1. Health Systems Development
and Strengthening
Dr Nilar Tin

2. What is a Health System?
What are the Goals?
What are the functions?

3. What is a Health System?
A health system
consists of all
organizations, people and actions
whose
primary intent is to
promote, restore or
maintain health

4. Health Systems are thus defined as comprising
• All Organizations & Institutions
• People (health professionals both public/private)
• Supplies
• Information that are devoted to producing
– Health Actions- whether personal health care or public
health care or through intersectoral initiatives, primary
purpose is to improve health- good health
– World Health Report 2000 devoted entirely to Health
Systems
– WHO expands its traditional concern for people’s
physical and mental well being to emphasize two other
elements of good health; goodness and fairness
Goodness: HS responding well to what people expect of
it
Fairness : HS responds equally well to everyone without
discrimination

5. Looking back to history: How Health Systems have evolved?
• Health systems of some sort have existed for as long as
people have tried to protect their health and treat disease
(Traditional practices, spiritual healers, herbal– modern
medicine)
Looking back a century – organized HS barely existed
• What the people at that time would suffer from? LE at birth
• What kinds of health care were provided?
Evolution
• Founding of national health care systems
• Extension of social health insurance schemes
• Promotion of PHC approach--the goal of HFA

6. PHC is an approach to health development
“ essential health care based on practical, scientifically
sound and socially acceptable methods and technology
made universally accessible to individuals, and families in
the community through their participation and at a cost
that the community and country can afford to maintain at
every stage of their development in the spirit of self
reliance and self determination.
It forms an integral part of both the country’s health
system, of which it is the central function and main focus,
and the overall social and economic development of the
community.
It is the first level of contact of individuals, the family, and
the community with the national health system bringing
health care as close as possible to where people live and
work and constitutes the first element of a continuing
health care process”

7. 1970s--1980s PHC actual application & Experiences
1.
A package or a set of activities:
8 ELEMENTS of PHC; preventive and promotive more;
emphasis more on public health rather than medical care
2.
Level of care: Primary, Secondary and Tertiary levels of
care. PHC goes further down to community-based care
3.
An approach, which has been termed variously as the
PHC principle
-universal coverage (equity in health across all SE
groups)
-intersectoral collaboration (risk factors & Social
determinants affecting health)
-community participation (empowerment)
-appropriate technology (not only resource-constrained
countries but apply to all)

8. 1980s Changes in economy: Oil crisis in
middle east
•
•
•
•
•
SAPs- Structural Adjustment Policies
Health Sector Reforms especially affecting
African countries
Players WB & IMF
WB’s mandate: Promote sustainable economic
growth & contribute to poverty alleviation
Three pillars of WB’s poverty alleviation strategy
–
–
–
Sustained economic growth
Productive use of labour
Access to social service for the poor
WB lends money to poor countries: Loans were
there, but poor countries become poorer and
rich countries become richer

9. At the same time with economic changes Health Systems
was being challenged with
Demographic changes

Transitions where fertility and growth rate declined

Infant mortality has decreased and LE increased
---leading to increase in <15 years and elderly
population

Process of rapid urbanization
Epidemiologic changes

Migration and urban growth---led to resurgence of
diseases that were once considered controlled such as
cholera outbreaks + accidents, injuries, crime

AIDS pandemic

Still infectious diseases were giving problems

10. Health Sector Reforms:
–
–
–
User financing (Rational drug use by donors- Bamoko
Initiatives in 1987 in African countries)
Selective Primary Health Care (GOBI for child
survival) making priorities of elements of PHC
Privatization (promoting hospital setting and
sophisticated health measures)
What were the results……..
–
–
–
In Kenya introduction of user fee at STD clinic caused
reduction in attendance & increased no: of untreated
STDs in the population
SAPs contributed to rapid spread of AIDS in Africa
Many of 3 million deaths from TB in China during the
1980s might have been prevented if user fee was not
introduced

11. Socio-cultural transitions



Increased
levels
of
education,
improved
communications---shrunk distances between countries
Changes in life styles, nutritional, traditional, social
and family structures, values and even expectations
Led to ---social problems, adolescents problems,
mental
health
problems--NCDs
+
CDs--double
burden--increased demand of health care systems.
Political changes


Political orientation and ideologies in many countries
changed
Changes in policies, management and services in all
sectors.

