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Lesotho's National Primary Health Care Reform Achieving Universal Primary Health Care Through Health Systems Strengthening: Lesotho’s National Primary Health Care Reform The Harvard community has made this article openly available. Please share how this access benefits you. Your story matters Citation Seidman, Gabriel. 2017. Achieving Universal Primary Health Care Through Health Systems Strengthening: Lesotho’s National Primary Health Care Reform. Doctoral dissertation, Harvard T.H. Chan School of Public Health. Citable link http://nrs.harvard.edu/urn-3:HUL.InstRepos:42066832 Terms of Use This article was downloaded from Harvard University’s DASH repository, and is made available under the terms and conditions applicable to Other Posted Material, as set forth at http:// nrs.harvard.edu/urn-3:HUL.InstRepos:dash.current.terms-of- use#LAA ACHIEVING UNIVERSAL PRIMARY HEALTH CARE THROUGH HEALTH SYSTEMS STRENGTHENING: LESOTHO’S NATIONAL PRIMARY HEALTH CARE REFORM GABRIEL SEIDMAN A DELTA Doctoral Thesis Submitted to the Faculty of The Harvard T. H. Chan School of Public Health in Partial Fulfillment of the Requirement for the Degree of Doctor of Public Health Harvard University Boston, Massachusetts. May, 2017 Doctoral Thesis Advisor: Dr. Rifat Atun Gabriel Seidman Achieving Universal Primary Health Care through Health Systems Strengthening: Lesotho’s National Primary Health Care Reform Abstract This doctoral thesis examines how different aspects of health systems strengthening (HSS), such as human resources, supply chain, service delivery, and governance, can contribute to achieving universal health coverage (UHC). The doctoral thesis contains two key sections: the Analytical Platform, which examines key aspects of the existing literature on this topic, and the Results Summary, which presents a case study from Lesotho. The Analytical Platform consists of one narrative chapter focused on the role that values can play in setting health system priorities, and two systematic reviews which examine whether different HSS interventions - namely 1) task shifting and 2) improvements to health product procurement and supply chain - can improve health system efficiency in low- and middle-income countries (LMICs). The first review finds that substantial evidence exists for task shifting as a means to generate cost savings for care related to tuberculosis, HIV/AIDS, and various other diseases at the primary health care (PHC) and community levels. The second review finds that substantial evidence exists for pooled procurement as a means to achieve cost savings, and that a wide range of supply chain interventions can increase drug availability in different contexts. The Results Summary synthesizes Lesotho’s experience with a National PHC Reform, which sought to strengthen health systems to create universal access to comprehensive PHC and which can in turn serve as the foundation for broader UHC in the country. The Reform consisted of interventions at multiple levels, including a Village Health Worker (VHW) program, ii expanded services at clinics, decentralized management of the district health system, and central oversight of the Reform. Documentation of the Reform noted several key insights. First, in this model, VHWs do not simply have discrete clinical tasks, but rather have cross-cutting activities that aim to increase patient utilization of services across multiple disease areas. Second, by taking a comprehensive approach to improve population health, the Reform model specifically aims to build state capability in strengthening health systems. The findings from the Analytical Platform and Lesotho’s experiences documented in the Results Summary are relevant for policymakers, practitioners, and researchers working to achieve UHC through HSS in LMICs, especially in a post-2015 agenda. iii Contents Abstract ........................................................................................................................................... ii List of figures .................................................................................................................................. v List of tables ................................................................................................................................... vi Introduction ..................................................................................................................................... 1 Analytical Platform ....................................................................................................................... 10 Aligning Values and Outcomes in Priority-Setting for Health ................................................. 10 Does task shifting yield cost savings and improve efficiency for health systems? A systematic review of evidence from Low- and Middle-Income Countries ................................................. 25 Do changes to supply chains and procurement processes yield cost savings and improve availability of pharmaceuticals, vaccines, or health products? A systematic review of evidence from low- and middle-income countries ................................................................................... 53 Results Statement .......................................................................................................................... 79 Overview of the Lesotho National Primary Health Care Reform (Problem Statement and Theory of Change) .................................................................................................................... 79 DEPLESET Analysis of Lesotho .............................................................................................. 83 Village Health Worker Activities along the Care Delivery Value Chain: The Case of Lesotho ................................................................................................................................................. 101 Building State Capability to Strengthen Health Systems: The National Primary Health Care Reform in Lesotho ................................................................................................................... 123 Conclusion .................................................................................................................................. 144 References ................................................................................................................................... 156 iv List of figures Figure 1 - Framework for aligning values and outcomes when setting priorities for health ........ 12 Figure 2 - Study selection for inclusion in the systematic review (task shifting) ......................... 32 Figure 3 - Study selection for inclusion in systematic review (supply chain and procurement) .. 61 Figure 4 - DALYs per 100,000 population, 1990-2015, all ages193 ............................................. 92 Figure 5 - DALYs per 100,000 population, 1990-2015, Under-5193 ............................................ 92 Figure 6 - Coverage rates for select population health indicators .............................................. 103 Figure 7 - Overview of the National PHC Reform ..................................................................... 104 Figure 8 - List of interviewees' professional titles ...................................................................... 106 Figure 9 – List of select VHW-related documents reviewed for this research ........................... 107 Figure 10 - VHW competency-based activities and tasks along the CDVC .............................. 109 Figure 11 - Suggested topics for a pitso...................................................................................... 110 Figure 12 - List of interviewees' professional titles .................................................................... 127 Figure 13 - Summary of Reform pilot interventions at different levels of the health system .... 129 Figure 14 - % of total DALYs in Lesotho's population (2015)193 .............................................. 130 Figure 15 - Schematic of steps in the Reform process using the PDIA framework ................... 133 Figure 16 - Summary of PDIA approach to development initiatives and approach taken by the Reform ........................................................................................................................................ 134 v List of tables Table 1 - Full list of citations included in systematic review ....................................................... 41 Table 2 - Full list of references with cost implications from programs ........................................ 71 Table 3 - Full list of references with drug availability implications from programs .................... 76 Table 4 - Select World Development Index indicators for Lesotho (LSO), Swaziland (SWZ), South Africa (ZAF), and Sub-Saharan Africa (SSA)8 .................................................................. 85 vi Introduction Since the signing of the Alma-Ata Declaration in 1978, public health policymakers, practitioners, and researchers have debated the merits and effectiveness of using a primary health care (PHC)-based approach to achieving universal health coverage (UHC).1 Since then, dominant approaches to improving public health have vacillated between using “horizontal” approaches to deliver health services (e.g. comprehensive PHC platforms, health systems strengthening [HSS]) and more targeted, “vertical” interventions focused on addressing specific disease areas. For example, shortly after the signing of the Alma-Ata declaration, some practitioners advocated
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