Global Health Systems Strengthening: PEPFAR Experience, Plans, and Field Realities

1. Global Health Systems Strengthening: PEPFAR Experience, Plans, and Field Realities Dr. Michael Friedman CDC Atlanta December 2, 2009

2. 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

3. 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

4. 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

5. What is Health Systems Strengthening? • 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.

6. WHO Health System Framework

7. 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

8. 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

9. 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.

10. 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.

11. PEPFAR HSS Matrix

12. PEPFAR HSS Model

13. Applying PEPFAR HSS Framework Treatment

14. 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

15. 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

16. 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

17. 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

18. 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.

19. 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

20. 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 Infectious Diseases Working Group Metrics and Research Working Group 20

21. 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

22. 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 - ???

23. 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.

24. 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?