12. Impact of all these Trainsitions / Health Systems
Challenges

Impact of ageing population with need of provision of
chronic care/ social security

Threats of AI, H1N1-affecting more on poor countries
and HR issues

Competition for resources between hospitals and
between public and private sector

High tech in diagnosis and life long treatment could not
protect people from catastrophic spending

Universal coverage, tax based funding, Social Health
Insurance, Microcredit-- financing schemes need major
demand on managerial capacity

Migration of health workforce had made the sender
country to suffer more
PHC,

13. Impact of all these Trainsitions/HS Challenges
•
Where providers depend largely on out-of-pocket
payments for their income, there is over-provision of
services for people who can afford to pay, and lack of
care for those who cannot pay.
•
•
OPPORTUNITIES
The global health landscape has been transformed in the
last ten years with the emergence of multiple, billiondollar global health partnerships such as the Global
Fund and the GAVI Alliance.
•
WHO- Health Metrics Network, Global Health Workforce
Alliance, Commission for Social Determinants of Health,

14. Health system challenges: a few facts and figures
•
Globally, health is a US$3.5 trillion industry, or equal
to 8% of the world's GDP.
•
Large health inequalities persist: even within rich
countries such as USA and Australia, life
expectancy still varies across the population by over
20 years.
•
Recent essential medicines surveys in 39 mainly
low- and low-middle-income countries found that,
while there was wide variation, average availability
was 20% in the public sector, and 56% in the private
sector.

15. Health system challenges: a few facts and figures
•
Each year, 100 million people are impoverished as a result of
health spending.
•
Extreme shortages of health workers exist in 57 countries; 36
of these are in Africa.
•
In over 60 countries, less than a quarter of deaths are
recorded by vital registration systems.
•
An estimated 50% of medical equipment in developing
countries is not used, either because of a lack of spare parts
or maintenance, or because health workers do not know how
to use it.

16. Health system challenges: a few facts and figures
•
Private providers are used by poor as well as rich people.
For example, in Bangladesh, around ¾ of health service
contacts are with non-public providers.
•
In 2000, less than 1% of publications on Medline were on
health services and systems research.
•
Globally, about 20% of all health aid goes to support
governments' overall programmes (i.e. is given as general
budget or sector support), while an estimated 50% of health
aid is off budget.
•
There has been a rapid increase in global health
partnerships. More than 80 now exist, of which WHO houses
over 30.

17. Discussions for today
In Two Groups (30 minutes)
• Myanmar in the context of Health
Systems Development…
• What are the Health Systems
Challenges?
• What are the opportunities????
• Where are we now ?????

18. Health system functions and goals
Goals
Good health outcomes
Responsiveness
Fairness in financing
Functions
Service delivery
Resource generation: HWF, supplies, information
Financing
Governance and stewardship

20. The six building blocks of a health system
1.Good health services are those which deliver..
• effective,
• safe,
• quality
• personal and non-personal health interventions
to those that need them;
when and where needed;
with minimum waste of resources.
2. A well-performing health workforce is one that works in
ways that are..
responsive,
fair and
efficient to achieve the best health outcomes possible,
given available resources and circumstances (i.e. there are
sufficient staff, fairly distributed; they are competent,
responsive and productive).

21. The six building blocks of a health system
3. A well-functioning health information system is one that
ensures..
• the production,
• analysis,
• dissemination and
• use of reliable and timely information on health
determinants, health system performance and health status.
•4. A well-functioning health system ensures equitable access
to..
• essential medical products,
• vaccines and
• technologies of
• assured quality, safety, efficacy and cost-effectiveness,
and their scientifically sound and cost-effective use.

22. The six building blocks of a health system
5. A good health financing system raises adequate funds for
health, in ways that ensure
• people can use needed services,
• and are protected from financial catastrophe or
impoverishment associated with having to pay for them.
• It provides incentives for providers and users to be
efficient.
6. Leadership and governance involves ensuring
• strategic policy frameworks exist
• and are combined with effective oversight,
• coalition building,
• regulation,
• attention to system-design and accountability.

