1. STRENGTHENING HEALTH SYSTEMS Anne Mills DCPP Editor London School of Hygiene and Tropical Medicine

2. BACKGROUND Core of DCP2 is evidence and analysis of burden of disease and cost-effectiveness Interventions usually delivered through a health system Cost-effectiveness data usually reflect a reasonable level of technical efficiency – may not be readily achievable in real life Need to know how best to strengthen health systems so they are able to deliver interventions cost-effectively and at scale

3. AIM OF PRESENTATION Summarise key messages from the wealth of evidence in the chapters of DCP2 concerned with strengthening national health systems

4. STRENGTHENING HEALTH SYSTEMS Stewardship/regulation Organisational structures and their financing General management functions - human resources and quality assurance NB: 1.Lack of evidence 2.Effectiveness of approaches depend on starting point

5. STEWARDSHIP/REGULATION Strengthen accountability to communities and increase user voice (eg Burkina Faso; Ceara) Enforce regulations (where capacity exists) Use approaches that work with the private sector

6. ORGANISATIONAL STRUCTURES AND FINANCING Clarification of purchaser and provider roles within public health sector Decentralisation to hospitals and ‘districts’ Vertical versus horizontal modes of organising and managing service provision Contracting out service provision

7. Improved health care coverage rates CONTRACTING EXPERIMENT IN CAMBODIA 1997- 2001 (Swartz and Bushan 2004 ) Poor benefited more than richer groups

8. HOSPITAL CONTRACTS IN SOUTH AFRICA Contractors’ costs lower than public; similar quality Cost advantage largely due to higher staff productivity Contract cost to government > government cost of provision Study led to re- negotiation of contract terms

9. CONTRACTS WITH GPs IN SOUTH AFRICA Formal aspects of contracts had little influence (eg design, monitoring, sanctions) Social and institutional factors important Contracts highly ‘relational’ and context specific Policy implications: emphasise cooperation, shared interests, professionalism

10. HUMAN RESOURCES Use local cadres (not internationally mobile); give specific skills (eg Malawi: caesarean section training to clinical officers) Use incentive payments if can be regulated and controlled Otherwise use broader performance management approach emphasising non financial rewards

11. QUALITY ASSESSMENT/ASSURANCE Good quality possible even in highly resource constrained settings Evidence that two approaches can work:  Policies which directly affect individual and group practice (eg shopkeepers, Kilifi)  Policies which change structural conditions and indirectly affect providers (eg contracting)

12. TARGETING RESOURCES Systems level – eg resource allocation formulae; financial incentives to users Service level – eg planning and budgeting frameworks; consumer education and information

13. THE TANZANIA ESSENTIAL HEALTH INTERVENTIONS PROJECT (TEHIP) (de Savigny et al 2004) Provided tools for district level decision makers to influence resource allocation Linked burden of disease data with expenditure on interventions Showed improved match between disease burden and district budget

14. THE CONTRIBUTION OF TEHIP TO IMPROVED HEALTH OUTCOMES

15. SELECTED KEY MESSAGES 1.Keep the health of the system in mind whenever major new programmes are put in place - ensure disease-specific efforts contribute to system strengthening 2.Reforms affecting organisational structures and human resource management more likely to be successfully implemented if they are incremental and gradual 3.Successfully linking financial incentives to performance dependent on careful monitoring; difficult in low income settings without continuing external involvement 4.Capacity strengthening required at all levels

16. SELECTED RESEARCH PRIORITIES Cost and effectiveness of approaches to strengthening system capacity Identification of delivery strategies that can maintain high coverage for specific interventions Identification of governance and institutional arrangements that will help achieve health improvements for the poorest

17. RESEARCH CAPACITY STRENGTHENING (Source: Alliance for Health Policy and Systems Research 2004) Project funding for health systems research < 0.02% of annual developing country health expenditure More than half of research projects had budgets < $25,000 A third of institutions engaged in health systems research had no doctoral level staff Only 5 percent of health systems research literature in Medline concerns developing countries  Great need for strengthening capacity in health systems research