Surgical Care, Health Systems, and Health Systems Strengthening?
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1 Surgical Care, Health Systems, and Health Systems Strengthening? David A. Spiegel, M.D. Children s Hospital of Philadelphia Associate Professor of Orthopaedic Surgery University of Pennsylvania School of Medicine
2 Flight of Ideas 1) Define health system and health systems strengthening 2) Integrating surgical services within a health system
3 Health Systems all the activities whose primary purpose is to promote, restore and/or maintain health WHR 2000: health systems: improving performance. Geneva, WHO (
4 Programming/Inputs: Vertical, Horizontal, Diagonal? Vertical Horizontal Polio Eradication Initiative Expanded Program on Immunization Integrated Management of Childhood Illness Comprehensive Primary Health Care Vertical Horizontal Oliveira-Cruz V, et al. J Int Dev 2003;15:67-86.
5 Evolution in Conceptual Frameworks Evans et al (1981) Hurst et al (1991) Mills and Ranson (2006) Roberts et al (2003) World Health Organization (2000) World Health Organization (2007) World Health Organization (2008) Atun (2006) Main actors in health care systems Population to be served Health care providers Third-party payers Health Systems Conceptual Frameworks Government (regulation) Fund flows and Payment Methods 7 Subsystems for financing and delivering services o Voluntary insurance schemes Private reimbursement o Contract models Integrated models Compulsory insurance or tax funded models Public reimbursement model Contract models Integrated models o Direct, Out of pocket expenditures Capacity Framework: Map = interplay between 4 key functions and 4 key actors Key Functions o Regulation o Financing o Resource allocation o Service provision Key Actors or stakeholders o Government or professional regulatory bodies o Population (including patients) o Financing agents o Service providers Reforms Framework Structural components and their interactions lead to goals or desired outcomes of system Control knobs o Financing o Macro-organization o Payment o Regulation o Education/persuasion Performance Assessment Framework 4 Key functions to transfer inputs into outcomes o Resource generation o Financing o Service Provision o Stewardship Building Blocks People (Supply side) System (Demand Side) o Governance, Service Delivery, Medicine and technologies, Human resources, Information, Financing Primary Health Care Universal coverage People at center of service delivery Integrating health into public policy across sectors Inclusive leadership for health governance Systems Thinking framework Interaction of health system elements within local context [demographic, economic, political, legal and regulatory, epidemiologic, sociodemographic and technological (DEPLESET)] Goals = health, financial risk protection, consumer satisfaction 4 Levers for policy makers o Stewardship and organizational arrangements o Financing o Resource allocation and provider payment systems o Service provision
6 Supply WHO Building Blocks Framework (2008) Demand
7 Health Systems are Complex Nonlinear Feedback loops Cause and effect separated by time and space Adam et al. Health Policy Plan 2012;27 Suppl 4:iv9-19. Adam T, de Savigny D. Health Policy Plan 2012;27 Suppl 4:iv1-3. Atun et al. Health policy and Planning 2012;27:iv4-iv8. Sundewall et al. Lancet. 2011;377: Sterman JD. American Journal of Public Health 2006;96:3.
8 Policy Resistance
9
10 Health Systems Strengthening Lack concensus on definition, strategies Most vertical or GHI Long term iterative process Literature sparse Sundewall et al. Lancet. 2011;377: Cavalli et al. PLoS Negl Trop Dis 4:e798. Marchal et al. PLoS Med. 2009;28;6(4):e Adam et al. Health Policy Plan 2012;27 Suppl 4:iv9-19. Adam T, de Savigny D. Health Policy Plan 2012;27 Suppl 4:iv1-3. Swanson et al. PLoS Med Dec Shakarishvili et al. Global Health Governance 2010;III(2):1-17. Samb et al. Lancet. 2010;376: Kruk ME, et al. Health Policy. 2008;85:
