1、Maximizing Positive Synergies Between Health Systems and Global Health Initiatives A Mixed Methods Approach,Dr. Jim Yong Kim Harvard Medical School Harvard School of Public Health October 2, 2008,Positive Synergies,“How can global health initiatives and national health systems optimize their interac
2、tions to capitalize on positive synergies and minimize negative impacts, thereby achieving their common goal of improving health outcomes?”,What are the best methods to answer this question and lead to the desired outcomes?,What are the Desired Outcomes?,Healthier People/Equity/Social Justice Highly
3、 functioning health systems that are responsive to everyone and deliver across the priorities Better policies that shape donor behavior, health system design and health service delivery Evidence-based implementation and delivery by systems and practitioners at all levels Evidence that links system d
4、esign, implementation strategy, management structure, degree and nature of integration of services, civil society involvement, health system architecture etc. to health outcomes Methodologies and researchers that fit the task,Choosing the right methods,What kind of data/information exists and does i
5、t point the way to further studies? What is the state of framework and theory development around the problem? Are researchers who represent “unusual” disciplines working on the problem? Are civil society actors and affected communities involved at every step? Will the methods used and research done
6、be helpful to practitioners at the country level and lead to real health improvements for people?,Proposed Methodological Approach,Cross-country Quantitative Analysis Country-level Mixed Methods Analysis Provider Unit-Level Analysis,Research Questions,How do GHI-funded programmes interact with healt
7、h systems in varied country contexts? What positive synergies or negative interactions emerge when GHI funded programmes interact with local health systems? In various contexts, which factors influence the extent and nature of interaction between GHI-funded programmes and local health systems?,Resea
8、rch Questions,3. What are the specific system designs and delivery strategies funded by the GHIs that have lead to the most positive impacts on health systems?a. How do these designs and delivery structures influence the coverage of targeted and non-targeted interventions and health outcomes?,Adapte
9、d from: WHO six building blocks and RA Atun et al, 2006,Conceptual Framework,Health Systems Infrastructure/Hardware,Governance,Country-level mixed methods analysis,Cross-country quantitative analysis,Provider-unit level analysis,Levels of Analysis,Identifying relationships,Understanding relationship
10、s,Understanding the impact,Mixed Methods Approach,Appropriate for complex systems and relationships Either quantitative or qualitative methods alone are insufficient Employs multi-disciplinary teams Allows for triangulation with different types of data,GHI investments,Government health expenditure,C
11、overage of skilled-attendance at delivery,Coverage of immunization,Child mortality,Cross-country quantitative study,Country-level mixed methods analysis,Case study library Level 1 National level analysis of GHI-Health System Interaction Level 2 Regional, district, and provider unit level analysis of
12、 systems design and local impact,Country Selection,Develop sampling matrix in consultation with partners: Geographical representation GHI investment as a percentage of total health expenditure High burden of GHI-targeted disease Existing connections with partner institutions,GHI investment/ Total he
13、alth expenditure,Burundi Rwanda Zambia Somalia Liberia Guyana Uganda Gambia Ethiopia Tanzania Malawi Haiti Mozambique Kenya Swaziland,GFATM, PEPFAR, GAVI disbursements through 2005,HIV Prevalence,Swaziland Botswana Lesotho Zimbabwe Namibia South Africa Zambia Mozambique Malawi Central African Republ
14、ic Gabon Cote dIvoire Uganda Kenya United Republic of Tanzania,WHO Statistical Information System (WHOSIS), Accessed: July 2008,TB Incidence,Swaziland South Africa Djibouti Namibia Lesotho Zimbabwe Timor-Leste Zambia Botswana Sierra Leone Cambodia Mozambique Cote dIvoire Congo Rwanda,WHO Statistical
15、 Information System (WHOSIS), Accessed: July 2008,Proposed countries,Proposed countries,Other Likely Candidates,Cameroon Senegal Ghana Viet Nam Philippines India China,Data Cross-country,Time series cross sectional data GFATM, PEPFAR, GAVI disbursements National Health Accounts OECDs Credit Reportin
