Wednesday 30 May 2012

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KNOTS blogger

Blog roundup from iHEA 2011

Posted: 13 Jul 2011 06:16 AM PDT

In addition to Future Health Systems, several other large-scale projects have been sharing their thoughts and reactions to the 8th World Congress on Health Economics (iHEA 2011).

The Center for Health Market Innovations (CHMI) has recently posted two interesting blogs from the event. The first blog provides an overview of some interesting sessions and presentations. They highlight two from FHS:

The second blog is a guest post by Birger Forsberg on a special issue of Health Policy and Planning that looks at the role of the private sector in health. FHS also contributed to this special issue, with an article entitled 'Making health markets work better for poor people: the case of informal providers'.

The SHOPS project posted about their participation in the pre-congress session on Private Sector in Health.

Karen Grepin (NYU) has also been actively sharing her reactions to various iHEA sessions, both on Twitter and on her blog. She too highlights the pre-session symposium on the private sector in health and reviews the special issue of Health Policy and Planning. She notes that all presentations from the symposium are available at Dominic Montagu's (UCSF) website, 'Private Healthcare in Developing Countries'.

Jed Friedman of the World Bank focuses more on pay-for-performance innovations in health systems, citing presentations from Rwanda and the Philippines.

From private sector to health markets

Posted: 10 Jul 2011 08:45 AM PDT

By DR GERALD BLOOM, INSTITUTE OF DEVELOPMENT STUDIES

At a plenary discussion during the iHEA pre-congress session on 'the Private Sector in Health', Gerry suggests an important reframing of the terms of engagement. No longer are we talking about working with the private sector, but rather we are now 'engaging with health markets'. In the video below he looks to the future and suggests that we must focus on regulatory frameworks and the shift in the locus of innovation, especially to rapidly growing middle-income countries.

Going to Extremes

Posted: 09 Jul 2011 10:20 AM PDT

BY DR. DAVID BISHAI, Johns Hopkins Bloomberg School of Public Health

In his plenary speech on July 9, 2011 to the iHEA pre-session on Private Sector in Health in Toronto, Tim Evans, Dean of BRAC University of the Health Sciences, laid out the poles of the debate on universal access to health care.

At one extreme there would be model of all medical care financed and delivered by the state. At the other extreme there would be no state intervention in private markets for health insurance and medical care.  What is supposed to happen next, according to the standard script of the dialectic, is a triumphal arrival at the golden middle.

However, something has derailed our arrival there.

Neither pole is especially attractive or realistic.  The discussion should have moved on by now. Why does this unnecessary “either-or” debate go on and on?  In my opinion the explanation lies in the advantages of being provocative.

Passion and enthusiasm are critical parts of the communication of ideas: The heat generated by an  idea is inverse to its distance from the middle.

By “heat”, I mean the ability of an idea to generate the excitement of journal editors, conference organizers, and bloggers.  With heat comes a desire by those in agreement to start movements and finance studies. With heat also come movements and finance by those opposed. In the past the mutual desire for truth would have moved the poles closer together. When provocation doesn’t matter, successive thinkers looking for truth would be disinclined to stray further and further from the mass of thought. These days, straining the pole even further away from the middle can be a winning strategy in the struggle to get attention and support.

The irony is that most people who think about health reform benefit more from discourse on non-polarizing options. Textbook economics treatments of the problems of health care do not support either pole. The welfare theorems suggest that unregulated health care markets will fail to provide adequate quality and will fail to protect the poor. Economists’ professional attraction to market solutions is based on shared recognition that they are seldom trouble-free. The public goods problems in health care (and other sectors) warrant collective action of some sort, but do not automatically support a solution based on 100% collective finance and provision.

This week at the International Health Economics Association, professional economists from around the world will gather to discuss and hone their craft. They mostly realize that health reform will have to be based on solving public goods problems. The toolkit for these solutions will need to include the best features of markets and the best features of enlightened collective action. The best solutions will not be the hottest—they will be squarely in the middle.  Let’s hope the light that shines from them makes up for their lack of heat.

* Editor's note: FHS will be participating in a wide variety of activities at this year's iHEA congress. See a list of activities, and stay tuned for future blogs and updates live from the event.

