Guiding health systems development in the Western Pacific

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WHO Library Cataloguing-in-Publication Data Guiding health systems development in the Western Pacific: summary report of a review on the use and utility of six regional health systems strategies.

1. Delivery of health care. 2. Health care reform – organization and administration. 3. Health systems plans – organization and administration. I. World Health Organization Regional Office for the Western Pacific.

ISBN 978 92 9061 634 4

(NLM Classification: WA 540)

© World Health Organization 2013 All rights reserved. Publications of the World Health Organization are available on the WHO web site (www.who.int) or can be purchased from WHO Press, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel.: +41 22 791 3264; fax: +41 22 791 4857; e-mail: bookorders@who.int).

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Contents Preface ..................................................................................................................................... vii Summary and recommendations.......................................................................................... viii A. Introduction........................................................................................................................ 1 B. Review methodology......................................................................................................... 3

1. Objectives...................................................................................................................................................... 3

2. Methodology in brief................................................................................................................................. 3

3. Scope and limitations................................................................................................................................ 5

C. Regional context ................................................................................................................ 6

Economic progress and widening social gaps......................................................................................... 6

Demographic transition................................................................................................................................... 6

Epidemiological transition.............................................................................................................................. 7

Box 1.

Causes of deaths in Mongolia, both sexes, all ages, 2010...................................... 7

Box 2.

Universal health coverage and the health system.................................................... 8

D. Review findings.................................................................................................................. 9

D1. Findings on Objective 1............................................................................................................................ 9

D.1.a

Health care financing........................................................................................................ 10

Box 3.

OOP as % THE 2005–2011............................................................................................... 10

Box 4.

Health care financing expenditure (US$) in China 1995–2011.......................... 10

D.1.b

Access to essential medicines........................................................................................ 11

Box 5.

% Outpatients receiving Antibiotics, 2012................................................................ 12

D.1.c

Human resources for health........................................................................................... 12

Box 6.

Inequity in skilled birth attendance, 5 countries, 2010/2011............................. 13

D.1.d

Health system performance and health outcomes............................................... 13

D.1.e

Equity, gender and human rights................................................................................. 14

D.1.f

Key country actions or events....................................................................................... 15

Box 7.

Health system levers to reduce maternal mortality in Cambodia.................... 16

D.1.g

WHO Secretariat core functions (WHO Secretariat work).................................... 16

D.1.h

Resource mobilization for health system development...................................... 17

D.1.i

Initiating global developments .................................................................................... 17

Table 1. Data on 33 of 47 indicators to monitor health system performance, 1994–2003............................................................................................................................ 18 Table 2. Data on 33 of 47 indicators to monitor health system performance, 2004–2012............................................................................................................................ 19

Figure 1. China key country events impacting on health system development........... 20

D.2. Findings on Objective 2........................................................................................................................ 21

D.2.a

Usefulness of the regional health system strategies to countries.................... 21

Box 8.

Fiji’s aspirations................................................................................................................... 21

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GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Box 9.

The Philippines Health Care Financing Strategy..................................................... 23

D.2.b

Usefulness of the regional health system strategies to WHO regional disease and programme-based activities................................................ 24

D.2.c

Usefulness of the regional health system strategies to development partners..................................................................................................... 24

Table 3. Summary of regional health system strategy actions in national health plans.......................................................................................................................... 26

D.3. Findings on Objective 3........................................................................................................................ 28

D.3.a

Gaps in whole-of-system approaches........................................................................ 28

D.3.b

Gaps in guidance on policy options............................................................................ 28

Box 10.

Whole-of-system approaches........................................................................................ 29

D.3.c

Gaps in working with non-state and non-health sectors.................................... 29

D.3.d

Gaps in knowledge management................................................................................ 30

D.3.e

Gaps in information on strategy indicators.............................................................. 31

Table 4. Number and level of indicators in the six regional

health system strategies ................................................................................................. 32

D.3.f

Gaps in hospital management and efficiency......................................................... 32

D.3.g

Gaps in responsiveness to Regional Committee resolutions............................. 32

E. Discussion on findings..................................................................................................... 35

E.1. Future health system challenges....................................................................................................... 35

E.2. Framework arising from the Review................................................................................................. 37

Figure 2. Knowledge and processes for effective technical partnership......................... 38

E.3. Discussion: Knowledge about the country and context........................................................... 41

E.3.a

Region sets context for the future............................................................................... 41

E.3.b

Primacy of country context and country plans....................................................... 42

E.3.c

Accelerate improving country health system trends............................................ 43

E.3.d

A new country focus for WHO Secretariat’s information..................................... 43

E.4. Discussion: Technical knowledge and learning networks........................................................ 44

E.4.a

Strategy qualities and gaps............................................................................................ 44

E.4.b

Knowledge generation and learning networks...................................................... 45

E.5. Discussion: WHO Secretariat processes and work in countries............................................... 47

E.5.a

WHO health system strategies and work valued by countries.......................... 47

E.5.b

Coordinated health system work................................................................................. 47

E.5.c

Synthesizing health systems work in countries...................................................... 48

Box 11.

Knowledge management: An urgent problem....................................................... 49

E.5.d Supporting WHO staff...................................................................................................... 49

E.5.e

Secretariat accountability to the Regional Committee........................................ 50

E.6. Discussion: Effective technical partnership.................................................................................... 51

F. Summary of Review findings and implications for WHO.............................................. 53 G. Statement from the high-level meeting......................................................................... 56

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Annexes ............................................................................................................................... 59 Annex 1.

Review of Regional Health System Strategies Briefing Paper....................................... 60

Annex 2.

Health System Strategies Review work and documents................................................. 61

Annex 3.

Context of developing regional health system strategies and frameworks............. 62

Annex 4.

Main goals, high-level objectives and strategic areas of action in each of the six regional health system strategies...................................................................................... 63

Annex 5.

Quotes on UHC from national health plans of 10 Review countries.......................... 64

Annex 6.

Influence of WHO on health system policies or key events (motivation, development, implementation) reported by national Key Informant Interviewees................................................................................................................................... 66

Annex 7.

Focus of Western Pacific WHO Regional and country office health system activities by WHO core functions............................................................................................. 67

Annex 8.

Partial indication of country health system activities mapped against actions requested of Member States in World Health Assembly and Regional Committee Resolutions related to six regional health system strategies................ 68

Annex 9.

Partial indication of WHO country office health system activities mapped against activities requested of WHO in World Health Assembly and Regional Committee Resolutions related to the six regional health system strategies......... 69

Annex 10. Summary of links between WPRO disease programme strategies and six regional health system strategies............................................................................. 70 Annex 11. Summary of links between strategies of five development partners and concepts in six health system strategies................................................................................ 71 Annex 12. Reference information on indicator fixed points used in Tables 1 and 2 in section D. Review Findings......................................................................................................... 72 Annex 13. Status of 10 Review countries on essential medicines, 2011 baseline......................... 74 Annex 14. Status of 10 Review countries on human resources for health indicators, most recent data from 2004–2011....................................................................................................... 76 Annex 15. Status of nine Review countries on health financing indicators.................................. 77 Annex 16. Status of 10 Review countries on indicators recommended in the Traditional Medicine Strategy, 2011................................................................................................................ 78 Annex 17. Status of 10 Review countries on health equity, available data from 1993–2011..... 79 Annex 18. Causes of deaths in the 10 Review countries, 2010............................................................ 82 Annex 19. Contributors to the Review process........................................................................................ 84

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“The road to universal health coverage starts with the realization that health is not a luxury.

It is a basic right… a public good… and one of the most cost-effective investments in development a country can make.”

Dr Shin Young-soo, WHO Regional Director for the Western Pacific vi

Preface The Western Pacific Region is the largest and most diverse of WHO’s six regions. Despite multiple epidemiological and socio-economic transitions and challenges, every country and area has made some progress over recent years in the health of its population. More recently, this progress has been measured in terms of the United Nation’ Millennium Development Goals (MDGs), particularly those related to reducing maternal and child mortality and ill-health.

Beyond the MDGs and their 2015 deadline, the goal of universal health coverage (UHC) is of growing importance, with its core elements of better health outcomes, greater equity and improved financial protection. It is vital that countries’ policy decisions be guided by the best available knowledge. In this context, WHO’s role as a knowledge-based technical support agency is becoming more crucial. To support Western Pacific Member States’ advance towards UHC, WHO has in recent years to produced adaptable regional strategies for health system development.

This innovative review of the six current regional health system strategies has assessed their usefulness to countries across the Region. This summary report outlines the main findings of the review as well as its objectives, methods, limitations, and implications for the future.

The review serves three purposes. First, the review indicates the value of the strategies to the ten participating countries. Second, it helps all countries in the Region to assess their own policies and plans that cover the same major issues contained in the six strategies.

Third, it helps the WHO Secretariat improve its work on behalf of all Member States. It does this by identifying gaps that may jeopardize the effectiveness of the strategies and of WHO’s technical support. To prepare for future health system challenges, Member States, the WHO Secretariat and health partners must work together more closely, especially in gathering and sharing the latest knowledge about effective health systems development. Each source of information contributes to our understanding of what works and what does not. Cooperation and collaboration through learning networks will enrich the pool of knowledge contributing to real and lasting positive change for health and health equity.

Dr Shin Young-soo WHO Regional Director for the Western Pacific October 2013

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Summary and recommendations In recent years, WHO in the Western Pacific Region has developed six regional strategies and action frameworks related to health systems that have been endorsed by the Regional Committee for the Western Pacific. The strategies recommend actions for Member States and indicators for reviewing progress in the areas of human resources, health financing, essential medicines, laboratory services, traditional medicine and overall health system strengthening based on the values of primary health care. All the strategies have a common goal to support health system functioning for better health, health equity and financial protection—all key components of universal health coverage (UHC). UHC is fundamental to achieving the Millennium Development Goals and is likely to be the central health-related focus in the post-2015 development agenda.

This Summary Report, Guiding Health System Development in the Western Pacific: Summary of a Review on the Use and Utility of Six Regional Health System Strategies, emerges from a comprehensive Review that has been conducted to provide feedback to the Regional Committee for the Western Pacific on the collective use and utility of the six health system strategies and action frameworks to Member States, regional partners and the WHO Secretariat. The Review employed mixed methods including document reviews, key informant interviews, dialogue with technical units and analysis of indicator data. Ten low- and middle-income countries were included: Cambodia, China, Fiji, the Lao People’s Democratic Republic, Malaysia, Mongolia, Papua New Guinea, the Philippines, Solomon Islands and Viet Nam, representing diversity in the Region. The Summary Report has been revised and updated to reflect the discussions and recommendations of a High-level Consultation on the draft report, held in Manila on 22–24 July 2013 and attended by 25 representatives of 18 Member States, as well as WHO Secretariat staff.

The six Western Pacific regional health system strategies form a technical knowledge component of effective technical partnership between WHO Member States and the Secretariat (see Figure 2).

Key informant interviews indicated that guidance from WHO is generally highly regarded and that the health system strategies and frameworks are seen as valuable sources of evidencebased policy options and ideas, as well as support for advocacy. However, use and utility of the strategies cannot be considered in isolation from the systems and contexts in which they are used. The consultation confirmed the value of the six regional health systems strategies, but also stressed that the implementation of any strategy is context dependent and countries’ own health and development plans are of foremost importance. Therefore, all global and regional strategies and action frameworks must be adapted to the context of each country.

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The Review found a general recognition that WHO is trusted by countries as a neutral ally in health sector development. Trust is gained through long-term presence in countries with staff being on hand to respond quickly to requests for support and advice across a wide spectrum of technical areas. Trust in the competence of technical staff and in the soundness and evidence base of advice offered are also critical. The Review also found that WHO staff are seen as equally

SUMMARY AND RECOMMENDATIONS

or even more important than the WHO strategies themselves. It is the WHO staff who work with countries to appropriately adapt strategy recommendations to national contexts and to sequence recommended actions to achieve balanced progress in functioning of health system components.

The Review identified several examples of the direct use of the regional strategies in informing development of country health system policies or plans. Most of the ten countries already include UHC or its components in their national health policies and plans, along with many other actions proposed in the health system strategies. Further, most of the national health plans of the ten Review countries include many of the recommended actions and principles from the strategies (Table 3). Whether these are realistic and funded for implementation needs further monitoring that is not yet being undertaken by the WHO health system teams.

Clearly, the challenges that Member States face in planning and developing health systems that are effective, universal, equitable and sustainable are complex and daunting. Despite this, information available on indicators recommended by WHO headquarters for measuring health system performance and progress towards UHC (Tables 1 and 2) show generally positive trends in the ten Review countries, for example in increasing government expenditure on health and reducing out-of-pocket payments as a percentage of total health expenditure (Annex 16).

The traffic light colour coding on essential medicines show many positive results, but less progress on some aspects of drug control that could have devastating consequences, such as antimicrobial resistance, which has the potential to create even more health problems for the future (Annex 13). Continuing inequities in distribution of health workers have progressively compounding negative effects on health outcomes (Annex 14). All the Review countries need better information disaggregated by key social stratifiers to properly monitor and take action on inequities in health.

Although not their intended focus, the six regional health system strategies provide little guidance on integrated services or “whole-of-system� approaches on engaging with non-state sectors in health or with non-health sectors. The rise of noncommunicable diseases, antimicrobial resistance and increasing inequities demonstrate failures in prediction, recognition and system actions in health and other sectors, even in developed countries. The demographic, socioeconomic and epidemiological transitions currently taking place in the Region require health systems to engage more fully with all sectors on mitigating negative effects of social, environmental and economic determinants of health. It is becoming increasingly clear that the post-2015 agenda and anticipated challenges in health mean that future approaches to health system development will have to include these critical dimensions. The consultation asserted that WHO Secretariat work on health sector development should support more practical application of whole-of-system approaches and reduce the strongly vertical nature of Secretariat functioning.

Countries emphasized that the Secretariat should be more agile and adaptable in its efforts to work with Member States in building resilient health sectors in the Western Pacific Region.

Faster and more efficient sharing of knowledge, ideas and lessons on health sector development will depend on WHO Member States and the Secretariat together making optimum use of new information technologies. WHO has an essential future role in promoting and supporting networks of learning and exchange within and between countries and subregions. Vibrant

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GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

learning networks will assist in enhancing health sector resilience—the ability of health systems to learn, adapt and respond appropriately to changing needs and challenges in a timely manner. The evidence base of policy options and technical information is dynamic, and during the consultation countries requested the WHO Secretariat to support timely availability of information so that they can stay abreast of advances.

Review recommendations for WHO Member States in the Western Pacific Region include: • • •

•

• •

Identify and continue to strengthen the areas in which progress is being made and ensure balance in functioning across health system components and programmes.

Take active leadership in implementing national health plans to achieve realistically ambitious progress in all areas necessary for universal health coverage and equity in health outcomes.

Progressively integrate health service delivery towards a seamless continuum of quality care for patients and greater efficiency in the use of health system resources—whole-of-system approaches.

Improve actions in areas of weakness identified by this Review, such as: ºº Strengthen civil registration and vital statistics ºº Consistently collect data disaggregated by social stratifiers on a small set of key indicators to routinely monitor equity in health outcomes ºº Improve education and distribution of the health workforce ºº Take action to reduce antimicrobial resistance, including control on the use of antimicrobial medicines.

Engage more fully with non-health sectors so that health is reflected in all policies to minimize negative impacts of social and environmental determinants of health.

Engage more fully with non-state sectors in health to harness their potential in contributing to national health objectives while also enacting sufficient controls to mitigate negative effects on health equity.

Review recommendations for the WHO Secretariat in the Western Pacific Region include: A: With Member States • Continue to identify the best mechanisms for working in partnership with Member States and making best practices on health system development readily available for practical application.

• Establish and support networks for knowledge generation and rapid sharing of lessons on health system development within and among countries and subregions in the Western Pacific.

• Enhance guidance for countries on selection and contextualization of appropriate components from global and regional health system strategies.

• Put more effort into enhancing countries’ stewardship role in health.

• Work with countries to engage more fully with non-health sectors and non-state sectors in health.

• Strengthen guidance for countries on effects of markets and the private sector on health.

• Support more regular monitoring of country progress on core health system performance indicators, disaggregated by relevant stratifiers.

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SUMMARY AND RECOMMENDATIONS

• •

Collaborate with WHO and Member States in other regions to identify practical solutions to health system challenges for small island states.

Strengthen WHO’s role in working with middle- and high-income countries on health system issues such as health equity, system efficiency, service quality and patient safety.

B: Internally for the Secretariat • New ways of working, better knowledge management, more focus on country plans and implementation.

• Adjust structure, processes and funding to be more agile and flexible.

• Consider developing fewer discrete regional strategies and action frameworks and ensure greater consistency and coherence between them to facilitate country use.

• Strengthen capacity of WHO staff for health systems work, whole-of-systems approaches and working in teams across programmes in individual countries—country focus • Support WHO staff by better technical (as distinct from administrative) orientation to country contexts; better information on Secretariat and country health systems work, progress and impact; and more team approaches to technical support and partnerships.

• Improve and synthesize Secretariat knowledge on health system structure and functioning in each country for practical use by all WHO staff and consultants.

• Ensure more regular monitoring and evaluation of WHO’s health system work in the Region including collection of information on strategy adaptation, implementation and outcomes at the country level.

