• 1

    WHO, 1999. Meeting on the Impact of Targeted Programmes on Health Systems: A Case Study of Polio Eradication Initiative (WHO/V&B/00.29). Geneva: World Health Organization.

  • 2

    Lee JW, 2003. Global health improvement and WHO: shaping the future. Lancet 326 :2083–2088.

  • 3

    WHO, 2000. The World Health Report 2000, Health Systems: Improving Performance. Geneva: World Health Organization.

  • 4

    Murray CJL, Evans DB, 2003. Health Systems Performance Assessment: Debates, Methods and Empiricism. Geneva: World Health Organization.

  • 5

    Bennett S, Fairbank A, 2003. The System-Wide Effects of The Global Fund To Fight AIDS, Tuberculosis and Malaria: A Conceptual Framework. Technical Report No. 031. Bethesda, MD: The Partners for Health Reformplus Project, Abt Associates Inc.

  • 6

    Ngwira B, Barrett L, 2004. Report of a Meeting on Measuring the Impact of Lymphatic Filariasis Elimination Programme in National Health Systems and as Individual Quality of Life. Geneva: World Health Organization, www.filariasis.org.

 

 

 

 

 

2.8 HEALTH SYSTEMS

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Summary of Prioritized Research Needs

  1. Test the current LF/Health Systems assessment tool (matrix) in a variety of endemic countries to determine if the data necessary for each proposed indicator can be feasibly acquired,
  2. Identify which health system functions represent the best opportunity for assessing LF impact,
  3. Determine baselines for health systems performance in endemic countries at each level where the LF program is likely to have an impact,
  4. Identify ways to disaggregate the health systems effects of the LF program from those of other concurrent disease control programs.

2.8.1 Overview

Elimination/eradication programs and the health system.

Programs against several diseases currently targeted for global elimination or eradication (EE) are operating in many of the world’s least developed countries where health systems are extremely fragile. The primary goals of these EE programs are explicitly disease related and only secondarily, if at all, related to health system effects. Criticism increasingly directed at such programs is that they not only might not contribute to the strengthening of health systems or health services delivery but also might have unintended negative consequences. The experience of the Polio Eradication Initiative (PEI) is most often cited with proponents emphasizing the positive contributions of the PEI on health systems, particularly in building surveillance and laboratory capacity, while opponents emphasize the disruption in health services delivery that often accompanies national immunization days.1 Since implementing EE strategies to meet disease control targets requires health systems to devote considerable resources to the effort, health systems advocates have begun to argue for assessing EE programs not just on their ability to reduce the burden of a disease, but also based on their ability to strengthen health systems in the implementing countries. Despite the growing recognition that the implementation of EE programs can impact health systems, there is still much that is unknown about the interaction between vertically initiated, disease-specific control programs and health systems.

The GPELF recognizes that to achieve the goals of interrupting transmission of infection and alleviating and preventing suffering and disability caused by LF, health systems in endemic countries play a critical role. It is also clear that there must be a convergence between the GPELF and global efforts to assess health systems performance; indeed, WHO has recently stressed the urgency of strengthening health systems as a sine qua non in accomplishing the millennium development goals as well as the ambitious 3 × 5 HIV/AIDS treatment target.2

Measuring the performance of health systems.

The World Health Report 20003 defined the boundaries, functions, and goals of health systems, but there is still controversy over the methods used to measure and assess health systems performance. Murray and Evans4 provide a set of potential indicators to measure health system performance, but measuring health system performance is not yet standardized. Assessing the impact of a single program/intervention on a health system or on a health system’s performance has not yet been achieved. The Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) is currently engaged in an effort to monitor and evaluate the system-wide effects of its activities.5

Acknowledging the synergistic relationship between health systems and the implementation of disease elimination and eradication programs, the GPELF has begun to develop a tool and methodology that can be used to assess the health system-wide effects that LF program implementation has in participating endemic countries.6 The data derived from such a tool will chart the impact that program implementation is having on the overall health system, allowing program managers to make adjustments if a negative impact occurs, or to share positive results with other countries.

2.8.2 Research Needs

Testing and improving current tools: The LF/health systems matrix.

