Health System Strengthening Quick Scan
A tool for identifying and addressing health system barriers to tuberculosis prevention, care and control
ABSTRACT The Health System Strengthening Quick Scan is a tool for identifying and addressing health system barriers to tuberculosis (TB) prevention, care and control. It provides managers of national TB control programmes tools to assess the performance of the general health system in providing essential functions of the TB control programme. The Health System Strengthening Quick Scan was developed under the partnership between WHO and the Netherlands by the KNCV Tuberculosis Foundation. The Health System Strengthening Quick Scan is based on the WHO Stop TB policy paper: contributing to health system strengthening: guiding principles for national tuberculosis programmes.
Keywords HEALTH SERVICES INTEGRATED HEALTH CARE SYSTEMS OUTPATIENT CARE PUBLIC HEALTH TUBERCULOSIS, MULTI-DRUG RESISTANT
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CONTENTS Page
1. Introduction ................................................................................................................... 1 2. Methods ........................................................................................................................ 3 2.1 Introduction to the workshop ................................................................................ 3 2.2 Understanding the roles of various stakeholders ..................................................... 3 2.3 The concept of health system strengthening ........................................................... 3 2.4 Overall performance of the TB services .................................................................. 3 2.5 Developing a vision .............................................................................................. 4 2.6 SWOT related to the actual performance ................................................................ 4 2.7 Challenges in improving TB service delivery ............................................................ 4 2.8 Identify the health system obstacles ...................................................................... 5 2.9 Identify the root causes of the health system obstacles ........................................... 5 2.10 Developing a joint plan of action .......................................................................... 6 2.11 Evaluation .......................................................................................................... 6 References ........................................................................................................................ 6
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1. Introduction Effective and sustainable tuberculosis (TB) prevention, control and care rely on the strong general health care system, especially well-functioning primary health care. This is explicitly acknowledged by including health system strengthening in the WHO Stop TB strategy (1), the Roadmap to prevent and combat drug resistant tuberculosis (2) and innovative care and bold policies of the post-2015 global TB strategy (3). In 2005, a task force was created to provide expert guidance to develop a policy paper on health system strengthening. The work of the task force resulted in Stop TB policy paper: contributing to health system strengthening: guiding principles for national tuberculosis programmes (4). The policy paper explains: • •
why the Stop TB strategy includes a health system strengthening component; what contributing to health system strengthening means in practice for national TB control programmes in: – – – –
analysing health system weaknesses identifying opportunities and threats in health sector development processes addressing weaknesses and challenges and seizing opportunities; and how to incorporate health system strengthening into a programme review.
For its analysis of the health system weaknesses, it uses the WHO’s framework on health system strengthening that is based on six building blocks (5) (Fig. 1). Fig. 1. Six building blocks for health system strengthening
Health systems Six building blocks Service delivery Health workforce Information Medical products, vaccines, technologies Financing Leadership and governance
Overall goals and outcomes Improved health (level and quality) Responsiveness
Access Coverage
Quality Safety
Social and financial risk protection Improved efficiency
The policy paper on health system strengthening defines for each building block a list of potential health weaknesses, provides background to ongoing policy changes and reforms in the health sector and provides for each of the building blocks a list of dos and do nots to address weaknesses and challenges and seize opportunities and discusses several core non-negotiable functions for TB control. This valuable policy paper clearly describes how national TB control programme managers can involve themselves in the overall sector policy dialogue and processes. The policy paper does not
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cover how to assess the performance of the general health system related to essential functions of the TB control programme. In 2010, the WHO Regional Office for Europe in consultation with the Member States and partners prepared a five-year Consolidated Action Plan to Prevent and Combat Multidrug and Extensively Drug-resistant Tuberculosis (M/XDR-TB) (6). The Consolidated Action Plan and its accompanied resolution were fully endorsed at the 61st session of the WHO Regional Committee for Europe. Under the auspices of the Special Project of the WHO Regional Director for Europe and in order to operationalize the health system strengthening aspects of the Consolidated Action Plan, the WHO Regional Office for Europe established a multidisciplinary task force in 2010, and under the WHO–Netherlands Partnership Project, engaged the KNCV Tuberculosis Foundation to work on a tool to identify and address health system barriers to TB and M/XDRTB prevention and control. KNCV prepared a draft version, which was piloted in several countries of the Region in 2011–2012, and the tool was finalized in December 2013. This publication was developed as a result of the following process. In response to the alarming problem of multidrug- and extensively drug-resistant TB (M/XDR-TB) in the WHO European Region, the WHO Regional Director for Europe has established a Special Project to Prevent and Combat Multidrug- and Extensively Drug-resistant Tuberculosis in the Region. The Regional Office set up a task force in 2013 to contribute to scaling up a comprehensive response to prevent and control M/XDR-TB. The prime objective of the task force is to review existing tools on health systems for M/XDR-TB and to document the lessons learnt from the pilot implementation of the health system Quick Scan, developed under the partnership between WHO and the KNCV Tuberculosis Foundation. The set-up chosen for doing the Health System Strengthening Quick Scan is a workshop of 2–3 days, in which staff members of national TB control programmes, decision-makers of the general health system and partners participate jointly. It closely follows Stop TB policy paper: contributing to health system strengthening: guiding principles for national tuberculosis programmes (4). It aims: • • •
to improve the capacity of the health system to effectively deliver TB control services; to optimize the synergy between specific TB control programme activities and the general health system; and to ensure non-negotiable core functions for effective TB control.