• Establish mechanisms for stronger accountability of the Secretariat to the Regional Committee for the Western Pacific.

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A. INTRODUCTION

A. Introduction Over the past 10 years, and in response to increasing questions and requests for support from countries, the Division of Health Sector Development (DHS) in the WHO Regional Office for the Western Pacific has developed six health system strategies and action frameworks: • • • • • • • • •

Regional Strategy for Improving Access to Essential Medicines in the Western Pacific Region 2005–2010, followed by Regional Framework for Action on Access to Essential Medicines in the Western Pacific (2011–2016) Regional Strategy on Human Resources for Health 2006–2015, followed by Human Resources for Health Action Framework for the Western Pacific Region (2011–2015) Strategy on Health Care Financing for Countries of the Western Pacific and South-East Asia Regions (2006–2010), followed by Health Financing Strategy for the Asia Pacific Region (2010–2015) Asia Pacific Strategy for Strengthening Health Laboratory Services (2010–2015) Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care (published 2010) Regional Strategy for Traditional Medicine in the Western Pacific (2011–2020).

The main goals, high-level objectives and strategic areas of activity in each of the current six health system strategies are summarized in Annex 4.

The strategies draw on international evidence and practice to guide objectives and actions to reach overarching health goals. They all have universal access or coverage as a goal, objective or principle. Collectively, they aim to support health system development for better health, financial risk protection and equity in health outcomes all key components of universal health coverage.

They are intended for use by WHO Member States, WHO staff and development partners.

WHO in the Western Pacific has been innovative in developing health system strategies, generally in the absence of global strategies on the same subject (see Annex 3). The Regional Strategy on Human Resources for Health 2006–2015 was written before the World Health Report 2006: Working Together for Health. The first regional health financing strategy pre-dated the World Health Report 2010. The Western Pacific Regional Strategy on Health Systems Based on the Values of Primary Health Care brings the details of two separate global documents on health systems1 and primary health care2 together into one overall document . There is no similar global strategy.

The purpose of the Review of the six strategies, from which Guiding Health System Development in the Western Pacific: Summary of a Review on the Use and Utility of Six Regional Health System Strategies has been derived, was to provide feedback to the Regional Committee for the Western Pacific on progress in health system development and on the collective use of the strategies in the Region, with an overall health system perspective. There were several reasons for conducting 1 2

WHO (2007). Everybody’s business: strengthening health systems to improve health outcomes.

WHO (2008). World health report 2008. primary health care: now more than ever.

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GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

the Review. First, the six health system strategies and frameworks have been endorsed by the Regional Committee for the Western Pacific and require progress reports on their use. Also, with the 2015 deadline for the Millennium Development Goals (MDGs) approaching and discussion on the post-2015 development agenda gathering momentum, it was felt timely to collectively review the strategies for reporting to the Regional Committee in 2013 (Annex 1). In addition, the Review has been undertaken in the context of WHO global and regional reforms, which, among other objectives, aim to develop a stronger evaluation culture within the WHO Secretariat.

The wide-ranging Review has been conducted over the past year, beginning in mid-2012, to assess the utility of the six regional strategies and action frameworks to Member States and partners across the Region. The Review also considers the history and status of the countries’ health system development, and likely future health system challenges. The countries involved were: Cambodia, China, Fiji, the Lao People’s Democratic Republic, Malaysia, Mongolia, Papua New Guinea, the Philippines, Solomon Islands and Viet Nam. An important aspect of this Review is the degree to which it gives voice to the views of senior national officials involved in the health sector through 61 key informant interviews—a rich source of insights. These interviews were conducted in eight of the ten Review countries. The aim was to gather information on the utility of WHO’s regional health system strategies from those most closely involved in country-level health system policies and development processes. Ten senior WHO staff and 12 representatives from development partner organizations in the Western Pacific Region were also interviewed on their experience of policy dialogue and system development.

This summary of the Review has been revised and updated to reflect the discussions and recommendations of a High-level Consultation on the Review, held in Manila on 22–24 July 2013 and attended by 25 representatives of 18 Member States, as well as WHO Secretariat staff. This summary presents the key findings of this extensive process, which is reported in full in the companion technical report. Based on consolidated findings and the High-level Consultation, this Summary Report also outlines recommendations regarding possible next steps for both Member States and the Secretariat.

By considering the use and usefulness of the strategies—and the regional health system context for which they have been developed—the Review provides a wealth of observations that Member States in the Western Pacific Region can use to strengthen their own health system development in order to meet the health challenges of the coming decades.

In addition to the main body of this Summary Report, the annexes are offered as a valuable resource for Member States, partners and a wider readership. The 18 annexes give background on the basis and context of developing the strategies, their main goals, high-level objectives and strategic areas of action. The annexes also provide information on the status of the ten Review countries on essential medicines, health financing, human resources, traditional medicine and health equity indicators in the regional health system strategies. In addition they show the proportion of deaths in the ten countries due to communicable diseases, noncommunicable diseases, (NCDs) and injuries. Tables 1 and 2 show country status on health system performance indicators across two time periods, including for example life expectancy, maternal and under-5 mortality, HIV and tuberculosis prevalence, alcohol consumption, tobacco use, total health expenditure and out-of-pocket payments at the point of care.

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B. REVIEW METHODOLOGY

B. Review methodology 1. Objectives The Review on the Use and Utility of Six Regional Health System Strategies has four main objectives that involve looking back and looking forward: 1. review implementation of key policies and programmes related to the six regional health system strategies by countries, WHO and partners; 2. assess the usefulness of the six Western Pacific Region health system strategies to countries, WHO and partners; 3. identify gaps and future needs to inform appropriate Western Pacific Region health system development approaches; and 4. identify major lessons learnt regarding WHO support to health system development.

The Review encompasses WHO, Member States and development partner activity relating to the areas of health system development covered by six regional health system strategies: • • • • • • •

Regional Framework for Action on Access to Essential Medicines in the Western Pacific (2011–2016) Regional Strategy on Human Resources for Health 2006–2015, and the Human Resources for Health Action Framework for the Western Pacific Region (2011–2015) Health Financing Strategy for the Asia Pacific Region (2010–2015) Asia Pacific Strategy for Strengthening Health Laboratory Services (2010–2015) Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care (published 2010) Regional Strategy for Traditional Medicine in the Western Pacific Region (2011–2020).

The Review takes a collective sector-wide view of the six health system strategies and activity relating to them. It was not the intention of the Review to assess the strategies individually or to arrive at recommendations relating to individual strategies.

2. Methodology in brief This was a mixed-methods review, conducted in a pragmatic and iterative manner over one year. It was conducted with the active collaboration of Member States, development partners and WHO staff in the Regional Office and country offices. The Review also benefitted from the support, direction and oversight of a Steering Committee comprised of independent health system and evaluation experts drawn from across and outside the Region (TD1). Methods of data collection, collation, synthesis and analysis, along with key limitations, are described in full in the Technical Report.

3

The Review retrospective reference period is July 2004 to June 2012, the former date being the earliest introduction of any of the six WHO regional strategies. Three linked dimensions guided the Review’s data collection and processes: 1. assessment of health sector development activities by WHO, countries and partners; 2. assessment of health system performance and health outcome indicators from 1995 onwards in order to consider trends before and after regional and national strategy implementation; and 3. assessment of utility and implementation of the regional strategies, and identifying lessons learnt and issues for the future.

Ten low- and middle-income Member States in the Western Pacific Region were involved: Cambodia (KHM), China (CHN), Fiji (FJI), Lao People’s Democratic Republic (LAO), Malaysia (MYS), Mongolia (MNG), Papua New Guinea (PNG), the Philippines (PHL), Solomon Islands (SLB) and Viet Nam (VNM). The countries were selected to represent the range of size and of economic and health system development in the Region.

Methods for individual Review elements included: desk review and analysis of relevant documentary sources (including WHO sources, national strategies and policy sources); key informant interviews (with national officials and health system personnel, development partners and WHO staff ); extensive dialogue with relevant Western Pacific Region technical units; collation and analysis of indicator data, principally from the WHO World Health Statistics and Global Health Observatory, with other data sources used where appropriate. In order to elicit the richest information possible, the interviews considered policy and health system development in its broadest sense encompassing the health system strategies rather than focusing on them directly. Strategies and related work were considered on characteristics such as relevance, coherence, technical quality, usefulness and sensitivity to local context.

The prospective reference period for looking forward extends to around 2020. The Review commissioned a paper to examine the challenges and opportunities for health system development in the Western Pacific Region, with particular reference to changing demographic, economic, epidemiological and political contexts.

Evidence was synthesized and analyzed using methods designed to provide information and observations to fulfil the Review’s objectives. Observations drawn from these analyses were then combined to arrive at overall observations.

Several research approaches have been adopted to ensure that the Review and its observations are as robust as possible. The review process has at all stages been transparent, and all documents and raw data are available, though with confidentiality protected. The wide range of data sources allow for triangulation of the evidence, and where observations are supported by more than one source and type of evidence this is recorded explicitly.

Gathering, synthesis and interpretation of evidence have been conducted by more than one researcher, usually working independently. Raw data and reports resulting from finished work

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B. REVIEW METHODOLOGY

strands have been independently reviewed and observations checked by members of the Review Steering Committee.

The draft Summary Report was reviewed at a High-level Consultation in Manila in July 2013 attended by 25 representatives from 18 Member States, eight WHO country office health system staff, six members of the Steering Committee, the Review team and many other Secretariat staff.

This final report has been revised as suggested by the consultation.

3. Scope and limitations Several limitations in the Review’s scope and methodologies must be acknowledged.

No high-income countries were included, which affects the ability of the Review’s analyses to consider differences between those countries and low- and middle-income countries. However, representatives from Japan, New Zealand and the Republic of Korea attended the High-level Consultation and commented on the Review and its findings.

The two Pacific Island countries included in the Review, Fiji (multi-ethnic) and Solomon Islands (predominantly Melanesian) are not representative of Micronesia, Polynesia or small Pacific Island countries and areas in general.

On the advice of the Steering Committee at the outset, the Review has focused primarily on the regional strategies and frameworks on Essential Medicines, Health Care Financing, Human Resources for Health and Health Systems based on the Values of Primary Health Care, and less on Laboratory Services and Traditional Medicines. However, the latter are included in the strategy content analysis, and analyses of national health plans and strategy indicators.

Much of WHO’s work on policy dialogue and influence is not easily measured or recorded. In other areas, inadequate and inconsistent WHO Secretariat recording practices, as well as staff shortages and turnover, especially in WHO country offices, limited the ability of the Review to assess health system development activities comprehensively in the ten countries. These issues contributed to the development of the framework in Figure 2.

Identification of interviewees—national key informants and WHO and development partner staff—was purposeful, with the aim of interviewing knowledgeable people in order to elicit information of value to the Review. Selection was necessarily opportunistic to some extent because the calibre of personnel sought meant that they were not always easily available for interview. These factors could have introduced some selection bias. The relatively limited numbers of interviewees, a result of resource and time limitations, may limit the strength of the evidence gathered.

The date of latest data available for health system performance indicators varies from indicator to indicator and country to country. In addition, aggregated data have been used in the analysis, which can mask health inequity in service provision, access and use. The Review had no way to validate data quality. The Review cannot, and does not, provide any attribution of links between the regional strategies and national health outcomes.

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GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

C. Regional context The Western Pacific Region is home to approximately 1.8 billion people, around 28% of the world’s population. One of the most diverse of the WHO regions, the Western Pacific has the largest continental country (China) and smallest island country (Niue) in the world, as well as some of the least-developed nations and the most rapidly emerging economies. It includes highly developed countries such as Australia, Japan, New Zealand, the Republic of Korea and Singapore, and fast-growing economies such as China, Mongolia, the Philippines and Viet Nam. Challenges that are evident globally are also seen across the Western Pacific, where changes are unfolding with equal, if not greater momentum. Spurred in recent years by political reforms and dynamic economic development, most of the Region’s Member States that were formerly classified as low-income countries are now graduating to middle-income countries.3 For example, in 2010, Viet Nam advanced from low-income to lower middle-income country status, with an annual average growth rate of 7.3% and a per capita income that has increased fourfold in the last 20 years.4

Economic progress and widening social gaps Economic progress has had significant health benefits for the populations concerned. Although the Region has been less severely impacted by the 2008 global recession and austerity measures required in many countries, notably in Europe, progress is unequally spread within and between countries, with rural and vulnerable groups being left behind. Health gaps between the richer and poorer sections of societies are growing ever wider. Large numbers of poor people are faced with difficult situations when illness strikes and they have little or no access to formal health care as they cannot afford to pay for it, or if they do manage to pay for it but have no additional financial protection, they are faced with a further descent into poverty. Inequity in access and in health outcomes is associated with social determinants of health such as nutrition, housing, geographical location, education, income, sex, gender and age. Persisting health inequities in many Western Pacific countries explain why the goal of universal health coverage (Box 2) is essential and why it is receiving increasing attention and support.

Demographic transition Demographics are also changing, with increasing life expectancies and growing proportions of elderly people. Regionally, overall life expectancy at birth for both men and women rose from 70 years in 1990 to 76 years in 2011.5 The increase in the proportion of people aged over 60 years is especially rapid in low- and middle-income countries. For example, while Australia, Japan and http://data.worldbank.org/about/country-classifications/country-and-lending-groups#Lower_middle_income World Bank (2012). Viet Nam development report 2012: market economy for a middle-income Viet Nam. 5 WHO (2013). World Health Statistics 2013.

3 4

6

C. REGIONAL CONTEXT

New Zealand took five decades to double their ageing population from 7% to 14%, Cambodia, the Lao People’s Democratic Republic and Papua New Guinea are projected to achieve the same increase in less than 30 years. In 2010, 77% of the 235 million people aged 60 years and above in the Region lived in low- and middle-income countries.

This situation has been accompanied by falling birth rates, especially in developed countries, and a continuous flow of rural to urban migration. These trends in part reflect the success of countries’ development and public health policies, but also present challenges to communities and health systems as they aim to maximize the health and functional capacity of older people and their social participation and security. The fast rate of population ageing in low- and middle-income countries significantly narrows the window of time available for governments and societies to prepare for and respond to the complex social, economic and public health implications.

Epidemiological transition Economic, social and demographic transitions have been accompanied by an epidemiological transition: a shift from infectious diseases, which historically have been the main global challenge, especially their impact on children, to noncommunicable diseases (NCDs), which mainly affect adults. In the Western Pacific Region, four out of every five deaths are due to the most common NCDs— cancer, cardiovascular disease, chronic respiratory conditions and diabetes. The growth in prevalence of NCDs is driven in Area shows the proportion relative to the total number of deaths. See Annex 18 part by the ageing population, but for explanation of abbreviations. also by environmental and lifestyle Source: Institute for Health Metrics and Evaluation. factors associated with economic and social change, such as urbanization, pollution, changing diets, tobacco use and reduced exercise. Box 1 demonstrates the predominance of NCDs (blue) among the proportion of deaths compared to communicable diseases (red) and injuries (green) in Mongolia. Graphs showing the proportion of deaths in all 10 of the Review countries are in Annex 18.

Box 1. Causes of deaths in Mongolia, both sexes, all ages, 2010

The rapid rise in the prevalence of NCDs and associated chronic disability poses major challenges for health systems and has wider economic and social implications: NCDs reduce productivity, negatively affect development trends, and increase individual and household poverty. Across the Region, the poorest people have the highest burden of NCDs, as they have greater exposure to risk factors and less access and use of preventive and therapeutic services. Dealing with

7

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Box 2. Universal health coverage and the health system The WHO health system framework* identifies and addresses six interconnected components of a health system: service delivery, health workforce, information, medicines and equipment, financing, and governance. The major goals of the health system are to attain better health and increased responsiveness, financial protection, equity and efficiency. These health system components and goals are fundamental to the achievement of universal health coverage.

Universal health coverage is defined by WHO** as ensuring that all people can use the promotive, preventive, curative, rehabilitative and palliative health services they need, of sufficient quality to be effective, while also ensuring that the use of these services does not expose the user to financial hardship. This definition embodies three related objectives: • equity in access: those who need health services should get them, not only those who can pay; • the quality of health services is good enough to be effective in improving health; and • people are protected from the risk of financial hardship due to the cost of using services.

Universal health coverage is firmly based on the WHO Constitution of 1948 declaring health as a fundamental human right. Achieving the health Millennium Development Goals and the next wave of targets beyond 2015 will depend largely on how countries strengthen their overall health system, both public and private, using whole-of-system approaches (see Box 10), and engaging with others sectors on social determinants of health and social protection, in a whole-ofgovernment approach to health. * Everybody’s business: strengthening health system to improve health outcomes. WHO, 2007. ** http://www.who.int/healthsystems/universal_health_coverage

NCDs are a major challenge for all Western Pacific countries. For low-income countries, the NCD epidemic adds to the loss of lives from communicable diseases, causing a double burden.

It has been estimated that the average treatment cost for an elderly person is seven or eight times higher than the cost of treating a child.6 As treatment is often long-term as well as expensive, meeting these growing needs will require tremendous increases in resources and innovative approaches to service delivery.7 Recent reports have highlighted diabetes and cardiovascular epidemics in Viet Nam8 and China9 and the difficulties they present to health systems. “These changes will require an integrated government response to improve primary care and undertake required multisectoral action to tackle key risks. Analyses of disease burden provide a useful framework to guide policy responses to the changing disease spectrum in [countries],” according to the findings of a recent study on the global burden of disease.10 It is in this context that the Western Pacific Region’s six health system strategies and frameworks were developed in order to guide health system development in Member States as well as the work of WHO staff.

