Upload
alicia-ledbetter
View
217
Download
0
Tags:
Embed Size (px)
Citation preview
1Management Sciences for Health
Stronger health systems. Greater health impact.
Health systems approach to integration of family planning: A critical look
Reconvening Bangkok : 2007 to 2010
Halida H. Akhter, Global Technical Lead FP/RH March 6-11, 2010, Bangkok, Thailand
2Management Sciences for Health
HUMAN RESOURCES
MEDICINE AND TECHNOLOGIES
FINANCINGINFORMATION
LEADERSHIP AND GOVERNANCE
SERVICE DELIVERY
Six Building Blocks of Health Systems (WHO)
3Management Sciences for Health
Stronger Health Systems save lives and improve health
Stronger health systems.1. Leadership,
management, & governance
2. Health service delivery
3. Human resources for health
4. Pharmaceutical management
5. Health care financing
6. Health information
Greater health impact.1. HIV & AIDS
2. Tuberculosis3. Communicable
diseases: malaria, avian & pandemic influenza
4. Maternal, newborn, child health
5. Family planning / reproductive health
4Management Sciences for Health
Barriers are overcome using six health systems building blocks
AccessChoiceQuality
Barriers to FP and RH services
Fragmented services
Socio-cultural norms
Cost
Process
Physical
Inappropriate eligibility
criteria
Poor CPR
Provider bias
KnowledgeLocatio
n
Time
1.Leadership, management & governance
2. Health service delivery
3. Human resources for health
4.Pharmaceutical management
5. Health care financing
6. Health information
6 pillars of health systems
5Management Sciences for Health
Six pillars of health systems
1. Leadership, management & governance Policy support reinforcing advocacy efforts with factual evidence leading to enabling policies, strategies, approaches and guidelines.
2. Health service deliverySustainable use of integrated FP/RH services—Fully Functional Districts with technical and operational support and referral system. Services through a mix of delivery points gets methods to potential users.
3. Human resources for healthHigh performing staff, task-shifting and improving performance cultivates a sustainable health care workforce.
.
6Management Sciences for Health
4. Pharmaceutical management A strong logistics system, including procurement, sufficient equipment, drugs, supplies and infrastructure and, a plan for contraceptive security - ensure method availability
5. Health care financingSocial marketing, incentive based partnerships with private sector, CBO and NGO.
6. Health informationEvidence-based programming yields important information to guide program decision-making. Well designed MIS needs to be in place.
Six pillars of health systems
7Management Sciences for Health
A strong health system helps integrate
services to offer greater health impact Integration means offering multiple health
care services at the same facility or through a community-based program to benefit clients, providers, programs
Integrated services are more efficient and ensure financial sustainability.
Combination of well selected interventions address a range of health needs, creates synergies, enhance impact.
They demand a strong political commitment and additional resources
8Management Sciences for Health
Integration of FP and reproductive health: Bangladesh case
Bangladesh Family planning program created a success story 1965: Started as a vertical program Early ‘80s: MCH was integrated with Family
planning Post-ICPD: Reproductive Health was
integrated 1996: HPSS, Health and Population Sector
Strategy A five year (1998-2003) HPSP: A Sector-
Wide Approach ($3 bill budget) Moved from Project approach to Program
approach. HPSP: sector as a whole
9Management Sciences for Health
Integrated sector-wide approach of HPSP
HPSP: world’s first example of Sector-Wide Approach (SWAP) donors pooled resources implementation and annual operations plan (AOP) to cover a range of integrated services (e.g., health, FP)
HPSP emphasized structural reform i.e. unification as indicator of program success as opposed to health outcome Unify two Directorates : Health and Family Planning (lower levels) Merged functions: BCC, logistics, and Information Systems Transition: domiciliary FP to static community clinics (CCs) Focus: Essential Services Package (ESP) Delivered from facilities close to the population affected
10Management Sciences for Health
Essential Service Package: RH care content
Essential Service Package (ESP )elements:
1. Reproductive health care
2. Child health care
3. Communicable diseases control
4. Simple curative care
5. Behavior change communication(BCC)
HPSP Reproductive Health Care:
1. Safe motherhood
2. Family planning
3. Prevention and control of RTI/STD/AIDS
4. Maternal nutrition
5. Adolescent care
6. Neonatal care
11Management Sciences for Health
HPSP’s Reproductive Health Strategy
HPSP’s reproductive health strategy matched well with the WHO recommendations, Identified 5 key areas of action1. strengthening health system capacity2. mobilizing political will3. creating supportive legislative and
regulatory frameworks4. improving information for setting priorities5. strengthening monitoring, evaluation, and
accountability.
