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
Atun,
Ohiri, College
Adeyi, 2008
© Professor Rifat Atun.
Imperial
London, 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
Most to all outcomes
Partially integrated
Mixed outcomes
Not integrated
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
Dengue
Cuba (ToledoRomani2007)
?
Malaria
Colombia (Rojas2001)
© Professor Rifat Atun. Imperial College London, 2008
Extent of integration & success as documented in
studies
Schistosomiasis control
?
?
?
?
Brazil (Filho1992)
?
?
Burundi (Engels1993,1995)
Cameroon (Bausch1995,Cline1996)
China (Sleigh1998)
Saudi Arabia (Ageel 1997)
Uganda (Kabatereine 2006)
?
?
?
?
© Professor Rifat Atun. Imperial College London, 2008
?
Extent of integration & success as documented in
studies
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
Nutrition
Peru
Bangladesh (Hossain2005)
?
Various (Deitchler2004)
?
?
© Professor Rifat Atun. Imperial College London, 2008
Extent of integration & success as documented in
studies
Child health & development
IMCI*
ICDS - India
(Agarwal2000, Kapil1999)
?
?
?
Dular - India (Dubowitz2007)
© Professor Rifat Atun. Imperial College London, 2008
Extent of integration & success as documented in
studies
Family Planning services
Bangladesh – FPHSP
(Philips1984, de Graff 1986)
?
?
?
?
?
Pakistan – LHWP
(Douthwaite 2005)
?
?
Nepal (Tuladhar 1982)
© Professor Rifat Atun. Imperial College London, 2008
?
?
Extent of integration & success as documented in
studies
HIV/AIDS & STD services
Haiti (Peck 2003)
?
?
© 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
Holistic
Embedded
Single
Multiple
Russia TB
Estonia PHC
Africa HIV
Euro PHC
Russia HIV
© Professor Rifat Atun. Imperial College London, 2008
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
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
• NTDs + malaria + TB + HIV
• Malaria, TB, HIV?
• Malaria, TB, HIV?
© Professor Rifat Atun. Imperial College London, 2008