United Nations Population Fund (2012). Ageing in the twenty-first century: a celebration and a challenge.

Regional-Director’s speech, World Health Summit Regional Meeting, Singapore, 9 April 2013.

8 Diabetes surges in Viet Nam, International Herald Tribune, 5 June 2013.

9 Under-diagnosis of hypertension reveals bigger health system gap in China, South China Morning Post, 2 June 2013.

10 Yang G, Wang Y, Zeng Y, et al. (2013). Rapid health transition in China, 1990–2010: findings from the global burden of disease study 2010. The Lancet, 2013, Volume 381, Issue 9882:1987–2015.

6 7

8

D. REVIEW FINDINGS

D. Review findings This section of the Summary Report presents the main findings relating to each of the Review’s objectives. Objectives 1 and 2 are retrospective and consider previous health system development activities and the utility of the strategies, while Objective 3 considers gaps in strategies and future needs. Objective 4 is more prospective, aiming to consider lessons that can be applied in the future. Thus, the findings for Objective 4 are presented as discussion of the findings on the first three objectives and implications for future health system work.

A set of 20 technical documents (TD) generated during the Review, referred to throughout this Summary Report, is presented in Annex 2. These technical documents form the evidence base of the Review and reflect the breadth, depth and detail of the exercise. They provide details on the extensive and varied data collection and analyses conducted, and, along with comprehensive methodology, comprise the detailed Review Technical Report companion to this Summary Report, available on the Review SharePoint.11

D1. Findings on Objective 1 Objective 1: Review implemen­tation of key policies and programmes related to the six regional health system strategies by countries, WHO and partners.

The regional strategies are syntheses of the evidence on health system development and expressions of WHO’s values. Targets and strategic areas are summarized in Annex 4.

They inform the work of WHO staff and guide Member States on actions to improve health system functioning (TD1).#

Summary of findings — Objective 1 Country health system features: • increases in data available • overall progress on indicators • insufficient disaggregated data to fully monitor health equity, but data available show inequity in access to and use of services • some key events are linked to changes on indicator trends • generally increases in government expenditure on health and decreases in out-of-pocket expenditure as a percentage of total health expenditure (THE) • essential medicines and human resources data are difficult and/or expensive to collect, but data available show inequities in access to medicines and in human resources distribution

All the strategies contain indicators to monitor • outpatients receiving antibiotics exceed 10% target in all seven Review countries that have data country progress and performance in each of the health system areas. Implementation • antibiotics are available without prescription in all eight Review countries that have data of key actions in the regional strategies is examined through analysing country timelines, national health plans and trends on indicators. In the following sections, notable results are presented along with responses from key informant interviews related to the findings. http://intranet.wpro.who.int/sites/health_systems_strategies_review/default.aspx, username: WPPRD75\wpro_Review; password: Password123 # All numbers in italics and brackets throughout the text refer to numbered technical documents listed in Annex 2.

11

9

D.1.a Health care financing The Health Financing Strategy for the Asia Pacific Region (2010–2015) emphasizes evidencebased policy-making, monitoring and evaluation. The strategy includes four key indicators and benchmarks: • out-of-pocket (OOP) spending not above 30%–40% of total health expenditure; • total health expenditure (THE) at least 4%–5% of the gross domestic product (GDP); • over 90% of the population covered by prepayment and risk-pooling schemes; and • close to 100% coverage of vulnerable populations with social assistance and safety nets (Annex 4).

Many countries used the health financing policy as a guiding document for high-level policy dialogues to put health higher on the national development agenda and to raise the importance of multisectoral contribution to health (see also Box 9).

Analysis of national health and health financing plans reveals that seven of the ten countries have recognized the need for action to address OOP health expenditure and most are making some progress (Box 3). Fiji, Papua New Guinea and Solomon Islands have mainly taxbased health systems and have low OOP spending.

Box 3. OOP as % THE 2005–2011

WHO has been actively engaging Box 4. Health care financing expenditure (US$) in countries to monitor and to evaluate China 1995–2011 progress through survey data and routine statistics on the key health financing indicators. Annex 15 and Box 4 present annual data from the WHO global health expenditure database for 1995 to 2011 in the ten Review countries on THE, government health expenditure (GHE) as a proportion of THE, and OOP as a proportion of THE. All countries show some increase in THE over the period, and most also show some reduction in OOP as a proportion of THE.

10

For example, in China increases in GHE can be linked with a decline in OOP as a percentage of THE since 2007 (Box 4). China has made concerted efforts over several years to extend staffing and quality for primary care services, in addition to enrolling more poor and rural people in various insurance schemes. Collectively, these policies with increased GHE could be said to have resulted in reduced OOP. However, increased THE and GHE do not always result in decreased OOP (Annex 15). An increase in the proportion of OOP can accompany increased GHE and THE,

D. REVIEW FINDINGS

for example where improving economies result in a growing middle class and increased use of private health care, as in Malaysia and the Philippines. During the Review process, Malaysia expressed a need for WHO support in regulating the private health sector.

D.1.b Access to essential medicines Strategic action areas in the Regional Framework for Action on Access to Essential Medicines in the Western Pacific (2011–2016) include national medicines policy and medicines regulation, medicines procurement and supply system, substandard and counterfeit medicines, adequate financing and affordable prices, and intellectual property rights and international trade agreements (Annex 4).

Key informant interviews show that WHO plays a strong role in helping countries develop their national medicines policies and is a source of technical guidance on pharmaceuticals, particularly emphasized in China, Malaysia and Viet Nam (TD5).

Five of the Review countries have national medicines policies that could be accessed: Cambodia, Fiji, Lao PDR, Malaysia and the Philippines. These country medicines policies cover training on drug issues, demand-side strategies and collaboration. However, areas recommended in the Regional Essential Medicines Framework that are not well covered include: monitoring of the effects of trade policies, information on medicines financing, price monitoring, efficiency (including cost-containment and financial management), use of WHO pre-qualified products, pharmaceutical sector assessment and antimicrobial resistance (Table 3, pp26–27).

For the other five Review countries, their national health plans were assessed for provisions relating to essential medicines. Mongolia’s national health plan mentions access to essential medicines, regulation and quality assurance, and rational use of medicines, as well as identifying related challenges. Access, regulation and rational use are mentioned only briefly in Viet Nam’s national health plan. Policy and access and rational use are discussed in China’s plan. Only policy and access are discussed in Papua New Guinea’s plan, while none are included in the plan of the Solomon Islands (TD5).

Weaker areas identified in countries’ plans are also reflected in the essential medicines indicators (Annex 13). Limited data are available relating to the availability of medicines, public procurement prices, rational use and compliance with standard treatment guidelines. Availability and procurement prices can be monitored through relatively simple, inexpensive systems. Rational use and adherence to treatment guidelines are more challenging and expensive to measure, but some countries have developed self-monitoring indicators that are routinely reported by lowerlevel facilities (e.g. China).

All countries providing data have some provisions in place for the regulation and licensing of pharmaceutical production and supply. Data that are available suggest that most countries are implementing actions related to financial coverage for essential medicines. However, limited disaggregated data are available on access to medicines. Data on service access suggest that access to use of and funding for medicines is inadequate for poor and difficult-to-reach populations. For health outcome indicators, where correct use of quality medicines is critical,

11

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

such as maternal and child health and NCDs, available disaggregated data suggest that there is inequitable coverage (TD5).

% Outpatient prescriptions with antibiotics

All seven countries for which data Box 5. % Outpatients receiving Antibiotics, 2012 are available report percentages of 70 outpatients receiving antibiotics 60 in excess of the 10% regional 50 target. In the Philippines, Lao PDR 40 and Cambodia percentages are 63%, 57% and 55% respectively 30 (Box 5 and Annex 13). Antibiotics 20 are dispensed over the counter 10 without prescription in all eight 0 MYS CHN MNG VNM KHM LAO PHL of the Review countries reporting on this issue. Only the Philippines’ See Annex 13 National Medicines Policy includes approaches on antimicrobial resistance, but the degree to which they are currently implemented is uncertain (TD5).

D.1.c Human resources for health The Human Resources for Health Action Framework for the Western Pacific Region (2011–2015) outlines four key result areas for the health workforce: 1) response to population health needs; 2) education and continuing competence; 3) deployment, management and retention; and 4) governance and partnerships for sustained health workforce contributions to improved health outcomes (Annex 4).

In Cambodia, Lao PDR and Papua New Guinea, 20 of 34 key informants expressed the view that capacity-building in human resources for health is an important and valued part of the WHO Secretariat’s work, but it is also an area in which more could be done (TD17). Participants at the high-level consultation (22–24 July 2013) that formed part of this Review, requested more support for health workforce capacity-building in health system development. Summary analyses of WHO Secretariat health system work suggest that 30% of reported activities at country office level and 13% at Regional Office level are associated with health worker capacitybuilding (Annex 7 and TD16).

Notably successful WHO human resources work, such as the workforce retention initiatives in Lao PDR and the Pacific Open Learning Health Net (POLHN) continuing education initiative, have been characterized by common elements. These include close collaboration with national agencies and development partners that has been sustained over time; flexibility and responsiveness to local contexts, needs and capacities; and activities and methods that are in line with the Regional Strategy on Human Resources for Health 2006–2015 and the Human Resources for Health Action Framework for the Western Pacific Region (2011–2015) (TD14).

12

Effective strategic planning and management of human resources for health depends upon good information, but capacity to monitor the workforce in countries appears to be poor. Data on

D. REVIEW FINDINGS

Box 6. Inequity in skilled birth attendance, 5 countries, 2010/2011

80

98 99

95

100

99 91

80

77

60

48

40

91

98

99

99 85 72

80

67

60

97

100

By education level of mother

Poorest Richest

By wealth quintile

Rural Urban

By place of residence

49

KHM

LAO

MNG

PHL

VNM

91

45

47

KHM

LAO

MNG

PHL

VNM

20

16

20

11

0

0

100

96 100

40

20

20

93

91

80 60

48

40

31

100

Lowest Highest

0 KHM

LAO

MNG

PHL

VNM

KHM: Demographic and Household Survey 2010: www.measuredhs.com/pubs/pdf/FR249/FR249.pdf LAO: Social indicator survey 2011 http://www.measuredhs.com/publications/publication-fr268-other-final-reports.cfm MNG: Multiple Indicator Cluster Survey 2010: www.childinfo.org/files/MICS4_Mongolia_SummaryReport_Eng.pdf PHL: Family Health Survey 2011: www.census.gov.ph/old/data/pressrelease/2012/pr1279tx.html VNM: Multiple Indicator Cluster Survey 2011 www.childinfo.org/files/MICS4_Vietnam_FinalReport_2011_Eng.pdf

indicators recommended in the human resources action framework are presented in Annex 14.

Data are available for strategic response, staffing levels, education training and competence indicators in many countries, but not for indicators on workforce utilization, management, retention, governance, leadership and partnerships.

The data available (Annex 14) highlight inequities in access to and use of health care. In Lao PDR only 22% of health workers are rural, while 66% of the national population lives in rural areas. In Papua New Guinea the mismatch is even more marked, with only 18% of health workers being rural, while 88% of the national population lives in rural areas. In the Philippines the number of qualified health workers per capita is highest of the ten Review countries, and this is especially true of midwives. Yet the percentage of births attended by trained health professionals is lower than several countries with significantly fewer health workers and shows greater inequity than in other countries except Lao PDR (Box 6). While countries might have more up-to-date data on national average for skilled birth attendance, disaggregated data such as that presented in Box 6 tends to rely on population-based surveys undertaken around every five years (e.g. Demographic and Household Surveys, and Multiple Indicator Cluster Surveys).

D.1.d Health system performance and health outcomes The Review collated data on many of the indicators proposed in the six regional health system strategies in order both to describe the context for the Review and to assess countries’ current status in health system strengthening and health outcomes. The data for access to essential medicines, human resources for health, health financing and traditional medicines are presented in Annexes 13–17 (TD10).

In Tables 1 and 2, information is presented on 33 of the 47 indicators proposed by WHO headquarters for monitoring health system performance12 and universal health coverage.

The two tables present data from 1994 to 2003 and 2004 to 2012, with the latest data for each country favoured in each time period. The strength of countries’ performance is illustrated by means of colour gradation, with darker shades indicating better performance. Fourteen of the 12

WHO and the International Health Partnership (IHP+) (2011). Monitoring, evaluation and review of national health strategies

13

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

47 indicators are not included either because they could not easily be graded or because data are not available or not feasible to collect. These include indicators on quality, International Health Regulations (2005) and characteristics of national health planning processes (TD10).

In Tables 1 and 2, the country columns are ordered horizontally according to total health expenditure (THE) per capita (top row), while vertically the indicators have been arranged in accordance with their visual matching to the top-row ordering. Differences between the two time periods illustrate improving health system information, services and outcomes. Table 2 has both more data and more dark green than Table 1, indicating better outcomes. For example, in the earlier period, three countries have seven to 11 indicators with levels worse than the poor level, while in the more recent period, the same countries have only two to five indicators with levels worse than the poor level. Similarly, in Table 1, 47% of the data is missing while in Table 2, only 15.5% is missing. In the earlier period, there were no data from any of the ten Review countries on 16 of the 33 indicators, while in the more recent period, all of the 33 indicators have data reported from at least two of the countries, though 11 of the indicators have data reported from less than seven of the ten countries.

In the upper rows of Table 2, countries with higher THE per capita appear to have better outcomes on indicators such as life expectancy and mortality, and on service delivery such as skilled attendance at birth and DPT3 immunization coverage. However, patterns of shading in lower parts of the chart suggest that outcomes may be less influenced by THE and more by other factors. Lower prevalence of overweight in some countries with lower per capita THE possibly reflects nutrition deficits or more rural subsistence lifestyles, while increased antiretroviral coverage among HIV-positive adults likely reflects increased financial assistance to countries.

D.1.e Equity, gender and human rights Equity is discussed by all the current strategies and frameworks. Collectively they aim to protect citizens from the consequences of ill health and ensure universal coverage of services for equitable health outcomes. They note that equity occurs within a system where staff members are aware of equity and resources are present to foster equity in the long term. Only three of the six strategies mention the importance of disaggregating information by social stratifiers to monitor equity, and only two propose any disaggregation of indicators. The Human Resources for Health Action Framework for the Western Pacific Region (2011–2015) proposes disaggregation on a number of human resource input and production indicators, while Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care proposes a small number of outcome and impact indicators with social stratifiers. The regional health system strategies and action frameworks say much less about gender and human rights.

A review of national health plans in the ten Review countries indicates that frequent reference is made to equity, gender and human rights (Table 3, part 4), but with great variation. For example, equity is mentioned in all ten of the national health plans, and four include specific actions to address inequities. Gender is discussed in only half of the plans. References to human rights or the right to health are made in few national plans and without any specific actions identified. Data

14

D. REVIEW FINDINGS

aggregated at the national level (as in Tables 1 and 2) often mask inequalities in the distribution of, access to and use of health care. This is demonstrated by the graphs in Box 6 and Annex 17.

Disaggregated data offer the potential to consider health service development and health outcomes among different subgroups of the population, defined, for example, by gender, sex, age, income, and rural or urban domicile. Published health statistics from eight of the Review countries shows countries collect disaggregated data on a diverse range of indicators. Most commonly they are stratified by subregion, rural/urban domicile, followed by sex and then age (TD12).

Box 6 and Annex 17 show that in most of the Review countries for which data are available, infant and under-5 mortality rates, skilled birth attendance, antenatal care coverage, immunization, stunted growth in children, and access to improved water and sanitation are better in urban than in rural settings, and for those in higher than lower income groups, with Mongolia being a notable exception where greater equity is more evident.

D.1.f Key country actions or events To review the implementation of policies and programmes related to the strategies, efforts were made to collect country information and information on the work of the WHO Secretariat. The Review, with guidance from WHO country offices and technical units, collected information on key country actions and events that were associated with health system development or led to the creation of other policies. The main events were plotted on a timeline for each of the ten countries. The timeline for China is presented as Figure 1 as an example. The others can be found in TD8 as listed in Annex 2.

Country actions and events give an overview of strategy implementation and overall health system development. Events can be linked to changes in trends on indicators, but it is not possible to attribute causality. Almost invariably, improving trends in health indicators are affected by more than one policy or event, and several policies may be needed for sustained effects. Box 7 describes several actions taken by Cambodia to reduce maternal mortality.

Although it is not possible to attribute these initiatives directly to the regional health system strategies, they are in line with recommendations in the strategies.

15

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Box 7. Health system levers to reduce maternal mortality in Cambodia Cambodia has recorded one of the world’s biggest reductions in maternal mortality, with a fall in the number of deaths of about two thirds since 1990. This compares to a global average drop of almost half over the last 30 years. While in 2000 only 39% of pregnant women had at least one antenatal check-up with a health care provider, this figure was almost 90% by 2010.