It does this for each of the six interrelated building-block components of a health system and for the integrated health system as a whole. The expected output of the workshop is a joint plan of action to address major health system obstacles that hinder the delivery of TB services. This publication explains the Health System Strengthening Quick Scan. An accompanying facilitator’s guide is available (7).
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2. Methods The Health System Strengthening Quick Scan includes the following 11 sessions. 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11.
Introduction to the workshop Understanding the roles of various stakeholders The concept of health system strengthening Jointly assess the overall TB performance of the national TB control programme in terms of case-finding and treatment results in the country or region Jointly develop a vision of how the TB service delivery system should ideally operate Strengths, weaknesses, opportunities and threats (SWOT) related to the actual performance Define challenges in improving TB service delivery Identify the health system obstacles Identify the root causes of the health system obstacles that hinder the delivery of TB services Developing a joint plan of action to address the health system obstacles Evaluation
2.1 Introduction to the workshop This first session starts by collecting the expectations of the participants. Then an overview is given of the purpose, programme and set-up of the workshop.
2.2 Understanding the roles of various stakeholders In this session, participants learn that health system strengthening initiatives are usually developed in a complex environment that requires positive interaction between the stakeholders as they begin to understand each other’s situation and logic. By the end of the session, the expected contribution of each stakeholder and the return they get are defined more clearly.
2.3 The concept of health system strengthening In this session, participants become familiar with the concept of health system strengthening from the perspective of TB service delivery, using Stop TB policy paper: contributing to health system strengthening: guiding principles for national tuberculosis programmes (4). The guiding principles for national TB programmes are explained and discussed.
2.4 Overall performance of the TB services This session assesses the burden of disease of TB and the national response. The session starts with a plenary presentation on case notification and treatment results of both sensitive and (multidrug-) resistant TB. Information can be provided by the national TB control programme or
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be taken from the WHO global TB database. The performance assessment includes a trend analysis of the last 5–20 years. To the extent possible, data on case notification and treatment results are disaggregated by region, age groups and sex. Major events that may have affected the TB epidemic and the response by the national TB programme are identified and explained in the presentation when possible. After the formal presentation, a plenary discussion follows. By the end of the session, agreement is reached on a list of major performance issues of the TB control system in the country or region.
2.5 Developing a vision In this session, the participants of the workshop divide into small groups. Each group is asked to develop their vision on the ideal TB service delivery system in the country or region. Groups are asked to make a drawing of how the ideal TB service delivery system would look in the future. All groups report back to plenary, where the different visions are discussed and synthesized. By the end of the session, a joint vision is developed on the ideal TB service delivery system in the country or region.
2.6 SWOT related to the actual performance 1 This session compares the ideal TB service delivery system as defined in the previous session and the daily reality in the country or region. For this purpose, the participants again divide into smaller groups. Each group first identifies major strengths and weaknesses in the TB service delivery system. If possible, they should be linked to the performance in case notification and treatment results as identified in the first session – for example, if the case notification is low, one can question the access to diagnostic services. Each group presents to the plenary on small cards a list of three major strengths of and opportunities for and three weaknesses of and threats to the TB service delivery system. Subsequently, the cards with strengths and weaknesses are clustered in areas that constitute parts of the service delivery system. Possible clusters could be quality of ambulatory care, access to diagnostic services, patient support, etc. By the end of the session, agreement is reached on several TB service delivery areas in which improvements can be made.
2.7 Challenges in improving TB service delivery In this session, the group makes a list of the most important challenges to be addressed in the health system that form obstacles to TB service delivery. Participants familiarize themselves with the difference between a problem and a challenge. A problem is external and often blamed on outside forces. A challenge is something the participants own. A challenge entails
1
SWOT analysis aims to identify the key internal and external factors seen as important to achieving an objective. It groups key pieces of information into two main categories: internal factors – the strengths and weaknesses internal to the organization; and external factors – the opportunities and threats presented by the environment external to the organization.
