by Dr Vijayashree HY
This session started with Prof. Freddie Ssengooba’s (Makerere University School of Public Health, Uganda) presentation. He talked about the health system evidence to guide disease control. He emphasized that public health interventions are often implemented without much pre-trial development research and invariably there will be program adaptations during implementation. Thus, the evaluation methods need to take into account the complexity and evolutionary adaptions. He also stressed the importance of using randomization methods for evaluating public health innovations in such situations where contextual and implementation learning are not vital.
Some discussions surrounding this presentation:
- Before any innovations, it is essential to assess the readiness of system, whether it is stable/mature to absorb the innovation and thus the innovation is sustainable. There is a need to have a feedback loops through communication and learning from downstream to upstream.
- Evaluation results based on Randomised Control Trials are not a good strategy to initiate a good dialogue with policy makers. They do not really understand the term ‘control’. We need to deliberate on how we can be more clear and be more effective in communicating the issues of in complex health system with policy makers.
- What drives performance in the health system: sometimes Performance Based Financing (PBF) can pose a problem to the system. International donors need to understand the local priorities and social ingredients well before the implementation. In the majority of the cases, it affects the generation of quality data which can be used for surveillance.
- Role of administrators is crucial in disseminating the policy to grass root level workers in a way that; they understand the message which eventually gets absorbed into their daily routine. There should be a feedback loop in the system, to enable grass root level workers to flag constraints to higher authority
- How does one measure motivation and contextual factors affecting health system functioning? Measuring these environmental factors add scientific credibility. There are some things which need to be understood and some need to be quantified. Health system research using quantitative and qualitative methodology is ideal to measure a health system holistically.
- What are alternative explanations that may account for changes – plausible explanations in addition to statistical reduction? How does a broader context help build explanations?
- How can one use multiple methods for observation and measurements to rule out (or support) alternative explanations?
- How can one become sufficiently familiar with the relevant contexts to understand and capitalize on contextual drivers and barriers?
The second key note speaker, Prof. Venkat Raman (Faculty of management studies university of Delhi), talked about public private interface in disease control strategies. By providing some examples of Public Private partnerships (PPP) in health care, he discussed the advantages of working with the private sector but stressed the challenges in partnering with private sector health providers. Some issues which deserves further discussion are:
- Most PPPs in health sector are ‘partnerships of good faith’, not based on policy or institutional guarantee, thus lack continuity. How do we improve this?
- Senior bureaucrats are enthusiastic, but lower officials are suspicious of PPP.How do we ensure all the players are on the same page ?
- Will a Professional Contracts and Intermediary management agency between the private sector and the government will reduce the tension between public and private sector?
The third key note speaker, Prof. Guy Kegels (Institute of Tropical Medicine, Antwerp), talked about Vertical analysis. He discussed ‘operational analysis’ following Piot’s model, the ‘learning cycle’ for Action Research. He stressed the need to involve generalist program implementers in program design, whenever possible.
The fourth speaker, Dr Melissa Parker (Centre for Research in International Medical Anthropology, Brunel University) spoke about her experiences of working in Uganda and Tanzania on the uptake of drugs for neglected tropical diseases. She stressed the need to understand how social, political, economic and historical issues influence the uptake of drugs, and pointed out that anthropologists can fill in the gaps in understanding the contextual issues in the health system for certain outcomes.
Editor’s note: If the above quoted six questions are not thought-provoking enough, here are some additional questions you may want to elaborate on in the comments:
- Things should be made as simple as possible, but not simpler’: agree or not agree?
- Funders, program designers, program managers and generalist implementers (the ‘systems people’) often have quite different systems of reasoning, each of them tending to apply ‘single-metric’ systems of logic. These ‘single-metric’ systems* can be so internally coherent (and intellectually elegant) that it becomes almost impossible to listen to people using a different one. How to deal with this, if we want to optimise the interface programs-systems?? *eg Funders: ‘single-metric’ cost-effectiveness. Program managers: effectiveness (‘does it work?’). System-people: logic of equity, or feasibility. Others: ‘performance-based financing’. Others: regulation, discipline, bureaucratic model. Others: internalised deontology of the medical professional.
- MDA for NTDs is driven by normative assumptions, and the quest for funding. Evidence is a distraction. Is this a fair assessment of current strategies?
- Why are so few public health professionals interested in grappling with the social and political issues affecting MDA?