23. What is Health System
Strengthening?

24. Defining Health Systems Strengthening
At its broadest, health system
strengthening (HSS) can be defined as an
array of initiatives and strategies that
improves one or more of the functions of
the health system and
that leads to better health through
improvement in access, coverage, quality,
or efficiency.
(Health system Action Network)

25. Health System Strengthening
• Stewardship / governance / leadership : defining
sector strategies, clarifying roles, managing competing
demands
• Health financing : ensuring fair and sustainable
financing, including financial protection
• Human resources : having a sufficient and
productive workforce
• Information and knowledge : ensuring the
generation and use of information
• Technology and infrastructure : ensuring adequate
drugs, equipment, infrastructure
• Service delivery : improving organization,
management, and quality of services

26. Health Service Delivery
Integrated service delivery packages
WHO will continue to produce and disseminate costeffectiveness data for prevention and treatment, and define
service standards and measurement strategies for tracking
trends and inequities in service availability, coverage and
quality.
It will help define integrated packages of services, and the
roles of primary and other levels of care in delivering the
agreed packages, as part of its health policy development
support.

27. Health Service Delivery
Service delivery models
WHO will consider the whole network of public and private
providers in order to enhance equitable access, quality and
safety.
It will synthesize and share experience of the costs, benefits
and conditions for success of strategies to improve service
delivery. These may include
-community health workers,
-task shifting, outreach, contracting,
-accreditation,
-social marketing,
-uses of new technologies such as telemedicine,
-hospital service organization and management,
-delegation to local health authorities,
-other forms of decentralization, etc.

28. Health Service Delivery
Leadership and Management
WHO will support Member States to improve management of
health services, resources and partners by health authorities,
as a means to expand coverage and quality.
This will be done through:
-promoting tools for analyzing barriers to care, and
management weaknesses;
-generating and sharing knowledge on strategies to
improve management, often in the context of
decentralization;
-developing local resource institutions’ capacity to
support local health managers; and
-developing methods to monitor progress.

29. Health Workforce
International norms, standards and databases
WHO will maintain and strengthen the Global Atlas on the
health workforce.
It will facilitate the generation and exchange of information on
health workforce availability, distribution and performance by
supporting regional workforce observatories.
Realistic strategies
WHO will increase its support for realistic national health
workforce strategies and plans for workforce development.
These will consider the range, skill-mix and gender balance of
health workers (health service providers and management
and support workers) needed to deliver the agreed package
of services across priority programmes.
They will address workforce education, recruitment, retention
and performance and define regulatory options

30. Health Workforce
Costing
WHO will generate knowledge about the financial costs of
scaling-up and then maintaining the expanded health
workforce, as well as ways to address financial sustainability,
and use this in dialogue with international financing institutions.
Training
WHO will support the redesign of training programmes to
produce the spectrum of health workers (service providers
and management and support workers) to deliver health
services.
It will explore and document ways to maximize the use of
priority programme training initiatives, and mechanisms such
as accreditation to assure quality of training programs.

31. Information
National information systems
Support improved population and facility-based information
systems, so that they can generate, analyse and use reliable
information from multiple data sources, in collaboration
with partners (e.g. UN, other agencies, the Health Metrics
Network partnership, the Institute of Health Metrics and
Evaluation).
Stronger national surveillance and response capacity
Public health systems that are equipped with up-to-date
technologies and dedicated personnel and are able to detect,
investigate, communicate and contain threats to public health
security, and be part of an unbroken international line of
defence against such threats.

32. Information
Tracking performance
Establish a set of core and additional health system metrics to
track health system performance for use by countries and
external agencies financing investments in health systems.
Standards, methods and tools
These include the International Classification of Diseases,
Global Burden of Disease updates, MDG monitoring tools;
development and measurement of Health System Metrics;
and standards for electronic medical records.
A key role will be played by expert groups, including
the Advisory Committee for Health Monitoring and Statistics.

33. Medical Products, VACCINES AND TECHNOLOGIES
Establish norms, standards and policy options
Set, validate, monitor, promote and support implementation of
international norms and standards to promote the quality of
medical products, vaccines and technologies, and
ethical, evidence-based policy options and advocacy.
Procurement
Encourage reliable procurement to combat counterfeit and
substandard medical products, vaccines and technologies,
and to promote good governance and transparency in
procurement and medicine pricing.

