global health systems strengthening: pepfar experience, plans, and field realities

U.S. Department of Health and Human Services

Global Health Systems Strengthening: PEPFAR Experience, Plans,

and Field Realities

Dr. Michael Friedman

CDC Atlanta

December 2, 2009


Purpose of the Meeting

Technical Update to Leadership on Health Systems Strengthening (HSS)

Definitions of a Health System and HSS Lessons from PEPFAR on HSS PEPFAR HSS Conceptual Framework Promising Practices and Recommendations The challenge of HSS monitoring: Governance Global Health Initiative and HSS Impressions from the Field: Africa, India, Thailand


HSS and PEPFAR

“Establish a roadmap to link investments in specific disease programs to the broader goals of strengthening health systems and infrastructure”

“Integrate and coordinate HIV/AIDS, TB, or malaria programs with other health or development programs as appropriate”

PL 110-293


What is the Health System?

The health system includes all the individuals and organizations that focus primarily on ensuring health outcomes.

It includes national, state, district and community levels, and the public, non-for profit and for-profit sectors.

There is no universal criteria for what constitutes a “good” vs. a “bad” health system.

There is no consensus model of what a good health system in a resource poor setting should look like.

HSS – SOPA


Programs, policies, or interventions that improve the delivery of quality, equitable, and sustainable health services and ultimately improve health outcomes in a community or country.

In practice “health systems strengthening” means different things to different people in different contexts.

What is Health Systems Strengthening?


WHO Health System Framework


HSS and the PEPFAR Process

PEPFAR HSS Steering Committee- OGAC, USAID, Peace Corps, CDC, and HRSA

Listening Sessions- University/Academics

- Community/Advocates

- Donors

- Open Public Forum

State of the Program Area (SOPA) document as an outcome


HSS Steering Committee

Janis Timberlake, OGAC Paul Bouey, OGAC Pamela Martin, Peace Corps Jordan Tappero, CDC Michael Friedman, CDC Jin Park, HRSA Estelle Quain, USAID Karen Cavanaugh, USAID Scott Stewart, USAID


Lessons Learned from PEPFAR

There is a perception that investing in HSS implies trade-offs with investments to reach immediate targets.

What is measured/monitored, gets done…PEPFAR is a prime example of that.

The underlying health system really makes a difference in PEPFAR’s work.


Lessons Learned from PEPFAR (2)

Many health system problems can be solved without reforming the entire system.

Not all HSS focused investments can be implemented, and those that can, will have varying degrees of impact.

PEPFAR implementation can enhance the functioning of the health system beyond HIV/AIDS.

The absence of a HSS strategy led to variable patterns of health system investments in PEPFAR.


PEPFAR HSS Matrix

Service Delivery

Human Resources

Health Financing

Medical Products,

Vaccines and Technologies

Information Systems

Leadership/Governance

3-12-12 Focused:

Positive Synergies/Intentional Spillover:

Impacts on HSS at no or minimal

cost to USG

Leveraging: Collaborate with other partners to

generate HIV/AIDS and other benefits


PEPFAR HSS Model

Service Delivery Information Systems Human Resources Health Finance Commodities/Procurement

Leadership/Governance

3-12-12Focused: HIV-focused treatment, care, and prevention activities

• Strengthen ARV referral systems and care

networks, service integration

• Basic laboratory services for monitoring ART side effects, community linkages

• Decentralization of ARV services and planning to districts

• Strengthen systems to plan, monitor and

improve ARV delivery using DHS/AIS, SPA, ARV M&E, drug resistance

surveillance• Implementation of HIVQUAL (continuous quality improvement for HIV)

• Develop sufficient ARV service providers via task- shifting, improved HR efficiencies, in

service trainings, capacity building of

HIV training institutions

• Sustainable ARV financing including ARV price negotiations, ARV cost modeling, mainstreaming

ARVs into national health plans and insurance schemes• Optimizing costs per

person treated

• Supply chain and procurement systems for ARVs, CD4 and other lab reagents to monitor ARV

