1. Health Systems 16/12 www.ki.se/phs/hsp Goran.tomson@ki.se

2. ”organisations, institutions, and resources that are devoted to producing health actions” - the performance is best measured by the impact on the health outcomes [WHO]

4. Health systems Health systems vary greatly in their performance - in how efficiently they improve health conditions, extend access and contain expenditure growth; yet there remains a surprising lack of information on the performance of systems and on how policies have affected performance. (Ad Hoc Committee on Health Research)

6. Health System Health centres Pharmacies Hospitals Households 20% 80%

7. The inverse care law  ”The availability of good medical care tends to vary inversely with the need for it in the population served” Hart J.T. Lancet 1971

8. Distribution of the global health workforce Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization

9. Source: WHO (2005). The World Health Report 2005 – Make Every Mother and Child Count. Geneva, World Health Organization Maternal mortality ratio per 100 000 live births in 2000

10. The boundaries and names shown and the designations used on this map do not imply the expression of any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country, territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on maps represent approximate border lines for which there may not yet be full agreement. © WHO 2006. All rights reserved Total expenditure on health per capita, in US$, 2003

11. Public Health Spending

12. 00 090100 Resourses for health research: 106 billion US$ Healthproblem: 1.5 billion “healthy years lost” Goal: better allocation of resourses prioritising problems representing most global disease burden 10/90 gap 90 100 Total resourses for health research must be increased Total burden of disease must also be decreased Of this 90% is spent on problems causing 10% of all ill health Only 10% of funding for diseases causing 90% of disease burden

13. Where are 10 million children dying every year? Each dot represents 5000 deaths (Black RE, et al., Lancet 2003)

14. Health Millennium Development Goals (MDGs)  Goal 4 – Reduce child mortality (reduce by two-thirds, between 1990-2015, under five mortality rate  Goal 5 – Improve maternal health. (Reduce by three-quarters, between 1990-2015, the maternal mortality ratio)  Goal 6 – Combat HIV/AIDS, malaria and other diseases, (have halted by 20015, and begun to reverse, the spread of HIV/AIDS and have halted by 2015, and begun to reverse, the incidence of malaria and other major diseases)  Goal 8 – Develop a global partnership for development (in cooperation with pharmaceutical companies, provide access to affordable, essential drugs in developing countries)

15. Health System barriers to MDGs  lack of demand for the interventions at the individual and community level;  policies that do not support the use of effective and affordable drugs;  multiple uncoordinated actors (public and private sectors) who have different priorities and modes of working;  underdeveloped service management capacity;  inefficiency and/or inequity in financing and resource allocation;  weak health information systems; and  limited availability and suboptimal performance of human resources. Travies et.al., Lancet, 2004

16. What is the health workforce? The health workforce is “all people engaged in actions whose primary intent is to enhance health" Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization

17. Health workers save lives.

18. Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization

20. Causes of shortages vary from country to country  the health workforce is not a priority  poor HRH planning  insufficient capacity for HRH production  inadequate budgets for training  migration  unjustified control of HRH production by professional organizations

21. World Report on Knowledge for Better Health – WHO 2004  Strengthen Health Systems  Health Systems Research Bookorders@who.int http://www.who.int/rpc/meetings/pub1/en/

22. Available Resources for Health ► 59 of WHO's 192 Member States are low-income – GNI per capita < US$825 in 2003 ► In 48 of them, total health expenditure per capita < $30 in 2003 (at official exchange rates). ► In 12, it was under $10. Includes external assistance ► Average expenditures $2840 in OECD countries and over $5600 in the USA; ► Even a minimum package of health services – personal and non- personal – would cost US$40-50 per person per year

23. Non Use of Health Services Up to 40% of people reporting Illness do not use health services Many others do not continue treatment Costs are a major deterrent

24. Summary Large global inequalities in health remain Resources available to improve health still inadequate in many countries Many countries – low and middle income particularly - rely heavily on out-of-pocket payments to finance health High out-of-pocket payments as % of total health expenditure lead to:  Financial barriers to access and continuation of treatment for the poor  Catastrophic expenditure and impoverishment for people who use services

25. WHO Principles: World Health Assembly resolution May 2005  All people should have access to essential interventions when needed, without the risk of financial catastrophe and impoverishment – universal coverage

26. Requirements  In many countries – more funding for health – revenue collection  Reduced reliance on out-of-pocket payments, increased reliance on prepayment – collection and pooling  Greater efficiency and equity in the use of available resources (existing and new) – purchasing/provision

27. Health Systems Research Characteristics

28. Why has health systems research been the poor relation?  Investments in health systems research might be lagging because:  Health systems research in addition to e.g. epidemiology includes ”soft” sciences like anthropology, political science and sociology.  Health systems research involves a range of disciplines and hence it lacks an institutional home in universities.  The types of interventions that interest health systems researchers tend to be implemented as a part of larger, messier reform programs.  The effects of health policy and systems interventions frequently depend upon multiple aspects of the environment in which they are implemented. (Alliance HPSR, 2004)

29. Leadership Infrastructure Evidence Health Systems Beaglehole, Lancet, 2008 ”Scorecard” for Global Public Health

30.  How scale up delivery of evidence-based interventions in a complex health system?  For Perinatal, Child, ”Chronic” conditions  Identify constraints to scale-up, address them, re- evaluate – ”Plan, Do, Study, Act” (incoming EU project ”EQUIP”  Partner with Implementers and Local Academic Institutions

31.  Systems thinking  How can we fund implementation research in partnerships between Universities ( S & N), MoH and donors– can we tap into the “5% of funds for research and development”  How to bridge research and policy…  What lessons learnt from capacity building, individual, institutional, even mutual….

32. Suggested topics for Health Systems Research Financial and human resources -Community-based financing and national health insurance -Human resources for health at the district level and below -Human resource requirements at higher management levels Organisation and delivery of health services -Community involvement -Equitable, effective and efficient health care -Private sector and approaches to the organization of health services -Drug and diagnostic policies Governance, stewardship, knowledge management -Governance and accountability -Health information systems -Priority setting and evidence-informed policy making -Effective approaches for intersectoral engagement in health Global influences Effects of global initiatives (GHI) on health systems