beyond scaling up: change and complex health systems

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Management of Change in Complex Health Systems

May 24, 2010David H Peters

Johns Hopkins University

Beyond Scaling Up

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The Problems of Implementation in the Health Sector

Many cost-effective solutions are known to save lives

Why can’t health systems consistently deliver solutions at large scale? to vulnerable populations?

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Understanding Change in Complex Health Systems

Do we ask the right questions?

Do we have the right models & assumptions?

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Knowing What vs. How vs. Why

What works“Evidence” for simple interventions

How does it work Knowledge of context, actors, &

implementation processes for complex change

Why do itBeliefs and values for motivated and

sustained action

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What Do We Want to Know? Questions, Inferences, How To Investigate

Primary question Inference Design Implications

Is any measured health effect due to the implemented strategy?

Probability Controlled (cluster randomized) trials; health strategy implemented in some areas and not in others

Is any measured health effect likely due to the strategy rather than other influences?

Plausibility Concurrent, non randomized clusters; strategy implemented in some areas and not in others; before-after or cross-sectional study in program recipients and non-recipients

Are health indicators changing among beneficiaries of a strategy?

Adequacy Before-after or time-series in program recipients only

How did implementation of the strategy lead to effects on health behavior, services or status?

Explanatory Mixed methods: Repeated measures of context, actors, depth and breadth of implementation across subunits +Qualitative methods: key informant interviews, focus groups, historical reviews, and triangulation of data sources

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Do We Have The Right Models?

The Conventional Pathway For Improving Health Outcomes

1.Choose the right (cost-effective) health interventions

2.Set ambitious, common targets

3.Fund them adequately

4.Implement interventions as designed

Do Countries Follow a Common Pathway for Delivering Immunizations? Trends in DPT3 Coverage (All LMICs)

Multi-level models, each line represents one country

How Strategies are Implemented Matters: Odds of Success from Systematic Review

Randomized Controlled

Trials

All “Adequate”

Studies

Odds ratio Odds ratio

Community coordination and organization.. 4.6**

Local adaptation of the intervention 9.3 4.3 * Broad-based support of various stakeholders

.. 3.9 *

Consultation and engagement of powerful interest groups

2.8 3.8**

Flexibility and modification through stakeholder feedback

.. 3.4 *

Representation from powerful interest groups

2.4 3.0 *

Constraints reduction plans 6.7 2.7 *

* Pvalue<0.05; ** Pvalue<0.01

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Literature on Models for Scaling Up Health Services: Two Views

Domain Scaling up to Reach the MDGs

Scaling up Innovations and Pilot Projects

Defining Concerns

“Becoming large”; more people reached

Expanding impact, becoming sustainable in quantitative, functional, organizational, political terms

Time Frame Short to medium term

Medium to long term

Funding Money is a binding constraint

Money is necessary but not sufficient

Absorptive Capacity

Ability to spend external funds

Ability to find a fit between capabilities of beneficiaries, programs, and organizations

Subramanian et al (2010). Under review

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What we should have learned

o Focus on quantitative coverage provides little insight on actions needed for sustainability or continued growth

o Pay attention to political, organizational, and functional scale up, and need to nurture local organizations

o Bias toward supply side & public sector ignores importance of demand side and market systems

Need

HEALTH SERVICES

RULES

Supply Demand

Informing & Communicating

Setting & Enforcing Rules

HEALTH SYSTEMS INPUTS

MACRO CONTEXT

KEY ACTORS

PATHWAYS FOR LARGE SCALE

CHANGE

IMPACT Health Status (MDGs) Empowered Communities

& Households

EFFECTIVE HEALTH SERVICES

Access Coverage Utilization Quality Equity Cost Efficiency

UNINTENDED CONSEQUENCES

Marginalized populations Disorganized markets Narrow range of services Unsustainable strategies Crowding out key actors Loss of public goods

Pathways to Changing Health Services

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A B C

Feedback

Pathways in Complex Adaptive Systems

A

B

C

D

B1

B2

D1

D2

C2

C1

Path dependence

Scale-free networks

Emergent behavior

Phase transitions

Uganda Safe Deliveries Pilot Project

Pregnant woman transported to

Nkond Health Center

Discussion with pregnant women in Kidera Village

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Institutional Deliveries in Kamuli District

InterventionControl

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Uganda Safe Deliveries Pilot Project: Emergent Behavior, Non-linear Response, Possible Phase Transition?

Intervention

Intervention:• Transport Voucher with Motorcyclists• Small Subsidy for Health Workers based on services provided

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Changing Health Systems: Embracing Complexity

Focus on purpose of system Build on interventions shown to be effective Scrap the blueprint Engage key stakeholders Stimulate innovation to align institutional

arrangements, incentives and accountability Use data for systematic learning & problem-

solving Anticipate unintended consequences