Ergo shah framework02

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

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1. “What is” – Elements of the HS




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2. Tools - HSS

Strengthening the Health System

Interventions within the health system

Health System Strengthening

Initiatives

Scope and degree of policy-change involved




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Dynamic Perspective




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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


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

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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


Resulting interventions: Emergency Human Resource Program, incl.

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




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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

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,




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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




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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”

The preceding slides were presented at theCORE Group 2010 Fall Meeting

Washington, DC

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

http://www.coregroup.org/resources/meetingreports

Ergo shah framework02

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