34. Sustainable Finanacing & Social Protection
Health financing policy option
Assess and disseminate information about what works and
what does not work in health financing strategies;
Facilitating the sharing of country experience in various types
of health financing reforms;
Sharing of key information required by country policy makers;
and the development of tools, norms and standards including
those required to assist countries to generate and use
information in their own settings.
Improve or develop pre-payment, risk pooling
and other mechanisms to reduce the extent of financial
catastrophe and impoverishment due to out-of-pocket
payments, and to extend financial and social protection.

35. Leadership and Governance
Develop health sector policies and frameworks
that fit with broader national development policies and resource
frameworks, and are underpinned by commitments to human
rights, equity and gender equality.
Generate and interpret intelligence and research on policy
options .
At the international level, it will facilitate access to knowledge
on approaches to policy and systems development:
-by promoting a more systematic health systems
research agenda; through the Alliance on Health Policy
and Systems Research;
-by building capacity in regional observatories or their
equivalent; and
-by increasing access to and use of new knowledge
management technologies.

36. Have the health system goals
been achieved?
SEAR countries

37. Infant Mortality Rate
200
180
160
Infant deaths ( per 1000 live births)
140
1990
120
2005
100
88
HFA 2000 target of
IMR < 50
80
61
60
51
50
35
40
22
20
0
61
60
22
14
12
DPR Korea
Sri Lanka
Thailand
Maldives
Indonesia
Reference year of data for 2005 vary from 2000 to 2005
Source : Country reports on MDG
Bhutan
India
Bangladesh
Myanmar
Nepal
Timor-Leste

38. Under-5 Mortality Rate
(Reduce by two-thirds b/w 1990-2015) (UN MDG Goal-G4, T5,
Deaths of under five years old children ( per 1000 live births)
200
180
160
1990
140
2005
2015 Target
HFA 2000 target of
U5MR < 70
120
100
80
60
40
20
0
Nepal
Bangladesh
Myanmar
India
Indonesia
Bhutan
Maldives
Baseline data for 1990 for Timor-Leste is an estimate and 2015 is target set as MDG
Reference year of data for 2005 vary from 2000 to 2005
Source : Country reports on MDG
Thailand
DPR Korea
Sri Lanka
Timor-Leste

39. Deaths of childeren under-5 years of age (per 1000 live births)
Trends in under-five m ortality in the SEA Region, by
country, 1975 - 1999
250
Bhutan
Bangladesh
200
Nepal
India
150
Myanmar
Indonesia
Maldiv
es
SEAR
W ORLD
100
HFA 2000
tar ge t of
U5M R < 70
Thailand
DPR Korea
50
Indonesia
Sri Lanka
0
1975-79
1980-84
1985-89
1990-94
Ye ar
Source:
W HO Genev
a, Bulletin of the W orld Health Organization, 2000, 78:1175-1191
1995-99

40. 100
Proportion of 1 year-old children immunized for measles
births attended by skilled health personnel
1990
90
80
Percentage
60
2003
72
67
56
94
88
97
99.7
95
85
80
77
75
70
99
80
75
69
71
65
57
Nepal
Indonesia Bangladesh
60
57.5
50
40
30
20
10
0
India
Source : Country reports on MDG
Bhutan
Myanmar
Sri Lanka
Thailand
Maldives
DPR Korea Timor-Leste

41. How have health system been performing in SEAR?
• Fairness in Financing
Com posi t i on of t ot a l h ea l t h spen di n g
i n SEA R
27%
3%
4%
66%
OOPs
soc ia l in su r a n c e
pr iv a t e in su r a n c e
tax

42. Why have they failed to achieve
the goals?

43. What does this mean?
Health Systems of SEA regional countries
have failed to achieve the health system
goals in relation to maternal and child
health services,
- in terms of disease burden,
- fairness in financing and
- responsiveness

44. Why have they failed?
• Political commitment even at the highest
level MDGs
• Lots of development work has taken place
Many donor agencies have come forward
• Lots of funds are available and being used
• However health outcomes did not improve
as expected
WHY?