The policies and actions Cambodia used for this achievement resonate with recommendations of the six health system strategies. Elements of particular relevance are in italics in the text below. Rapid economic growth and improvements in health care in Cambodia help explain why fewer women are dying in or around childbirth. But important specific factors are the strategic planning and implementation of innovative health policies.

Among these, ensuring universal access to skilled birth attendants is essential in reducing maternal and newborn deaths. Cambodia has been pursuing this since the mid-2000s with support from WHO and other international agencies and partners. Health centres began operating 24 hours a day, and other measures made maternity services more accessible.

The Ministry of Health also adopted a strategy of increasing the training of midwives and their absorption into the health system through deployment based on population need. Now all health centres nationwide have a primary midwife with one year of training, and more than half have a secondary midwife with three years of training.

To increase further the proportion of births attended by a skilled midwife, the ministry offered financial incentives to staff.

For every live birth at a health centre, the birth attendant receives a US$ 15 bonus, while every live birth at a referral hospital carries a US$ 10 incentive.

Skilled birth attendant-assisted deliveries rose from 46% in 2007 to 70% in 2010, and deliveries taking place in health facilities rose from 26% to 59% over the same period. The increase in facility-based deliveries occurred across the whole Cambodian population. The proportion doubled among the richest 20% of the population and quadrupled amongst the poorest 20% of the population.

Source: http://www.wpro.who.int/about/administration_structure/dhs/story_cambodia_reduces_maternal_mortality

D.1.g WHO Secretariat core functions (WHO Secretariat work) Sections D.1.a to D.1.f present various aspects of country health system work and progress. The next three section focus on aspects of the Secretariat’s work.

From 2010 to 2012, WHO in the Western Pacific Region has invested on average approximately US$ 24 million annually in health system work by the Regional Office (50%) and the country offices in the ten Review countries collectively (50%). This involves the cost of staff and the activities they support. The number of health system posts has increased from 24 in 2004 to 52 in 2012.

While the reference period for the Review was intended to be 2004 to 2012, changes in procedures and staff and generally poor recording and electronic archiving meant that the Review was able to collect only limited information on WHO Secretariat work prior to 2009 and even less prior to 2007.

16

D. REVIEW FINDINGS

WHO health system work at regional and country levels in the Region is spread across all six Secretariat core functions, but not evenly. Annex 7 provides a summary overview of the focus of regional and country office health system activities by WHO’s six core functions. Although there is broad consistency, there are also some notable differences. For example, the major emphasis for the Regional Office is on national health policies, strategies and plans, but for country offices it is on training and capacity-building in human resources for health. A key informant in Papua New Guinea expressed particular appreciation of capacity-building, noting that “WHO works hard to develop local capacity rather than just to deliver support that cannot be sustained.” Work on norms and standards appears to receive more attention at the country level than at Regional Office level. From a health system development perspective, the analysis reveals a low focus on multisectoral work by the health system teams at both regional and country office levels (TD16).

D.1.h Resource mobilization for health system development At both the regional and country office levels, WHO staff have helped countries mobilize large amounts of funding for health system strengthening. Since 2007, WHO staff have supported Joint Annual Health Reviews in Viet Nam. In 2010, the results of such a review were used in a successful application to the GAVI Alliance health system funding platform that secured US$ 24.4 million for health system strengthening (TD9).

Between 2006 and early 2010 the health system teams supported Cambodia, China, Fiji, Lao PDR, Mongolia, Papua New Guinea and Solomon Islands to raise a total of US$25.7 million from the GAVI Alliance for health system strengthening, and a further US$ 200 million for Cambodia, China, Fiji, Lao PDR, Mongolia, Papua New Guinea and Viet Nam from the Global Fund to Fight AIDS, Tuberculosis and Malaria (TD9).

In 2010 and 2011 the Region again was successful is helping Lao PDR, the Solomon Islands and Viet Nam to raise a total of US$ 28.9 million through the GAVI/Global Fund joint health system funding platform where the two global health initiatives (GHI) attempted to harmonize their application processes (TD9).

WHO supports not only proposal development but also technical assistance for implementation, monitoring and reporting of these GHI-funded health system strengthening activities (TD9).

D.1.i Initiating global developments In developing the current and previous regional health system strategies, the Western Pacific Region has spearheaded work on a number of issues that now are accepted globally. For example, in 2004 the Region launched a Rapid Alert System (RAS) as a portal to enhance surveillance of counterfeit medicines and facilitate exchange of information between countries. The RAS is a Western Pacific Region project that is now being implemented globally. Starting with Cambodia, Mongolia and the Philippines, the RAS expanded to over 40 countries in the Western Pacific and South-East Asian Regions. Some countries also developed national alert systems (TD14).

17

18

Indicator Total health expenditure (THE) per capita at exchange rate (US$) Maternal mortality ratio per 100 000 live births Under 5 mortality rate per 1000 live births Children aged <5 years who are stunted (%) Skilled attendance at birth (% of live births) TB prevalence in population (per 100 000) TB case detection rate (% of estimated cases) Life expectancy at birth (years) (female) Adolescent fertility rate for women 15–19 years (per 1000) Population using improved drinking-water sources (%) DPT3 immunization coverage (% of infants 12–23 months) Life expectancy at birth (years) (male) General government health expenditure as % of GDP Antenatal care coverage (1+ visit) (% of pregnant women) Alcohol consumption among ≥15 yrs (litres of pure alcohol/person/yr) Contraceptive prevalence (% of women 15–49 years) HIV prevalence among 15–49 years old (%) Low birth weight among newborns (%) Population using improved sanitation facilities (%) TB treatment success rate (% of cases) Tobacco use: adults aged 15+ (%) (male) Tobacco use: adults aged 15+ (%) (female) Out of pocket as % of total health expenditure (THE) Condom use in adults 15–49 with more than 1 sexual partner (%) - M Average availability of 14 selected essential medicines (public) (%) Infants exclusively breastfed for the first 6 months of life (%) Median price ratio for tracer medicines (public) Children <5 years with respiratory symptoms taken to a health facility (%) Vitamin A supplementation among children <5 years (%) Children <5 years with diarrhoea receiving oral rehydration therapy (%) Antenatal care coverage (4+ visits) (% of pregnant women) Children <5 years sleeping under insecticide treated nets (%) Prevalence of raised BP among adults aged ≥25 years (%) (male) Prevalence of raised BP among adults aged ≥25 years (%) (female) ARV coverage among people with advanced HIV infection (%) Overweight adults aged 20+ (body mass index (BMI) >/=25) (%) (male) Overweight adults aged 20+ (body mass index (BMI)>/=25) (%) (female) Cervical cancer screening: women 18–69 years (%)

Poor 40 200 65 50 25 500 30 60 100 30 50 60 1 25 10 30 1 25 30 70 60 60 60 40 10 15 18 30 0 30 25 0 50 50 20 60 60 0

Better 500 10 5 5 100 20 100 80 10 100 100 80 5 100 0 80 0 5 100 95 0 0 20 70 95 80 1 100 100 100 100 90 10 10 80 10 10 70 11

0.8 10 19 63

18

1

59

56

34

1.2 23 18 91

0.1 18 28 77

2

58

2

6

35 68 57 3

59

44 69 57 2

45 49 61 1

45 530 56 62

PNG 25 310 72

17

KHM 26 510 102 49 32 1619 26 59

LAO 18 870 81 48 21 961 13 63

96 74 29

63

1 22 0.3 6 55 92

77 99 70 6

VNM 25 100 34 35 85 344 56 74

77 59

47 21

0.1 14 65 88

4

89 84 66 1

PHL 33 120 39 34 60 775 47 73

KHM=Cambodia CHN=China FJI=Fiji LAO=the Lao People’s Democratic Republic MYS=Malaysia MNG=Mongolia PHL=the Philippines PNG=Papua New Guinea SLB=the Solomon Islands VNM=Viet Nam Shading is against fixed points and does not refer to country reduction targets against 1990 baselines, or the new NCD reduction targets.

See Annex 12 for information on the fixed points used. Numbers in the lefthand column are reference numbers used in Annex 12.

Sources: World Health Statistics 2013, Global Health Expenditure Database, Global Health Observatory, World Health Survey 2003, Western Pacific Region Health Information & Intelligence Platform

No 1 40 39 34 17 42 26 38 45 32 18 38 2 16 30 19 43 35 33 12 28 28 46 37 9 36 10 20 22 21 16 23 29 29 24 31 31 27

Table 1. Data on 33 of 47 indicators to monitor health system performance, 1994–2003

87

88

48

0.1 3 49 87

2

65 98 60 3

MNG 42 96 63 30 99 433 51 68

53

12

0.1 10 74 85

2

91 94 65 3

98 107 33 71

FJI 94 31 22

49

56

2 45 93

80 86 70 2 90 4

CHN 61 61 35 22 89 170 33 73

29

28

0.4 9 92 78

0

96 96 69 3

MYS 185 39 11 21 84 138 68 75

Countries are sorted by Total Health Expenditure (THE - first row) Blank = data not available. Light green = poor. As green darkens means more positive

65

4

13 25 81

78 76 65 2 76 1

85 364 40 67

SLB 45 120 31

(latest available data for each country from within the period)

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Indicator Total health expenditure (THE) per capita at exchange rate (US$) Maternal mortality ratio per 100 000 live births Under 5 mortality rate per 1000 live births Children aged <5 years who are stunted (%) Skilled attendance at birth (% of live births) TB prevalence in population (per 100 000) TB case detection rate (% of estimated cases) Life expectancy at birth (years) (female) Adolescent fertility rate for women 15–19 years (per 1000) Population using improved drinking-water sources (%) DPT3 immunization coverage (% of infants 12–23 months) Life expectancy at birth (years) (male) General government health expenditure as % of GDP Antenatal care coverage (1+ visit) (% of pregnant women) Alcohol consumption among ≥15 yrs (litres of pure alcohol/person/yr) Contraceptive prevalence (% of women 15–49 years) HIV prevalence among 15–49 years old (%) Low birth weight among newborns (%) Population using improved sanitation facilities (%) TB treatment success rate (% of cases) Tobacco use: adults aged 15+ (%) (male) Tobacco use: adults aged 15+ (%) (female) Out of pocket as % of total health expenditure (THE) Condom use in adults 15–49 with more than 1 sexual partner (%) - M Average availability of 14 selected essential medicines (public) (%) Infants exclusively breastfed for the first 6 months of life (%) Median price ratio for tracer medicines (public) Children <5 years with respiratory symptoms taken to a health facility (%) Vitamin A supplementation among children <5 years (%) Children <5 years with diarrhoea receiving oral rehydration therapy (%) Antenatal care coverage (4+ visits) (% of pregnant women) Children <5 years sleeping under insecticide treated nets (%) Prevalence of raised BP among adults aged ≥25 years (%) (male) Prevalence of raised BP among adults aged ≥25 years (%) (female) ARV coverage among people with advanced HIV infection (%) Overweight adults aged 20+ (body mass index (BMI) >/=25) (%) (male) Overweight adults aged 20+ (body mass index (BMI)>/=25) (%) (female) Cervical cancer screening: women 18–69 years (%)

Poor 40 200 65 50 25 500 30 60 100 30 50 60 1 25 10 30 1 25 30 70 60 60 60 40 10 15 18 30 0 30 25 0 50 50 20 60 60 0

Better 500 10 5 5 100 20 100 80 10 100 100 80 5 100 0 80 0 5 100 95 0 0 20 70 95 80 1 100 100 100 100 90 10 10 80 10 10 70 81 28 24 53 12 18

32 18 51

75 26

LAO 37 470 42 48 37 540 32 69 110 70 78 66 1 71 7 38 0.3 11 62 91 51 4 40

KHM 51 250 43 41 71 817 64 66 48 67 94 64 1 89 5 51 0.6 9 33 94 42 3 57 40 98 74 6 64 71 34 59 82 23 17 95 11 14 2.2 29 33 21 18 68 45 50

40 61 61 3 65 4 36 0.7 10 19 58 58 31 12

PNG 79 230 58 44 43 534 61 65

73 83 66 60 63 29 23 58 9 11 7.7

56 17

VNM 95 59 22 31 92 323 56 77 35 96 95 73 3 94 4 78 0.5 5 75 92 48 2 56

PHL 97 99 25 32 62 484 76 73 53 92 80 66 1 91 6 49 0.1 21 74 91 47 10 56 22 15 34 17 50 76 59 78 97 29 24 51 25 29 4.9 65 71

65 40 27 26

74

13 29 87 46 19 3

SLB 134 93 22 34 70 162 70 71 70 79 88 68 8 74 1 35

45 33 27 41 46

80 59 3 87 61 56 81

MNG 161 63 31 28 99 348 68 73 20 85 99 64 3 99 3 55 0.1 5 53 86 48 6 40

33 30 87 60 73

39

87 67 18 3 21

0.1

100 33 92 72 30 96 99 67 3 100 3

FJI 168 26 16

30 26 32 25 25 16.5

1

CHN 278 37 15 9 96 104 89 77 6 92 99 74 3 94 6 85 0.1 3 65 96 51 2 35

29 25 37 42 50 23

2

25

0.4 11 96 80 50 2 42

MYS 346 29 7 17 99 101 85 76 14 100 99 72 2 83 1

(latest available data for each country from within the period)

KHM=Cambodia CHN=China FJI=Fiji LAO=the Lao People’s Democratic Republic MYS=Malaysia MNG=Mongolia PHL=the Philippines PNG=Papua New Guinea SLB=the Solomon Islands VNM=Viet Nam Countries are sorted by Total Health Expenditure (THE - first row) Shading is against fixed points and does not refer to country reduction targets against 1990 baselines, or the new NCD reduction targets.

Blank = data not available. Light green = poor. As green darkens means more positive See Annex 12 for information on the fixed points used. Numbers in the lefthand column are reference numbers used in Annex 12.

Data sources: World Health Statistics 2013, Global Health Expenditure Database, Global Health Observatory, Global status report on noncommunicable diseases, Western Pacific Region (WPR) Health Information & Intelligence Platform, WPR Country Health Information Profiles (CHIPs) 2010 and WPR Essential Medicines survey (2011).

No 1 40 39 34 17 42 26 38 45 32 18 38 2 16 30 19 43 35 33 12 28 28 46 37 9 36 10 20 22 21 16 23 29 29 24 31 31 27

Table 2. Data on 33 of 47 indicators to monitor health system performance, 2004–2012

D. REVIEW FINDINGS

19

Urban health care system

Guideline on Pharmaceutical Production and Quality Management Practices

Urban Employee Basic Medical Insurance system, Medical Saving Account and a Social Pooling Account

Law on Practicing Doctors

Economic reform

1952

1999

1978

1998

Decision on Health Reform and Development, focusing on a community-based health care system

1997

New Rural Cooperative Medical System

Severe Acute Respiratory Syndrome (SARS) outbreak

2003

Urban Resident Basic Medical Insurance System governmentsubsidized voluntary insurance scheme, targeting urban unemployed residents

2007

Development Research Centre report on health system reform ‘China’s health system reform has failed’

Reform of Public Hospitals

2010

2012

Guideline for deepening health system reform To achieve universal health coverage of primary health services by 2020 1. To accelerate the establishment of the basic medical security system 2. To set up the structures for the national essential medicines system 3. To improve the grass-roots health care services system 4. To gradually press ahead with the equalization of basic public health services 5. To push forward pilot projects for public hospital reform

Guideline for Urban Community Health Services Development Complete a comprehensive community health care system by 2010 1. Making health insurance coverage available to all urban and rural residents 2. Improving access to care by strengthening primary care capabilities in small hospitals and CHCs

2006

Urban Medicaid System

2005

Rural Medicaid System

2004

Centre for Disease Prevention and Control established

2002

Medical Finance Assistance

Rural health care system: Cooperative Medical System

Division of Traditional Chinese Medicine

2000

1950

20

1950s

2009

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Figure 1. China key country events impacting on health system development

D. REVIEW FINDINGS

D.2. Findings on Objective 2 Objective 2: Assess the usefulness of the six Western Pacific Region health system strategies to countries, WHO and partners

D.2.a Usefulness of the regional health system strategies to countries Analyses of national health plans and health system policies in the ten Review countries reveal that they reflect many of the recommendations in the strategies (Table 3, Annex 4, TD5). The ten national health plans also have explicit or implicit references to universal health coverage (UHC) and the associated values of equity, gender and human rights (Annex 5). Country goals reflect local aspirations for access to quality health services and financial risk protection for the population, especially the poor and vulnerable. Box 8 gives an example from Fiji.

It is difficult to attribute this directly to the regional health system strategies or to WHO partnership with countries; the Secretariat has no systematic processes for recording its work or assessing its impact in countries (TD14).#

Summary of findings — Objective 2 The regional health system strategies are: • technical, evidence-based knowledge • expressions of WHO values • used by countries as benchmarks for evidence-based ideas and advocacy for policy-makers • used in national health plans • most useful when the country office has dedicated staff with the relevant skills • used in 14 WHO regional programme strategies and frameworks.

Box 8. Fiji’s aspirations “The Strategic Plan has been developed (so that) communities (will) have access to effective, efficient and quality clinical health care and rehabilitation services…

Government has recognized the need to strengthen health care services and through the Peoples Charter has made a commitment to have an annual increase to the health budget.”

However, interviews with national key informants who have been involved in national health planning indicate that the Strategic Plan 2011–2015: Shaping Fiji’s Health, Ministry of Health.

