Health system design priority IS questions Margaret E. Kruk, MD, MPH Associate Professor of Global Health Harvard T.H. Chan School of Public Health

Priority implementation science questions for health systems design: scale and effectiveness What is the extent of effectiveness leakage? How to optimize fit between patients and systems for better outcomes? Why does quality vary? 1

Effectiveness leakage 2

1. Efficacy ≠ effectiveness 3

Coverage of individual care components was high 4 Souza, J. P., et al. (2013). "Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study." The Lancet 381(9879):

5 Modeled outcomes Souza, J. P., et al. (2013). "Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study." The Lancet 381(9879):

6 Actual outcomes Souza, J. P., et al. (2013). "Moving beyond essential interventions for reduction of maternal mortality (the WHO Multicountry Survey on Maternal and Newborn Health): a cross-sectional study." The Lancet 381(9879):

The total is less than the sum of parts How do we measure continuum of care? What are efficient measures of quality? For managers For researchers 7

Optimizing fit between patients and systems 8

If you build it they may not come 9

People don’t adhere to treatment, don’t return to clinic 10 Sibanda, E. L., I. V. Weller, et al. (2013). "The magnitude of loss to follow-up of HIV-exposed infants along the prevention of mother-to-child HIV transmission continuum of care: a systematic review and meta-analysis." Aids 27(17):

What HIV service design do patients prefer? 11 Which clinic would you prefer to use for HIV care, knowing you will need to return every 3-6 months?

Mixed logit regression: Ethiopia 12 AttributeMeanSE Non-HIV services available at the same consultation ** Providers are respectful and welcoming ** Mother support groups available ** Counseling services available ** Hospital (vs. health center) ** Cost, continuous in 100 Birr (5.12 USD) ** Model diagnostics Number of respondents 1,013 Number of observations 16,192 Log-likelihood Likelihood ratio χ

Mixed logit regression: Mozambique 13 AttributeMeanSE Non-HIV services available at the same consultation ** Providers are respectful and pleasant ** Providers involve husband/family in care ** Counseling services available ** Health center (vs. mobile clinic) ** Hospital (vs. mobile clinic) ** Cost, continuous in 100 MTn (3.20 USD) ** Model diagnostics Number of respondents 1,020 Number of observations 16,156 Log-likelihood Likelihood ratio χ

Poor interpersonal quality 14 Kruk, M., S. Kujawski, et al. (2014). "Disrespectful and abusive treatment during facility delivery in Tanzania: a facility and community survey." Health Policy and Planning in press.

Why does quality vary? 15

Quality of delivery care index v. delivery volume in 5 countries 16

Careful diagnosis needed before implementing Traditional QI approaches (training, supervision, PDSA) are not appropriate Health system redesign may be required Shifting place of delivery to high-volume centers 17

What can Donna do? Improve and rank quality of methods to study large-scale health system reform, policy change Identify data sources to inform intervention design: administrative data, population surveys Design valid and efficient measures of processes of care; propose methods to integrate these in outcome evaluations 18