1. Maximizing Positive Synergies Between Health Systems and Global Health Initiatives A Mixed Methods Approach Dr. Jim Yong Kim Harvard Medical School Harvard School of Public Health October 2, 2008

2. Positive Synergies “How can global health initiatives and national health systems optimize their interactions to capitalize on positive synergies and minimize negative impacts, thereby achieving their common goal of improving health outcomes?” What are the best methods to answer this question and lead to the desired outcomes?

3. What are the Desired Outcomes? Healthier People/Equity/Social Justice Highly functioning health systems that are responsive to everyone and deliver across the priorities Better policies that shape donor behavior, health system design and health service delivery Evidence-based implementation and delivery by systems and practitioners at all levels Evidence that links system design, implementation strategy, management structure, degree and nature of integration of services, civil society involvement, health system architecture etc. – to health outcomes Methodologies and researchers that fit the task

4. Choosing the right methods What kind of data/information exists and does it point the way to further studies? What is the state of framework and theory development around the problem? Are researchers who represent “unusual” disciplines working on the problem? Are civil society actors and affected communities involved at every step? Will the methods used and research done be helpful to practitioners at the country level and lead to real health improvements for people?

5. Proposed Methodological Approach Cross-country Quantitative Analysis Country-level Mixed Methods Analysis Provider Unit-Level Analysis

6. Research Questions 1.How do GHI-funded programmes interact with health systems in varied country contexts? –What positive synergies or negative interactions emerge when GHI funded programmes interact with local health systems? 2.In various contexts, which factors influence the extent and nature of interaction between GHI- funded programmes and local health systems?

7. Research Questions 3. What are the specific system designs and delivery strategies funded by the GHI’s that have lead to the most positive impacts on health systems? a. How do these designs and delivery structures influence the coverage of targeted and non-targeted interventions and health outcomes?

8. Adapted from: WHO six building blocks and RA Atun et al, 2006 Health Outcomes Fairness of Financing Responsiveness GHI investment Health workforce Governance Monitoring and Evaluation Health Technologies DELIVERYDELIVERY Private expenditure Government expenditure Financing Other external expenditure Epidemiological PoliticalDemographic Environmental Technological Social Economic Legal Communities/Civil Society Conceptual Framework Health Systems Infrastructure/Hardware Governance

9. Country-level mixed methods analysis Cross-country quantitative analysis Provider-unit level analysis Levels of Analysis Identifying relationships Understanding relationships Understanding the impact

10. Mixed Methods Approach Appropriate for complex systems and relationships Either quantitative or qualitative methods alone are insufficient Employs multi-disciplinary teams Allows for triangulation with different types of data

11. GHI investments Government health expenditure Coverage of skilled- attendance at delivery Coverage of immunization Child mortality Cross-country quantitative study

12. Country-level mixed methods analysis Case study library Level 1 – National level analysis of GHI- Health System Interaction Level 2 – Regional, district, and provider unit level analysis of systems design and local impact

13. Country Selection Develop sampling matrix in consultation with partners: –Geographical representation –GHI investment as a percentage of total health expenditure –High burden of GHI-targeted disease –Existing connections with partner institutions

14. GHI investment/ Total health expenditure 1.Burundi 2.Rwanda 3.Zambia 4.Somalia 5.Liberia 6.Guyana 7.Uganda 8.Gambia 9.Ethiopia 10.Tanzania 11.Malawi 12.Haiti 13.Mozambique 14.Kenya 15.Swaziland GFATM, PEPFAR, GAVI disbursements through 2005

15. HIV Prevalence 1.Swaziland 2.Botswana 3.Lesotho 4.Zimbabwe 5.Namibia 6.South Africa 7.Zambia 8.Mozambique 9.Malawi 10.Central African Republic 11.Gabon 12.Cote d'Ivoire 13.Uganda 14.Kenya 15.United Republic of Tanzania WHO Statistical Information System (WHOSIS), Accessed: July 2008

16. TB Incidence 1.Swaziland 2.South Africa 3.Djibouti 4.Namibia 5.Lesotho 6.Zimbabwe 7.Timor-Leste 8.Zambia 9.Botswana 10.Sierra Leone 11.Cambodia 12.Mozambique 13.Cote d'Ivoire 14.Congo 15.Rwanda WHO Statistical Information System (WHOSIS), Accessed: July 2008

17. Proposed countries Country GHI/total expenditure HIVTB Partner involvement Rwanda215 Lesotho35 Kenya14 Tanzania1015 Mozambique 13812 Ethiopia9

18. Proposed countries Country GHI/total expenditure HIVTB Partner involvement South Africa62 Zambia378 Malawi119 Uganda713 Haiti12 DRC14

19. Other Likely Candidates Cameroon Senegal Ghana Viet Nam Philippines India China

20. Data – Cross-country Time series cross sectional data GFATM, PEPFAR, GAVI disbursements National Health Accounts OECD’s Credit Reporting System DHS, MICS, administrative data, data from UN or WHO

21. Data – National and Regional Document review Semi-structured interviews with key informants Collection and analysis of appropriate, available quantitative information All data collected in cooperation with Ministries of Health

