1. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I BearingPoint I Bitrán y Asociados I BRAC University I Broad Branch Associates I Forum One Communications I RTI International I Tulane University School of Public Health I Training Resources Group Demystifying Health Systems How to Assess Strengths & Weaknesses of Health Care Systems Mursaleena Islam Senior Associate and Economist May 27, 2008

2. Presentation Outline Background for the Health Systems Assessment Approach: A How-To Manual Overview of framework and indicator-based approach Technical content - module description Applications

3. Background and Purpose Increased attention on health systems Need an approach that helps to: Diagnose health systems strengths and weaknesses Prioritize key constraints and areas for interventions Identify potential solutions for health systems strengthening Existing tools (in early 2005) did not offer comprehensive health systems assessments Some focused on profiles (PAHO, European Observatory) None allowed for integration across health systems functions and included guidance to develop recommendations

4. Objectives Rapid yet comprehensive/integrated approach to systematize health systems assessments Inform stakeholders of critical systems strengths and constraints Help prioritize interventions Create consensus and momentum to act

5. Tool Development Partners USAID/Global Health Partners for Health Reform plus (PHR plus ) Now Health Systems 20/20 Rational Pharmaceutical Management plus (RPM plus ) Quality Assurance Project (QAP) Input from various external reviewers

6. Tool Provides Operational and Technical Guidance Background, definitions, examples Overview, conceptual framework, list of indicators Planning and conducting the assessment Defining the scope of the assessment How to organize the assessment team Sample scopes of work Developing a budget Scheduling the assessment Synthesizing findings, developing recommendations

7. Conceptual Framework Drilled down into each function to structure assessment approach and added link to performance and impact

8. Overview of Approach Technical Modules: Core (mandatory) Governance Health Financing Service Delivery Human Resources Pharmaceutical Management Health Information System Performance Assessment: Equity Access Quality Efficiency Sustainability Identification of Health System Strengths/ Weaknesses Recommend Priority Interventions

9. Module Content Introduction and definitions Desk-based assessment (Component 1 indicators) Standardized indicators across countries Data available electronically on Health Systems Database : http://healthsystems2020.healthsystemsdatabase.org/

10. Module Content (cont d) In-country assessment (Component 2 indicators) Country reports and other country sources Stakeholder interviews No additional primary data collection required Summarizing findings and developing recommendations Stakeholder workshop Key references

11. Indicator Specifics in Each Module For each indicator, the following information is provided: Definition Rationale Interpretation Suggested data sources Stakeholders to interview Links to other modules on cross-cutting issues Issues to explore Notes and caveats

12. Technical Modules (1) – Core Political and macroeconomic environment Business and investment climate Top causes of morbidity and mortality Structure of the main government Main private organizations involved in health care system Organization of the health system and delivery of services Donor mapping and coordination

13. Technical Modules (2) - Governance Information/assessment capacity Policy formulation and planning Social participation and system responsiveness Accountability Regulation

14. Technical Modules (3) - Financing Organization of financial system and flows Revenue collection Pooling and allocation of financial resources Purchasing and provider payments

15. Technical Modules (4) – Service Delivery Availability of services Access, coverage, and utilization Service delivery outcomes Organization of service delivery Quality assurance of care Community participation

16. Technical Modules (5) – Human Resources Planning Policies Performance management Training and education

17. Technical Modules (6) – Pharmaceutical Management Policy, laws, and regulations Selection Procurement Storage and distribution Appropriate use Availability and access Financing

18. Technical Modules (7) – Health Information System Health status and health system indicators Resources, policies, and regulation Data collection and quality Data analysis Use of information for management, policymaking, governance, and accountability

19. Example of a Component 1 Indicator

20. Web-based Data Tool - Health Systems Database http://healthsystems2020.healthsystemsdatabase.org/

21. Health Systems Database – Data for Component 1 Indicators Health Systems data Country level data Average value of regional comparator Average value for income group comparator Benin Year of Data Sub-Saharan Africa Year of dataLow income Year of dataSource of data Core Module Population, total8,177,208200415,439,321200443,077,9912004 The World Bank-World Development Indicators-2006 Population growth (annual %)3.2120042.1620042.282004 The World Bank-World Development Indicators-2006 Rural Population54.66200462.58200468.62004 The World Bank-World Development Indicators-2006 Urban Population (% of total)45.34200437.42200431.42004 The World Bank-World Development Indicators-2006 Contraceptive prevalence (% of women ages 15-49)18.6200116.07200119.212001 The World Bank-World Development Indicators-2006 Fertility rate, total (births per woman)5.720045.1920045 WHO-The World Health Report-2006 Mortality rate, infant (per 1,000 live births)89.6200492.24200486.412004 The World Bank-World Development Indicators-2006 Mortality rate under-5 (per 1,000)1522004149.432004135.542004 The World Bank-World Development Indicators-2006 GDP per capita (constant 2000 US$)327.552004931.542004342.262004 The World Bank-World Development Indicators-2006

22. Example of a Component 2 indicator

23. Tool Provides Strategy for Synthesizing Findings and Recommendations For each module – SWOT and other analysis Across modules – analysis and prioritization Identify overall health systems strengths and weaknesses Develop recommendations for systems strengthening Validation of conclusions and recommendations through stakeholder workshops Refine and finalize findings based on feedback

24. Application of the Tool Full application of all seven modules requires 6-8 person-weeks in country for data collection and synthesis of findings Applications to date range from use of a single module to use of complete package Uses by USAID include: health programming, preparation of bilateral contracts, determination of specific areas of support The tool has been used by and for Ministries of Health and contribute to their health sector reviews and health sector plans

25. Documented Uses of Tool to Date CountriesPrimary AudienceObjectives AngolaUSAIDInput for health programming BeninMinistry of HealthInput for 5-year prioritization strategy S. SudanMinistry of HealthInput into GAVI HSS proposal PakistanUSAIDPriority for health system activities MalawiUSAIDInput into bilateral design AzerbaijanUSAIDInput into supporting pharmaceutical management at MOH GhanaUSAIDInput into assessment of insurance YemenMinistry of HealthFramework health sector review

26. Modules Used by Country Modules usedAngBenSSPakMalAzeGhYem Core Governance Private Sector Not available as a separate module Service Delivery N/A Human Resources Pharmaceutical Info Systems Financing

27. Benin Application Context : Ministry of Health just initiating process for development of 5-year health strategy USAID had developed their country strategy, awarded major health bilateral, and in process for awarding second bilateral Second pilot test of tool – April 2006 4-person US-based team plus local consultant

28. Conclusions from users It helped me think through or think differently about various aspects of the health system I was able to be more comprehensive. I used it as a guide, more informally, and as a reference. Even the areas that one has no information about--it is useful to understand what is not known. Just the fact that key information cannot be quickly obtained from key individuals can be very telling. The tool provided me with a framework to structure and analyze the data I was collecting. It helped me produce a more thoughtful report.

29. Abt Associates Inc. In collaboration with: I Aga Khan Foundation I BearingPoint I Bitrán y Asociados I BRAC University I Broad Branch Associates I Forum One Communications I RTI International I Tulane University School of Public Health I Training Resources Group Thank you Reports related to this presentation are available at www.healthsystems2020.org