Turning the World Upside Down Health systems strengthening for the MDGs

1. Turning the World Upside Down Health systems strengthening for the MDGs Commonwealth Health Ministers’ Meeting 16th May 2010 Nigel Crisp Turning the World Upside Down The search for global health in the 21st century

2. Turning the World Upside Down • New approaches to health systems are being developed in middle and low income countries – as important as the introduction of ideas and practices from richer countries • There is a need for co-development and mutual learning – not just the one way traffic of international development • System strengthening without continuous improvement is a waste of money Turning the World Upside Down The search for global health in the 21st century

3. This presentation • Innovations in middle and low income countries • Systems and systems thinking • Systematic quality improvement as a means of strengthening systems and implementing policy • Recommendations for the Commonwealth Turning the World Upside Down The search for global health in the 21st century

4. Specific innovations • The development of treatments for HIV/AIDS • The management of conditions such as Clubfoot • Policy initiatives such as Conditional Cash Transfers • Product development by Aravind and others • Telemedicine development in many countries • The potential for innovation is now being identified by GE , McKinseys and others Turning the World Upside Down The search for global health in the 21st century

5. 3 2 14 15 8 High-volume, low-cost heart surgery hospital Low-cost eye-care solution Midwife led, low-cost maternal care Remote chronic disease care Valencia: Integrated HC 6 9 10 13 21 20 Mauritania complete low-cost obstetric care Weighing children to predict and prevent diseases Training for reproductive health clinics Innovative emergency response model 16 Veteran’s Health Administration Integrated care solution Mini clinics in retail stores 12 Remote advice and mobile care solution 1 Remote triage/referral 19 5 PDA: Social marketing (humorous) for reproductive health Real-time weighing and diagnosis 22 Co-operative medical system 4 11 Social marketing program of PSI Low-cost eye-care solution 18 17 Integrated primary care units 7 50 global locations: social marketing for killer diseases Franchise network of stores for deadly diseases Innovation in health care delivery is taking place around the world 5 SOURCE: McKinsey analysis

6. A different approach – and an evolving tradition • Social enterprises – using business methods to social goals – and building on the strengths of community, family and women • Public health linked to clinical medicine both in the training of workers and in their practice • Health services connected with education, and employment – and an emphasis on helping people to be independent • Training for the job and not just the profession Turning the World Upside Down The search for global health in the 21st century

7. Training for the job and not just for the profession • There is a well-documented staffing crisis affecting the poorest countries most of all • The training and deployment of community and mid level workers with increasing evidence about the criteria for success • The GHWA Task Force brought together what is known to work – much of this is simple common sense Turning the World Upside Down The search for global health in the 21st century

8. Scaling up the health workforce Turning the World Upside Down The search for global health in the 21st century

9. Co-development • Learning for high income countries where standard models of health and health systems are based around physicians, hospitals, technology and an exclusive professionalism – and where everyone is seeking efficiency and effectiveness • Recognition that these developing models may point the way to the future Turning the World Upside Down The search for global health in the 21st century

10. Systems and systems thinking • Widespread experience of disconnected, fragile and inefficient systems • The WHO 6 building blocks – service delivery, financing, governance, health workforce, information systems and supply management are a vital starting point • Additionally we need systems thinking – and an understanding of how systems work and can be improved Turning the World Upside Down The search for global health in the 21st century

11. Spread and improvement • Every action affects the whole system - and simply adding resources without improving the way a system operates is a waste of money • Systems can be re-designed and improved so that they work better without extra resources • There is increasing understanding and evidence of how, reliably, to improve systems and spread good practices Turning the World Upside Down The search for global health in the 21st century

12. Improvement in practice • Bringing relevant health workers together to address the problem • Understanding the problem and setting measurable goals for improvement • Using PDSA improvement cycles • Collaborative learning across sites • Reaching higher up the system to District and national level Turning the World Upside Down The search for global health in the 21st century

13. South Africa: W Cape Results Initiation of HIV population on HAART:SOURCE: Dr Pierre Barker, IHI .

14. Some implications • Engagement of the “front line” • Strengthening systems whilst achieving goals • All health workers need to have some understanding of improvement as part of their training – crucial as systems develop • This can provide a means of improving services with little cost – although more resources and particularly more health workers are needed to make the massive improvements necessary Turning the World Upside Down The search for global health in the 21st century

15. Recommendations • Create arrangements for sharing knowledge of successful system strengthening • Share experience and knowledge of training and deploying community and mid level workers and help identify appropriate mixes of health workers for different environments • Adopt methods of quality improvement as the prime implementation mechanism for systems strengthening Turning the World Upside Down The search for global health in the 21st century