WHO Secretariat’s health system work is highly valued. WHO is often regarded as the lead health sector partner, whose long-term presence and technical partnership with countries are appreciated (TD17).

Where national key informants were familiar with the strategies, they regarded them as useful sources of evidence-based ideas and benchmarks, providing easy access to best practices, and for leverage in convincing governments to commit support and funding for health system development. There are several examples showing that WHO regional health system strategies and WHO staff advocacy for their recommendations have influenced Member States’ health system planning.

In Malaysia, seven of the eight informants were aware of the six health system strategies, and regarded them and support from WHO as instrumental in health system development. Four interviewees commented that WHO’s evidence-based strategies had been used even without WHO staff or funding support (TD17). Interviewees in Malaysia specifically mentioned WHO as the key catalyst for development of their National Medicines Policy (2007). #

All numbers in italics and brackets throughout the text refer to numbered technical documents listed in Annex 2.

21

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Two of the eight interviewees in Papua New Guinea commented “WHO is the main source of evidence-based policies and advice” for health system development, and highlighted the usefulness of the Health Financing Strategy for the Asia Pacific Region (2010–2015) as a source of evidence for use in lobbying. “In the past they [government] said we [DoH] are just spending money, but I think the message is now getting to people that health is an investment. WHO can come with some good arguments.” (TD17) In China, the 2005–10 Essential Medicines Strategy had been used as a principal reference in the development of national essential medicines policy and action plans. It was translated into Chinese for use by the Ministry of Health and provincial institutions (TD14). The financing strategy (2010–2015) was regarded by one interviewee in China as having been directly useful, providing ideas on how to monitor government and out-of-pocket expenditures (TD17). Similarly in the Philippines, the two WHO regional financing strategies contributed to development of the national financing strategy and approaches to universal health coverage (Box 9).

Despite these notable examples, the health system strategies are not usually the primary motivating factor for Member States in developing their policies or plans. Rather, national strategies most often stem from domestic political decisions (Annex 6, TD17), though external influences, such as the MDGs, global agendas (e.g. tobacco control) or WHO publications (e.g. the World Health Report) do play a part.

In Malaysia, the Philippines and Viet Nam awareness of the regional strategies is mostly good, but in several other Review countries awareness appeared low among the interviewees. However, this could be due to selection of the interviewees. Dissemination of the strategies appears to have been neither systematic nor thorough. In Papua New Guinea seven of the eight interviewees thought that awareness of the strategies was low in the Department of Health, and four were unaware personally. In Lao PDR interviewees were frequently unaware of the strategies (TD14, TD17).

Where awareness of the strategies is low, the role of WHO staff in spreading health system technical knowledge is crucial (TD14, 17, 18). In Lao PDR, for example, although many interviewees did not know of the strategies, the Review researcher reported that during the key informant interviews, the main strategy messages appeared to have been understood.

A further view, expressed in China, and related to health financing, is that “the strategies themselves are less important than the WHO staff in the country and Regional Offices who helped shape the policies” (TD17). This is an important finding, reinforced by development partners and WHO staff themselves (TD18, TD19). The regional health system strategies inform the work of WHO staff, and it is the staff rather than the strategies that emerged from interviews as being critical in supporting development of national policy.

22

The Review shows that Member States, development partners and other stakeholders regard WHO as a technical agency—not a funding agency—playing a vital role in policy dialogue, advocacy, technical support and capacity-building (TD17). As an interviewee in Viet Nam put it, “WHO is usually the first place we think to ask for help”. WHO was described by 26 of 56 interviewees in Cambodia, Lao PDR, Papua New Guinea and the Philippines as being primarily a technical support organization.

D. REVIEW FINDINGS

According to key informant interviewees in PNG, “Technical advice … that is what they are known for,” and “WHO has the best technical support, they have the experience and skills in these areas.”

The key informant interviews suggest that WHO is generally trusted by countries as a neutral ally in health sector development, and that they regard WHO’s health system expertise as effective (TD17). “WHO was always helpful, always available, and nearly always present,” an interviewee in the Philippines said. An interviewee in China commented: “For the past decade, the relationship has been very equal—WHO really respects member countries.” None of the country key informants reported any difficulty with country ownership of national policies and plans. WHO is seen as a partner in health system development rather than as dictating what direction a country should take (TD17). WHO is also seen as bringing a broader perspective to health system support than some of its development partners, and its ability thereby to link together all parts and concepts of the health system is seen as an important advantage (TD13, 17, 18).

Interviewees in Cambodia and Papua New Guinea commented that although often timely and appreciated, support could be more effective if sustained over longer periods: “Just a consultant for a number of weeks ... helpful, but not sufficient”, “Often we need someone to help for longer—not just 7 to 21 days”, and “less one-off things”. One interviewee in Papua New Guinea said: “Although we [the Department of Health] reside together in the same building [with WHO], I think they assist us on a piecemeal, inconsistent basis….” While many external consultants were seen as very effective and helpful, it was noted that some consultants lacked understanding of developing country contexts and were therefore less effective.

Some country interviewees feel that WHO could do better in setting an example and acting as a role model (TD17, 18, 19) particularly with regard to integrating services, by more effectively linking disease programmes, using whole-of-system approaches and sharing health system lessons. One interviewee in the Philippines noted that “WHO needs to start reforming itself before it tells countries what to do … There are many strategies coming from many different offices within WHO that are not talking to each other or choose not to talk to each other.”

Box 9. The Philippines Health Care Financing Strategy A health care financing strategy for the Philippines was prompted by a WHO regional consultation in 2006 introducing the Strategy on Health Care Financing for Countries of the Western Pacific and South-East Asia Regions (2006–2010). The Philippines participants’ takehome plan was to develop a strategy to fix the country’s fragmented health financing.

The Department of Health (DoH), with support from WHO, held a series of meetings, dialogues and consultations with key stakeholders. The WHO health care financing strategy was used as one of the primary references for deciding strategic areas, targets and benchmarks.

The Philippine health financing strategy provides a road map to increase overall health spending, promote universal coverage, and improve allocative and technical efficiency. As Philippine Health Secretary Enrique Ona puts it, the “2010–2020 health care financing strategy of the Philippines, Toward Financial Risk Protection, is the blueprint for meeting the challenge posed to us by President Benigno Aquino III, serbisyong pangkalusugan on universal health coverage, with a goal to achieve health services for all within three years through PhilHealth,” the Philippine Health Insurance Corporation.

23

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

D.2.b Usefulness of the regional health system strategies to WHO regional disease and programme-based activities The Review examined regional programme strategies or frameworks in several areas, such as tobacco control, reproductive health and communicable disease control, for their linkages with health system actions promoted in the six WHO regional health system strategies. Many of the recommendations of the six health system strategies are reflected in the strategies and frameworks examined (Annex 10 and TD6).

For example, the current regional strategy on tuberculosis13 adopts a diagram from the Human Resources for Health Action Framework (2011–2015). Similarly, the latest reproductive health strategy14 completely follows the WHO health system framework (Annex 10 and TD6). However, although the disease programmes are integrating health system approaches in their work, one staff member noted that “the current global vaccine strategies are difficult to understand, even for us, as they adopted a health system approach which we are very unfamiliar with.” Such remarks suggest that greater awareness and understanding of integrated services and whole-of-system approaches should be promoted within the WHO Secretariat (TD6). This was also noted by several key informants.

D.2.c Usefulness of the regional health system strategies to development partners The Review examined three areas of work regarding development partners: linkages between development partners’ health-related strategies and WHO health systems strategies (TD7); development partners’ health system work in the Region (TD13); and key informant interviews (TD18).

The five development partner strategies that examined linkages in health system concepts promoted in the six WHO regional health system strategies and are summarized in Annex 11 were: • UNICEF Joint Health and Nutrition Strategy 2006–2015 (United Nations Children’s Fund) • Healthy Development: The World Bank Strategy for Health, Nutrition and Population Results (2007) • An Operational Plan for Improving Health and Outcomes under Strategy 2020 (Asian Development Bank) • JICA’s Operation in Health Sector: Present and Future (Japan International Cooperation Agency) • USAID’s Global Health Strategic Framework: Better Health for Development 2012–2016 (United States Agency for International Development).

These five agencies link their plans with global agreements such as the MDGs, and three have time frames that run until about the 2015 deadline for the MDGs. Each has its own particular health system focus related to their respective comparative advantage. For example, the World Bank focuses on health financing and UNICEF focuses on maternal and child health programmes and nutrition. The United Nations Industrial Development Organization (UNIDO), though not having a specific health strategy, undertakes work on developing pharmaceutical and health

13 14

24

WHO Western Pacific Region (2011). Regional strategy to stop tuberculosis in the Western Pacific (2011–2015).

WHO Western Pacific Region (2013). Regional framework for reproductive health in the Western Pacific.

D. REVIEW FINDINGS

technology industries in countries, an important factor in promoting affordable and sustainable access to care (TD13, TD18).

All five of the agency plans have activities and support for health care financing and health information systems, including research. Four include contents on governance and health system strengthening, two have essential medicines and laboratory services, and only one has human resources, while three refer to equity, gender and human rights (Annex 11 and TD7). For the most part, the content appears to be in line with the regional health system strategies.

Ten of the 12 development partners interviewed were aware of and use at least one of the six regional health system strategies (TD18). For example, a key informant working for the Australian Agency for international Development (AusAID) in Papua New Guinea said: â&#x20AC;&#x153;Absolutely we use them â&#x20AC;Ś all of our work is based on them.â&#x20AC;? (TD18) Four development partner interviewees noted that health system approaches require work beyond the health sector, and that this appears to be an area in which WHO is lacking knowledge and experience (Asian Development Bank, JICA, UNIDO and the World Bank). A World Bank interviewee stressed the need to work with both the private and public sectors in health, as the private sector plays a significant role in many countries (TD18). WHO health system strategies provide little advice to countries on the stewardship needed to overcome potential negative impacts of private sector activity on health equity, an omission that renders the strategies less useful.

25

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Table 3. Summary of regional health system strategy actions in national health plans

Table 3, Part 1. Publication dates of National Health plans and sub-sector plans National Health Plan National Health Care Financing plan National Health Accounts developed after 2006 National Human Resources for Health plan National Essential Medicines plan National Laboratory plan National Health Information System plan National Research Plan KHM=Cambodia MNG=Mongolia

CHN=China PHL=the Philippines

KHM 2008 2008 Yes 2006 2010 2010 2008

CHN 2009 Yes 2006

FJI=Fiji PNG=Papua New Guinea

FJI 2011

LAO 2011 2011 draft Yes Yes 1997 2009 1994/07 2003 2011 2011 2011 2009 2008 2007

MYS 2011

MNG 2005 2010 Yes 2009

Yes 2007

2010 2011

PNG 2010

PHL SLB 2006/12 2011 2010 Yes Yes Yes 2012 2005 2012 2011 draft 2012 2011 draft 2012 2010/12 2011

VNM 2010 Yes

LAO=the Lao People’s Democratic Republic MYS=Malaysia SLB=the Solomon Islands VNM=Viet Nam

Table 3, Part 2. Inclusion of strategic areas of health system strategies in national health plans and sub-sector plans Health system building blocks and strategic areas KHM Governance

Health Workforce (HW) (see also Annex 14)

HW strategic response to evolving, unmet population health &health service needs * HW education, training and continuing competence * HW utilization, management and retention, including remuneration and incentives, monitoring and evaluation * HW governance, leadership & partnerships for sustained Human Resources contributions to improved health outcomes Health care financing (see also Annex 16)

Increasing investment and public spending on health * Improving aid effectiveness for health * Improving efficiency by rationalizing health expenditures * Increasing the use of prepayment and risk-pooling * Improving provider payment methods Strengthening safety-net mechanisms for poor & vulnerable * Improving evidence and information for policy-making Improving monitoring and evaluation of policy changes Essential medicines (see also Annex 13)

Policy and access to essential medicines * Regulation and quality assurance * Rational selection and use of medicines * Areas related to health service delivery (see also Annex 12)

Quality * Patient safety Accreditation of providers Patient-centred health care Antimicrobial resistance * Laboratory services Coherent national framework for laboratory services Sustainable financing for laboratory services Build capacity for laboratory services Quality assurance for laboratory services Rational use of laboratory services Improving safety of laboratory services Support research and ethics in laboratory settings Health information systems and research (HS-PHC values) # National health information system, strategy, plan or policy * Sufficient resources and technical capacity to manage system * Sufficient disaggregation of information

Monitoring of health system performance * Research

CHN

FJI

MYS

MNG

PNG

PHL

SLB

*

* *

* *

* *

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

*

* * * *

*

*

*

*

* * *

*

*

LAO

* * *

*

* * *

*

VNM

*

*

*

*

* * * *

* * * *

*

* *

*

* *

*

*

*

* *

* * *

*

*

*

# Areas for health information systems as in the Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care

* Challenges identified in this area

26

No mention in the national health plan or national plan or no existing document.

Briefly mentioned but without further discussion, objectives, strategies, actions, budget, time plan and indicators.

Mentioned and with two or more of the following: discussion, objectives, strategies, actions, budget, time plan and indicators.

D. REVIEW FINDINGS

Table 3, Part 3. Content of national health plans on universal health coverage (see also Annex 5) Universal Health Coverage Mention of Universal Health Coverage Coverage with needed health services Coverage with financial risk protection Mention of Primary Health Care

KHM

CHN

FJI

LAO

MYS

MNG

PNG

PHL

SLB

VNM

Green indicates “yes” # Areas for health information systems as in the Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care

Table 3, Part 4. Content of national health plans on equity, gender and human rights Values

KHM

CHN

FJI

LAO

MYS

MNG

PNG

PHL

SLB

VNM

Equity

Gender

Human Rights

Assessment

White

Yellow

Equity

No mention

Refers to “equity” and discusses equity issues

Gender

No mention

Refers to “gender” and discusses gender issues

Human rights

No mention

Refers to “human rights” or “right to health” including discussion on right to health issues

KHM=Cambodia MNG=Mongolia

CHN=China PHL=the Philippines

FJI=Fiji PNG=Papua New Guinea

Green Includes specific actions to improve equity Includes specific remedial actions that tackle gender inequalities or address gender needs Includes specific actions that explicitly apply a human rights-based approach to health

LAO=the Lao People’s Democratic Republic MYS=Malaysia SLB=the Solomon Islands VNM=Viet Nam

27

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

D.3. Findings on Objective 3 Objective 3: Identify gaps and future needs to inform appropriate Western Pacific Region health system development approaches

D.3.a Gaps in whole-of-system approaches The regional health system strategies lack guidance on interconnectedness needed for whole-of-system approaches (Box 10) for optimal system functioning (TD5). Several of the strategies were developed prior to the growing discussion on whole-of-system approaches in health, and only the Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care makes explicit reference to it. The other strategies relate only to single technical areas, although they all use the health system framework or refer to WHO’s six health system building blocks.

Summary of findings — Objective 3 Gaps: • a whole-of-system approach • guidance on country adaptation and sequencing of steps to take • explanation of policy options in specific contexts • working with non-state sector in health • links to social determinants of health • knowledge management • monitoring and evaluation frameworks • work on hospitals • health system work not systematically guided by Regional Committee resolutions.

The WHO Secretariat itself is structured vertically in units focused on specific disease or technical areas, and often do not consult each other sufficiently. Even the work of the health system technical teams is not integrated, and this fact is of concern to countries. Three of eight key informants in the Philippines and four of eight in Papua New Guinea commented that the WHO Secretariat has a highly vertical structure, which undermines the system-wide message, and the separate health system strategies may also contribute to this problem (TD4, TD17). “Even the DHS (Division of Health Sector Development) unit is part of that vertical structure,” said an informant in the Philippines. “WHO is still working in programmes,” said an informant in PNG (TD17, 18).

D.3.b Gaps in guidance on policy options Although the WHO health system strategies are sources of evidence-based policy options, these need to be adapted to each country’s particular health, social and economic contexts.

The health system strategies were regarded by Asian Development Bank interviewees as standards that are not fully achievable, applicable or relevant to some lower-income countries.

There is little guidance in the strategies on how they may best be adapted to these or other contexts (TD18).

There exist areas of dissonance between WHO’s health system approaches and policies and those of other development partners, as well as between different partners. Together, these potentially present policy options to Member States, but they can be confusing and decisions can be skewed if they are linked with funding, as they often are. The WHO health system strategies presently offer little advice to the countries on how to decide between different policy options (TD18).

28

D. REVIEW FINDINGS

Box 10. Whole-of-system approaches Any system involves elements such as inputs, processes, flows, outputs and outcomes. Systems thinking is about the interconnectedness of all parts of the system. Whole-of-system approaches acknowledge the complexity of government systems within which the health system operates and the interrelationships among those elements. The objectives are balance, coordination and optimal system functioning to best achieve desired system outcomes.

Systems in any area of functioning are nested and overlapping. For example, the system of health financing falls within whole government financing system, overlaps with social protection, national supply and regulatory systems, within the overall national economy.

For a health decision-maker, a whole-of-system approach means assessing the impact of a decision or change in one part of the system on other parts of the system. For example, increased demand will require access to additional resources, the introduction of new equipment will have running and maintenance costs and will need staff skills for effective use and laboratory capacity to analyse results. Patient acceptance of the new equipment may also be important.