The scale and scope of private contributions to health systems

Posted: 07 Dec 2010 08:02 AM PST

BY HEALTHER KINLAW, GUEST BLOGGER FROM THE UNIVERSITY OF CALIFORNIA, SAN FRANCISCO, GLOBAL HEALTH GROUP


The private sector provides more than half of the health services in Africa and Asia, measured both by source of financing for health services, and place of health service delivery.  While new data and better mapping of providers are improving the understanding of the scale of private healthcare services in low- and middle-income countries (LMICs), issues of dual public-private employment, undercounting of unregistered practitioners, and public sector distrust remain barriers to a full accounting of the size or the activities of the sector. To encourage filling this knowledge gap, in May 2010, the 63rd World Health Assembly passed a resolution called, “Strengthening the capacity of governments to constructively engage the private sector in providing essential health-care services,” which acknowledged that private providers are a major source of care in most countries, that private provision of services can lead to innovation as well as great challenges,  and that governments in LMICs can more effectively engage with and regulate private providers.

On November 17, 2010 researchers held a session entitled “The scale and scope of private contributions to health systems” as part of the First Global Symposium on Health Systems Research (HSR) - Science to Accelerate Universal Health Coverage hosted by the World Health Organization (WHO) and partners in Montreux, Switzerland to provide updates of current research on the private sector, highlight innovative financing mechanisms, and address future topics for research. The session was conducted as a “fishbowl conversation” to encourage audience participation; the design includes speaker chairs arranged in an inner circle that represents the fishbowl with one chair left empty for any member of the audience to occupy, at any time, at which point an existing member of the fishbowl must voluntarily leave to free a chair.  Speakers represented a growing group of researchers that have met regularly for the last five years to share findings and advances in research methods for studying the private sector from the perspective of public health, epidemiology, health economics, public policy, and management.  They included:

  • Sara Bennett,  Johns Hopkins Bloomberg School of Public Health (chair)
  • Ruth Berg, Abt Associates
  • Gerry Bloom, Institute of Development Studies
  • Tania Boler, Marie Stopes International
  • Kara Hanson, London School of Tropical Medicine and Hygiene
  • Birger Forsberg, Karolinska Instituet
  • Gina Lagomarsino, Results for Development Institute
  • Dominic Montagu, Global Health Group, University of California, San Francisco
  • Stefan Nachuk, Rockefeller Foundation
  • Gustavo Humberto Nigenda Lopez, National Institute of Public Health, Mexico

Speakers were asked to share their individual and institutional experience on innovative financing mechanisms which included: the Affordable Medicines Facility – malaria (AMFm), several national health insurance experiences, and public-private partnerships for regulation and otherwise.  Speakers also addressed communities of practice and other tool-sharing platforms that aim to make advances towards adoption of standardized methods for assessing private practitioners, their patients, and private funding flows using both secondary data sources and primary data collection, including: Social Franchising 4 Health (SF4Health.org), the Center for Health Market Innovation (healthmarketinnovations.org), Strengthening Health Outcomes through the Private Sector (shopsproject.org), The Alliance for Health Policy and Systems Research, Future Health Systems, Eldis on health systems, id21, and more by the World Bank and others.

Speakers and audience members suggested the following areas for future research: more anthropological studies around private provider behavior, motivations, and incentives; regulating counterfeit drugs within the private sector; consideration of the human resource aspects of the private sector, including recruitment and training, in their work; payment mechanisms and incentiving patients as well as providers; the increase of “payer” attention to the private sector, including governments; the role of purchasing (financial accounting, standards, etc.); the efficacy of various regulatory partnerships; quality of clinical service delivery; quality of chemical sellers (given that one longitudinal study by KEMRI found no significant difference between quality of chemical shops routinely inspected and those not).

Speakers reported on several upcoming literature reviews underway around the private sector: the Global Health Group at UCSF is conducting a Cochrane Review on health outcomes in publicly-vs-privately provided settings in LMICs and a review with Results for Development and the CHMI on informal providers.  At least one systematic review on voucher programs and health is also in progress.

Throughout the session, speakers also emphasized the economic booms occurring in Asia, and the private health sector growth that has quickly followed and stressed that in many significant amounts of delivery and care are happening outside of the regulatory system, including a prominent informal sector in many countries.  Finally, speakers called for greater transparency around public-private partnerships to ensure efficacy and lesson sharing.