11 Monitoring HS Performance: Frameworks and Indicators No Concensus Contextual Where is surgery?
12 Technical advisors Each system is unique, context is critical We need a practical, actionable model
13 Literature Review (Guidance?) Search Terms Ø Surgery, health system, health systems strengthening, developing country, financing, governance, health information system, integration Databases Ø Pubmed, SCOPUS, EMBASE, Cochrane, Health Systems Database (McMaster University)
14 3432 citations 171 abstracts reviewed 117 papers reviewed None focus on surgical care
15 Integration extent, pattern, and rate of adoption and eventual assimilation of health interventions into each of the critical functions of a health system Atun R, et al. Health Policy and Planning 2010;25:
16 Governance Financing Planning Service Delivery Monitoring and Evaluation Demand Generation Atun R, et al. Health Policy and Planning 2010;25:
17 Governance Financing Planning Service Delivery Monitoring and Evaluation Demand Generation Universal access? Large public health burden Treatment highly successful Treatment is cost-effective Mock et al. World J Surg 2010;34:
18 an internationally agreed list of essential surgical procedures in support of primary healthcare that would help countries decide on their own list and related training and equipment. Mahler H. Surgery and Health for All. Address to the Biennial World Congress of Surgeons, Mexico City, Mexico, Available at ( strategies/mahler1980speech.pdf)
19 Patient Safety Don t forget the health workers Courtesy of Dr. Omar Saleh, WHO Somalia
20 Human Resources Who? Where and How? Distribution and retention MOC Alternative providers?
21 Governance Financing Planning Service Delivery Monitoring and Evaluation Demand Generation
22
23 Governance Financing Planning Service Delivery Monitoring and Evaluation Resolution National health policy Regulatory function Ø Human Resources Management Demand Generation
24 Governance Financing Planning Service Delivery Monitoring and Evaluation Demand Generation
25 Governance Financing Planning Service Delivery Monitoring and Evaluation 1) Epidemiology/BOD 2) Service availability 3) Outcomes/Quality Demand Generation
26 Service Availability Infrastructure Physical Resources Human Resources Interventions District, Essential
27 Deficiencies in availability documented Process measures? Kushner et al. Arch Surg 2010;145:154. (8 countries) Kingham et al. Arch Surg 2009;144:122. (Sierra Leone) Taira et al. World J Surg 2010;34:428. (Sri Lanka) Contini et al. World J Surg 2010;34:473. (Afghanistan) Spiegel et al. World J Surg 2011;35:272. (Mongolia) Iddriss et al. Bull WHO 2011;89:565. (The Gambia) Choo et al. Trop Med Int Health 2010;15:1109. (Ghana) Natuzzi et al. World J Surg 2011;35:1183. (Soloman Islands) Penoyer et al. BMJ Open 2012;2:e (Tanzania) Sherman et al. Arch Surg 2011;146:35. (Liberia) Bowman et al. J Pediatr Surg 2013;48:1363. (Zambia)
28 Harvard Humanitarian Initiative Tool Greater depth, Birds eye view Chao et al, World J Surg 2012;36: (Ethiopia) LeBrun DG, et al. World J Surg 2013;37: (Bangladesh) Linden et al. World J Surg. 2012;36: (Uganda) Notrica et al. World J Surg 2011;35: (Rwanda) Knowlton et al. World J Surg 2013;37: (Liberia) Petroze et al. Br J Surg. 2012;99: (Rwanda) Henry et al. World J Surg 2012;36:2811. (Nigeria) Hsia et al. Health Policy and Planning 2012;27:234. (5 countries) Lavy et al. Ann Roy Coll Surg Engl 2007;89:722. (Malawi)
29 Availability # OR s # Surgical procedures # Accredited surgeons Day of surgery death ratio Postop in hospital death ratio
30 Where are we? Information needs vary National Manager at individual facility Snapshot need Monitoring
31 PDAs, GPS Service Availability Mapping Analysis and mapping
32
33 Governance Financing Planning Service Delivery Monitoring and Evaluation Demand Generation
34 Governance Financing Planning Service Delivery Monitoring and Evaluation Demand Generation
35 Governance Financing Planning Service Delivery Monitoring and Evaluation Incentives Ø Conditional cash transfers Ø Insurance Ø Waiving user fees Education and health promotion Demand Generation
36 Take Home Messages Integration requires inputs at each block in the system Systems are complex Context!
37 Thank You!
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