health Coverage.

Charlie Chaplin is in town but can’t make it to the Symposium. He’s buried just down the road. But I wonder what his Little Tramp, bowler-hatted and down-at-heels, would make of it. Would he be considered part of the System? Am I? My interest is in the determinants of disease in the turbulent social, economic and natural environment and what that understanding can contribute especially to prevention. Read the rest of this entry »

Catalysing political will to build health systems research capacity

In Global Symposium on Health Systems Research on November 19, 2010 at 10:55 am

BY KATE HAWKINS, INSTITUTE OF DEVELOPMENT STUDIES

Sara in plenarySara Bennett, from Johns Hopkins School of Public Health, gave a rousing plenary speech on the final day of the Global Symposium. She argued that all stakeholders – policy makers, service providers, the leaders of research organisations, funders and health development partners – need to come together to support capacity development for health systems research. Health systems research capacity development can be seen as worthy but dull and it may not be compelling to donors. Yet there are a lot of exciting innovations in research capacity development occurring in low and middle income countries. Read the rest of this entry »