Positive Synergies between Global Health Initiatives Professor Rifat Atun Professor of International Health Management, Imperial College London & Director Strategy, Policy and Performance Cluster, The Global Fund to Fight AIDS, TB & Malaria © Professor Rifat Atun. Imperial College London, 2008
Key Research Questions • What are the extent and nature of integration of GHIs (programmes they finance) and health systems to achieve synergies in varied contexts? • Which factors influence the extent and nature of integration? • How the varied health system designs and delivery structures influence outcomes? © Professor Rifat Atun. Imperial College London, 2008
Key variables affecting the nature and extent of integration 1. 2. 3. 4. 5. The Problem being addressed The Intervention The Adoption System The Health System characteristics The Broad Context © Professor Rifat Atun. Imperial College London, 2008 Atun, Ohiri, Adeyi, 2008
Integrate or not to integrate: framework for analysis Broad Context Health System Characteristics Adoption System Intervention Problem Broad Context © Professor Rifat Atun. Imperial College London, 2008
The Problem • Necessity and Urgency • Burden – Economic and social • Perceived and real • Social Narrative • Transmission dynamics © Professor Rifat Atun. Imperial College London, 2008
The Intervention • Complexity • Simpler to more complex* • Scalability • Replicability * See next slide © Professor Rifat Atun. Imperial College London, 2008
Intervention: simple versus complex Single episode Less complex Multiple elements Few elements More complex Multiple episodes Atun and Kyratsis 2007 © Professor Rifat Atun. Imperial College London, 2008
Intervention: simple versus complex Few stakeholders Less complex Multiple levels Few levels More complex Multiple stakeholders Atun and Kyratsis 2007 © Professor Rifat Atun. Imperial College London, 2008
Intervention: simple versus complex User engagement lower Less complex Behaviour dominates Technology dominates More complex User engagement higher Atun and Kyratsis 2007 © Professor Rifat Atun. Imperial College London, 2008
The Adoption System • Receptivity • Individual & organisational • Political economy • Incentives – agency/provider/user incentive alignment • Legitimacy – – Cognitive Technical Normative Economic © Professor Rifat Atun. Imperial College London, 2008
Health System Characteristics • Feasibility • • Governance Structure and organization Financing Provider payment methods Resource availability Service delivery M&E system © Professor Rifat Atun. Imperial College London, 2008
The Context • Sustainability • Fiscal space – Overall and health sector specific • Frailty • Attributability • Reporting needs © Professor Rifat Atun. Imperial College London, 2008
The Context • Opportunity • Critical events – Visibility • Synergy • Technology / innovation • Desirability • Political economy • Socio-cultural factors © Professor Rifat Atun. Imperial College London, 2008
Analysing the extent and nature of integration © Professor Rifat Atun. Imperial College London, 2008
Integration into Critical Health System Functions 1. Governance – Reporting – Accountability 2. Financing – Pooling – Provider payment 3. Planning – Needs assessment – Priority setting – Resource allocation © Professor Rifat Atun. Imperial College London, 2008
Integration into Critical Health System Functions 4. Service Delivery – Structural • • – Human resources, Shared infrastructure Operational integration • • • Supply chain Guidelines Procurement 5. Monitoring and Evaluation – Data collection and analysis 6. Demand Generation – – Financial incentives – e. g. CCT, insurance Population interventions – e. g. education and promotion © Professor Rifat Atun. Imperial College London, 2008
Some Initial Results © Professor Rifat Atun. Imperial College London, 2008
Intervention Complexity Intervention frequency/number of episodes Single Dular - India Onchocerciasis - Uganda Nutrition - Peru, etc. Intervention elements STD - Mbofana FP/MCH - Matlab, Bangladesh FP; STD - Lafort Few FP/MCH - Pakistan - LHWP FP/MCH - Nepal (Tuladhar) Dengue - Cuba Schistosomiasis Brazil, Burundi, Cameroon, China, Saudi Arabia, Uganda Malaria - Colombia Leprosy - India, Sri Lanka HIV/AIDS - Haiti ICDS IMCI Mental health - Whetten Substance abuse - Friedmann Multiple © Professor Rifat Atun. Imperial College London, 2008 Many
Extent of integration & success as documented in studies Fully integrated Partially integrated Mixed outcomes Not integrated ? Most to all outcomes Few to no outcomes Unknown ? © Professor Rifat Atun. Imperial College London, 2008 Unknown
© Professor Rifat Atun. Imperial College London, 2008
Extent of integration & success as documented in studies n tio n a y io lu a at er iv Ev ner el & g e e d ge nc anc nin ce ng d s i a rn Fin lan ervi itor an es e c P m S ov uc on De S G M Dengue Cuba (Toledo. Romani 2007) ? Malaria Colombia (Rojas 2001) © Professor Rifat Atun. Imperial College London, 2008
Extent of integration & success as documented in studies n u y r ve li de ng Schistosomiasis control ? ? ? Brazil (Filho 1992) ? ? Cameroon (Bausch 1995, Cline 1996) China (Sleigh 1998) Saudi Arabia (Ageel 1997) Uganda (Kabatereine 2006) E l va ? ? ? ? © Professor Rifat Atun. Imperial College London, 2008 ? n io at r e en e & e g nc anc nni ice ng ri nd na Fin a v a r to Pl Ser ve ni em o D Go M ? Burundi (Engels 1993, 1995) io at s Su c s ce
Extent of integration & success as documented in studies ce n n na io at n r u ry tio ve al e o ra iv Ev /G e ne el & d ip c ng ge s sh an nni ice ng es ri nd rd Fin a v c a to Pl Ser m wa uc ni e S o De St M Leprosy India (Rao 2002, Thakar 2003) Sri-Lanka (Kasturiaratchi 2002) © Professor Rifat Atun. Imperial College London, 2008 ? ?