Funding from the Alliance for Health Policy and Systems Research awarded to the Uganda team

Posted: 06 Dec 2010 06:59 AM PST

We are delighted to announce that our Uganda Team has received a grant from The Alliance for Health Policy and Systems Research from their new Implementation Research Platform.

The Platform has been set up to identify common implementation problems, develop and test practical solutions to these problems and determine the best way of introducing these solutions into the health system and implement at scale.

The study will build on Future Health System's research into the use of motor bike transport to improve the uptake of maternal health care. It will look at how two types of interventions, one aimed at increasing access to institutional deliveries and care for complications through vouchers, and the other aimed at improving newborn care and uptake of PMTCT through home visits by community health workers, can be integrated and scaled-up within the existing health system in Uganda. It will also explore the effect of implementing the integrated intervention on the proportion of deliveries that occurs in health facilities, and on neonatal mortality.

You can read more about the work in Uganda on our website.

Blog round up

Posted: 26 Nov 2010 04:36 AM PST

BY KATE HAWKINS, INSTITUTE OF DEVELOPMENT STUDIES

We have all arrived home from the Global Symposium and I've had a little bit of time to browse web coverage to see what news and views filtered out from Montreux into the public realm. Given the conference organisers' desire to archive learning from the meeting and reach out to a wide audience to prompt interest in this area of research it's useful to see what areas captured people's imagination.

Scidevnet have covered the symposium with regular updates from T V Padma their South Asia Regional Coordinator. Issues covered included:

  • The need to increase research capacity in developing countries and encourage collaborative learning and research into policy

  • Researching complex systems

  • Tackling TB and HIV in Ukraine and Russia through a system wide approach

  • The challenge of tackling health financing

  • Gaps in universal health coverage in Sub-Saharan Africa


Meanwhile in their news section Aisling Irwin covers the announcement made in the closing session of the creation of a new international entity under their headline, "Ailing Global Forum for Health Research joins COHRED."

We are big fans of the BMJ and were happy to see our friend and colleague Tracey Koehlmoos of ICDDR,B was providing them with updates. She commented,
"In addition to the plethora of great plenary speakers and interesting sessions, is the real benefit of coming together with so many of my global colleagues. For many of us, we fight the war on poverty and disease from the frontlines in developing countries. Some groups work in relative isolation or grouped on the occasional multi-country study. We often only hear of one another or read one another's research findings through publications.   After exercising early, I sat alone at breakfast the other morning, and within twenty minutes I was surrounded by a large group of South Asian colleagues most of whom had not met previously but we had all heard of one another and some of us had corresponded with one another via e-mail.  It was transformational to sit face to face and talk about our common challenges in the region.  I left the table feeling empowered —and pretty sure that we will figure out a way to work together in near future."

If you see any other good news reporting on the symposium please do let us know…

See Sara on film talking in the plenary at the Global Symposium

Posted: 25 Nov 2010 08:22 AM PST

Exploring the spread and scale up of health interventions and service coverage

Posted: 24 Nov 2010 07:14 AM PST

BY KATE HAWKINS, INSTITUTE OF DEVELOPMENT STUDIES

The Future Health Systems Consortium has invested in a stream of work called, "Beyond Scaling Up: Pathways to universal access." This research has looked at some of the challenges involved in rapid scale up and what can be learnt from successes in this area. Drawing on a background paper, co-authored with Peroline Ainsworth, Gerry Bloom opened a parallel session at the Global Symposium with an overview of learning in this area.

Gerry argued that there are many challenges that might impact upon the scaling up process. Recent years have seen many political commitments to increase access and an improved financing environment for health systems strengthening underpinned by new global organisations. There is a recognition that scaling up means managing change in a dynamic and complex context (where there has been a shift from absolute scarcity to problems with safety, quality and cost with changing patterns of inequality, the introduction of new technologies and institutional arrangements, the rise of patient and citizen movements and mixed systems). Unexpected outcomes and unintended consequences caused by the scaling up process point to the need for systematic knowledge and shared understandings amongst a range of actors.

