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Maximizing Positive Synergies Between Health Systems and Global Health Initiatives A Mixed Methods A


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Title: Maximizing Positive Synergies Between Health Systems and Global Health Initiatives A Mixed Methods A

Maximizing Positive Synergies Between Health
Systems and Global Health Initiatives A Mixed
Methods Approach
  • Dr. Jim Yong Kim
  • Harvard Medical School
  • Harvard School of Public Health
  • October 2, 2008

Positive Synergies
  • How can global health initiatives and national
    health systems optimize their interactions to
    capitalize on positive synergies and minimize
    negative impacts, thereby achieving their common
    goal of improving health outcomes?

What are the best methods to answer this question
and lead to the desired outcomes?
What are the Desired Outcomes?
  • Healthier People/Equity/Social Justice
  • Highly functioning health systems that are
    responsive to everyone and deliver across the
  • Better policies that shape donor behavior, health
    system design and health service delivery
  • Evidence-based implementation and delivery by
    systems and practitioners at all levels
  • Evidence that links system design, implementation
    strategy, management structure, degree and nature
    of integration of services, civil society
    involvement, health system architecture etc. to
    health outcomes
  • Methodologies and researchers that fit the task

Choosing the right methods
  • What kind of data/information exists and does it
    point the way to further studies?
  • What is the state of framework and theory
    development around the problem?
  • Are researchers who represent unusual
    disciplines working on the problem?
  • Are civil society actors and affected communities
    involved at every step?
  • Will the methods used and research done be
    helpful to practitioners at the country level and
    lead to real health improvements for people?

Proposed Methodological Approach
  • Cross-country Quantitative Analysis
  • Country-level Mixed Methods Analysis
  • Provider Unit-Level Analysis

Research Questions
  • How do GHI-funded programmes interact with health
    systems in varied country contexts?
  • What positive synergies or negative interactions
    emerge when GHI funded programmes interact with
    local health systems?
  • In various contexts, which factors influence the
    extent and nature of interaction between
    GHI-funded programmes and local health systems?

Research Questions
  • 3. What are the specific system designs and
    delivery strategies funded by the GHIs that have
    lead to the most positive impacts on health
  • a. How do these designs and delivery structures
    influence the coverage of targeted and
    non-targeted interventions and health outcomes?

Conceptual Framework
Health Systems Infrastructure/Hardware
Adapted from WHO six building blocks and RA Atun
et al, 2006
Levels of Analysis
Cross-country quantitative analysis
Identifying relationships
Country-level mixed methods analysis
Understanding relationships
Provider-unit level analysis
Understanding the impact
Mixed Methods Approach
  • Appropriate for complex systems and relationships
  • Either quantitative or qualitative methods alone
    are insufficient
  • Employs multi-disciplinary teams
  • Allows for triangulation with different types of

Cross-country quantitative study
Government health expenditure
Coverage of immunization
GHI investments
Coverage of skilled-attendance at delivery
Child mortality
Country-level mixed methods analysis
  • Case study library
  • Level 1 National level analysis of GHI-Health
    System Interaction
  • Level 2 Regional, district, and provider unit
    level analysis of systems design and local impact

Country Selection
  • Develop sampling matrix in consultation with
  • Geographical representation
  • GHI investment as a percentage of total health
  • High burden of GHI-targeted disease
  • Existing connections with partner institutions

GHI investment/Total health expenditure
  • Burundi
  • Rwanda
  • Zambia
  • Somalia
  • Liberia
  • Guyana
  • Uganda
  • Gambia
  • Ethiopia
  • Tanzania
  • Malawi
  • Haiti
  • Mozambique
  • Kenya
  • Swaziland

GFATM, PEPFAR, GAVI disbursements through 2005
HIV Prevalence
  • Swaziland
  • Botswana
  • Lesotho
  • Zimbabwe
  • Namibia
  • South Africa
  • Zambia
  • Mozambique
  • Malawi
  • Central African Republic
  • Gabon
  • Cote d'Ivoire
  • Uganda
  • Kenya
  • United Republic of Tanzania

WHO Statistical Information System (WHOSIS),
Accessed July 2008
TB Incidence
  • Swaziland
  • South Africa
  • Djibouti
  • Namibia
  • Lesotho
  • Zimbabwe
  • Timor-Leste
  • Zambia
  • Botswana
  • Sierra Leone
  • Cambodia
  • Mozambique
  • Cote d'Ivoire
  • Congo
  • Rwanda

WHO Statistical Information System (WHOSIS),
Accessed July 2008
Proposed countries
Proposed countries
Other Likely Candidates
  • Cameroon
  • Senegal
  • Ghana
  • Viet Nam
  • Philippines
  • India
  • China

Data Cross-country
  • Time series cross sectional data
  • GFATM, PEPFAR, GAVI disbursements
  • National Health Accounts
  • OECDs Credit Reporting System
  • DHS, MICS, administrative data, data from UN or