22. Data – Provider Unit-Level System Design – Implementation Strategies Available Services Laboratory Services Essential Medicines Human Resources Infrastructure Targeted Outcomes (HIV, TB) Coverage of non-targeted interventions

23. Expected Outcomes Global cross-country analysis Case study library of more than 10 countries – detailed information on health system design, implementation strategy etc. Provider unit-level analysis in select countries Literature review Identification of knowledge gaps for further study Improved methodology Input for WHO policy recommendations

24. Timeline Late October: Finalized methodology with partners Early November: Begin in-country data collection November 17-19: Bamako Ministerial meeting January – March: Continued data collection and analysis March – April: Preparation of results and reports

25. Academic Partners Rifat AtunImperial College, London/Global Fund Ruairi BrughaRoyal College of Surgeons in Ireland Eric Buch Alex Coutinho University of Pretoria Makerere University, Uganda Peter Godfrey- Faussett Alan Greenberg London School of Hygiene & Tropical Medicine George Washington University Gorik OomsInstitute of Tropical Medicine, Antwerp Peter NdumbeUniversity of Buea, Cameroon K. Srinath Reddy Papa Salif Sow Public Health Foundation of India University of Dakar, Senegal David SandersUniversity of Western Cape, Cape Town

26. Conclusions April is tomorrow Much very important work has already been done Must be clear about the question we are trying to answer We must look to “unusual” methods and “unusual” partners This effort is just the beginning of a much larger effort – lead to the development of a “science” of health care delivery? This has to be a team effort with collaborations in all directions – a “community of practice”

27. Selected References Atun, RA, Turcan, L, Berdega, V et. al. (2005). Review of Experience of Family Medicine in Europe and Central Asia. (In five volumes) Volume V: Moldova Case Study. World Bank Report No. 32354-ECA. Human Development Sector Unit, Europe and Central Asia Region. Washington, DC: The World Bank. Atun RA, Menabde N, Saluvere K et al. Introducing a Complex Health Innovation – Primary Health Care Reforms in Estonia (Mulitmethods Evaluation). Health Policy 79 (2006) 79-91. Atun RA, Bennett S, Duran A. When do Vertical (Stand-Alone) Programmes Have a Place in Health Systems? Policy Brief, WHO European Ministerial Conference on Health Systems, 25-27 June, 2008, Tallinn, Estonia. Banteyerga, H, Kidanu, A, Stillman, K. (2006). The Systemwide Effects of the Global Fund in Ethiopia: Final Study Report. Bethesda, MD: PHRplus. Abt Associates Inc. Daniels N, Flores W, Pannrunoathai S (2005). An Evidence-Based Approach to Benchmarking the Fairness of Health Reform in Developing Countries. Bulletin of the World Health Organization. 83: 534-40. Frontiers Development and Research Group. Global HIV/AIDS Initiatives in Zambia: Issues of Scale Up and Health Systems Capacity: Interim District Report. (2008). Global HIV/AIDS Initiative Network. OSI. GAVIAlliance. Accessed July 2, 2008 at: http://www.gavialliance.org/about/in_partnership/index.php. http://www.gavialliance.org/about/in_partnership/index.php

28. Selected References Global HIV/AIDS Initiative Network (GHIN). (2006). A Generic Guide to Research Practice: Following discussion at Lilongwe workshop of GHIN African teams. Global HIV/AIDS Initiative Network (GHIN). (2006). GHIN African District Studies: Detailed Research Questions and Methods. Gbangbadthoré, S, Hounsa, A, Franco, LM. (2006). Systemwide Effects of the Global Fund in Benin: Final Report. Bethesda, MD: Health Systems 20/20. Abt Associates Inc. Loevinsohn, B, Aylward, B, Steinglass, R et. al. (2002). Impact of Targeted Programs on Health Systems: A Case Study of the Polio Eradication Initiative. American Journal of Public Health; 92(1):19-23. Mtonya, B, Chizimbi, S. (2006). Systemwide Effects of the Global Fund in Malawi: Final Report. Bethesda, MD: PHRplus. Abt Associates Inc. Murray CJL, Evans DB, eds. Health systems performance assessment: debates, methods and empiricism. Geneva: World Health Organization, 2003. Semigina, T, Griga, I, Bogdan, D, Schevchenko, I, Bondar, V, Fuks, K, Spicer, N. (2008). Tracking Global HIV/AIDS Initiatives and their Impact on the Health System in Ukraine: Interim Report. Global HIV/AIDS Initiative Network. OSI.

29. Selected References WHO. Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes. WHO, 2007. WHO. The Global Fund Strategic Approach to Health Systems Strengthening. Report from WHO to the Global Fund Secretariat, September, 2007. WHO. Maximizing Positive Synergies Between Health Systems and Global Health Initiatives. Report on the expert consultation, WHO, Geneva, 29-30 May 2008. WHO. Opportunities for Global Health Initiatives in the Health System Action Agenda. WHO Department of Health Policy, Development and Services, Evidence and Information for Policy, 2006.