Overview of Health Systems Constraints in Developing Countries David Peters November 30, 2005

Graduate student ranking of health system constraints in low income countries Inadequate funding 2. Personnel – poor motivation & training 3. Corruption/poor governance 4. Poor management Poor management 2. Corruption/poor governance 3. Personnel – poor motivation 4. Poor systems to allocate funding

International agency identification of health system constraints ConstraintWorld Bank WHOHLFGFATMGAVIDFID Poor management (at district & central levels) X X XX Poor accountability of providersXX XX Lack of incentives for health workersXXX XX Lack of trained health workersXXXX X Inadequate & unreliable public spending on health XXX XX Lack of knowledge by publicXXX X Poor drug supply chain managementX XXXX Poor monitoring of health servicesX X X

Broad international consensus Overall goals and priorities – MDGs, HIV Cost-effective interventions Importance of strengthening health systems Identification of health system constraints Commitment to increasing funding and donor harmonization/coordination So why don ’ t health systems deliver?

What will it take? More time, more resources A Global Fund for Health Systems? Real commitment to local leadership? More attention to performance? Less ad hocracy?

Levels of constraints I. Household & Community II. Health Services Delivery (inputs, processes, outputs) III. Health Systems Organization & Functions IV. Accountability Relationships V. Context

Why categorize? Understand types of intervention required Recognize dependence on other parts of health system – know where to look for unintended consequences Recognize dependence on external factors Understand timeframe for change

I. Household & community

II. Health services delivery

III. Health systems organization and functions

IV. Accountability relationships

V. Context

A paradigm for understanding health systems Purpose Impact level Health Service Outcomes level Actors and relationships Functions

Health services delivery framework Purpose (Level/Spread) Health status Financial protection Trust in health system GOVERNMENTGOVERNMENT Oversight & Compact s Client Power Political Voice PROVIDERS Management systems Performance Management; Human Resources; Financial Management; Information Systems; Logistics: Drugs & Technology, Buildings, Auxiliary Services Political Environment Social Conditions Economic Factors Physical Environment Health Service Outputs (Level/Spread) Utilization Coverage Quality Efficiency Informatio n Performance ; Disclosure; Research Financing Revenue; Pooling; Allocation; Payment Leadership Strategic direction; Values External Development Partners Non-Health Sectors Education Water Agriculture Transport Power COMMUNITY PEOPLE Poor / Non-Poor Organization of Health Services

Some observations Health systems are complex and inter- dependent; intervening in one part of the system affects other parts How you organize assistance in a health system drives behavior of staff

HIV and health systems considerations Transmission is sparked by highly motivated behaviors – can ’ t just address disease in health care setting HIV is highly stigmatized – greater trust in health system is needed Chronic disease requires repeated health care visits, tiered levels of care, increased financial vulnerability – higher demands from health system Co-morbidity and multiple disease manifestations, need for integrated services organized around patient and family rather than single sets of services

Some final questions Is there a magic bullet to fixing health systems, or do you need to address all parts of the health system at once? Can programmatic approaches “ do no harm ” to a health system? Can health systems focus on HIV and a few priorities and still succeed? How can you strengthen health systems to take on priority conditions?