1. Overview of Health Systems Constraints in Developing Countries David Peters November 30, 2005

2. Graduate student ranking of health system constraints in low income countries 2001 1. Inadequate funding 2. Personnel – poor motivation & training 3. Corruption/poor governance 4. Poor management 2005 1. Poor management 2. Corruption/poor governance 3. Personnel – poor motivation 4. Poor systems to allocate funding

3. International agency identification of health system constraints ConstraintWorld Bank WHOHLFGFATMGAVIDFID Poor management (at district & central levels) X X XX Poor accountability of providersXX XX Lack of incentives for health workersXXX XX Lack of trained health workersXXXX X Inadequate & unreliable public spending on health XXX XX Lack of knowledge by publicXXX X Poor drug supply chain managementX XXXX Poor monitoring of health servicesX X X

4. Broad international consensus Overall goals and priorities – MDGs, HIV Cost-effective interventions Importance of strengthening health systems Identification of health system constraints Commitment to increasing funding and donor harmonization/coordination So why don ’ t health systems deliver?

5. What will it take? More time, more resources A Global Fund for Health Systems? Real commitment to local leadership? More attention to performance? Less ad hocracy?

6. Levels of constraints I. Household & Community II. Health Services Delivery (inputs, processes, outputs) III. Health Systems Organization & Functions IV. Accountability Relationships V. Context

7. Why categorize? Understand types of intervention required Recognize dependence on other parts of health system – know where to look for unintended consequences Recognize dependence on external factors Understand timeframe for change

8. I. Household & community

9. II. Health services delivery

10. III. Health systems organization and functions

11. IV. Accountability relationships

12. V. Context

13. A paradigm for understanding health systems Purpose Impact level Health Service Outcomes level Actors and relationships Functions

14. Health services delivery framework Purpose (Level/Spread) Health status Financial protection Trust in health system GOVERNMENTGOVERNMENT Oversight & Compact s Client Power Political Voice PROVIDERS Management systems Performance Management; Human Resources; Financial Management; Information Systems; Logistics: Drugs & Technology, Buildings, Auxiliary Services Political Environment Social Conditions Economic Factors Physical Environment Health Service Outputs (Level/Spread) Utilization Coverage Quality Efficiency Informatio n Performance ; Disclosure; Research Financing Revenue; Pooling; Allocation; Payment Leadership Strategic direction; Values External Development Partners Non-Health Sectors Education Water Agriculture Transport Power COMMUNITY PEOPLE Poor / Non-Poor Organization of Health Services

15. Some observations Health systems are complex and inter- dependent; intervening in one part of the system affects other parts How you organize assistance in a health system drives behavior of staff

16. HIV and health systems considerations Transmission is sparked by highly motivated behaviors – can ’ t just address disease in health care setting HIV is highly stigmatized – greater trust in health system is needed Chronic disease requires repeated health care visits, tiered levels of care, increased financial vulnerability – higher demands from health system Co-morbidity and multiple disease manifestations, need for integrated services organized around patient and family rather than single sets of services

17. Some final questions Is there a magic bullet to fixing health systems, or do you need to address all parts of the health system at once? Can programmatic approaches “ do no harm ” to a health system? Can health systems focus on HIV and a few priorities and still succeed? How can you strengthen health systems to take on priority conditions?