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Health system assessments

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1 Health system assessments
Has DOTS expansion reached its limits through existing health systems? Christy Hanson WHO Geneva

2 Health system assessments
Aims: Enhance DOTS expansion efforts by tapping into underutilized strengths of the existing health system Recognizing and addressing limitations of the health system in supporting DOTS expansion Enhancing the contribution of DOTS expansion to the aims of health systems strengthening Promote complementarity Application: Planning within NTP Global lessons learned Partners Forum

3 System aspects explored
Infrastructure Coverage of health facilities by type / capacity Public and private sectors Human resources Distribution Activities by cadre Training Monitoring mechanisms Supplies / logistics Funding Planning

4 Measuring DOTS coverage

5 DOTS coverage within limited PHC
Ethiopia DOTS coverage within limited PHC 45% of rural population within walking distance from PHC facility 85% of pop. lives in rural Wide regional variance in facilities per population 33% have access to safe water 45% live on <US$1 / day 30% of existing facilities implementing DOTS

6 DOTS Coverage within strong PHC
Vietnam DOTS Coverage within strong PHC 11% of population in areas with limited geographical access to PHC North / south variance: human resources Hospital use: 36% of users from highest income quintile 8% from lowest income quintile

7 Where the system provides DOTS
Kenya Where patients go vs. Where the system provides DOTS

8 Private sector Overall: limited awareness of the role or magnitude of private sector, limited engagement in TB control Ethiopia:limited but exists, pharmacies, hospitals Kenya: almost equal use of public and private providers as entry point Pakistan: 40% of health care provided by private sector 79% of TB patients seek care initially in private sector Vietnam: 60% of outpatient visits with private clinics

9 Kenya Human resources 300 trained clinical officers unemployed

10 Human resources: distribution
Ethiopia Human resources: distribution

11 Human resources: distribution
Nigeria Human resources: distribution

12 Human Resources: Training
Vietnam: systematic training for TB 10,000 general health workers / year Training not integrated in other general health training No examples of TB integrated within pre-service training No examples of NTP involvement in general PHC in-service training Kenya: TB training of clinical officers stopped Nigeria: States responsible for training own staff in PHC NTP supports state training of 60 workers / year Pakistan: training lady health workers for TB Ethiopia: New cadre of health workers to be trained / deployed at most decentralized level (PHC)

13 Human resources involved in TB control
Vietnam Human resources involved in TB control Total: 15,772 staff involved in TB control

14 Decentralization issues
Increased decision-making and budget authority at decentralized levels Variable levels of political commitment to TB Variable resources to invest in TB Shifting of resources (human, financial) Ethiopia: process Nigeria: release of funds, planning Vietnam: poor provinces, less to invest in health Pakistan:

15 High costs for patients
Nigeria: 70% of health expenditures private, mostly out-of-pocket Kenya: cost-recovery in 68% of public facilities Vietnam: 80% of health expenditures - direct household spending Per capita household spending US$20 Documented wealth inequalities in utilization of services: Kenya, Vietnam

16 TB compared to other disease control programmes
Coverage Kenya: immunization services in 80% of public facilities, reproductive health in 75% of facilities TB control in 30% of public facilities Ethiopia: leprosy has broader coverage than TB Drug supplies: TB supplies generally more stable than other essential drugs

17 Summary Has DOTS Expansion reached its limits through existing health systems? Strengths Integrated lab networks Stable drug supplies Challenges Political commitment at decentralized levels Utilizing and building capacity of PHC Recognizing types of facilities and workers, tailoring NTP Engaging private sector and pharmacies Training Limited coverage of PHC in some countries

18 Discussion Any messages that would be useful to bring to Partners Forum?


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