1. Health System Strengthening for Greater Health Impact Dan Kraushaar Management Sciences for Health We all say we do it and do it well, but what is it? How strong is the evidence base?

2. We now have more and better “what”, “why” and “how much” Understanding of the problem Proximal and distal of causes Evidence on intervention efficacy and effectiveness Improved modeling Much improved normative guidance

3. Fragmented HSS efforts have created evidence on how to improve inputs and processes Leadership & governance Financing Information Health workforce Delivery Medical products, vaccines and technologies Inputs processes outputs outcomes impact

4. The evidence base on system strengthening for health impact is weak The black box of health system strengthening for health impact remains a black box. Weak health systems remains the primary barrier Lack of an agreed upon conceptual framework Lack of appropriate evaluation designs and limited scientific method applied to HSS efforts Consequently limited evidence of what works, why and under what conditions

5. Two promising practices 1.Causal pathway analysis as a means of linking health system strengthening interventions to health outcomes. 2.Systematic application of key policy and managerial levers applied against concretely defined system bottlenecks.

6. Most effective programs have defined HSS efforts based on causal pathway analysis in some way or another Allowing for system strengthening, program design and management along that defined causal path. Higher coverage Reduced problems, goals attained HSS against specific health system bottlenecks Evidence based interventions & coverage levels Problems and causes Measurable goal System requirements Right inputs & processes

7. That, coupled with use of five policy and management levers for improved system performance *Modified from Hsiao, William C. (2009). Inside the Black Box of Health Systems: What Are the Policy Control Knobs? Five key features of the health system which can be manipulated by policy makers and managers. When systematically applied have shown to influence the structure and function of the health system. They are a promising approach to improving health system performance for greater health impact.

8. What are those levers? Applied against system bottlenecks can improve system performance 1. Changing how resources are mobilized and allocated and how risks are pooled 2. Changing the organization of financing and the appropriate involvement of public and private sectors 3. Changing the payment and incentive structures for providers and consumers and modifying costs of inputs 4. Use of the coercive power of government through policy & regulation 5. Influencing beliefs, preferences and behavior of people, organizations and providers Source: Roberts, Marc, William Hsiao, Peter Berman, and Michael Reich. Getting Health Reform Right - A Guide to Improving Performance and Equity. New York: Oxford University Press, 2008. Oxford Scholarship Online. Oxford University Press.

9. Convincing evidence Retrospective analysis of effective programs Bill Hsiao, Harvard: 22 country analyses Specific examples of country programs Multiple examples the past few days

10. Thailand national FP program 1. Mobilize, allocate and manage resources 2. Organization, roles of public and private sectors 3. Changing the payment and incentives and costs 4. Policy and regulation 5. Influencing beliefs, preferences and behavior 1. Massive and preferential increase in FP funding sustained by gov’t over time. Subsidies to private sector 2. Expanded community level gov’t facilities. Encouraged private provision. Created midwifery cadre and established midwifery schools for community FP delivery. Expanded FP logistics. Integrated FP into MCH system. Encouraged private sector. 3. Free services. FP currently covered by 30Bht scheme? 4. Policy allowed for private sector innovation. Allowed research on FP methods. 5. Studied KAP of providers and consumers. Identified resistance points. Educated and trained all levels of providers. Multi media campaign. LeverPolicy and management action

11. HSS in Jordan (Dr. Hamsa’s presentation) 1. Emergency financial allocations for mag sulfate. Cost analysis. Preferential financing. 2. Improved logistics and supply. Altered purchasing processes. Improved monitoring and supervision. Creation of motherhood committees. Improved program execution. 3.Improved accountability through use of motherhood committees. 4. Improved policies on use of mag. Sulfate. Clinical guidelines. 5. Competency based training. Use of expert clinicians. Use of data and access to global evidence to influence provider attitudes and behavior. Self directed learning. 1. Mobilize, allocate and manage resources 2. Organization, roles of public and private sectors 3. Changing the payment and incentives and costs 4. Policy and regulation 5. Influencing beliefs, preferences and behavior LeverPolicy and management action

12. Thinking Causally and application of policy levers: What are the benefits? 1. Evidence based. 2.Justifies multiple yet calculated policy and managerial actions based on predicted outcomes in a way that is empirically testable. 3.Defines policy and managerial tools for changing system performance. 4.Identifies the vital few interventions and the critical path to impact. 5.Helps identify the most appropriate indicators along that critical path. 6.Helps policy makers and managers focus on outcomes and impact vs inputs and processes using the 5 levers for HSS.

13. What needs to be done? More systematic application of causal pathway analysis. Greater attention evidence More rigorous analysis of health system bottlenecks based on causal analysis. More systematic application of policy and management levers. Creation of empirical evidence through more systematic evaluations to determine effectiveness of this approach