45. What are the health systems factors
that affect MCH service delivery
•
•
•
•
Health workforce
Organization and management of services
Governance stewardship
Essential drugs and medicine, logistics,
infrastructure
• Health information
• Health Financing

46. System wide barrier study 2004
• Identified key barriers / bottlenecks to increasing
sustained coverage which were beyond the control
of the immunization system:
– human resource numbers and motivation
– transport to reach the hard to reach (especially for
outreach)
– Fund flow issues especially to district level
– Peripheral level management, logistics and monitoring
– Coordination with and between partners

47. Does Health workforce shortages affect
health outcomes?

48. Health workers save lives … but
we need enough of them
High
Probability of survival
Maternal Survival
Child Survival
Infant Survival
Low
Low
Proportion of health workers per population
High
Source: WHO (2006). The World Health Report 2006 – Working Together for Health. Geneva, World Health Organization

49. Proportion of births attended by skilled health personnel
100
90
1990
80
86
2005
85
99
85
68
68
70
Percentage
97
95
60
51
48
50
42
40
36
32
30
20
20
10
24
22
14
24
15
7
0
Nepal
Bangladesh
Bhutan
Timor-Leste
India
Reference year of data for 2005 vary from 2000 to 2005
Source : Country reports on MDG
Myanmar
Indonesia
Maldives
Thailand
Sri Lanka DPR Korea

50. Relationship between Coverage of deliveries by skilled birth attendants and Maternal Mortality, 2005
(Countries with higher level of coverage of deliveries by skilled birth attendants tend to have
lower maternal mortality )*
Thailand
98
DPR Korea
98
Sri Lanka
97
Maldives
14
97
47
87
72
Indonesia
72
Myanmar
68
India
307
380
54
301
Timor-Leste
32
Bhutan
32
Bangladesh
30
Nepal
20
Deliveries attended by
skilled health personnel (%)
660
225
380
281
MMR (maternal deaths per 100,000 live births)
* Not a univariate relation as there are other determinants of it
Notes : Reference year of data vary from 200 to 2005
Source : :Country reports on MDG

51. Is there a critical level of health
workers needed to achieve
essential health interventions?
• To have 80% coverage in skilled births and
measles vaccination there should be a minimum
threshold of 2.5 (Docs + Nur + Midwives) / 1000
population - JLI
• To have 80% coverage in skilled births there
should be a minimum threshold of 2.28 (Docs+
Nur + Midwives) / 1000 population - WHO

52. Where are we in relation to
this population norm?
Number of (Doctors + Nurses + Midwives) per 1,000 population
8.000
7.000
6.000
5.000
4.000
3.000
Threshhold 2.28
2.000
1.000
0.000
BAN
BHU
DPRK
IND
INO
MAV
MMR
NEP
SRL
THA
TLS

53. How to move forward?

54. 1.
Identify key barriers / bottlenecks to increase
sustained coverage which are beyond the
control of the immunization system
HRH shortages, distribution, quality, motivation etc.
transport to reach the ‘hard to reach’ (especially for outreach)
affordability and fund flow issues especially to district level
infrastructure at periphery, logistics
management monitoring & supervision
coordination with and between partners
2. Identify what caused lead to these problems
problem analysis
3. Identify how to overcome them
formulate your objectives
identify interventions

55. At what level are the performance
constraints & bottlenecks?
SYSTEM LEVEL
Policy & sector
analysis: NHSS,
PRSP, MDGS
PROGRAM LEVEL
Strategy analysis:
RED, MPA, demand
vs. supply driven
OPERATIONAL
LEVEL
Needs analysis
HR: skills, skills mix,
retention
Capital: stores,
equipment, vehicles

56. Goals and Objectives
Goals
SMART Objectives
Expected outcome, outputs
Activities
Resources / Budget
Monitoring and Evaluation

57. Strengthening interventions
ISS
ISS
ISS
Drug
Supply &
Quality
Logistics
Service delivery
Surveillance
ISS
Advocacy &
Communication
ISS

58. Strengthening Systems
MoF, World
Bank,
HIPC
Gov’T,
UNDP,
MoP
HSS
Drug Supply &
Quality
Logistics
HSS
Service delivery
Surveillance
HSS
UNICEF
PRSP
Advocacy &
Communication
SWAp

59. Policy space
ACCESS
EQUITY
Drug Supply &
Quality
Logistics
Service delivery
Surveillance
STEWARDSHIP
Advocacy &
Communication
PRO-POOR

60. Thank you