Tx employed• MOH staff trained on

ARV procurement and forecasting

• Recognition of HIV as national problem, reducing stigma and

increases testing rates• Anti-stigma policies enacted• Multi-sector strategic planning for

ARV scale-up• HIV accreditation for both public

and private sector• National ARV treatment guidelines

Spillover: impacts on HSS at no or minimal cost to USG

• Improved referral systems for other diseases

• Basic lab services for all patients• HIV Tx model adapted

for other chronic diseases

• Quality improvement drives models for other diseases

• DHS/AIS/MIS informs other disease programs (TB, malaria, MCH)

• PHE efforts stimulate operational research in other areas

• Improve HR efficiencies

across clinic/hospital • Broader institutional capacity-building• Task-shifting in non-

HIV services & departments

• Governments perform cost modeling for other health issues

• Governments better negotiate better non-HIV drug pricing• Financial accountability increases beyond HIV in gov’t and NGO sectors

• Newly acquired forecasting and delivery skills used for other drugs and vaccines

• ARV procurement systems adopted for other drugs

• More open policies for other health and social issues

• Multi-sector and civil society engagement approaches adopted

for other health issues• National guidelines created for

other diseases• Journalists use HIV training to

report on other health issues

Leveraging: collaborate with other partners to generate HIV/AIDS and other benefits

• Clinic renovations = increased use of HIV and non-HIV services• MCH assessments and strategic planning lead

to improved MCH services and ART coverage of HIV+

pregnant women, integration of

reproductive health services

• Quality MOH HMIS improved and ARV M&E integrated into this

system• HRIS created/ improved• Data for decision-

making courses developed for key

health decision- makers

• DfID, IHP+ joint partnership in

expanding pre-service training

• Expansion of community health worker schemes and trainings in partnership with MCH programs

• HRH strategic planning

• National health accounts and costed national

health plans • Health insurance.

Schemes cover HIV and non-HIV services & drugs

• Support to MOF improves other ministries better health finance

policies/procedures

• Multi-donor efforts to assess and strengthen national procurement/ logistics systems for essential drugs

(eventually allowing ARVs, other drugs

used in HIV care, lab reagents to be mainstreamed into

general supply chain and procurement systems)

• Health Systems assessments pinpoint key system weaknesses to be addressed if further ARV scale-up and other disease control efforts are to succeed

• General management training for hospital administrators and district officials leading to better services

and planning• General accreditation and

performance assessment schemes strengthened


Applying PEPFAR HSS FrameworkTreatment

Elements Service Delivery

Focused Goal: HIV-focused treatment

• Strengthen ART referral systems and care networks; service integration • Expand quality controlled laboratory services for monitoring ART • Provide outreach to special populations (MARPs) • Decentralize ART services to the district level; community linkages

Intentional Spillover: impact on HSS at no or minimal cost to USG

• Improve referral systems for other diseases • Expand quality laboratory diagnostic and monitoring services beyond HIV• Adapt service model for chronic diseases (e.g., depression, hypertension)• Decentralization strategy used for other health issues

Targeted Leveraging: collaborate with partners to generate HIV/AIDS and other benefits

• Clinic renovations = increased use of HIV and non-HIV services• MCH assessments and strategic planning lead to improved MCH services, ART

coverage of HIV+ pregnant women, and integration of reproductive health services

• Partner with Global Fund, Clinton Foundation, GAVI and PMI to expand ART and immunization coverage, TB screening and bed net distribution


PEPFAR Promising Practices in HSS

Health system assessments

Modeling as a strategic planning and budgeting tool

Performance-based Financing

Task Shifting

Integrated information systems

Integrated drug procurement, logistics and management systems


PEPFAR HSS Recommendations

Staffing for Success…building up HSS expertise within the USG

Investing in a formal health systems assessment process for each country

Expanding PEPFAR’s emphasis on monitoring of HIV services to including strategies to monitor broad health system changes

Investing more strategically to develop human resources for health


PEPFAR HSS Recommendations (2)

Emphasize innovative strategies for the private sector to become a more integral component of a country’s HSS plan

Continue to transition to indigenous implementing partners

Focus on building the country’s capacities to manage a health system that effectively serves its people


