Health service provision and Information Systems

Main objective: Understand the domain in which we work Two parts:

• and the debate on how to provide it – Some history of WHO and so-called «» – Comprehensive vs selective PHC – Implications on information systems

• The Health District – Why is the software called DHIS? – District as the area of managing primary health care Part one: Primary health care and the debate on how to provide it • Main learning points

– WHO (founded 1948) early focused on eradicating certain diseases – The Alma Ata declaration from 1978 changed the focus towards general health, taking into account social and economic issues also – Decentralized Primary Health Care was seen as the core of government health provision, a change away from curative hospital-based care – How to implement it remains a debate: an integrated comprehensive (and complex) way, or a selective (simpler) way? – A selective approach has become dominant, and it has led to a fragmentation of efforts – Fragmentation remains a challenge for health provision, and for information systems WHO’s history of relative success with focused programmes • Smallpox eradicated in 1977 • Eliminating polio in the Americas in 1985 • Eliminating measles in Southern Africa • Reducing guinea worm disease by 99% in 20 African countries between 1986 and 2005

• Relative successful compared to other UN agencies (such as World Bank). • Each disease eradication program operated autonomously, with its own administration and budget and very little integration into the larger

4 Health systems continued to be inefficient

• Short-term successes were not addressing poor populations' overall disease burden • Health systems were urban based, high- technology, curative oriented.

• Gave little contact with the population for preventive care • Health is socioeconomic: – Health services, economy, security, education, nutrition…

More comprehensive approaches emerged in a number of developing countries

5 The Alma Ata declaration (1978) and Primary Health Care (PHC) “Primary Health Care is 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 full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination”

6 Primary Health Care

• Promotive + preventive + curative • Involves related sectors (education, food, agriculture etc), and wider aims (equity, affordability etc) • Promotes community and individual involvement and committment • Came as a reaction to older, high-tech, curative approaches. Based on bottom-up experiences from ”developing world” • How to implement it? Comprehensive vs selective? Overarching question ever since.

7 Comprehensive PHC

• Original vision of PHC is a comprehensive, intersectoral approach to all aspects of health • Cuba a good example where it has been tested, and worked. Also Mozambique and Nicaragua in the 1980s • Abandoned as a WHO strategy already a year after it’s formulation in 1978 • “Some argue that comprehensive primary health care was an experiment that failed; others contend that it was never truly tested.” – Magnussen, Ehiri, Jolly 2004

• Why?

8 Selective PHC

• Launched just one year after Alma Ata, as an ”interim” strategy to achieve results • Abandoned the social and economic side of the health strategy, and systems thinking in general. This is reflected in the information systems • Narrow selection of specific conditions, mostly for women of child bearing age, and children – Immunization, growth monitoring, breastfeeding, oral rehydration therapy – Family planning, female education, food supplementation added later

• Why? – PHC is complex. Costly – Global politics

9 Neoliberalism and structural adjustment

• Increasingly «popular» from the 80s onwards: – Stronger roles of markets to provide efficiency, also in healthcare

• When an instrument of the global development agencies (World Bank, IMF, etc); developing countries also needed restructuring. • «Cost-effectiveness only reason to let government do things» • Favoured selective approach (more easily positive cost- benefit analysis) • Comprehensive approach is costly, benefits hard to measure (accurately) Comprehensive vs. selective now?

• Strong historical legacy of selective approaches • WHO is still very fragmented in specific programs, which are replicated at country level • https://www.who.int/entity/en/

• Cross-cutting units have been created (and died); Health Metrics Network • In other areas, new agencies have been created to target specific areas: Global Fund, UNAIDS, GAVI Alliance

• Increased awareness of interconnectedness: One Health • New names: Universal Health Coverage

11 Sustainable Development Goals can be seen as more comprehensive More recently, One Health drives a more comprehensive agenda Comprehensive vs. selective: information systems

• Comprehensive: integration, comprehensive information needs, varied outputs • Selective: Silos, fragmentation, inefficient development and utilization of infrastructure. Closed-boundary ICT systems. Potential for cross-comparison of indicators is lower.

