Greetings from Havana

The Global Forum for Health Research has just wrapped up its Forum 2009, and I will be heading back home after spending a very enjoyable week in Cuba. There were participants from all over the world, with 60% coming from low and middle income countries. Here are some highlights of the conference, as they relate to a consensus on HSS:

-As is the case at all of the global health conferences that I have attended recently, there is growing momentum to not only strengthen health systems, but approach the subject rigorously (though that will be quite difficult).

-The Alliance for Health Policy and Systems Research launched a hundred-some page document outlining a ten-step process of health systems strengthening, “Systems thinking for health systems strengthening”. I think that the report is timely and important. There is still a need, in my mind, for a more focused set of principles targeted toward externally-funded global health planners and policy makers. That will be the role of our consensus statement.

-The First Global Symposium on Health Systems Research will be held on November 16-19 in Montreux, Switzerland.

Report from conferences: CORE group, and Health Impact Assessment

This past month has been a busy travel month for me. I lead discussions about the HSS Consensus Statements at the CORE group fall meeting in Washington, DC, USA, and the Health Impact Assessment Conference in Rotterdam. Here are a few common themes from those conferences:

1. There truly is a broad recognition that health systems strengthening is a key to consistent, sustainable health improvements.

2. The timing for this movement is ideal.

3. Reaching a true consensus will be very difficult.

4. It will be necessary to engage a variety of stakeholder.

I’m heading off to the Global Forum for Health Research in Havana in a couple weeks, and I’ll update you as to how things went.

HSS Consensus Statement: More Resources

Here are some more resources that I have found useful

-Declaration at Alma Ata

-Getting Health Reform Right: A Guide to Improving Performance and Equity

-Overcoming health-systems constraints to achieve the Millennium Development Goals

Preliminary, Rough Outline of HSS Consensus Statement

This is a preliminary draft, and is posted only to give reviewers an idea where this is headed. It should not be disseminated or quoted. Comments are appreciated.

A strong health system:
1. Improves and maintains health in the most efficient manner possible.

a. The structure should match the need. For example, community/household level interventions for child survival.
b. The research and funding focus matches the need.
c. Practice is evidence based, whenever possible.
d. Duplication should be avoided.
e. Financial management is inefficient when funds are unpredictable and sporadic.

2. Develops human and institutional capacity long-term.

a. New public health challenges like emerging infections, drug resistance, environmental changes, etc. are most efficiently addressed by trained locals.
b. Behavior change and institutional development take many years. Programs should consider this when planning time-lines.
c. Development and maintenance of effective leaders is crucial.
d. Quality assurance is a cyclic, iterative, gradual process that must be planned for.

3. Recognizes that ill health is at least as much a social problem as it is a biomedical one.

a. Public health successes often require social mobilization and change.
b. Health systems should be accountable to the population that they serve.
c. Earns the trust and respect of the community.

4. Is equitable.

HSS as a social movement (and I’m on Twitter!)

The discussions this week at the Health Impact Assessment Conference got me thinking, once again, about health as a social movement. I remember well first reading the words “health systems activism.” I was an intern, during my neurosurgery rotation. Perhaps I was reading McCoy, et al’s article “Expanding Access to Antiretroviral Therapy in Sub-Saharan Africa: Avoiding the Pitfalls and Dangers, Capitalizing on the Opportunities” to escape the tedious, never-ending neurosurgical rounds. In any case, I was immediately sold: health systems strengthening needs the same passion and social mobilization as human rights movements and political campaigns.

The virtues of health systems strengthening have always seemed self-evident to me. It’s obvious, after all, that patients don’t go to clinics with diagnosed diseases, they go with symptoms, suffering. I recognized that health depends on multiple relationships between individuals and institutions, companies and organizations. A health system is a complex, connected network that must be treated as such in order to produce health effectively, efficiently, and equitably.

A health system is much more than a way to respond to biological challenges. A health system reflects society; it is a social institution. The way that health systems are structured and funded are based on societal values (through action or inaction). In addition, the health system is full of human interactions and responses that are explained by behaviors based on social reasons as opposed to rational data. Mothers decide to bring children to a clinic based on socially-reinforced perceptions and assumptions. Politicians and caregivers make decisions based on social reasons as well.

As such, health systems strengthening could learn something from social movements. We need charismatic leaders, committed, passionate, volunteer followers, and an organized strategy. What do you think about HSS as a social movement? I’ll start by tweeting. My name is “HSStrengthening”

Introductory Health Systems Readings

There has been an increasing number of students and others that have expressed interest in getting involved. Prior to meeting and discussing, I recommend the following reading:

1. WHO’s website on health systems topics.
2. Henry Mosley’s lectures on leadership and health systems.
3. A call for health systems impact assessments.

