Strengthening Health Systems to improve Maternal, Neonatal & Child Health OutcomesA Framework

Alex ErgoNirali Shah

Core Fall MeetingSeptember 14, 2010

Impact on Maternal, Neonatal and Child Mortality and Morbidity

Financing Organization Regulation CommunicationHealth System Control Knobs

Coverage & Quality of MNCH Interventions

Community

Physical Environment Population density Climate / terrain

Social Environment Gender inequality Social cohesion/homogeneity Poverty/social inequality Cultural/social norms

Health Care Sector

Enabling Environment & Governance Leadership Oversight Policies and regulations Financing Provider payment

Service Delivery Organization Infrastructure Health workforce Information Medical products Vaccines and technologies

Households

Household Characteristics Size and composition Wealth / Education Intra-household power relations

Individual factors Biological factors Psychological factors Behavioral factors

Other Sectors

External Shocks

Health System

Impact on Maternal, Neonatal and Child Mortality and Morbidity

Financing Organization Regulation CommunicationHealth System Control Knobs

Coverage & Quality of MNCH Interventions

Community

Physical Environment Population density Climate / terrain

Social Environment Gender inequality Social cohesion/homogeneity Poverty/social inequality Cultural/social norms

Health Care Sector

Enabling Environment & Governance Leadership Oversight Policies and regulations Financing Provider payment

Service Delivery Organization Infrastructure Health workforce Information Medical products Vaccines and technologies

Households

Household Characteristics Size and composition Wealth / Education Intra-household power relations

Individual factors Biological factors Psychological factors Behavioral factors

Other Sectors

External Shocks

Health System

1. “What is” – Elements of the HS

Impact on Maternal, Neonatal and Child Mortality and Morbidity

Financing Organization Regulation CommunicationHealth System Control Knobs

Coverage & Quality of MNCH Interventions

Community

Physical Environment Population density Climate / terrain

Social Environment Gender inequality Social cohesion/homogeneity Poverty/social inequality Cultural/social norms

Health Care Sector

Enabling Environment & Governance Leadership Oversight Policies and regulations Financing Provider payment

Service Delivery Organization Infrastructure Health workforce Information Medical products Vaccines and technologies

Households

Household Characteristics Size and composition Wealth / Education Intra-household power relations

Individual factors Biological factors Psychological factors Behavioral factors

Other Sectors

External Shocks

Health System

2. Tools - HSS

Strengthening the Health System

Interventions within the health system

Health System Strengthening

Initiatives

Scope and degree of policy-change involved

Impact on Maternal, Neonatal and Child Mortality and Morbidity

Financing Organization Regulation CommunicationHealth System Control Knobs

Coverage & Quality of MNCH Interventions

Community

Physical Environment Population density Climate / terrain

Social Environment Gender inequality Social cohesion/homogeneity Poverty/social inequality Cultural/social norms

Health Care Sector

Enabling Environment & Governance Leadership Oversight Policies and regulations Financing Provider payment

Service Delivery Organization Infrastructure Health workforce Information Medical products Vaccines and technologies

Households

Household Characteristics Size and composition Wealth / Education Intra-household power relations

Individual factors Biological factors Psychological factors Behavioral factors

Other Sectors

External Shocks

Health System

Dynamic Perspective

Impact on Maternal, Neonatal and Child Mortality and Morbidity

Financing Organization Regulation CommunicationHealth System Control Knobs

Coverage & Quality of MNCH Interventions

Community

Physical Environment Population density Climate / terrain

Social Environment Gender inequality Social cohesion/homogeneity Poverty/social inequality Cultural/social norms

Health Care Sector

Enabling Environment & Governance Leadership Oversight Policies and regulations Financing Provider payment

Service Delivery Organization Infrastructure Health workforce Information Medical products Vaccines and technologies

Households

Household Characteristics Size and composition Wealth / Education Intra-household power relations

Individual factors Biological factors Psychological factors Behavioral factors

Other Sectors

External Shocks

Health System

Impact on Maternal, Neonatal and Child Mortality and Morbidity

Financing Organization Regulation CommunicationHealth System Control Knobs

Coverage & Quality of MNCH Interventions

Community

Physical Environment Population density Climate / terrain

Social Environment Gender inequality Social cohesion/homogeneity Poverty/social inequality Cultural/social norms

Health Care Sector

Enabling Environment & Governance Leadership Oversight Policies and regulations Financing Provider payment

Service Delivery Organization Infrastructure Health workforce Information Medical products Vaccines and technologies

Households

Household Characteristics Size and composition Wealth / Education Intra-household power relations

Individual factors Biological factors Psychological factors Behavioral factors

Other Sectors

External Shocks

Health System

2000 2010

Snapshot 1 Snapshot 2

Health Systems Strengthening initiatives

Changes

Main challenges Actions takenRemaining challenges

Possible actions

Other sectors and external shocks

Improvements

Malawi - national perspective

Used HSS framework to get overview of Malawi context

Specifically looked at MNCH indicators Key points of concern in 2000:

MMR=1120, having risen 80% since 1992 CPR = 21% Less than 2% of facilities able to provide

BEmOC

Malawi - national perspective Delve deeper into reasons driving the

indicators Service Delivery:

Severe human resource shortage High rates of hospital infections

Household: High HIV prevalence (12-15%) Large household size (TFR > 6) Difficulty to access health facility during

pregnancy

20 1020 00 20 04 20 0820 0620 02

Rose dies Henderson in nursing school

Zandile attempts abortion

SWAp

Emergency HR program

Pre-service training plan

SLA’s with CHAM facilities

Decentralization act

CHAM salary MOU New president; Decentralization progress improves

Community based MNH

TBA role change

EHP developed

Infection Prevention interventions

IP becomes govt program

SBM-R for MNH

National RH strategy

Road map for MNH

Global fund HSS grant

ART provided for free

HSAs provide DMPA

Gladys gives birth

Health System Strengthening Initiatives: Timeline

Malawi - national perspective Resulting interventions:

Emergency Human Resource Program, incl. HSA

Regulation which changed role of TBA Financing mechanism (SWAp) for health

Impact on Maternal, Neonatal and Child Mortality and Morbidity

Financing Organization Regulation CommunicationHealth System Control Knobs

Coverage & Quality of MNCH Interventions

Community

Physical Environment Population density Climate / terrain

Social Environment Gender inequality Social cohesion/homogeneity Poverty/social inequality Cultural/social norms

Health Care Sector

Enabling Environment & Governance Leadership Oversight Policies and regulations Financing Provider payment

Service Delivery Organization Infrastructure Health workforce Information Medical products Vaccines and technologies

Households

Household Characteristics Size and composition Wealth / Education Intra-household power relations

Individual factors Biological factors Psychological factors Behavioral factors

Other Sectors

External Shocks

Health System

Malawi - community perspective National strategies and constraints impact

community based interventions Regulatory change banning TBA assisted

delivery Health worker shortage leads to culture of

mistrust of health facilities in community Decentralization gives more power to district

health management teams Adaptation of community based interventions

to work within changing contextKnowledge of national context allows for effective design of local initiatives

MCHIP community based interventions Community based maternal and neonatal

health care Extended role of Health Surveillance Assts

(HSA) Community action groups for maternal

health Household provision of Depo-Provera by

HSAAddressed: Social norms, transportation constraints, knowledge of appropriate care practices, intra-household power dynamics,

Impact on Maternal, Neonatal and Child Mortality and Morbidity

Financing Organization Regulation CommunicationHealth System Control Knobs

Coverage & Quality of MNCH Interventions

Community

Physical Environment Population density Climate / terrain

Social Environment Gender inequality Social cohesion/homogeneity Poverty/social inequality Cultural/social norms

Health Care Sector

Enabling Environment & Governance Leadership Oversight Policies and regulations Financing Provider payment

Service Delivery Organization Infrastructure Health workforce Information Medical products Vaccines and technologies

Households

Household Characteristics Size and composition Wealth / Education Intra-household power relations

Individual factors Biological factors Psychological factors Behavioral factors

Other Sectors

External Shocks

Health System

Community initiatives impact policy

MCHIP demonstrated effect of each initiative, through survey, case study, and ongoing evaluations

Highlighted ability of HSA and community to work around systemic constraints

Led to adoption of community MNH and FP provision by HSA at the national level

Kenya - community perspective Social environment: creation of care

groups in community Service delivery organization: changed

role of dispensary health committee from administration to management

External factor: Security problems in the border district

Other sectors: involved district security council in health activities

Kenya - national policies impact community Financing: User fees abolished, leading to drug and

nurse shortage Financing: Constituency development fund, allows

regional decision making on development activities Organization: Kenya Essential Package for Health

gave community-based care a more prominent place and created new paid CHW cadre

Regulation: Changed treatment protocol for malaria, leading to change in planned project activity

Impact on Maternal, Neonatal and Child Mortality and Morbidity

Financing Organization Regulation CommunicationHealth System Control Knobs

Coverage & Quality of MNCH Interventions

Community

Physical Environment Population density Climate / terrain

Social Environment Gender inequality Social cohesion/homogeneity Poverty/social inequality Cultural/social norms

Health Care Sector

Enabling Environment & Governance Leadership Oversight Policies and regulations Financing Provider payment

Service Delivery Organization Infrastructure Health workforce Information Medical products Vaccines and technologies

Households

Household Characteristics Size and composition Wealth / Education Intra-household power relations

Individual factors Biological factors Psychological factors Behavioral factors

Other Sectors

External Shocks

Health System

Usefulness of HSS framework

Assessment tool - use while defining problems

Programming tool - use while planning interventions

Evaluation and research tool - use while designing evaluation

Advocacy tool - Community interventions can impact “control knobs”

Your task If you were to design a community based

intervention to improve maternal and neonatal health in the country, what do you think would be the main health systems challenges you would face? How are these captured in the framework?

What type of health systems strengthening initiatives could address these challenges? Under what control knobs do they fall?

Impact on Maternal, Neonatal and Child Mortality and Morbidity

Financing Organization Regulation CommunicationHealth System Control Knobs

Coverage & Quality of MNCH Interventions

Community

Physical Environment Population density Climate / terrain

Social Environment Gender inequality Social cohesion/homogeneity Poverty/social inequality Cultural/social norms

Health Care Sector

Enabling Environment & Governance Leadership Oversight Policies and regulations Financing Provider payment

Service Delivery Organization Infrastructure Health workforce Information Medical products Vaccines and technologies

Households

Household Characteristics Size and composition Wealth / Education Intra-household power relations

Individual factors Biological factors Psychological factors Behavioral factors

Other Sectors

External Shocks

Health System

The preceding slides were presented at theCORE Group 2010 Fall Meeting

Washington, DC

To see similar presentations, please visit:www.coregroup.org/resources/meetingreports