A whole-of-system approach in health also ensures that each facility and level of the system is used most effectively; for example ensuring primary care services are used when appropriate rather than unnecessary and more expensive hospital services. For this to work, other systems are also needed, such as information, referral and management systems to achieve quality services in the most efficient manner. It also means ensuring sufficient funds are allocated to each level of service within the system.

Paraphrased from: Western Pacific Regional Strategy for Health Systems based on the Values of Primary Health Care. WHO, 2010

D.3.câ&#x20AC;&#x201A; Gaps in working with non-state and non-health sectors Summary analyses of WHO regional and country office activities suggest that multisectoral approaches constitute less than 1% of reported activities at both levels (Annex 7, TD16). The six health system strategies lack guidance on multisectoral work, social determinants of health and on the role of non-state actors in health.

Health system development and health outcomes depend not only on health-specific statutory bodies and actions, but on non-state actors such as the health-related private sector, civil society, nongovernmental organizations and other sectors related to social determinants of health, such as nutrition, housing, environment, education, economy and employment.

Thus moving towards improved health outcomes requires a multisectoral approach to health system development.

Four development partner interviewees stressed the importance of looking in particular towards the non-state sector in health, which plays a significant role in many countries. However, they felt that the WHO Secretariat currently has a lack of experience in engaging with sectors outside of state health system (TD18). This may be an area in which the WHO Secretariat should seek to develop its evidence base, methods and capacities.

29

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

D.3.d Gaps in knowledge management The Review found that while WHO is strong on technical knowledge, it is weak in gathering and synthesizing knowledge about each country’s particular health and socioeconomic context— and knowledge of previous health system development work—whether by the country, by the WHO Secretariat or by other partners. There is information everywhere, but not well enough synthesized to be practically useful.

This was evident in the review process as it was hampered by a lack of systematic recording of Secretariat activities and their impact, and of countries health system development. The desk review of Secretariat activities at the regional and country levels revealed some duplication or activities that were poorly sustained or sequenced (TD5, TD10, TD14–15).

Only a limited amount of the information the Secretariat has about a country is available on the country pages of the Western Pacific Region’s web site. Instead, most country information is on the web site pages of individual programmes or technical units. For example, the health financing country profiles15 that the Western Pacific Region prepared over recent years are not on the country web pages but on the health care financing page. The recent NCD country profiles16 are not on the country web pages, but on the NCD programme pages.

Even though institutionalization of national health accounts (NHAs) has become a WHO priority globally and in the Region, completion of NHAs in countries had not been documented at the Regional Office for the Western Pacific. The two experienced technical staff members who comprise the health care financing team—and who are new to the Regional Office—were not able to find any summary overview on NHAs from previous WHO staff.

Moreover, health system information available at the Secretariat is not comprehensive. For example, the Western Pacific Region does not have documented or easily accessible overviews of country health financial protection benefits packages, or laboratory services or development partner work in the countries. Similarly, history of country health system development does not seem to exist, except to some extent in the recently completed reviews in the series Health Systems in Transition,17 produced by the Asia Pacific Observatory on Health Systems and Policies (presently available for four countries).

One reason could be high staff turnover in WHO regional and country offices. Between 2004 and 2012, 49 new members of staff filled health system positions in the Regional Office and 54 new members in the ten country offices. This was a mix of replacements and new posts. Each year during 2004 to 2012, an average of 29% (range 12% to 54%) of all the WHO health system positions in the Region had turnover with new staff. The tacit knowledge that is essential to inform health system work often resides with individual WHO staff members and is often lost when they leave. Despite this, there are no systematic means of recording work and handing over to facilitate orientation of new staff for the provision of consistent, continuous and seamless support (TD14).

WHO Western Pacific Region. Health Care Financing country profiles web site: http://www.wpro.who.int/health_financing/en/index.html WHO Western Pacific Region. NCD country profiles web site: http://www.wpro.who.int/noncommunicable_diseases/documents/ncd_in_wpr/ en/index.html 17 Asia Pacific Observatory on Health Systems and Policies web site: http://www.wpro.who.int/asia_pacific_observatory/hits/en/ 15 16

30

D. REVIEW FINDINGS

The problem of poor knowledge management and institutional memory was also raised in key informant interviews. In Cambodia, an interviewee expressed frustration, saying, “We spent a lot of time providing background and context of our health system [to consultants] but then the consultant has ended. A new TA [technical adviser] came in and we have to brief the TA on the context and background again. We are very tired of doing this and it is often a waste of our time.” An interviewee in the Philippines commented that the frequent turnover of WHO staff means that work is sometimes forgotten (TD17).

The importance of personalities and staff orientation was also reflected. “The main frustrations stem from personalities rather than differences in strategies or approaches,” said an AusAID interviewee in Papua New Guinea. A UNICEF interviewee felt that “a lot of the problems, as well as a lot of the good work, are personality led” (TD18). “For both WHO and UNICEF, there is a need for better oriented staff on our mandates and roles. There should be proper orientation for new staff before sending them to assignments,” said a UNICEF interviewee (TD18).

D.3.e Gaps in information on strategy indicators All six of the regional health system strategies recommend indicators that can be used to determine progress in implementation and towards health system strengthening. Monitoring these or similar indicators provides opportunities for countries to see their current status and progress in health system strengthening. However, reliability of data on indicators requires robust civil registration and vital statistics (CRVS) for accurate denominators, but CRVS is not strong in many of the Review countries.

Approximately 37 of the 122 indicators in the six strategies are not used by countries and neither are they collected by the WHO Secretariat (Table 4). Some strategies recommend qualitative indicators that may be difficult to collect or open to interpretation. Indicators most commonly used by the countries are two of the four in the Health Financing Strategy for the Asia Pacific Region (2010–2015), and about 30 of the 40 in the Western Pacific Regional Strategy on Health Systems Based on the Values of Primary Health Care (HS-PHC), which are proposed globally by WHO as a set for monitoring health system performance. Out-of-pocket expenditure is the only indicator proposed in more than two of the strategies, albeit with different targets, emphasizing its overall importance as a key indicator for monitoring universal health coverage and as a proxy for equity.

Senior WHO staff working on information systems indicate that within countries health information is fragmented by function, disease or condition, donor, or global health initiative.

There is little data integration and sharing with lack of clarity of data ownership. MDG, NCD and other health indicator reporting is challenging, expensive and often incomplete. Thus while valuable data are often gathered, availability of useful information for decision-makers is poor.

While the collection of data on health system performance remains fragmented in countries and linked to single strategic areas in the WHO Secretariat, opportunities to identify systemwide opportunities for improved health outcomes are lost. For example, data relating to access to essential medicines is linked to health care financing (prices and costs to patients; system expenditure) and health service delivery (availability of drugs at facilities for care).

31

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Table 4. Number and level of indicators in the six regional health system strategies Health Systems based on the Values PHC

Health Financing Strategy ‡

Human Resources Framework

Laboratory Strategy ‡

Essential Medicines Framework

Traditional Medicines Strategy

Total

40**

4

17

14

26

21

Input *

5

1

15

12

15

21

Output

8

2

2

10

Outcome

19

2

Impact

8

1

Monitoring equity #

7

1

2

none

2

none

1

2

none

3

none

2

12

Not yet collected

25

13

Strategy  Level of Indicators 

In the HS-PHC list of 40 With up-to-date data readily available for most countries in the Region

33

1

‡ Cover the Asia Pacific region (two WHO regions: South-East Asia and Western Pacific) * Input, output, outcome and impact indicators are in line with the Health System Performance Framework – See Tables 1 and 2, and Annex 12 for full list of indicators ** Review is using 47 health system performance indicators to measure UHC, a list very close to the original 40. # Monitoring equity with disaggregation by any social stratifiers; or out-of-pocket payments (OOP) (the health financing strategy suggests OOP should be no more than 30%–40% total health expenditure (THE); the essential medicines framework recommends private OOP less than 50%)

D.3.f Gaps in hospital management and efficiency Hospitals are allocated and absorb a great share of health system resources than primary care, public health, promotion and prevention. Yet WHO in the Western Pacific Region has provided little support on hospital functioning or service delivery in recent years. Country office input has included assistance with ministry of health work on treatment guidelines, medicines and labs procurement systems, and management-related workshops for health professionals.

There are significant opportunities for increased efficiency in health spending through reductions in hospital waste in use of tests and more expensive procedures and drugs, as well as the length of admission. With the increasing interest of the private sector in health, there is a proliferation of hospitals that may not be the most effective or efficient way to meet population needs. Growing interest in medical tourism also has implications for the home population in terms of the use of health workers and access to services.

Associated with these and other health system issues relating to hospitals, there is substantial scope for increased research and evaluation and for more assistance from WHO.

D.3.g Gaps in responsiveness to Regional Committee resolutions

32

Resolutions of the Regional Committee for the Western Pacific that endorsed the six health system strategies also list actions requested of the Member States (TD2) and WHO Secretariat (TD3). The number of actions requested in the resolutions ranges from two for essential medicines to 47 for human resources. Annexes 7 and 8 show summarized partial mappings of Member States and Secretariat health systems work against the resolution requests. The two strategies with the lowest number of requests for action, essential medicines (with two) and laboratory services (with six or seven), have the highest proportion completed and by more countries. For the other three strategies, action has been taken on less than 50% of the resolution requests, and for many resolution requests, no actions have been taken. However, the significant differences in level of detail in the resolution requests causes problems with this analysis.

D. REVIEW FINDINGS

Work against Regional Committee resolutions is also an example of an area that the Review team would have expected the WHO Secretariat to monitor on a regular basis. Instead, the analysis was inhibited by overall lack of recording. The partial information collected appears to indicate that WHO Secretariat accountability to the Regional Committee is not specifically related to the resolutions (TD2, TD3).

“One of the greatest challenges today is not about keeping up with the latest clinical procedures or the latest high-tech equipment. Instead, it is about delivering safer care in complex, pressurized and fast-moving environments. In such environments, things can often go wrong.”

Margaret Chan WHO Director-General

“To err is human, to cover up is unforgivable but to fail to learn is inexcusable.”

Sir Liam Donaldson

WHO Envoy for Patient Safety

33

â&#x20AC;&#x153;I regard universal health coverage as the single most powerful concept that public health has to offer. It is inclusive. It unifies services and delivers them in a comprehensive and integrated way, based on primary health care.â&#x20AC;?

Margaret Chan, WHO Director-General

D. REVIEW FINDINGS

E. Discussion on findings This section addresses the Reviewâ&#x20AC;&#x2122;s fourth objective: Identify major lessons learnt regarding WHO support to health system development. It considers the findings on the first three objectives and seeks to identify lessons and their implications for future health system work.

E.1.â&#x20AC;&#x201A; Future health system challenges In order to plan effectively, it is essential to consider not only past and present activities, but also to look ahead to potential challenges and opportunities. For this reason, the Review commissioned a paper to examine the challenges and opportunities for health system development in the Western Pacific Region, with particular reference to changing demographic, economic, epidemiological and political contexts (TD20). The paper takes the view that many factors that will be important in the future are already here but invisible, and that other elements of the future that are here and visible are not well distributed. Current trends suggest possible directions to follow but are unreliable. History has shown that unexpected turning points or bends in trends often occur, demanding resilience to cope with the unknown.

Climate change, food security, financial stability and human health are all inextricably linked.

There is a strong case for adopting new organizational principles if these interconnected challenges are to be met. When considering future social risks, health issues feature highly.

These health issues include unsustainable population growth, mismanagement of population ageing, rising rates of chronic diseases and vulnerability to pandemics.

A particular health risk could be over-reliance on technologies that are becoming unstable or uncertain, such as antibiotics, leading to major system and population vulnerabilities such as antimicrobial resistance. The question is not whether another emerging disease will give rise to a pandemic but when and where, and how serious the impact will be. The Western Pacific Region is particularly susceptible, with high levels of humanâ&#x20AC;&#x201C;animal contact; the Region has been a recent locus for emerging infections. That vulnerability is likely to increase over the next 20 to 30 years.

Historically, developing countries in the Western Pacific have been recipients of global strategies and approaches, much of which originated in the more developed countries. With the Region becoming increasingly dominant in terms of global population, with a growing middle class and as the main bearer of the global disease burden, there will be an increasing onus on the Region to inform health system development in other regions.

Both regionally and nationally, the challenges facing those responsible for the planning and management of population health and services, including WHO, are vast and complex and may

35

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

seem overwhelming. While many interventions to address the challenges ahead already exist, they are currently poorly distributed and thus contribute to growing inequities.

Health systems will be profoundly affected by the trends that are occurring as a result of the various transitions (demographic, epidemiological and urbanization). At the same time, health systems themselves are changing as a result of new technologies and patterns of care. WHO has long argued for more rationally balanced systems centered on people, not on specific institutions or professions or individual episodes of illness or ability to pay. The sociological and economic reality of the Western Pacific Region means that unless a stronger preventive approach is taken, with public health and primary care more effectively used, country health systems will fail to achieve their objectives and may face bankruptcy.

With continually increasing urbanization, health systems will need to meet the problems of emerging urban environments—the provision of basic services, including safe water, food and housing—and address increasing and unhealthy slum development, violence, access to healthy recreational space, safe public transport and access to appropriate health services.

Strong ministry of health engagement in areas such as urban planning and social services will be essential to ensure the health needs of urban populations are met, particularly to address the large inequities between different groups in the cities. Noncommunicable diseases (NCDs) are driven by a rise in particular risk factors—smoking, over-nutrition, alcohol and lack of physical activity—all of which are amenable to preventive action on numerous fronts by several different sectors. System-wide approaches will be increasingly required within the health sectors of Member States and multisectoral approaches will become ever more important.

Despite the evident promise of economic development, the issue of inequities within the countries will take greater prominence, as few countries in the Region have achieved economic growth that is well distributed across their populations.

WHO’s role historically has been both technical and normative. The placement of WHO staff and the focus of its technical assistance has been on low- and middle-income countries. The future will see a continuing emphasis on WHO’s normative role on standards and best practices relevant to all countries’ health and health systems—for countries to use as they see fit. The need for direct technical assistance will gradually lessen. WHO will continue to strengthen its role as an information hub. Countries’ own health system work is likely to be on balancing levels of service for access and in relation to burden of disease, increasing standards and safety, reducing inequity, controlling costs and reducing wastage.

To meet these challenges, WHO needs to work more with countries on their problems of implementation, taking into account the countries’ unique contexts. In the past, success has often been judged in terms of policies adopted or laws passed; in the future, greater attention needs to be paid to implementation and outcomes.

Countries’ different points in the various transitions can be an advantage for the Region. For example, Japan’s experiences of how to care for an older population can be instructive for other

36

D. REVIEW FINDINGS

countries in the years ahead, if lessons on what works and what does not work are documented and disseminated.

A radical change is likely in terms of how knowledge is generated, disseminated and implemented.

Technology will immensely facilitate the transfer of technical knowledge—information that previously would have come from a WHO “expert” is now readily sourced via the Internet even in the least-developed countries. But not all knowledge is technical or written. The transfer of tacit knowledge occurs through extensive personal contact, trust and honest interaction.

Tacit knowledge is also highly context specific, developed through a deep understanding of the cultural and political economic setting in which the knowledge is used; the contextual differences between countries are extensive.

The key to preparing for the future is to build resilient health sectors with a strong values base consistent with WHO’s founding principles. The core values of WHO will become more important in guiding actions to address the complexity of future challenges in the Western Pacific Region.

Moving away from a hierarchical model of health development, where WHO and developed countries are assumed to hold the answers, to a more networked one that capitalizes on and increases the flow of knowledge and lessons within and between Member States, will assist in enhancing health sector resilience—health systems‘ ability to learn, adapt and respond appropriately to changing needs and challenges in a timely manner.

E.2. Framework arising from the Review Since its founding, WHO has acquired an international reputation as a knowledge-based technical agency. Technical support is one of the Secretariat’s six core functions.18 The health system strategies present evidence-based technical information to assist policy dialogue and technical support. A key purpose of technical support is to help bridge the “know–do gap” between countries knowing something and the practical application of that knowledge in the specific country context. In Figure 2, effective technical partnership incorporates this along with all the Secretariat core functions and the working relationship between the WHO Secretariat and Member States.

A premise of the Review at its outset was that much of the information needed to answer the Review questions, particularly on strategy implementation and previous health system work in countries, ought to have been available from the WHO Secretariat itself. However generally, this was not the case.

This Review shows clearly how important the gathering, creation and use of knowledge is. Over the year of the Review, and with feedback from the Steering Committee and representatives of the WHO Secretariat and Member States, the framework in Figure 2 has emerged. Although developed while looking at use of regional health system strategies, the framework can be applied to WHO Secretariat work in general and is hoped to be useful in the ongoing organizational reforms.

18

WHO (2006). Engaging for Health: 11th general programme of work 2006–2015, a global health agenda.

37

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Figure 2. Knowledge and processes for effective technical partnership

Knowledge about the country and context Adaptation to country context

Technical knowledge and learning networks

Basis for working with country and partners

Effective technical partnership Lessons on what works and does not work

WHO Secretariat processes and work history in country

Three aspects of knowledge—WHO’s technical knowledge and learning networks, knowledge about each country and its context, and knowledge about the WHO Secretariat’s processes and current and previous work in countries—are dynamically interlinked. For effective technical partnership between the WHO Secretariat and Member States, strength in all three spheres of knowledge is vital.