• Both: provision of health services decentralized. IS needs to allow local levels to collect, process, and use information

14 HMN Framework: An example of comprehensive approach to HIS

15 How this relates to our course

• Comprehensive aims embedded in DHIS2 software • Selective approach still embedded in existing information systems in countries • Changing landscape of global health: «One Health», Sustainable development goals, Universal Health Coverage

• Certain information system architectures can ease the tensions between these approaches • Integration and interoperability strategies to share data in both comprehensive and selective systems Comprehensive vs selective: What about Covid?

• From an information systems view, what are our choices? The Health District or Searching for efficient management of primary health care The opening slide from March 10 2020

What information is needed? Who needs it? When, how?

How do we address this?

What are the challenges? Short term? Long term? Part two: The Health District

• Main learning points – We talk about health management information systems; assisting in managing health services is the goal – The «District» as a concept of appropriate first level of management – There is no ideal district; it is a balance of resources, aims, organization etc. They exist in most countries under names like district, county, kommune, etc District: Bridge between primary, secondary, (tertiary care) Primary care: most health care, first point of consultation for all patients

Secondary care: provided by medical specialists who in general do not have first contact with patients. Referrals; for example to radiology (x-ray)

Tertiary care: specialized health care for inpatients in hospitals (not in districts) What are the characteristics of a health district ?

Clearly delineated geographical area

Population between 30,000 and 500,000 (most cases)

Identifiable form of local government

Managed by few officers

Balance between population size and availablity of technical specialised staff What advantages presents the health district ? It is close enough to the community, “the patient”, to understand and act on its problems and constraints

It is the most suitable place to provide support to health workers in the health posts and health centres It has easier communication with the community to ensure its participation in planning and organization It presents large potential for effective collaboration with other sectors towards the health of the community (school health) It is the most appropriate level for coordinating top-down and bottom-up planning It has the ability to handle decentralisation of resources and of decision-making Why size matters ? Finding the right balance

Too small Too large Unnecessary management structures and systems Irresponsive and bureaucratic

Cohesion and co-ordination more difficult at a national or Loses “service delivery" functions provincial level Costly and fail to leverage economies of scale Too remote from community involvement

Too few qualified experts to recruit from Relevance to local contexts lost, can lead to poorer quality

Dislocation between primary level services and district hospital Population size is too large services (many health districts with no district hospital)

District hospitals managed as separate entities from the rest of Geography size is to large primary level health care Health District functions

Health Centre . Curative care of acute and chronically sick patients (ideally up to 85% of all cases), antenatal care, family planning, infant care including vaccinations and development checks . Community development (disease prevention, medical back-up for traditional birth attendants, village health workers, social workers) District Hospital . Treatment of patients and management of emergencies, surgery, technically complex diagnostics (radiology, ultrasound, laboratory), training . Supervision of health centers

District Health Management Team . Planning and management (finance), personnel assignment and training . Management of physical resources including procurement of drugs, medical supplies and equipment, responsibility for drug supply . Coordination of operational research, monitoring and evaluation . Inter-sectoral cooperation Example: Norway

• Districts = Kommuner • Currently 356 kommuner

• Recent reform to reduce number of kommuner, and fylker (regions): the debates were about what makes services good? Larger units = more specialization, smaller units = more locally relevant, closer to people • From 2002 hospitals and specialist hospitals directly under the State, organized in 5 "health regions" Lov om kommunale helse- og omsorgstjenester

Comprehensive or selective PHC?

How large should a kommune be to offer these services? Kommunereformen/ District reform - analysis for Norwegian Directorate of Health 2015

• One of the goals of the reform is to give good and more equal (health) services • Greater districts: – Strengthen services due to larger pool of specialists – Change in way inter-sectoral health work is done. Trust can decrease • Utsira: 198 inhabitants • Oslo: 693 494 inhabitants What is the role of HMIS in the health district?

With what? Where? When? Who gets sick? Why?

District Health Information Software

What health For whom? When? services exist? Where?

Werner, D. (1979). Where there is no doctor: a village health care handbook.