Health system strengtheningA conceptual framework

Basile KeugoungMD, MPH, PhD

Regional workshop on HISHotel du Lac, Cotonou Bénin

16-18 Décembre 2015

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• Agenda of many organisations and Global HealthInitiatives (GHI)

• Huge resourcee are dedicated to HSS

• Major strategies of national health sector strategic

• Positive results of HSS interventions are published...

Health system strengthening (HSS)

HSS: Agenda of many organizations

HSS: Agenda of many organizations

HSS: Agenda of many organizations

RSS: Agenda des organisations

HSS: Agenda of many organizations

Increase investments in health systems

• GAVI: 524million USS$ committed to 44 countries and225 million US$ disbursed to 36 countries in 2012

• Global Fund: 22,4 billion US$ by mid-2011• GAVI HSS strategy:

– Strengthen the capacity of the health system toprovide immunization and other health services

– Target bottlenecks in the health system that impedeprogress in improving provision of and demand forimmunization and other child and maternal healthservices

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• Health systems remain weak santé

• All components are affected

• Many population needs are uncovered

• High preventable morbidity and mortality

• MDG: not achieved in most sub-Saharan Africancountries

General contex

One question ?

Where does money go?

• Indeed, official development assistance for health for theOECD: 13.3 billion US$ in 2006– Most of these funds were channeled through vertical

programs– HIV/AIDS, malaria and other communicable diseases

received nearly half (47%) in 2002-2006– HSS<10%

• GHI: focus on specific diseases

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WHO health system framework

Health Financing

Health information system

Leadership et governance

Human Resources

Health care delivery

Drugs, equipments and othermedical supplies

Health

Equity

ReactivityReeourcesgeneration

Stewardship

Financing

Health caredelivery

Components Functions Objectives

…Beyond Building blocks

But local health system

Public Health centresPrivate-for-profithealth Centres

Faith-based healthCentres

Tradiraticiens

Health DistrictManagement Teams

District hospital

Other supportServices

Local Government

Prestataires desanté individuels

CommunityCommunity health relaysIndividuals, households

Private Hospital

Traditional, politicaland religious leaders

NGO and civilsociety

Local services fromother Ministries

- Education- Water- Agriculture- …

Is made of many actors…

How do we manage information flux?

Local health system…

…is the implementation of rolesFor example for the District health management teams: 10 essentialfunctions1. Diagnostic and investigation of health problems and determinants2. Policy and development plans3. Resources management4. Health care delivery regulation5. Operational research6. Quality health care delivery7. Partner Mobilization (community, NGOs, funding agencies, …)8. Monitoring and evaluation9. Coordination10.Supervision

Local health system……Is a system : Intrants, Processes, Outputs, Impact

Intrants Legal and regulatory framework

o Directives, norms et standardso Policies

Resources : ICT equipment, drugs, funds…

Local health system…

Processes

Institutional arrangments Information flow management Platforms of management of fora Management procedures District health management teams functionality Redevability

Outputs Health care delivery

Impact Access , Quality, Efficiency, Service use

…Is a system : Intrants, Processes, Outputs, Impact

How can we strengthen localhealth systems?

Systemic capaciybuilding

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Potter & Brough (2004)Complexity

Intrants

Skills

Staff and infrastructure

Structures, systems and roles

Time

Support to the health system

HSS

Policy and regulationsOrganizational structureChangement de comportementInterrelations between compornentsHealth information system flowsStewardship

IntrantsperdiemsTrainingRehabilitation

Chee et al (2012)

Support vs HSS

Systemic capacity building and oursessions goals

• Intrants: Equipment : Smartphone 5A, 5B

• Human resources: 4C• Supervisory capacity: monitoring and evaluation systems:

6A, 6B

• Support services capacity: 8, 9

• Systemic capacity : 3; 6A, 6B• Structural capacity : 7B, 8• Role capacity: 6C, 7A

HIV/AIDS program and HSS in Cameroon?

Santé Publique 2015; 27(4): 547-556

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Specific training and supervision

HIV/AIDS therapeutic committeeCommunity relay enrolment

?

Reduced funding ofhospitalsFrequent out-of-stock

Parallel health information systemReduced ditrict health managementteams

Reduced motivation of staffHigh workload

Low implication of districthealth management teams

Laboratory equipment, HIVtests, Antiretroviral drugsMotobike, office equipment

Positiveeffects

Negativeeffects

Effets on pyramid of capacity

22Health system

District level

Regional level

Central level

International level

Why missed opportunities?

A vicious circle

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Missedopportunities

Individualfactors

Functionalfactors

Structuralfactors

Low implementation of HSSinterventions

Incitants

Increasedbottlenocks

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Opportunities

Stewards

HSSinterventions

Strong localhealth systems

Implementation of theStewardship componentsIncitative

measures

Detection andcorrection ofbottlenecks

Strengthenstewardship

Monitoring the healthsystem interventions

Strengthenstucturalcapacities

To strengthen health systems… transform the vicious circle into a vertuous circle

Conclusions

• We should optimize HSS interventions, need for

– A performant HIS

– A HIS leading to collective intelligence

– A learning organization

• We should regularly adapt our ICT technology to strengthenHIS

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Thank you

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