The three spheres also cover the three domains of the Review: a) inputs by countries, the WHO Secretariat and development partners; b) trends on indicators; and c) lessons for the future.

Results of this review process strongly indicate that all three spheres of knowledge and related processes need to be strong for WHO regional health system strategies to be of optimum use to Member States.

Each of the three areas of knowledge is explained below with a brief summary of related Review activities. The subsequent discussion on the Review findings follows the framework structure.

Sphere One: Technical knowledge and learning networks The six regional health system strategies covered by this Review are separate documents that crystallize and synthesize available evidence and technical knowledge on the topic area, as relevant to the Region, and as adjusted and agreed to by the Member States, through endorsement by the Regional Committee for the Western Pacific. Thus the strategies are not purely technical, but also politically adjusted and agreed.

38

D. REVIEW FINDINGS

In looking to the future, there will be changing roles for Member States in the generation of technical and process knowledge that will inform progressive system development. Rapid sharing and wide dissemination of this knowledge and lessons in translation to country contexts are likely to be achieved through extensive learning networks and effective technical partnership between WHO Member States and the WHO Secretariat. Vibrant learning networks will assist in enhancing health sector resilience—health systems‘ ability to learn, adapt and respond appropriately to changing needs and challenges in a timely manner.

In line with Objective 2, the Review included a content analysis of the six health system strategies (TD4),# their use in national health plans (TD5), WHO disease programme strategies (TD6) and the strategies of several development partners (TD7).

The use and application of a strategy in a specific country invariably requires adaptation to the country’s social, political and economic context as represented by the overlapping in Figure 2 of the technical sphere with the country sphere.

Sphere Two: Knowledge about the country and its context Adapting technical knowledge and planning effective technical partnership work needs information about the country and its socioeconomic, political, demographic and epidemiological contexts, technical capacity, and development partner work, if any.

In line with Objectives 1 and 3, the Review examined information on several aspects of country health system development and performance including: timelines of key events that have impacted health system development (TD8); burden of disease (Annex 18); information on indicators included in each of the strategies (Tables 1 and 2; Annexes 13 to 17; TD10 to 12); disaggregated data available in publications of national health statistics (TD12); health system assessments such as joint annual health system performance reviews (TD9); and summaries of partner work in the countries (TD13).

Sphere Three: WHO Secretariat processes and work history in the country In line with Objectives 1 and 3, the health system work undertaken by WHO regional and country offices in the ten participating countries during 2004 to 2012 was explored through desk reviews and discussions with WHO staff (Annexes 6 and 7 and TD14 to 16). Key informant interviews were undertaken with 61 country officials, 12 development partner representatives and ten WHO staff (Annex 6 and TD17, 18, 19).

Information on the country and its context, along with what, when, why and to what extent previous work has been successfully undertaken (or not), both by the WHO Secretariat and by partners (TD13) forms the basis for planning and sequencing future health system work in the country. This is represented by the overlap in Figure 2 between the country sphere and the WHO Secretariat work sphere.

#

All numbers in italics and brackets throughout the text refer to numbered technical documents listed in Annex 2.

39

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Lessons on what works and does not work in individual countries also influence future planning as well as being important to strengthen or extend technical knowledge generally, as represented by the overlapping of the technical sphere and the WHO Secretariat work sphere.

The center: Effective technical partnership Effective technical partnership acknowledges the role and capacity of Member States and refers to all the WHO Secretariat core functions: leadership in global health; evidence basedpolicy options, norms and standards; technical support; monitoring health trends; research; and knowledge generation.

The key to preparing for the future is to build resilient health sectors on a strong values base consistent with WHO’s founding principles. The core values of WHO will become more important in guiding actions to address the complexity of future challenges. Hierarchical models of technical assistance, where WHO and developed countries are assumed to know best, will change to more partnership networked models. WHO, as a trusted partner, will facilitate more “South–South” sharing of knowledge, experience and lessons.

The Review strongly indicates that all three spheres of knowledge and the related processes need to be strong for the regional strategies to be of optimum use to countries to build health system resilience to cope with future challenges and unpredictable bends in trends.

Organization of the discussion The discussion in the remainder of this section follows the framework presented in Figure 2, covering all three spheres of knowledge and related processes, as follows: 1. The findings on Objective 1 (strategy implementation) fit with the two spheres on country and context, and with Secretariat processes and work in countries.

2. The findings on Objective 2 (usefulness of the strategies) fit with the two spheres on country and context, and on technical knowledge and learning networks.

3. The findings on Objective 3 (gaps) also fit with the two spheres on country and context, and on technical knowledge and learning networks.

4. The discussion itself is related to Objective 4 (lessons).

A brief summary of findings from Section D is presented at the beginning of each part of the discussion.

40

D. REVIEW FINDINGS

E.3. Discussion: Knowledge about the country and context E.3.a Region sets context for the future The Western Pacific Region faces a multitude of health, social and environmental problems.

The population is ageing, and the Region is home to about one third of the world’s population, with nearly half living in urban areas.19 The health care and social security costs associated with NCDs have the potential to overwhelm health systems already under stress,20 as reflected by the Review findings in Section D. In tandem, the need to address infectious and vectorborne diseases continues, and advances in medicine and health technologies are matched by rising public demand for better services and new treatments.

The Region also grapples with mounting negative effects of climate change, ongoing natural disasters, zoonoses, and other public health risks and emergencies. These often hit hardest the poorest in societies, who have the least resilience to recover. The Region has experienced and learnt from the emergence of SARS (severe acute respiratory syndrome) and avian influenza, with the economic and international consequences of these outbreaks.

Considered together, factors such as these present all countries, rich and poor, with serious, perhaps unprecedented, challenges for funding adequate and equitable provision of health services. The rise of NCDs, antimicrobial resistance and increasing inequities demonstrate failures in prediction, recognition and system actions, and in health and other sectors, even in developed countries.

19 20

Figure 2 Knowledge about the country and context Adaptation to country context

Technical knowledge and learning networks

Basis for working with country and partners

Effective technical partnership Lessons on what works and does not work

WHO Secretariat processes and work history in country

Summary of findings from Section D that relate to this sphere of knowledge (Figure 2) Country health system features: • gradual increases in data available • overall progress on indicators • insufficient disaggregated data to adequately monitor health equity • where there is data, considerable inequities are evident • some key events are linked to changes on indicator trends • generally increases in government expenditure, and decreases in OOP • Essential medicines and human resources data difficult and/or expensive to collect • outpatients receiving antibiotics exceeds 10% target in all six Review countries with data • antibiotics available without prescription in eight Review countries.

WHO’s information on countries is: • not organized by country • located with programmes—both health system and disease • not easy to find • not comprehensive • weak on history of country health system development

WHO (2010). World Health Statistics 2010. Geneva.

Bloom D E, Cafiero E T , Jané-Llopis E, et al. (2011).The global economic burden of noncommunicable diseases. Geneva: World Economic Forum.

41

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

These challenges and the extensive range of experiences also present opportunities as the capacity for knowledge generation within the Region has the potential to inform health systems development worldwide.

E.3.b Primacy of country context and country plans The regional health system strategies are considered of value by many, but several interviewees in countries and development partner agencies regard them as standards too difficult or not relevant for some countries, while others use them for evidence-based ideas, benchmarks and tools for advocacy (TD17, TD18). Each country context must be considered and understood, and the strategy concepts and recommendations adapted accordingly, if indeed the country decides that any are appropriate and achievable in the coming time frame. Yet the strategies provide little assistance on adapting to different country contexts.

Health policy reflects economic development, and policy support can only succeed when it is realistic (TD19). While Member States may endorse WHO health system strategies, they may be unable to adopt them or may only do so in an aspirational way with the costs and practicalities of implementation not sufficiently considered (TD18, TD19). Table 3 (pp 26–27) shows that countries’ national health plans contain many of the health system strategies’ recommendations (TD5). Although this may suggest good awareness of the strategies, it does not necessarily demonstrate appropriate adoption or feasibility of strategy elements in the countries.

Frank discussion with Member States on options for action is needed when planning and sequencing health system development in countries.

Advice in the WHO health system strategies on how countries can decide among various policy options is primarily in terms of key values and principles. WHO could assist countries better if it also acknowledged the policy choices put forward by other development partners when they differ from those of WHO. Explanations on arguments for and against different policy options, particularly in specific country contexts, would be useful for countries, which can experience the negative effects of partner competition. Implementation complexity and costs would be especially useful, but this information rarely exists at the time the strategy document is created.

Getting the right balance between extending population access to services and meeting demands for technological health care advances is a challenge for all countries as they strive for both health equity and continuing progress towards universal health coverage. Achieving this balance is dependent upon context-specific national health system planning and financing. The example from Cambodia in Box 7 emphasizes that country success often results from actions on multiple fronts. Health systems that emphasize primary care, public health and health promotion are best suited to provide the preventive and educational interventions and access to long-term support necessitated by ageing populations and NCDs facing the Western Pacific Region.

42

Future health system work may need to focus more on supporting countries in developing comprehensive national health plans covering the whole health sector for integrated services delivery using whole-of-systems approaches relative to the country context. Effectiveness mandates that health systems engage with sectors outside of health, such as social protection,

D. REVIEW FINDINGS

education, employment, transport, urban design, housing, trade and agriculture. Broader health system work could guide countries on where to focus to benefit from wider sectoral engagement in each country context.

E.3.c Accelerate improving country health system trends A key health stewardship role is monitoring health system functioning and impact on health outcomes. Tables 1 and 2 and Annexes 13 to 17 present information collected by countries on health system status and progress. However, continued weaknesses in national civil registration and vital statistics put some of this data in doubt. Greater WHO support and country stewardship are needed to reduce fragmented data collection, often stimulated by donors. Stewardship needs good intelligence for policy and management.

Country data on health system performance indicators have not been previously presented as in Tables 1 and 2. This now forms the basis for regular reporting of health system performance and outcomes. In the earlier period (Table 1), three countries have seven to 11 indicators with levels worse than the poor level, and there was no data from any of the ten Review countries on another 16 of the 33 indicators. In Table 2 (the more recent period), the three weakest countries had only two to five indicators with levels worse than the poor level, and 11 of the 33 indicators had data reported from less than seven of the ten countries. All countries have shown progress in health system performance. However, there are continuing problems with data quality and reliability. CRVS and data collection must be strengthened, and countries need to assess whether they are satisfied with their levels and speed of progress in health system development and health outcomes.

E.3.d A new country focus for WHO Secretariat’s information Despite being a knowledge-based organization and attempting to be country focused, the WHO Secretariat’s knowledge management can be much improved. This is apparent not least on the Organization’s web sites. The Review found that while WHO is strong on technical knowledge, it is weak in gathering and synthesizing knowledge about each country’s particular health and socioeconomic context, and knowledge of previous health system development work, whether by the country, by the Secretariat or by other partners. Difficulties in bringing this information together mean that WHO health system staff do not have a ready basis for adapting strategies or sequencing work for specific country contexts.

The WHO Secretariat needs to put more effort into practical steps to being more country focused—not only bringing country information together, or making it searchable by country, but regularly synthesizing it for ready use by staff, consultants and the international community.

Regular country-focused briefings on individual countries for all professional staff in the Regional Office, which currently do not take place, would also be of benefit.

43

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

E.4. Discussion: Technical knowledge and learning networks E.4.a Strategy qualities and gaps WHO is mandated as the leading international technical agency for health and aims for close working relationships with other United Nations agencies and development partners.

It is unique in covering a wide range of diseases and programmes, as well as health systems, within one organization.

The regional strategies are syntheses of evidence on health system development and expressions of WHO values. The WHO Regional Office for the Western Pacific has been proactive in strategy development.

It responded promptly in addressing the relationship between health costs and poverty, and the Strategy on Health Care Financing for Countries of the Western Pacific and SouthEast Asia Regions (2006–2010) included consideration of universal coverage (Annex 3).

In response to the human resources crisis, the Regional Office its first regional human resources strategy when there was no WHO global strategy and while WHO headquarters was preparing the World Health Report 2006: Working Together for Health. The Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care brings the details of two separate global documents on health systems21 and primary health care22 together into one overall strategy. There is no similar WHO global strategy (TD4).#

Figure 2 Knowledge about the country and context Adaptation to country context

Technical knowledge and learning networks

Basis for working with country and partners

Effective technical partnership Lessons on what works and does not work

WHO Secretariat processes and work history in country

Summary of findings from Section D that relate to this sphere of knowledge (Figure 2) The regional health system strategies are: • technical, evidence-based knowledge • expressions of WHO values • used by countries for evidence-based ideas and advocacy for policy-makers • used in national health plans • used in 14 WHO regional programme strategies and frameworks.

Gaps in strategies and health system work: • cohesion or a whole-of-system approach • explanation of policy options in specific contexts • guidance on country adaptation • sequencing of steps to take • links to social determinants of health • working with the non-state sector in health • working with hospitals

• coherent monitoring and evaluation on health system Despite these initiatives and innovations, the strategy indicators. six Western Pacific regional health system strategies are separate documents—different in their layout and content—and with significant gaps considering future needs. They do not form a coherent set, nor do they adequately refer to each other for whole-of-system approaches (TD4). This latter concept may not have been strong when the strategies were developed, but whole-of-system approaches (Box 10) are considered to be important for resilience in future health system functioning (see Section E1).

WHO (2007). Everybody’s business: strengthening health systems to improve health outcomes.

WHO (2008). World Health Report 2008. Primary health care: now more than ever. # All numbers in italics and brackets throughout the text refer to numbered technical documents listed in Annex 2.

21 22

44

D. REVIEW FINDINGS

The Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care explicitly lists the values important to the WHO Secretariat in its guidance to Member States.

Most country national health plans include, and thus reaffirm, these WHO values. One of the few unifying factors across the six regional health system strategies is the overarching goal of universal access or coverage and related health equityâ&#x20AC;&#x201D;the underlying WHO value being health as a human right. The core values of WHO will become even more important in guiding actions to address the complexity of future health challenges.

In many countries in the Region, the private sector plays a significant role in health. WHO health system strategies could provide more advice to countries on the stewardship needed to harness private sector potential in assisting with national health objectives while also enacting controls to mitigate negative impacts on health equity. This is another area of technical knowledge missing from the health system strategies.

Even before the Commission on Social Determinants of Health delivered its report in 2008,23 WHO has expressed recognition of the importance of the social determinants of health. However, the six regional health system strategies contain little on interaction with other sectors or on promoting health in all policies. The ongoing transitions and anticipated challenges in health mean that future approaches to health system development will not be able to overlook these critical social dimensions or fail to engage with the non-state sector in health. Transformative ways of working are needed to overcome the failures in forecasting, recognition and action that are represented by escalating problems such as NCDs, antimicrobial resistance and inequities in health.

E.4.bâ&#x20AC;&#x201A; Knowledge generation and learning networks Some informants expressed a need for a stronger evidence base for WHOâ&#x20AC;&#x2122;s health system strategies. More monitoring, evaluation and research in health system development is needed to assess which approaches work and which do not in various country contexts. In 2010, the Multilateral Organisation Performance Assessment Network (MOPAN) review on WHO found that while WHO was just adequate in reporting on lessons learnt, it was inadequate in sharing lessons from practical experience across the Organization,24 a view reinforced by several key informants. So there is significant room for improvement for the WHO Secretariat, which also presents an opening for different ways of working.

The Western Pacific is increasingly significant in terms of global population and because it bears a major part of the global disease burden. This poses both challenges and opportunities for the Region to inform health system development worldwide. In the future, more health system knowledge generation will emerge from within the Western Pacific Region and be shared directly among countries.

WHO, 2008. Closing the gap in a generation: health equity through action on the social determinants of health.

MOPAN (2010). MOPAN Common Approach Institutional Report for the World Health Organization (Finding 19, page 45). http://www.mopanonline.org/upload/documents/WHO_Final-Vol-I_January_17_Issued1_1.pdf MOPAN is a network of 17 donor countries with a common interest in assessing the organizational effectiveness of the major multilateral organizations it funds.

23 24

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GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

This will be facilitated more by a networked model of health development, rather than the current situation in which WHO and developed countries are assumed to know best. Networked approaches facilitate South–South sharing of knowledge, experience and lessons. These can be supported by initiatives such as the recently established Asia Pacific Observatory on Health Systems and Policies, hosted by WHO Regional Office for the Western Pacific. Vibrant learning networks will assist in enhancing health sector resilience by strengthening health systems‘ ability to learn, adapt and respond appropriately to changing needs and challenges in a timely manner. Countries’ different points in the various transitions can be an advantage for the Region.

For example, Japan’s experiences of how to care for an older population can be instructive for other countries in the years ahead, if lessons on what works are documented, synthesized and disseminated for easy country use.

The WHO Secretariat has an imperative role to facilitate knowledge and learning networks among a wide range of stakeholders that generate, synthesize, and use knowledge and information.

More monitoring and better knowledge management does not mean more data but more concise information, more useful for practical application in specific country contexts.

Learning networks will include understanding the safety, benefits and limitations of traditional medicine and its knowledge base.

Charles, Prince of Wales (Dec 2013) comments on integrated medicine: “… care that integrates the best of new technology and current knowledge with ancient wisdom.”

