Bringing a Health Systems Perspective to Programming for HIV/AIDS and Health System Strengthening Peter Berman Lead Economist, The World Bank Adjunct Professor, Harvard School of Public Health Vienna, July 2010

Abandon the Antagonism Between Categorical Programs and Health System Strengthening Lets put it away! Competition over resources…by other means Evidence is inconclusive – categorical programs can strengthen wider systems or weaken them All health programs are means to improving outcomes Health systems perspective seeks to maximize outcomes There are synergies, but there are also real, and troubling, trade-offs across outcomes There are efficiencies in delivery, but there are also real, and troubling, inefficiencies in delivery Allocative efficiency issues are not unique to HIV/AIDS, but there are some unique problems “Do no harm” as minimum standard. “Seek out synergies” more proactive. (Essence of the “diagnonal approach”)

Ultimate Goals of Health Systems Risk Protection Public Satisfaction Health Status Level Distribution

From Control Knobs to Outcomes

“Diagnosis and Therapy” of the Health System

“Health System Analysis” – an analytical basis for programming for categorical programs and HSS Significant body of work across countries at all levels of income, e.g. National studies: Mexico, India Health in Transition series World Bank country studies, e.g. CSRs in Africa USAID supported “health system assessments” Distinction between description, analysis, prediction Review of 12 major World Bank studies (Bitran et al, 2010) Comprehensive reviews Overall framework sound Some key elements weak Organization and service delivery Health systems analysis of categorical programs Governance and institutional analysis Linkage to policy process More and better health system analysis needed to integrate categorical programs with national health strategies and their HSS elements

Typical HSA Structure

Programming from an HSS Perspective: Two Dimensions From Inputs to Reform: More, Better, New Approaches Addtn’l health system inputs: Reforms to health systems HRH, drugs, bldgs, vehicles improving access, quality, demand More Better New (Inputs) (mainly govt) (mainly non-govt) From Single Disease to Cross-Cutting Health System Elements Single Disease Multiple diseases Cross-cutting or interventions or intervention cluster elements not disease specific

Different programming strategies combine these dimensions in different ways More Better New (Inputs) (mainly govt) (mainly non-govt) Single Disease Multiple diseases Cross-cutting or interventions or interventions cluster elements not disease specific Increase essential supplies, such as LLINs Introduce RBF contracts for govt and non-govt providers Strengthen regulation to improve quality of non-government providers, like private maternities

An Example: Strengthening HIV/AIDS Service Delivery Objectives: Increase volume, access, quality, efficiency Range of strategies possible – for example: Increase inputs – expand capacity: human resources, supplies, etc. Improve support systems to assure distribution/delivery of inputs “Integrate” related services at point of front-line delivery Share (“integrate”) support services (e.g. laboratory, information) Redesign service delivery tasks, e.g. task-shifting Incentivize organizations or health workers, e.g. PBF Redesign service delivery organization (platforms) – new types of facilities and staffing patterns Engage new providers, e.g. public-private partnership, contracting These strategies span MORE—BETTER—NEW; differ in degree they require cross-cutting action and change; and involve different actors in system

Strategy Focus Categorical or Systemic? Focus on which actor? Increase inputs, expand capacity C Front-line Provider Improve support systems Facility/Org Manager “Integrate” linked services at front-line Share support resources C/S Facility/Org Manager Redesign service delivery tasks Incentive organizations and/or providers S Planner/Policy Maker Redesign service delivery platforms Engage new providers

Some take aways Strengthening HIV/AIDS service delivery to increase access, quality, and efficiency can be addressed through a wide range of strategies Strategies can be selected which are more categorical (single or several disease or problem focused) or more systemic (involve actions or changes which engage health systems more broadly). These characteristics are correlated with the actors more likely to be involved. More “systemic” strategies are likely to require changes beyond categorical programs or with wider effects; several or all “control knobs” Strategies should be chosen to achieve the objectives and based on an analysis of causes constraining that achievement. Need to fit the intervention to the causes…but feasibility is also an issue. As HIV/AIDs programs scale up, they bump against system-related constraints or themselves affect the wider systems The “do no harm” principle implies that responsible HIV/AIDS programmers consider these effects. Health system analysis can help. More dialogue with health system planners and capacity building may also be needed.

Concluding Thoughts Health system is not a “black box”, we have concepts and tools to analyze The tools have not been sufficiently applied to disease control programs and HIV/AIDS Evidence base on HSS strategies is imperfect, but not vacant. Aren’t there serious gaps in our knowledge about technical strategies for HIV/AIDS behavior change and case management? We can provide “conditional guidance” More integrated programming is essential as programs mature