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overcoming obstacles to achieve a result you are committed to achieving. Participants are instructed how to properly formulate a challenge. 2 Participants are then divided into small groups, each covering one of the clustered areas identified in the previous session. Each group defines the major challenge for its specific area.
2.8 Identify the health system obstacles In this session, the group identifies the major health system obstacles that comprise the major challenge to TB service delivery. Participants return to their groups. Each group agrees on formulating a challenge that best covers the cluster based on the elements identified during the SWOT analysis for that cluster. Each group copies the correct formulation of the challenge to a flip-chart.
2.9 Identify the root causes of the health system obstacles In a plenary session, participants first become familiar with the five whys exercise. 3 Asking “why” five times prevents mistaking symptoms for causes, so that one can work on addressing the underlying factors that are causing the problem rather than working on the symptoms. To visualize the model, it uses the well-known fishbone diagram that has been converted in this case such that it represents the five building blocks of the WHO model of the health system (Fig 2). Fig. 2. Outline of the fishbone diagram, in which the bones represent the five building blocks of a health system
Finances
Information
Detail Detail Detail
Detail Detail Detail
Workforce Detail Detail Detail Detail Detail Detail
Health system obstacle
TB service delivery challenge
Governance
Medical products
It is good practice to write out a challenge as a full and detailed question: for example: “How can we improve the quality of microscopy?” 3 The five whys exercise is a questioning technique developed by Imai Masaaki for identifying the primary or root causes of a problem.
2
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Participants are divided into small working groups. Each working group identifies a list of root causes that are attributable to the obstacles to effective TB services delivery. By the end of this session, the group generates several health system clusters of interrelated causes that are attributable to certain obstacles to providing TB services.
2.10 Developing a joint plan of action In this session, the participants develop a plan of action to remove the health system obstacles based on the causes identified in session 2.7. Participants in the plenary first discuss and agree on a maximum of five criteria selected from a list of common priority-setting criteria, which they use for setting priorities for the actions they propose. Then the participants return to their working groups. Each working group makes a list of actions to address the clustered causes that are attributable to the obstacle to TB service delivery. Each working group then makes a matrix that gives a list of proposed actions on one end and their semiquantitative scoring on the agreed priority-setting criteria of the listed actions. This is presented to the plenary and discussed. Once all groups have presented their priority list of actions, the group as a whole selects from this list a short list of actions. By the end of this session, agreement is reached on a short list of health system actions, aimed at removing obstacles to providing high-quality TB services.
2.11 Evaluation In this final session, the participants are asked to complete an individual evaluation form to assess the content, the process and the quality of the facilitation. Then the extent to which the expectations, presented by the participants in the first session have been met is assessed and the need to address unmet expectations after the workshop is questioned.
References 1.
Stop TB strategy: building on and enhancing DOTS to meet the TB-related Millennium Development Goals. Geneva: World Health Organization; 2006 (http://whqlibdoc.who.int/hq/2006/WHO_HTM_STB_2006.368_eng.pdf, accessed 27 June 2014). Roadmap to prevent and combat drug-resistant tuberculosis. Copenhagen: WHO Regional Office for Europe; 2011 (http://www.euro.who.int/en/publications/abstracts/roadmap-toprevent-and-combat-drug-resistant-tuberculosis, accessed 9 December 2014). WHO End TB Strategy. In: World Health Organization Tuberculosis [website]. Geneva: World Health Organization; 2014 (http://www.who.int/tb/post2015_strategy/en/, accessed 9 December 2014). Stop TB policy paper: contributing to health system strengthening: guiding principles for national tuberculosis programmes. Geneva: World Health Organization; 2008 (http://whqlibdoc.who.int/publications/2008/9789241597173_eng.pdf, accessed 27 June 2014). Everybody’s business: strengthening health systems to improve health outcomes. WHO’s framework for action. Geneva: World Health Organization; 2007
2.
3.
4.
5.
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(http://www.who.int/healthsystems/strategy/everybodys_business.pdf, accessed 27 June 2014). 6.
Consolidated action plan to prevent and combat multidrug- and extensively drug-resistant tuberculosis in the WHO European Region 2011–2015. Copenhagen: WHO Regional Office for Europe; 2011 (http://www.euro.who.int/en/about-us/governance/regionalcommittee-for-europe/past-sessions/sixty-first-session/documentation/workingdocuments/wd15-consolidated-action-plan-to-prevent-and-combat-multidrug-andextensively-drug-resistant-tuberculosis-in-the-who-european-region-20112015, accessed 9 December 2014). Facilitator’s guide for Health System Strengthening Quick Scan. A tool for identifying and addressing health system barriers. Copenhagen: WHO Regional Office for Europe; 2014).
7.