Ligia PainaLigia Paina and David Peters, Johns Hopkins School of Public Health, suggested that we might be using the wrong models for scaling up – that blue print, linear, one size fits all models are misaligned with the reality of health systems in practice. She explained how health systems are characterised by dynamic change which is rooted in local context. Complex adaptive systems thinking might help us to better understand a failure to scale up. It may explain why we cannot control the behaviour of communities and providers.

Emmanuel SokpoEmmanuel Sokpo and Jeff Mecaskey presented on the experiences of the Partnership for Reviving Routine Immunization in Northern Nigeria (PRRINN) project in northern Nigeria. Their work was rooted in an understanding of the social, political and economic history and context and included a political economy assessment. This assessment:

  • Deepened understanding of the positions of major stakeholders in the state with respect to the socio-political, institutional, structural and historical context as they pertain to the health sector

  • Identified issues which, in a general sense, appear to provide good opportunities for creating 'coalitions of interest' and for levering desired institutional changes

  • Provided input into the prioritisation of key interest groups and/or organisations that can be developed as a 'coalition of interests' to drive change


They found that political competition was largely occurring within the elite and was structured around the power struggles of individuals, and inter-familial tensions played out within the camps of political parties. There are few alternative centres of power and little check on executive power overall, making the programme highly reliant on key individuals. State power and resource control is in the hands of the state government, while those who still retain some influence over ideology are also under the financial influence of the government. In their opinion the link between policy, strategy , planning and implementation of health interventions was broken with more focus on capital inputs than on health outcomes. Finally they discovered that a fragmented primary health care system is convenient arrangement for States and LGAs to share health resources without accountability. This knowledge was invaluable to the successful scale up of their programme.

Wang YunPingZhenzhong Zhang and Wang YunPing, of the China Health Development Research Centre, a government think tank, provided an assessment of the rapid scale up of health insurance in China. She concluded that the success of the schemes rested on:

  • Political commitment and a change in values toward social and economic development. Health used to be a means to economic growth now it is one of the goals.

  • Learning by doing. The schemes were launched incrementally in a gradual move toward reaching the whole population. Work within the Health 8 and other health sector programmes provided a solid foundation of research which helped the Chinese Government move forward. They experimented with pilots which then spread and bridged the gap between research and policy.

  • The scheme was centralised and relatively decentralised. Central Government provided general principles but left space for local policy makers to think about the detail. They employed cross-ministry cooperation.

  • Changing role of communities. Rural residents are no longer passive recipients. Their needs and interests are the concern of the local officers. The government promoted the schemes with positive incentives and information about how they may benefit.


Vera at the SymposiumVera Schattan Coelho, Brazilian Centre for Anaysis and Planning,  reflected on the success of the SUS in Brazil. She explained how it reflected the aspirations of a movement that believed in health for all and was a process where local, federal and national levels worked together for change with the Support of social movements, public health practitioners and left wing parties. Vera explained that when the SUS began the institutions that we needed were not there. At the end of the 1970s the old system really wasn't working and so state innovations started to take place, for example, the Family Health Programme. There was a complete change in the relation between the national and the municipal level and clear contracts were established where the federal state was responsible for the policy but transferred the money to the municipalities and they were responsible for implementing. This happened by degrees not all at once so there was a gradual building of institutional capacity. The social movement, "the health movement", was involved in policy decision making through Councils that included civil society, health providers and Government. When it was discovered that health indicators for indigenous people were much poorer than for the general population minority groups pushed for new programmes targeted at. The indigenous health system was established in 1999. You can read more about this in our briefing. The lesson from this is that within scaling up processes there is a need to balance universalism and also the need for tailored services for some.

 

Learning by doing and applying our learning: What are the strategies and institutional options?

Posted: 23 Nov 2010 06:39 AM PST

BY KATE HAWKINS, INSTITUTE OF DEVELOPMENT STUIDES
BASED ON NOTES BY LIGIA PAINA, JOHNS HOPKINS SCHOOL OF PUBLIC HEALTH

Learning by doing sounds a nebulous concept but actually it is crucial in health systems development. If we can't understand the process of intervening in the system and the positive and negative outcomes of our actions how can we improve the work that we are doing? The last decade has seen a rapid increase in the number of institutions such as learning platforms, health observatories, and think tanks. But at the same time, there is a lack of clarity in the difference between them, as well as their pros and cons.