12Management Sciences for Health
The integration and merger of health and population sector components
Health and Family Planning MIS were merged
Former projects were grouped together under a small number of Line Directors
Financial authority was transferred from former Project Directors to Line Directors
Procurement of drugs, vaccines, and equipment centralized;
Training Procurement was centralized (not project-based)
13Management Sciences for Health
Effects of merger reform
HPSP contained long list of reforms Policy reforms of the systems, changing
attitudes Operational definition of SWAP during
HPSP
Many elements of the reform faced opposition -
However, MOHW moved quickly to implement difficult structural changes--it unified health & family planning
services at lowest admin tiers Initiated ‘one stop’ community clinics
to provide Essential Service Package.
14Management Sciences for Health
Impact of reform on nationwide program
Effects of these changes in the functioning of the health system included: Outreach services - disrupted by changes to
service delivery
Difficulties of restructuring health system
Some FP indicators became stagnant. Govt. lost a modest share of family
planning service provision, Transfer to Community Clinics needed more
time.
15Management Sciences for Health
Impact of reform on community
Household visits for family planning by GOB fieldworkers started to decline leading to low client worker contacts.
Community clinics were yetto be fully functioning 43.0
35.2
21.218.2
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
45.0
50.0
1993-94 1996-97 1999-2000 2004
Field Worker Contact
Trends of Worker Client Contact
16Management Sciences for Health
Effect on national FP indicators
“Stagnation" in fertility reduction:; TFR plateaued, although CPR went up, the use of clinical contraceptive declined
TFR
0
1
2
3
4
5
6
7
1971
-75
1984
-88
1986
-88
1989
-91
1993
-94
1996
-97
199-
00
2004
CPR among married women
Source: BDHS: 2004
0
10
20
30
40
50
60
1975
1983
1985
1989
1991
1993
-94
1996
-97
1999
-00
2004
17Management Sciences for Health
Benefits from a comprehensive reproductive health strategy
In spite of the short dip in some FP indicators, the Bangladesh case exemplifies the benefits from a comprehensive reproductive health strategy
During HPSP (1998–2003), MMR declined from 440 to 322 deaths per 100,000 live births
ANC grew from 26% to 56% Use of EOC rose from 5% to 27% Contraceptive Prevalence Rate went up-- Because, as the household visits by GOB
workers reduced, the couples switched to private outlets, pharmacies, NGOs
18Management Sciences for Health
Critical lessons learned
The critical issue related to integration of services or programs: Lack of ownership to the policy Lack of commitment and support from
domestic forces severely affects implementation
Integration will not bring desired impact unless ---• enough lead time is provided to strengthen health systems i.e. policy changes, creating strategies and guidelines for service delivery strengthening motivation and capacity of
appropriate human resources is instrumental to the success.
19Management Sciences for Health
Lessons from Bangladesh experience
1. Political commitment is key to success of Integration
2. The people who design and implement health care policies and programs need to pay attention to both technical and political
feasibility. 3. Strong systems in place help backup minor
short falls
4. Improving governance is key to improving service delivery.
5. A major critical ingredient to use of public health services is leadership and governance strengths.
20Management Sciences for Health
References
Jahan, R. 2003, "Restructuring the health system: Experiences of advocates for gender equity in Bangladesh", Reproductive health matters, vol. 11, no. 21, pp. 183-191.
Kamal, S.M. M., Akhter, S., Islam, A. "The Role of Proximate Determinants of Fertility Transition in Bangladesh”.
Osman, F.A. 2005, "Implementation Constrained by a Lack of Policy Ownership: Evidence from Bangladesh", The Asia Pacific Journal of Public Administration, vol. 27, no. 1, pp. 19-36.
Pearson, M. 1999, "Bangladesh - Health Briefing Paper", Department for International Development Health Systems Resource Centre.
Streatfield, P.K., Arifeen, S.E., Al-Sabir A. 2004, “Policy Implications of the 2004 BDHS.”
USAID 2009, "Health Systems Report to Congress", Sustaining Health Gains - Building Systems.
WHO 2007, "Everybody's Business: Strengthening Health Systems to Improve Health Outcomes; WHO's Framework for Action".
21Management Sciences for Health
Stronger health systems. Greater health impact.
Saving lives and improving the health
of the world’s poorest and most vulnerable people
by closing the gap between knowledge and action in
public health.