Health systems Flashcards
What is a good health system according to the WHO definition?
Delivers quality services to all people
- when and where they need them
What are the three requirements to have a good health system?
- Well-trained and adequately paid workforce
- Reliable info. in which to base decisions and policies
- Well-maintained facilities and logistics to deliver quality medicines and technologies
What is the state of health systems in LMICs?
> Mental health services often absent or available only in large cities
> Low proportion of health budget spent mental health
> Healthcare workers not trained in mental healthcare
> Lack of health management information systems
> Continuity and supply issues
What is the idea behind ‘system thinking’ approaches in global mental; health?
Alter the research planning and expectation of translation of results into clinical practice
to more realistically reflect the complexity of health systems = context of GMH work
- > from linear isolated process towards multilevel
- taking into account complexity of mutual interactions between different components and their effects on system as a whole
What is the type of research emerging from the systems thinking approach?
It multilevel and mixed methods
What do researchers try to do in the systems thinking approach to GMH research?
Close the gap between what happens in study context and what happens in real-life health systems
What is the stepped care model?
Currently, all care is stepped care
- aiming to match needs of people, population and patients to most appropriate level of care, depending on illness and social characteristics
- > we treat most people in lower pyramid
- > fewer people with most severe conditions require the most complex services (top of pyramid)
What is the difference between the effectiveness of packages of care across LMIC and HIC?
- Effectiveness of packages of care for depression is similar across LMIC and HIC settings
- Evidence suggests this is similar across disorders BUT adaptations are needed to ensure components are appropriate for particular health system contexts
What characterises the mismatch between burden and resources in LMICs?
> Lack of some resources for delivering stepped care
> Lack of MH services overall, particularly community-based
> Lack of specialists but pyramid is top-heavy (need of specialist services)
> Traditional / faith healer fill the gap
- BUT weak evidence of their effectiveness
- absence of evidence
- remain often expensive and unregulated
What is the problem of task-sharing in the scale-up of mental health services in LMICs?
How do we assess feasibility and acceptability of task-shared care in the context of lack of experience of mental health care?
What did the TaSCs trial in Ethiopia consist of?
- Non-inferiority trial
- Intervention group: primary healthcare service
- TAU was the existing service at Butajira hospital
- > moving from hospital -based care by psychiatric nurses to local primary care service delivered by non-specialists
What were the two steps of the TaSCs trial in Ethiopia?
> Step 1: Consultation meetings carried out with
- healthcare admins
- healthcare workers
- community leaders
- caregivers
- service users
> Step 2:
- Focus group discussions with caregivers and healthcare workers
- In-depth interviews with service-users
What did the results of the TaSCs trial in Ethiopia show?
> Transformative effect from treatment received, on the lives of services users and caregivers
-> Lack of disruption to the service was perceived as utmost priority
> From no treatment to treatment, build up trust and reliance on service
In the TaSCs trial in Ethiopia, why were the service users often more reticent to express their opinions than the other stakeholder groups?
> Perceived that possible changes to the service were outside of their area of expertise and control
> It was the responsibility of care providers / researchers to make decisions about changes
What are the consensus points across stakeholder groups generally supportive of primary care delivered service within the community?
- Ease of access (follow-up)
- Reduced costs
- notably of transportation - Reduced caregiver burden
- no need to travel to clinical appointments - Healthcare workers addressing unmet needs
- not turning people away for being ill-equipped to deal with mental health problems
What are five key concerns about primary healthcare delivery?
- Disruption to familiar service that is perceived to be working well
- Staff competence/knowledge complex cases, negligence
- priority on continuation of medication supplies - Respectful relationships
- Any problems will lead to use of alternative treatments
- perceived decreases in quality of care seen as threat to sustainability of services - No additional stigma anticipated
Why might there not be additional stigma anticipated in primary healthcare delivery in a community?
Community already knows the identity of those living with the conditions
-> accessing care in the community therefore not felt to incur any additional stigma
What is a health extension worker?
Frontline of primary healthcare in Ethiopia
- visiting homes to carry out promotion and prevention work on variety of physical health conditions
Which strategies did the participants in the TaSCs trial in Ethiopia come up with to address their concerns?
> Supervision and referral
> Training
> How to approach and work with service-users with confidence (healthcare workers)
> Monitoring to ensure equity with hospital service (caregivers)
> Supporting recovery (healthcare workers)
> Community awareness (healthcare workers)
What were the advantages of task-sharing in the TaSCs trial in Ethiopia?
> Broad agreement among stakeholders on the benefits of primary healthcare delivered service
> Strong foundation for community participation
> Healthcare workers motivated to address broader social needs (service-user priority)
> Closeness to local community
What were the challenges of task-sharing in the TaSCs trial in Ethiopia?
> Preparedness for change of healthcare workers, and primary healthcare are essential
> Starting from low knowledge base, skills gap
> Disruption to service -> mistrust -> threat to transition
What is the Theory of Change (ToC)?
A way to be able to conceptualise how, why and to what extent change happens
Why is the Theory of Change (ToC) useful?
> Useful to understand a non-linear process and how this might lead to impact
- whilst identifying barriers and facilitators along the way
> Useful way of building partnerships with stakeholders, and setting shared goal
What are the first three components of Theory of Change to identify?
- Impact - ultimate outcome
- Long-term goal
- outcome from the programme - Intermediate outcomes
- outcomes/milestones on the way to long-term goal
What are the components of Theory of Change to define, that lead to the desired intermediate outcomes?
> Indicator
- to measure progress
> Interventions
- needed to achieve outcomes
> Rationale
- evidence for why one outcome follows the next
> Assumptions
- external conditions that need to exist to achieve outcome
What are the benefits of using Theory of Change (ToC)?
> Can support feasibility and acceptability of programmes
> Helps identify key barriers and assumptions
> Provides roadmap of interlocking action for effective change
> Takes framework forwards
- how and why does a programme achieve impact
> Separates the effects of different components of programmes
> Re-draws map to reflect evidence
What does the PRIME project change map reflect?
Key elements that need to be in place for successful scale-up of mental health services in a district
Which factors serve as argument for carrying out work around interventions for mental health (e.g. depression) in the context of HIV centres?
> Higher prevalence of mental disorders in people with HIV than general population
> Evidence suggests depression has a range of adverse effects upon HIV outcomes
> Mental disorder may potentially play a role in determining HIV-related outcomes at multiple stages of continuum of care for HIV
> Research has been focused on adherence
What are the health system building blocks?
> Leadership/governance
> Healthcare financing
> Health workforce
> Medical products, tech
> Information and research
> Service delivery
What are the goals/outcomes of a health system with access coverage and quality safety?
> Improved health level and equity
> Responsiveness
> Financial risk protection
> Improved efficiency
What characterises adherence counsellors in HIV care in Nigeria?
They are effective lay counsellors often living with HIV themselves
How can you keep track of patient outcomes?
Track and monitor patient progress
-> health system will need to respond to their needs -> paper records entered retrospectively -> Data used to report on key government targets