The current LF effort to assess the GPELF’s impact on health systems is structured on the conceptualization of health systems in the World Health Report 2000, which defines four functions of health systems: stewardship, financing, resource development, and service delivery. Indicators addressing each of these four functions have been drafted but not yet tested in the field. Therefore, investigative efforts are necessary

  • to test the current tool to assess the LF/Health Systems interaction matrix in a variety of endemic countries to determine if the data necessary for each proposed indicator are reasonably available and accessible,
  • to assess the sensitivity and specificity of each indicator with respect to the four functions of the health system,
  • to identify key data gaps from the current matrix (tool) requiring further study.

Examining health system functions for their responsiveness to interventions.

Within the timeframe of LF programs, particularly the MDA, it is not clear which of the four health systems functions are likely to be most pliable/responsive to LF activities. For example, is it more realistic to expect that LF programs will strengthen the service delivery function of the health system, or the resource development function? Short run changes in health systems may be more amenable to LF interventions and more demonstrable by conventional monitoring techniques, but longer run effects cannot be ignored. Disaggregating the effects of LF programs from those of other disease control programs/strategies on health systems is likely to present a key methodological challenge. Therefore, research is needed

  • to identify which of the health systems functions—stewardship, financing, resource development and service delivery—represent(s) the best opportunity for the LF program to show impact,
  • to document the timing dimensions of health system effects due to the LF program,
  • to disaggregate the health systems effects of the LF program in a dynamic environment where other disease control programs are also affecting the health system,
  • to assess which changes in health systems over time will have the most effect on LF program goals.

Identifying usable indicators.

It is essential to identify indicators that can accurately and effectively demonstrate health system impacts, both positive and negative, of specific-disease, targeted programs. An essential aspect of indicator development includes determining reasonable targets for improvement (including ranges for measurement). Ordinarily, setting reasonable targets for indicators is guided by results from previous studies or programs. Since this is one of the first efforts of its kind, however, reasonable targets for health system improvement in a given district, region or nation, are unknown. Therefore, there are critical research needs

  • to determine baselines for health systems performance in LF endemic countries; such baselines being necessary for each level of the health system in a given country, but with emphasis on the levels at which the LF program might be expected to have the greatest impact,
  • to determine the most appropriate time interval for measuring indicators during program implementation to demonstrate effects of the LF program on health systems (e.g., annually, pre- and post-MDA?),
  • to identify the ways in which the GPELF can take advantage of lessons learned from similar efforts by the GFATM and WHO to assess and monitor health systems effects of various programs.

Identifying the locus of control for health system changes.

When considering the impact of a program on health status, the program manager has ability/authority to modify a program so that the intended results can be realized. When considering health system impact, however, the program manager alone may not be in the position to alleviate any negative impact to health systems. Therefore, research is needed

  • to define the most effective ways of collaborating with policy and decision makers so that any impact of the GPELF can be amplified (if positive) or mitigated (if negative), if the appropriate response to health system impact findings is beyond the control of an individual program manager.

**

Other participants in the workshop of LF and Health Systems are listed in Annex 3b.

2.8.3 References

  • 1

    WHO, 1999. Meeting on the Impact of Targeted Programmes on Health Systems: A Case Study of Polio Eradication Initiative (WHO/V&B/00.29). Geneva: World Health Organization.

  • 2

    Lee JW, 2003. Global health improvement and WHO: shaping the future. Lancet 326 :2083–2088.

  • 3

    WHO, 2000. The World Health Report 2000, Health Systems: Improving Performance. Geneva: World Health Organization.

  • 4

    Murray CJL, Evans DB, 2003. Health Systems Performance Assessment: Debates, Methods and Empiricism. Geneva: World Health Organization.

  • 5

    Bennett S, Fairbank A, 2003. The System-Wide Effects of The Global Fund To Fight AIDS, Tuberculosis and Malaria: A Conceptual Framework. Technical Report No. 031. Bethesda, MD: The Partners for Health Reformplus Project, Abt Associates Inc.

  • 6

    Ngwira B, Barrett L, 2004. Report of a Meeting on Measuring the Impact of Lymphatic Filariasis Elimination Programme in National Health Systems and as Individual Quality of Life. Geneva: World Health Organization, www.filariasis.org.

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