|





 
 

 


|


 | 
 



O

 

 

  

O
 
 



      
 
1
 Why this Initiative?
The ͚Making Health System Work͛ working
paper series is designed to make current
thinking & actual experience on different
aspects of health systems available in a simple
& concise format for decision makers.

2
 Working Papers in this Series
1. Strengthening Management in Low-Income Countries

2. Working with the Non-state Sector to Achieve Public

Health Goals

3. Improving Health System Financing in Low-Income

Countries

4. Opportunities for global Health Initiatives in the Health

System Action Agenda

5. Improving Health Services & Strengthening Health

System; Adopting & Implementing Innovative Strategies
3
 ˜urrent Topic


!  

" "

#




 
  #

 

$
 #

 
#
     #%&

4
 Introduction
· In recent years number of specific strategies for improving
health services and strengthening health systems have been
consistently advocated.

· he 2003 & 2004 World health report proposed improving

rewards to health workers to improve productivity, along with
deploying community health workers and engaging
communities in their health care.

· he world development report 2004 advocated Contracting,

Local government financing, Empowering communities, and
using Vouchers and other approaches to subsidize key health
services to the poor.
5
· In addition to analyzing the role of selected strategies in
specific countries over the last 5 years, the study examined
the salient features and dynamics of each national health
system and broader context within which it operates, and
highlighted developments and events that are likely to have
had a bearing on decision made in the health sector.

· The study considered both scale and scope so as to shed light

not only on the details of the strategies under review, but also
to explore factors enhancing or inhibiting the country-wide
implementation of the promising innovation.
6
 Study Approach
Selection Strategies: Was finalized at a meeting of WHO,
World Bank Staff and ˜onsultants. Focusing on the delivery
mechanisms and management systems and mixed bag of
diverse strategies, final list was chosen and it comprised of
following innovative strategies:
1. ˜ontracting
Organization
2. Delegation of authority
& financing 3. User fee exemptions
4. Subsidies for the poor
Human
resource
5. Performance-related pay and incentives
management 6. Reorganizing the outreach workers
˜reating 7. Social marketing
demand &
accountability 8. ˜ommunity engagement
7
Selection of the study countries:
In all 12 countries were selected with a view to covering a
wide spectrum of situations, including 3 falling in the
categories of ͞fragile states͟(according to the world bank͛s
country policy and institutional assessment). The selected
indicators were:

1. Population

2. GNI per capita

3. Under 5 mortality

4. Total fertility rate

8
· Method:
1. Multiple Indicator ˜luster Surveys
2. Data were gathered primarily by desk reviews
3. Literature search through PubMed
4. Searching for unpublished documents
5. Field visits: To explore in greater depth the factors
underlying health service results and constraints to
country-wide implementation

· Preliminary findings were further reviewed in key informant

interviews with selected WHO and World Bank staff.
· ˜onsultation were also held to review the findings and to
engage in a wide-range discussion of their implications for
WHO.
9
 ˜ontext
· here were divergent patterns of health services outputs
across each country, with each country demonstrating
improvements in some areas of health service delivery.

· In nearly all countries, when there was progress in health

service outputs, the changes tended to be small and gradual,
rather than showing radical change.

· Progress in the health service outputs tended to occur in one

or only a limited number of areas. Even where a particular
program is achieving some success in service delivery, there
was little positive effect on other program areas.
10
 Adaptation and Implementation
A framework was developed to assess how and to what extent the
individual strategies were developed, adopted and implemented.
Three distinguished categories were identified i.e.
1. Development & adoption strategy
2. Plans for scaled-up implementation
3. Record of actual implementation.

These categories were further classified depending upon varying

degrees of adoption and implementation of strategies, taking into
account the pilot project͛s
1. Full-scale implementation from outset
2. Timeframe of implementation
3. Geographical coverage.

11
 Indicators of health service output
1. Antenatal coverage

2. Skilled birth attendance

3. Full immunization

4. HIV knowledge

5. Child bed net use

6.
-case detection rate

7.
successful treatment rate

12
 Findings and Discussion
· evelopment & adoption of strategies:
Ministries of health in each country are either
implementing or planning to implement at least 2 of the
strategies under study, confirming the relevance of these
strategies across a wide range of low-income countries.

· Strategy development & adoption were categorized in to

1. No plan
2. Under review/development
3. Adopted strategy/plan
4. wo distinct strategies pursued

13
· he data suggested that there may be a
relationship between openness to innovation
and ability to deliver services that allows
countries

14
15
16
17
18
19
20
21
22
23
24
 Implications for Hospital Administrator
· Approaches to subsidize key health services for the poor and
their implementation (˜ontracting, local government
financing, empowering communities, and using vouchers etc.)
· Improving health services and strengthening health system by
developing, adopting and implementing innovative strategies

25
·



G'
26