Health Systems Strengthening Resources

As I have worked on the first draft of the consensus statement for health systems strengthening, several resources have proved very useful (in no particular order):

1. GAVI Alliance’s “Guiding Principles of HSS”
2. WHO’s “Strengthening Health Systems to Improve Health Outcomes”
3. Perry and Freeman’s “How Effective Is Community-Based Primary Health Care in Improving the Health of Children?”
4. The World Bank’s “Improving Health Service Delivery in Developing Countries”
5. The NGO Code of Conduct for Health Systems Strengthening
6. Paris Declaration on Aid Effectiveness
7. Brown’s “Lessons Learned in Institutionalization of Quality Assurance Programs: an International Perspective”
8. Taylor and Taylor’s “Just and Lasting Change: When Communities Own Their Futures”
9. World Bank’s “Health System Strengthening Workshop”
10. “Health system capacity building: review of the literature”

Let me know if there are other useful articles, books, and other resources.

Name Change: Health Systems Strengthening

The name of this blog has been changed to reflect the more broad focus on health systems strengthening. The call for GHSIAs was part of a larger recognition of the need for global health planners to consider the importance of a systems approach.

Invitation to Contribute to a Consensus Statement on Health Systems Strengthening

There is a growing recognition, even a consensus, that health systems must be strengthened to achieve long-term improvements in health, including reaching the MDGs, and that valid tools to assess health systems are needed. While increasing emphasis is being placed on these topics (see here, for example), many questions remain: How should health systems be defined? Which is the best framework? Which indicators should be used to assess health systems performance?, etc. For a more detailed discussion of this topic, see this World Bank health systems workshop.

While it seems likely that there will never be a consensus on health systems frameworks and indicators, it does seem clear that there are some underlying principles that should guide the process of assessing and strengthening health systems. I am not referring to abstract concepts that are difficult to define and apply. I am referring to concrete, widely-accepted principles that, when applied, will produce a health system that is robust, efficient, and equitable. Here are a couple examples of potential principles, based on conversations that I’ve had with Henry Mosley, David Sanders, Malcolm Bryant, and others:

1. The focus and structure of health systems should be appropriate for the underlying disease burden, anticipated disease burden, and most efficient interventions. For example, much of the disease burden in developing countries can be most efficiently addressed on a household level. As such, the focus and structure of the health system (and, therefore, health programs and initiatives) should reflect that reality (community health workers, household behavior change interventions, etc.)

2. Local health workers’ capacity to identify and solve problems independently should be a major component of health systems strengthening. The health needs of any given community is continuously in a state of flux due to emerging diseases, changing demographics, environmental change, drug resistance, etc.

A group has been formed to draft a consensus statement that outlines such principles, and we are planning on disseminating it widely. (See here, and here, for examples of consensus statements). Such a document could have a significant impact on global health planning and policy. I envision a team composed of 1-3 primary authors, a working group of 20-30 that revise drafts, and hundreds of other contributors. We will, I hope, publish it in a high profile journal, advertise it widely in the media, and use it to leverage health decision makers through out the globe. I am not aware of such a document. Does one already exist?

Your involvement in this project could range from occasional, brief comments, to assisting frequently with the writing and advertising. I will plan on organizing the contributors, working as the primary writer (unless someone else wants to), and advertising by attending several global health conferences in the next year. I personally view this as a very important project that can make a significant impact. I’m wiling to put in the work to make it happen.

About 15 experienced global health professionals and health systems experts have already volunteered to review the document. In addition, I will be attending a number of conferences in the coming year to advertise and seek guidance.

Please let me know what you think of this idea, and how you would like to contribute. Be specific; let me know even if you only want to be included on the discussion. Also, please forward this to any of your colleagues, especially those that have extensive “on the ground” experience. Comment below, or email: ghsias at gmail dot com.

Mounting Evidence of the Impact of Global Health Initiatives on Underlying Health Systems

Three scientific journal articles were recently published (within just a few months of each other) that review the impact of global health initiatives (mostly HIV related) on underlying health systems:

1. “An assessment of interactions between global health initiatives and country health systems” was published in the Lancet on June 20, 2009. This review is the most comprehensive of the three, and includes action points for all global health players. I was especially struck by their first of 5 recommendations: “Infuse the health systems strengthening agenda with the sense of ambition and speed that has characterized the GHIs.” Health Systems activism is needed!

2. “The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control” was published by the journal “Health Policy and Planning.” The authors found both positive and negative effects: “Positive effects have included a rapid scale-up in HIV/AIDS service delivery, greater stakeholder participation, and channelling of funds to non-governmental stakeholders, mainly NGOs and faith-based bodies. Negative effects include distortion of recipient countries’ national policies, notably through distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoring and evaluation systems.”

3. The authors of “Global Health Actors Claim To Support Health System Strengthening—Is This Reality or Rhetoric?” discussed the various uses for the term “health systems strengthening”, and found that “most current HSS strategies are in fact selective, disease-specific interventions, and their effects may undermine progress towards the long-term goal of an effective, high-quality, inclusive health system.”

4. (A fourth article, “Investment in HIV/AIDS programs: Does it help strengthen health systems in developing countries?” was published in late 2008).