systems thinking for health system strengthening presentation to
TRANSCRIPT
Health Systems Strengthening
How can we use more systems thinking?
Don de Savigny
Swiss Tropical and Public Health Institute
Taghreed Adam
WHO Alliance for Health Policy and Systems Research
Dar es Salaam, 3 February 2010
Foundations
2000 2007 20092008
Health system functional approach
WHO 2000. World Health Report: Health systems improving performance
System building blocks and values
WHO 2007: Everybody's’ Business. Strengthening health systems to improve health outcomes
Four revolutions
“There are four revolutions currently underway that will transform health and health systems. These are:
• Life sciences
• Information and communication technology
• Social justice and equity; and
• Systems thinking to transcend complexity”
Julio Frenk (2008) Acknowledging the past, Committing to the future.
Systems thinking
Systems thinking gives new insights into:
how a system works,
– why it has problems,
– how it can be improved
Graphic adapted from Ahn A.C. et al. PLoS Med 3:956-960 (2006).
Health systems are
more than the building blocks
How do we work them together for a more
high performance system?
WHO 2009: Systems thinking for health systems strengthening
Source
Of Funds
ESSENTIAL
MEDICINESARVs MALARIA TB OI
ARVs
Ped
REAGENT
Blood safety
(+ HIV test)
VACCINES CONDOMS CONTRACEPTIVESMEDICAL
SUPPLIES
GOVERNMENT
MULTILATERAL
DONOR
BILATERAL
DONOR
NGO/PRIVATE
GOVERNMENT
W
BGLOBAL
FUND
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A
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Health systems are complex systemsMedicines & Technologies building block – Tanzania 2007
Procurement
Agent/Body
Point of 1st
warehousing
Point of 2nd
warehousing
MEDICAL STORE
PRIMARY HEALTH CARE FACILITYDISTRICT STORE
ZONAL MEDICAL STOREREGIONAL/DISTRIC
T
VACCINE STORE
HEALTH FACILITY
AXIOSTEC
&CC
T
CRS IMA CUAMMHOSPITAL COLUMBIA HOSPITAL
TEC
&CC
T
HEALTH FACILITY
HEALTH FACILITY HOSPITALTEC
&CC
T
ZONAL BLOOD
SAFETY CENTRE
Point of
Distribution
R FTI
ARND D
HOSPITAL
TEC
&
CCT
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MEDICAL
STORE
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PATIENT
And all building blocks are increasingly fragmented !
Characteristics of all complex systems
And ….
• nest sub-systems within them
• but are part of larger systems
Skills of systems thinking
All health interventions have
system-wide effects
Typical
system-level
interventions
Synergy of connected system-level interventions
Decentralization,& local
ownership
Household health surveillance
District Health Profiles
New communication
tools
District Health Accounts
SWApBasket 1$ per capita
New mix of services; higher
coverage, quality, & utilization
Profiles
New planning & management
skills
Community voice tool
Accounts
Source: MOHSW TEHIP Tanzania
Impact of system level interventionsDistrict level
Source: de Savigny et al (2004)
Impact of system level interventionsNational level
Source: Masanja & de Savigny 2008 Lancet
A system-wide view of intervention design
Key components and
evaluation research questions
What questions does the report address?
� What is systems thinking?
� How can we apply it?
� What is systems thinking?
� How can we apply it?
� How can it help us understand and exploit synergies for system? strengthening?
� How can it contribute to better evaluations of system-strengthening interventions?
� How can it help us understand and exploit synergies for system? strengthening?
� How can it contribute to better evaluations of system-strengthening interventions?
Ideas for moving forward
• A task force on systems thinking for health systems;
• A systems thinking network or community of practice;
• Building capacity of system stewards;
• Systems thinking methods development;
• Health systems dynamic modeling;
• Applying the systems thinking steps in future HSS investments;
• Systems thinking in public health training curricula;
• An open-source Journal of Health Systems Development.
Some key messages from chapters
• With leadership, conviction and commitment, systems thinking can open powerful pathways to identify and resolve health system challenges;
• Health system stewards can use systems thinking to increase local ownership of multi-stakeholder processes and respond to the dynamic of disease-specific, and respond to the dynamic of disease-specific, sometimes donor-driven “solutions”;
• Engaging “street-level” policy implementers at the design stage of new interventions can enhance ownership of the intervention and increase the potential for successful implementation;
• Strengthening of leadership and governance of health system stewards is crucial in strengthening health systems
Select challenges in applying
a systems perspective
• Aligning policies, priorities and perspectives among donors and national policy-makers;
• Managing and coordinating partnerships and expectations among system stakeholders;expectations among system stakeholders;
• Implementing and fostering ownership of interventions at the national and sub-national level;
• Building capacity at the country level to apply a systems analytic perspective
Key message of the report
“A stronger systems perspective among
designers, implementers, stewards, and funders
is a critical component in strengthening
“A stronger systems perspective among
designers, implementers, stewards, and funders
is a critical component in strengthening is a critical component in strengthening
overall health-sector development
in low- and middle-income countries.”
is a critical component in strengthening
overall health-sector development
in low- and middle-income countries.”
Towards people driven health systems
People
Financing
Service delivery
Information
HumanResources
MedicinesTechnology
Governance
Thank you
Ahsanteni sanaAhsanteni sana