16、g System DHS, MICS, administrative data, data from UN or WHO,Data National and Regional,Document review Semi-structured interviews with key informants Collection and analysis of appropriate, available quantitative information All data collected in cooperation with Ministries of Health,Data Provider
17、Unit-Level,System Design Implementation Strategies Available Services Laboratory Services Essential Medicines Human Resources Infrastructure Targeted Outcomes (HIV, TB) Coverage of non-targeted interventions,Expected Outcomes,Global cross-country analysis Case study library of more than 10 countries
18、 detailed information on health system design, implementation strategy etc. Provider unit-level analysis in select countries Literature review Identification of knowledge gaps for further study Improved methodology Input for WHO policy recommendations,Timeline,Late October: Finalized methodology wit
19、h partnersEarly November: Begin in-country data collectionNovember 17-19: Bamako Ministerial meetingJanuary March: Continued data collection and analysisMarch April: Preparation of results and reports,Academic Partners,Conclusions,April is tomorrow Much very important work has already been done Must
20、 be clear about the question we are trying to answer We must look to “unusual” methods and “unusual” partners This effort is just the beginning of a much larger effort lead to the development of a “science” of health care delivery? This has to be a team effort with collaborations in all directions a
21、 “community of practice”,Selected References,Atun, RA, Turcan, L, Berdega, V et. al. (2005). Review of Experience of Family Medicine in Europe and Central Asia. (In five volumes) Volume V: Moldova Case Study. World Bank Report No. 32354-ECA. Human Development Sector Unit, Europe and Central Asia Reg
22、ion. Washington, DC: The World Bank. Atun RA, Menabde N, Saluvere K et al. Introducing a Complex Health Innovation Primary Health Care Reforms in Estonia (Mulitmethods Evaluation). Health Policy 79 (2006) 79-91. Atun RA, Bennett S, Duran A. When do Vertical (Stand-Alone) Programmes Have a Place in H
23、ealth Systems? Policy Brief, WHO European Ministerial Conference on Health Systems, 25-27 June, 2008, Tallinn, Estonia. Banteyerga, H, Kidanu, A, Stillman, K. (2006). The Systemwide Effects of the Global Fund in Ethiopia: Final Study Report. Bethesda, MD: PHRplus. Abt Associates Inc. Daniels N, Flor
24、es W, Pannrunoathai S (2005). An Evidence-Based Approach to Benchmarking the Fairness of Health Reform in Developing Countries. Bulletin of the World Health Organization. 83: 534-40. Frontiers Development and Research Group. Global HIV/AIDS Initiatives in Zambia: Issues of Scale Up and Health System
25、s Capacity: Interim District Report. (2008). Global HIV/AIDS Initiative Network. OSI. GAVIAlliance. Accessed July 2, 2008 at: http:/www.gavialliance.org/about/in_partnership/index.php.,Selected References,Global HIV/AIDS Initiative Network (GHIN). (2006). A Generic Guide to Research Practice: Follow
26、ing discussion at Lilongwe workshop of GHIN African teams. Global HIV/AIDS Initiative Network (GHIN). (2006). GHIN African District Studies: Detailed Research Questions and Methods. Gbangbadthor, S, Hounsa, A, Franco, LM. (2006). Systemwide Effects of the Global Fund in Benin: Final Report. Bethesda
27、, MD: Health Systems 20/20. Abt Associates Inc. Loevinsohn, B, Aylward, B, Steinglass, R et. al. (2002). Impact of Targeted Programs on Health Systems: A Case Study of the Polio Eradication Initiative. American Journal of Public Health; 92(1):19-23. Mtonya, B, Chizimbi, S. (2006). Systemwide Effects
28、 of the Global Fund in Malawi: Final Report. Bethesda, MD: PHRplus. Abt Associates Inc. Murray CJL, Evans DB, eds. Health systems performance assessment: debates, methods and empiricism. Geneva: World Health Organization, 2003. Semigina, T, Griga, I, Bogdan, D, Schevchenko, I, Bondar, V, Fuks, K, Sp
29、icer, N. (2008). Tracking Global HIV/AIDS Initiatives and their Impact on the Health System in Ukraine: Interim Report. Global HIV/AIDS Initiative Network. OSI.,Selected References,WHO. Everybodys Business: Strengthening Health Systems to Improve Health Outcomes. WHO, 2007. WHO. The Global Fund Stra
30、tegic Approach to Health Systems Strengthening. Report from WHO to the Global Fund Secretariat, September, 2007. WHO. Maximizing Positive Synergies Between Health Systems and Global Health Initiatives. Report on the expert consultation, WHO, Geneva, 29-30 May 2008. WHO. Opportunities for Global Health Initiatives in the Health System Action Agenda. WHO Department of Health Policy, Development and Services, Evidence and Information for Policy, 2006.,