Challenges

Transition from international organizations to local organizations and building/strengthening that infrastructure

Development of local expertise in health systems, strategic planning, M&E, and unique building block technical areas

Metrics of HSS are not unified or well defined

Coordination with other international donors to create synergy and avoid duplication in HSS


WHO Health Governance Indicators

• 1. Existence of up-to-date national health strategy linked to national needs and priorities

• 2. Existence of an essential medicines list updated within the last five years and disseminated annually:

• 3. Existence of policies on drug procurement which specify: (i) procurement of the most cost-effective drugs in the right quantities; and (ii) open, competitive bidding of suppliers of quality products.

• 4. TB: Existence of a national strategic plan for TB which reflects the six principal components of the Stop TB Strategy as outlined in the Global Plan to Stop TB 2006–2015

• 5. Malaria: Existence of a national malaria strategy/policy which includes drug efficacy monitoring, vector control, and insecticide resistance monitoring

• 6. HIV/AIDS: Completion of the UNGASS National Composite Policy Index Questionnaire for HIV/AIDS

• 7. Maternal Health: Existence of a comprehensive reproductive health policy consistent with the ICPD action plan

• 8. Child Health: Existence of an updated comprehensive, multi-year plan for childhood immunization

• 9. Existence of key health sector documents, which are published and disseminated annually (such as budget documents, annual performance reviews, health indicators).

• 10. Existence of mechanisms, such as surveys, for obtaining timely client input on the existence of appropriate, timely and effective access to health services.


WHO Health Governance Indicators

• 1. Human Resources: Health worker absenteeism in public health facilities

• 2. Health Financing: Proportion of government funds which reach district-level facilities

• 3. Health Service Delivery: Stock-out rates (absence) of essential drugs in health facilities

• 4. Health Service Delivery: Proportion of informal payments within the public health care system

• 5. Pharmaceutical Regulation: Proportion of pharmaceutical sales that consist of counterfeit drugs

• 6. Voice & Accountability: Existence of effective civil society organizations in countries with mechanisms in place for citizens to express views to government bodies


GHI Proposed Working Group Structure

Global Health Initiative Steering Committee

Integration &

Coordination Working Group

Health Systems

Strengthening Working

Group

MCH, Family Planning,

and Nutrition Working Group

Metrics and Research Working Group

20

Infectious Diseases Working Group


Impressions from the Field

Rapid Progress in HSS dialogue where HSS interest/expertise exists

Dialogue and strategy documents are very different than interventions and true health system change

USG and partners weak in Health Finance and Health Governance

The List of HSS issues is long but USG abilities and investments remain limited…thus the need for “prioritization of health systems investments”…but how?

Effective HSS interventions require higher levels of innovation and sophistication than we’ve seen in vertical programs

We need “System Thinkers” and cross fertilization of ideas from other development work

Little will be accomplished without true indigenous institutional capacity building


Potential Areas of HSS Innovation

Tapping into Women’s SHG (micro-credit groups) to provide community (nutrition) services and change community norms - India

Grassroots Health Financing Schemes – India Strong National Health Systems/Health Governance

Institutions and Leaders – Thailand Performance-incentive schemes for staff – Rwanda District Level Block Grants – Uganda New Health Cadre based on supply/demand realities –

South Africa Community Empowerment to monitor health system

performance - ???


Critical Need: A HSS Monitoring System

Measuring Health Systems at baseline and at routine intervals is key to monitoring HSS and assessing our collective impacts over time

A common set of HS indicators is required

The systems and investments to routinely collect the health system information required is currently the biggest barrier…and needs to change immediately

PEPFAR is investing in a 5 country health systems monitoring project…but more is needed.


Discussion Questions on HSS

What have your organizations/institutions done that is truly innovative in terms of systems strengthening? How did it happen?

What steps are you taking to create an environment where health systems innovations can take place?

All technical assistance and innovative models require someone “receptive” at the other end…what are you doing to ensure that that institutional and individual receptiveness is there so your ideas can take root?

global health systems strengthening: pepfar experience, plans, and field realities

Documents