This Future Health Systems Consortium session at the Global Symposium included presentations from the Asian Observatory on Health Systems, The Zambian Forum for Health Research, Health Intervention and Technical Assessment Program (HITAP) Thailand and The China National Health Development Research Center. It tried to better understand the work that they are doing as well as the challenges that they face.

Blogs we like: The Center for Health Market Innovations

Posted: 23 Nov 2010 12:12 AM PST

KATE HAWKINS, INSTITUTE OF DEVELOPMENT STUDIES

Sitting in the Global Symposium marketplace is a good way of finding more about other projects and the people that make them tick. We were lucky to have the Center for Health Market Innovations as our neighbour. Rose, their Program Officer, has been kind enough to link to our blog. You should check them out, this is what they say about their blog:

The Center for Health Market Innovations (CHMI) blog features news about promising new programs, innovative collaborations, relevant resource articles, and editorial pieces authored by members of the CHMI community. These editorial pieces are intended to further conversations about health market trends, national health policies, and improving health care for the poor. We encourage you to participate in this dialogue in the comments section or suggesting a post to rreis at resultsfordevelopment.org.

New Consortium launched at the Symposium: REBUILD

Posted: 22 Nov 2010 08:24 AM PST

BY TIM  MARTINEAU, GUEST BLOGGER FROM LIVERPOOL SCHOOL OF TROPICAL MEDICINE

Tim explaining the soft launchIn countries affected by political and social conflict, health systems often break down and emergency assistance provided by humanitarian organisations often constitutes the main source of care. As recovery begins, so should the process of rebuilding health systems but little is known about how effective different approaches are in practice. Health systems research has tended to neglect these contexts, because it may be more difficult to carry out studies in unstable environments and relevant capacity is often weak.

New Directions in Health-Environment Research: Implications for Health Systems

Posted: 22 Nov 2010 06:27 AM PST

BY MICHAEL LOEVINSOHN, GUEST BLOGGER FROM THE STEPS CENTRE

Michael chairing the sessionI chair a session on New Directions in Health-Environment Research: Implications for Health Systems. A bit off the beam of the Global Symposium's thrust: one of 13 concurrent sessions, perhaps 20 people attend.


Setting the stage, I describe the methodological challenges researchers are tackling to uncover how environmental change, of different kinds, is creating health risks; in identifying developmental processes that are loosening structures of risk and in clarifying how health and other sectors can collaborate to realize these opportunities.    


The first case describes an "unnatural experiment", the 2001-03 famine and its impact on the evolution of HIV in Malawi. Using existing data, I show how hunger profoundly affected the distribution of HIV and of people by pushing people into survival sex and distress migration. The data also show that hunger was less severe, maize price less volatile and migration and change in HIV prevalence less marked where people had access to robust crops like cassava, alongside the maize staple. Cassava appears to be providing a "prevention dividend".

Networking at the Global Symposium

Posted: 21 Nov 2010 07:55 AM PST

Whilst we were very busy at the conference the Future Health Systems Consortium also found some time to catch up with old friends and to meet new ones.

[slideshow]

[gallery orderby="rand"]

From Montreux – the First Global Symposium on Health Systems Research

Posted: 21 Nov 2010 06:21 AM PST

BY MICHAEL LOEVINSOHN, GUEST BLOGGER FROM THE STEPS CENTRE

You know you're a discipline or a significant sub-discipline when you can organize and find funding for a global symposium. Twelve hundred participants from umpteen countries also testify to the self-awareness that marks a field. And the Symposium's theme is fittingly ambitious: Science to Accelerate Universal Health Coverage.

Charlie Chaplin is in town but can't make it to the Symposium. He's buried just down the road. But I wonder what his Little Tramp, bowler-hatted and down-at-heels, would make of it. Would he be considered part of the System? Am I? My interest is in the determinants of disease in the turbulent social, economic and natural environment and what that understanding can contribute especially to prevention.

Applause for the rapporteurs

Posted: 19 Nov 2010 05:15 AM PST

There are many individuals that help to make a conference of the size and complexity of the Global Symposium run smoothly. The Future Health Systems Consortium is lucky to have a smart and dedicated group of note takers who are pushing out summaries from our sessions in between delivering papers and networking.

In particular many thanks to Adrijana Corluka for helping us out with the session on Improving Health Service Delivery and Ligia Paina for the Learning by Doing write up.

