beyond scaling up: change and complex health systems
DESCRIPTION
This presentation was given at the 'Beyond Scaling Up: Pathways to Universal Access' workshop which was held at the Institute of Development Studies, Brighton on the 24-25 May, 2010. This event was co-sponsored by the Future Health Systems Research Programme Consortium and the STEPS Centre. Peters presented on change in complex health systems.TRANSCRIPT
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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