Data National and Regional
  • Document review
  • Semi-structured interviews with key informants
  • Collection and analysis of appropriate, available
    quantitative information
  • All data collected in cooperation with Ministries
    of Health

Data Provider Unit-Level
  • System Design Implementation Strategies
  • Available Services
  • Laboratory Services
  • Essential Medicines
  • Human Resources
  • Infrastructure
  • Targeted Outcomes (HIV, TB)
  • Coverage of non-targeted interventions

Expected Outcomes
  • Global cross-country analysis
  • Case study library of more than 10 countries
    detailed information on health system design,
    implementation strategy etc.
  • Provider unit-level analysis in select countries
  • Literature review
  • Identification of knowledge gaps for further
  • Improved methodology
  • Input for WHO policy recommendations

  • Late October Finalized methodology with partners
  • Early November Begin in-country data collection
  • November 17-19 Bamako Ministerial meeting
  • January March Continued data collection and
  • March April Preparation of results and reports

Academic Partners
  • April is tomorrow
  • Much very important work has already been done
  • Must be clear about the question we are trying to
  • We must look to unusual methods and unusual
  • This effort is just the beginning of a much
    larger effort lead to the development of a
    science of health care delivery?
  • This has to be a team effort with collaborations
    in all directions a community of practice

Selected References
  • Atun, RA, Turcan, L, Berdega, V et. al. (2005).
    Review of Experience of Family Medicine in Europe
    and Central Asia. (In five volumes) Volume V
    Moldova Case Study. World Bank Report No.
    32354-ECA. Human Development Sector Unit, Europe
    and Central Asia Region. Washington, DC The
    World Bank.
  • Atun RA, Menabde N, Saluvere K et al. Introducing
    a Complex Health Innovation Primary Health Care
    Reforms in Estonia (Mulitmethods Evaluation).
    Health Policy 79 (2006) 79-91.
  • Atun RA, Bennett S, Duran A. When do Vertical
    (Stand-Alone) Programmes Have a Place in Health
    Systems? Policy Brief, WHO European Ministerial
    Conference on Health Systems, 25-27 June, 2008,
    Tallinn, Estonia.
  • Banteyerga, H, Kidanu, A, Stillman, K. (2006).
    The Systemwide Effects of the Global Fund in
    Ethiopia Final Study Report. Bethesda, MD
    PHRplus. Abt Associates Inc.
  • Daniels N, Flores W, Pannrunoathai S (2005). An
    Evidence-Based Approach to Benchmarking the
    Fairness of Health Reform in Developing
    Countries. Bulletin of the World Health
    Organization. 83 534-40.
  • Frontiers Development and Research Group. Global
    HIV/AIDS Initiatives in Zambia Issues of Scale
    Up and Health Systems Capacity Interim District
    Report. (2008). Global HIV/AIDS Initiative
    Network. OSI.
  • GAVIAlliance. Accessed July 2, 2008 at

Selected References
  • Global HIV/AIDS Initiative Network (GHIN).
    (2006). A Generic Guide to Research Practice
    Following discussion at Lilongwe workshop of GHIN
    African teams.
  • Global HIV/AIDS Initiative Network (GHIN).
    (2006). GHIN African District Studies Detailed
    Research Questions and Methods.
  • Gbangbadthoré, S, Hounsa, A, Franco, LM. (2006).
    Systemwide Effects of the Global Fund in Benin
    Final Report. Bethesda, MD Health Systems 20/20.
    Abt Associates Inc.
  • Loevinsohn, B, Aylward, B, Steinglass, R et. al.
    (2002). Impact of Targeted Programs on Health
    Systems A Case Study of the Polio Eradication
    Initiative. American Journal of Public Health
  • Mtonya, B, Chizimbi, S. (2006). Systemwide
    Effects of the Global Fund in Malawi Final
    Report. Bethesda, MD PHRplus. Abt Associates
  • Murray CJL, Evans DB, eds. Health systems
    performance assessment debates, methods and
    empiricism. Geneva World Health Organization,
  • Semigina, T, Griga, I, Bogdan, D, Schevchenko, I,
    Bondar, V, Fuks, K, Spicer, N. (2008). Tracking
    Global HIV/AIDS Initiatives and their Impact on
    the Health System in Ukraine Interim Report.
    Global HIV/AIDS Initiative Network. OSI.

Selected References
  • WHO. Everybodys Business Strengthening Health
    Systems to Improve Health Outcomes. WHO, 2007.
  • WHO. The Global Fund Strategic Approach to Health
    Systems Strengthening. Report from WHO to the
    Global Fund Secretariat, September, 2007.
  • WHO. Maximizing Positive Synergies Between Health
    Systems and Global Health Initiatives. Report on
    the expert consultation, WHO, Geneva, 29-30 May
  • WHO. Opportunities for Global Health Initiatives
    in the Health System Action Agenda. WHO
    Department of Health Policy, Development and
    Services, Evidence and Information for Policy,