Extent of integration & success as documented in studies n io at Nutrition n u y tio al er ra iv Ev ne el g e & e d n ge s nc anc nni ice ng es ri nd na Fin a v c a r to Pl Ser uc ve ni em S o D Go M Peru Bangladesh (Hossain 2005) ? Various (Deitchler 2004) ? ? © Professor Rifat Atun. Imperial College London, 2008
Extent of integration & success as documented in studies n io at Child health & development n u y io al er at r iv Ev ne el g e & e d n ge s nc anc nni ice ng d es ri n na Fin a v c a r to Pl Ser uc ve ni em S o D Go M IMCI* ICDS - India (Agarwal 2000, Kapil 1999) ? ? ? Dular - India (Dubowitz 2007) © Professor Rifat Atun. Imperial College London, 2008
Extent of integration & success as documented in studies n io at Family Planning services Bangladesh – FPHSP (Philips 1984, de Graff 1986) n u y tio al er ra iv Ev ne el g e & e d n ge s nc anc nni ice ng es ri nd na Fin a v c a r to Pl Ser uc ve ni em S o D Go M ? ? ? Pakistan – LHWP (Douthwaite 2005) ? ? Nepal (Tuladhar 1982) © Professor Rifat Atun. Imperial College London, 2008 ? ?
Extent of integration & success as documented in studies ce n n na HIV/AIDS & STD services Haiti (Peck 2003) io at n r u y tio ve al er o ra iv Ev /G e ne el g & d ip c n ge s sh an nni ice ng es ri nd rd Fin a v c a a to Pl Ser uc ni em ew S o D St M ? ? © Professor Rifat Atun. Imperial College London, 2008 ?
Conclusions 1. Extent and nature of integration varies 2. Context matters: complex adaptive systems at play 3. Reductionist approaches counterproductive: aim to ‘unpack’ what is meant by integration © Professor Rifat Atun. Imperial College London, 2008
Empirical Research © Professor Rifat Atun. Imperial College London, 2008
Case Study Approach • Exploratory • Descriptive • Explanatory © Professor Rifat Atun. Imperial College London, 2008
Design Logic of design key Single Holistic Embedded Russia TB Estonia PHC Russia HIV © Professor Rifat Atun. Imperial College London, 2008 Multiple Africa HIV Euro PHC Tech adoption Baltic PPP
Embedded units • • HIV TB Malaria NTDs • Regions © Professor Rifat Atun. Imperial College London, 2008
Analytic vs. Statistical Generalisation • Cases not sampling units but each akin to an individual ‘experiment’ • Analytic generalisation using theory developed a priori Replication logic – n number of case studies support the same theory – n number of case studies do not support a rival theory • Statistical generalisation Sampling logic © Professor Rifat Atun. Imperial College London, 2008
Careful case selection • Literal replication – Each predict similar results (n=4) • Theoretical replication – Predict contrasting results --- but for predictable reasons (n=4) © Professor Rifat Atun. Imperial College London, 2008
Theoretical framework and propositions key • State the conditions under which particular phenomena are likely to be found – Allows literal replication • State the conditions when particular phenomena are not likely to be found – Allows theoretical replication © Professor Rifat Atun. Imperial College London, 2008
Closed vs. flexible design • Closed but with inductive analysis – Retain replication logic – Build theory as an output – Test ‘additional’ new/alternative propositions • Flexible and inductive – Risk of drift © Professor Rifat Atun. Imperial College London, 2008
One or two tail design • Good outcome • Good and poor outcome © Professor Rifat Atun. Imperial College London, 2008
Data • • • Mixed methods Multiple sources Inductive Iterative Triangulation © Professor Rifat Atun. Imperial College London, 2008
Process Construct validity Agree theory Construct validity Internal validity Reliability Analytical tools approach & d/base Generate propositions Pilot cases Refine tools Propositions Case studies Literal replication Internal validity Rival propositions Theoretical replication Explanatory theory & Evidence © Professor Rifat Atun. Imperial College London, 2008 External validity
Cases Africa • Tanzania • Ghana SE Asia • Thailand • Viet Nam Embedded units of analysis • NTDs + malaria + TB + HIV • Malaria, TB, HIV? © Professor Rifat Atun. Imperial College London, 2008
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