More on this later…

Catalysing political will to build health systems research capacity

Posted: 19 Nov 2010 02:55 AM PST

BY KATE HAWKINS, INSTITUTE OF DEVELOPMENT STUDIES

Sara in plenarySara Bennett, from Johns Hopkins School of Public Health, gave a rousing plenary speech on the final day of the Global Symposium. She argued that all stakeholders – policy makers, service providers, the leaders of research organisations, funders and health development partners - need to come together to support capacity development for health systems research. Health systems research capacity development can be seen as worthy but dull and it may not be compelling to donors. Yet there are a lot of exciting innovations in research capacity development occurring in low and middle income countries.

Sexy, maybe. Fun, definitely!

Posted: 18 Nov 2010 12:49 AM PST

BY ELIZABETH EKIRAPA-KIRACHO, MAKERERE UNIVERSITY PUBLIC HEALTH


In response to Nandini's question can research make health systems sexier?  I guess it can it all depends on the researchers line of thought. I have been part of the Future Health Systems Consortium for five years and believe me I have realised that health systems research can be lots of fun! You must be wondering why. This particular consortium allows you to be creative and innovative. Nobody tells you what to research on, you decide what is relevant for you and you think of innovative ways to solve the problems that plague health systems in developing countries. This is a big lesson for developing countries we need to start thinking and doing what we think is best for us in our context. During this Global symposium, the issue of context is coming out strongly context matters in health systems research. We know our context best we should get into the driver's seat.


Two quotations will stay with me after all is said and done at this conference. The one by Davis Miles "don't play what's there play what's not there." I look forward to researching on health systems topics that are still a puzzle. As part of the safe deliveries study, we are piloting a study that gives mothers access to delivery and postnatal care services in Eastern Uganda using vouchers.  Institutional deliveries have increased tremendously! Great but the question remains how can you scale up this initiative in a resource constrained country?


The second quotation is by Abbas Bhuia "Leave a mark in the field where you are researching." I guess not only a mark of excellent research but a mark that you have made a difference in the lives of the people in that community.

A post on posters

Posted: 17 Nov 2010 02:05 PM PST

BY KATE HAWKINS, INSTITUTE OF DEVELOPMENT STUDIES

Time after time at international conferences I am amazed that people don't pay more attention to poster presentations. Often they provide a clear and coherent argument and compelling graphics and images which are far more effective than many oral sessions. You can keep a copy and refer back to them. What's more - when your energy is lagging due to conference overload you can count on them to be concise and to the point!

So I'm going to draw your attention to 2 poster presentations that are being given here at the Global Symposium by Future Health Systems Consortium researchers. The first is on "Experiences of Implementing a Demand Side Financing Scheme for Maternal Health Services in Eastern Uganda." It explains how the team are studying demand (vouchers for transport and maternal services) and supply side initiatives (training health workers and provision of essential equipment, drugs and supplies) to explore how we can improve the uptake of maternal health services. The second is "Exploring health researchers' perceptions of policymaking in Argentina: A qualitative study." This research took the form of semi-structured, indepth interviews with 20 key informants, representing sites in the Federal City of Buenos Aires and the provinces of Salta, Jujuy, Tucuman, Santiagodel Estero and Catamarca, in Argentina's north west region.

I'm not going to tell you what they concluded. You'll have to download the posters to find out... 

 

Would you like an injection with that Happy Meal?

Posted: 17 Nov 2010 01:23 PM PST

BY DANIELA LEWY, JOHNS HOPKINS SCHOOL OF PUBLIC HEALTH

I started my career in education, transitioned to corporate training, and then navigated into public health. But with each professional shift – not much seems particularly different. Universal Education and Universal Healthcare; supply/demand principles at Johns Hopkins Hospital and supply/demand principles at Mars Corporation; and increased salaries for teachers, nurses, or accountants doesn't always translate to better test scores, fewer infections, or less bankruptcy. 

So when yesterday's session on social franchising began with a reference to McDonalds – I sat up straight. I like the intersection of seemingly disparate fields. 

Future Health Systems' Researchers Enjoying the Symposium

Posted: 17 Nov 2010 06:59 AM PST

Sabina Faiz RashidOladimeji Oladepo and Hafiz RahmanAbbas Bhuiya
at