46

D. REVIEW FINDINGS

E.5. Discussion: WHO Secretariat processes and work in countries E.5.a WHO health system strategies and work valued by countries The six Western Pacific regional health system strategies are valued and used by Member States for evidence-based ideas, benchmarks and to support advocacy. Trust in the competence of technical staff and the soundness and evidence base of the advice offered are also critical. Use and utility of the strategies cannot be considered in isolation from the systems and contexts in which they are used. During key informant interviews for this Review, it is WHO staff, rather than the strategies, that are considered most important in assisting progress in health system development.

The Review found several examples of direct use of the regional strategies in informing development of country health system policies or plans. Further, most of the national health plans of the ten Review countries include many of the recommended actions and principles from the strategies. Whether these are realistic and funded for implementation needs further monitoring that is not yet being undertaken by the WHO health system teams.

Figure 2 Knowledge about the country and context Adaptation to country context

Technical knowledge and learning networks

Basis for working with country and partners

Effective technical partnership Lessons on what works and does not work

WHO Secretariat processes and work history in country

Summary of findings from Section D that relate to this sphere of knowledge (Figure 2) WHO’s health system work: • is valued by countries ºº supports resource mobilization ºº tackles sensitive issues ºº initiates global developments • is criticized as being vertical • does not cover actions in resolutions.

Secretariat mechanisms are needed to: • document and synthesize knowledge • avoid duplication, identify gaps or sequence activities

E.5.b Coordinated health system work

• harvest tacit country knowledge before staff leave

• orient staff to health system development in the The breadth of WHO knowledge and experience country across all aspects of health programmes • improve Secretariat accountability to the Regional and system functioning can be considered a Committee. comparative advantage. However, the Review findings show that the Secretariat is not always a good role model for Member States. Integrating services and linking better across disease programmes in whole-of-system approaches are areas of technical knowledge that WHO needs to crystalize and document, along with related lessons. Because programmes are involved in service delivery, how health systems best incorporate programme approaches is an important aspect of technical knowledge not yet covered in the six health system strategies. Sharing and application of these areas of knowledge could help countries accelerate progress in developing resilient health systems and positive health outcomes.

The Review attempted to collect examples of health system work undertaken together in countries by more than one of the health system teams—but failed. This reinforces comments

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GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

from both country and development partner interviewees that the WHO Secretariat works vertically and does not integrate its approaches, even within the health system team.

The Review identifies the need for the WHO Secretariat do more to assist countries in sequencing and implementing health system improvements in an integrated manner for all programmes in balance with the burden of disease, rather than continuing with vertical approaches.

On a more positive note, and as mentioned earlier, disease programmes, being an integral part of the health system, often engage in health system work and are incorporating health system concepts into their own strategies.

E.5.c Synthesizing health systems work in countries Throughout this Review, it was found that the recording and synthesis of the Secretariat’s health systems work is poor. It must be acknowledged and appreciated that much of what WHO staff members do in terms of policy dialogue and influence is not easily recorded or measured. Even so, information on previous WHO Secretariat activities is not easily available for staff except at a high level, such as the annual reports of the Regional Director for the Western Pacific, or at a very detailed and disjointed level in the integrated computer reporting system. And neither of these forms of reporting is organized by country. With a lack of synthesized knowledge on previous health system work in a country, lessons learnt can be easily lost. The efficiency of Secretariat work in that country is likely to be reduced, with potential duplication and gaps, or poor sequencing. This was noted repeatedly as the Review team attempted to follow work streams and was corroborated by key informants who reflected that while WHO is strong in areas where there is a strong staff member, when that staff member leaves, programmes and work areas tend to falter and fail.

Compounding this, the format for formal reporting on the Secretariat’s work and results in the integrated computer system has changed for each of the current and previous two biennia, meaning, for example, that information on countries included in baselines, targets and achievements in health system work across the biennia has not been adequately documented anywhere, according to WHO Western Pacific Region senior staff.

This general problem has been evident for some years25 and was acknowledged by the WHO Executive Board in 2011 (Box 11). “The fragmented knowledge base, typical of international organisations, is reflected in WHO’s technical and organisational systems, structure and culture.”26 Poor recording and knowledge management are compounded by staff turnover, as explained in the next section.

Lucas A, Mogedal S, Walt G, et al. (1997). Cooperation for health development: the World Health Organization’s support to programmes at country level, summary report.

26 Barrett M, Fryatt B, Walsham G, et al. (2005). Building bridges between local and global knowledge: new ways of working at the World Health Organisation, KM4D Journal 1(2):31–46. (http://journal.km4dev.org/index.php/km4dj/article/viewFile/22/18) 25

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D. REVIEW FINDINGS

Box 11. Knowledge management: An urgent problem In 2011, the WHO Executive Board acknowledged that “as a knowledge-based Organization, WHO’s ability to deliver results is dependent upon staff having rapid and easy access to information, evidence and experts. While considerable effort has been invested in improving access to administrative information, country-specific knowledge tends to be inadequately shared— contributing to the compartmentalization of WHO’s work. In an era of ever-more powerful means of communication, through electronic and other mass media, this is an urgent problem to address. Staff need to be able to access up-to-date information on what the Organization is doing, on a wide range of technical issues, and on how to access relevant expertise.”* * WHO reforms for a healthy future: report by the Director-General. Executive Board Special session on WHO Reform (October 2011)

E.5.d Supporting WHO staff The regional health system strategies inform the work of WHO staff, but it is the work of the staff themselves that the key informant interviews indicate as being most important in supporting country health system development. Key informants described long-term, trustbased relationships between ministries of health and WHO, resulting in adaption and adoption of strategy recommendations over time.

The personal skills, strengths and weakness of individual staff, and their day-to-day relationships with counterparts and partner agencies, influence collaboration on health system work.

Interviewees from seven development partner agencies commented on the importance of people and personalities in WHO’s work. However, over-reliance on individuals can also be a weakness. These comments are echoed in another recent WHO evaluation.27 Staff turnover compounds loss of institutional memory of country context and WHO’s previous work in countries. Both the spheres of Secretariat knowledge related to countries (Figure 2) can be diminished by a high rate of staff renewal. This is especially so when there is not good information on the Secretariat’s work in countries, as well as that of partners and the countries themselves. This lack of information challenges proper orientation of new staff to continue moving work forward in the most appropriate manner for the country.

WHO staff turnover also poses difficulties for development partners and national counterparts in terms of maintaining effective communication and relationships between agencies. This points to a need for more Secretariat work in teams and networks and less complete reliance on individuals.

In summary, WHO staff can be supported by better technical (as distinct from administrative) orientation to country contexts; better information on Secretariat and country health systems work, progress and impact; and more team approaches to technical support and partnerships.

WHO Western Pacific Region (2012). Placing countries at the centre: a report on a fresh approach to assessing WHO country performance in the Western Pacific Region.

27

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GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

E.5.e Secretariat accountability to the Regional Committee An important political consensus is forged by WHO Member States when major strategies are endorsed and requirements for progress reporting are specified by the Regional Committee for the Western Pacific, the WHO governing body in the Region. A strategy that is both technically robust and has the backing of Member States is more valuable than a purely technical strategy.

This political process also impacts the technical advice—it is not only evidence based but has been modified (appropriately) by a collective political process. For example, the current target agreed upon by Member States in the Western Pacific on out-of-pocket payments is less than 30% of total health expenditure (THE),28 even though best evidence indicates that less than 20% of THE is needed to mitigate negative impact on equity.29 Nevertheless, the Review found that the Regional Committee resolutions do not appear to guide either Member State or Secretariat health systems work (Annexes 8 and 9). However, this finding has to be treated with caution due to the lack of systematic Secretariat recording as mentioned in Section E.3.d and discussed above.

WHO Secretariat mechanisms could support better monitoring and recording for stronger and more candid feedback and accountability to the Regional Committee, specifically on the actions the Regional Committee requests of the Secretariat. This feedback could be coordinated across programmes and health system work, progress and impact, with a country-specific focus.

28 29

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WHO Western Pacific Region (2010). Health financing strategy for the Asia Pacific region (2010–2015).

WHO (2010). World health report 2010: health systems financing—the path to universal coverage.

D. REVIEW FINDINGS

E.6. Discussion: Effective technical partnership Figure 2 Knowledge about the country and context Adaptation to country context

Technical knowledge and learning networks

Basis for working with country and partners

Effective technical partnership Lessons on what works and does not work

WHO Secretariat processes and work history in country

All the issues so far in this discussion influence how WHO Member States and the Secretariat work together in developing and applying regional health system strategies for effective system functioning and better health outcomes—the central feature of the framework presented in Figure 2 at left.

A 1997 Review in 12 countries across four WHO regions found that WHO was not strategic in its work at the country level.30 In 2012, an evaluation of three WHO country offices in the Western Pacific Region came to the same conclusion, and further noted that WHO staffing is both a strength and a weakness; health system support is not strong enough; and the WHO Secretariat’s productivity is hampered by its own culture and systems.31 This Review has made similar findings and further identified problems in the Secretariat’s internal knowledge management and weak accountability to the Regional Committee for the Western Pacific.

Extending technical knowledge in areas of weakness as noted in this Review will be fundamental to future technical partnerships between WHO Member States and the Secretariat. These include health systems working with programmes, with non-health sectors on social and environmental determinants of health, and with non-state sectors in health.

The breadth of WHO’s knowledge and activity represents an opportunity that WHO can capitalize on. WHO’s expertise and experience in and across health system components are unique, but not used to maximum advantage because of the vertical nature of the Organization’s structure, funding and functioning.

Another essential area for technical partnership is stronger stewardship of the health sector—both state and non-state. For this, WHO also needs to play its dual role as both a friend and a critic of countries. Development partner interviewees suggest that WHO could do more to strengthen ministries of health and health system governance. Indeed, governance is only briefly covered in the Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care (2010), with some components in the other strategies. On the other hand, it could be said that all six strategies and action frameworks are entirely about health sector governance. WHO is ideally placed close to governments to strengthen ministries of health and their coherent functioning, but often takes a “softhand” approach and avoids being explicitly critical of government or ministry actions when necessary (TD18).

Lucas A, Mogedal S, Walt G, et al. (1997). Cooperation for health development: the World Health Organization’s support to programmes at country level, synthesis report.

31 WHO (2012). Placing countries at the centre: a report on a fresh approach to assessing WHO country performance in the Western Pacific Region.

30

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GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Agility in both thinking and procedures is required to identify and capitalize on windows of opportunity. Significant concerns were repeatedly raised by country, development partner and WHO staff key informants on the slow and cumbersome nature of WHO Secretariat procedures that hamper the smoothness and efficiency of WHO work. In this technological age and in this rapidly progressing region, WHO needs to be more agile. Further, excellent knowledge of the country, its context and WHOâ&#x20AC;&#x2122;s previous work are also necessary for taking the most appropriate action to maximize impact when opportunities arise.

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D. REVIEW FINDINGS

F. Summary of Review findings and implications for WHO Summary of findings

Lessons and implications for WHO

1. Knowledge about the country and context 1. Strategies are always context dependent and the Western Pacific Region has extreme regional diversities.

Work more with individual countries on their policies, plans and implementation taking into account their unique country contexts.

2. Few low-income countries in the Region.

A greater role for the Secretariat with middle- and high-income countries, for example on balancing levels of service access in relation to burden of disease, increasing standards and safety, reducing inequity, and controlling costs and reducing wastage.

3. There are increases in data available and overall progress on indicators in the 10 Review countries.

4. Key indicators show general increases in government expenditure on health and decreases in out-of-pocket (OOP) payments as a percentage of total health expenditure (THE).

5. Some essential medicines and human resources data can be difficult and/ or expensive to collect.

Continue to support progress and monitor a set of health system performance indicators that countries find most useful.

Support countries to collect at least some standard indicators on quality of care.

6. Most of the Review countries do not have accurate and comprehensive systems for civil registration and vital statistics.

7. There is insufficient disaggregated data available in countries or WHO to monitor equity adequately.

8. Where there is data, inequities are evident.

Support countries to establish robust systems for civil registration and vital statistics for accurate denominators for indicators and social stratifiers.

Support countries to collect and analyse disaggregated data on at least a small set of key health system performance indicators to monitor equity.

9. Outpatients receiving antibiotics exceeds 10% target in all six Review countries with data.

10. Antibiotics are available without prescription in 8 of 10 Review countries.

This has serious implications for antimicrobial resistance and needs rapid and concerted efforts by Member States.

11. Fragmentation in health systems.

Support countries to avoid or mitigate any further undermining of health system coherence through unbalanced funding from global health initiatives.

12. Growing role of the private sector.

Support countries to engage with the private sector towards national health objectives, but regulate and control to mitigate negative effectives on equity.

Technical and advocacy briefs to explain market failure in health to politicians.

13. In the Western Pacific Region, WHO health system-related knowledge on countries is fragmented, scattered, submerged, not comprehensive, not synthesized and not readily available to countries, partners or WHO staff for orientation or to strategically plan health system work.

Health system work should adapt global strategies to specific country contexts for greater country focus.

Regular summaries of WHO health system work and progress in each country. Use these summaries for orientation of all country office staff, and by all programmes in planning their country workâ&#x20AC;&#x201D;whether by staff or consultants.

14. Most of the country information the Secretariat has is not organized by country, but is located with programmes-both health system and disease programmes.

Organize more of the country information that the Secretariat has, by country as well as by programme.

Combine the different Secretariat country web pages to one single comprehensive web page for each country.

15. Significant information on country health systems is missing.

Systematically work with countries to improve knowledge in more areas of health system structure and functioning in each country, based on their priorities, e.g. laboratory and other diagnostic services, benefit packages, accreditation systems and so on.

16. Health issues feature highly among future social risks and complex global challenges.

Continue working with countries to build resilient health systems able to respond to national and global emerging issues, with broad engagement of stakeholders.

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GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Summary of findings

Lessons and implications for WHO

2. Technical knowledge and learning networks 1. The regional health system strategies present technical, evidence-based knowledge, express WHO values and have endorsement of the Regional Committee for the Western Pacific.

Health system knowledge generation and sharing are likely to change in the future with more knowledge emerging directly from the Region and shared directly among countries. The WHO Secretariat has an imperative role to facilitate learning networks.

2. The strategies and WHO support are appreciated and used by countries for benchmarks, ideas and support for advocacy.

3. Strategy recommendations or actions are widely found in national health plans.

4. However, the strategies are also viewed by some as standards to aspire to, but are too difficult for some countries to implement.

5. The strategies do not provide guidance on adaptation to specific country contexts, nor sequencing of steps for implementation.

Future health system work could direct more effort into frank discussion with countries on applicability of strategy recommendations and sequencing of steps for feasible implementation in each specific country context.

6. The strategies are not a cohesive set, do not refer to each other, do not provide a strong whole-of-system approach, and contain little or nothing on: a. explanation of advantages and disadvantages of different policy options in specific contexts; b. working with the non-state sector in health; c. links to social determinants of health; and d. hospitals.

Future health system strategies could provide: i. a more integrated and cohesive approach; ii. more advice in application to specific contexts; iii. more explicit advice and examples on working with other sectors on social and environmental determinants of health; and iv. more advice on working with the private sector to achieve national health objectives and to effectively mitigate associated negative impacts on equity.

7. Although all the strategies have suggested indicators, many are not used by countries and are not collected by the WHO Secretariat.

8. The strategies monitor and present information on their indicators in different ways, it is not a “linked-up” approach.

9. A collective framework is not used to monitor strategy implementation or indicators.

Countries will benefit from a more coherent WHO approach to monitoring progress in health system development in each country and focusing on indicators most useful to the country, with disaggregated data to monitor equity.

The WHO Secretariat could benefit from mechanisms to obtain most upto-date, or preferably “live” data on country health systems.

10. The health system strategy recommendations or actions are found in 14 WHO regional programme strategies.

This is a good basis for reducing verticality within the Secretariat and country programmes in a whole-of-system, balanced and coherent way across the health system components and their interactions with each other.

3. Secretariat processes and history of work in the country 1. Health system work is generally appreciated, but it is also criticized for functioning in a vertical manner.

The WHO Secretariat can act more as a role model and follow its own advice to Member States.

By demonstrating that it can integrate across health system teams and across different programmes, the Secretariat could provide a powerful message to countries.

2. The WHO Secretariat has no systematic processes for recording and synthesizing its health system work over time in an individual country.

WHO and Member States could benefit from improved Secretariat mechanisms that: i. document and synthesize the Secretariat’s previous and current health system work in countries; ii. avoid duplication, identify gaps and sequence WHO and country health system activities; and iii. support health system to become learning systems.

3. The Review found evidence that over the years WHO health system work in the Western Pacific Region has supported significant resource mobilization for country health system development, tackled sensitive issues and initiated some global developments.

4. The way WHO works with ministries and development partners tends to depend on individual relationships, and work often falters when those individuals leave. Staff turnover reduces institutional memory of country context and WHO’s previous work. This contributes to poor staff orientation for work in countries, and creates the danger of not following through on or duplicating previous work.

5. If WHO is too close to a ministry of health, it can lose its independence and its ability to advise the ministry on difficult or sensitive issues. Further, the special relationship with health limits work in other sectors on social determinants of health.

54

Countries could benefit from more Secretariat efforts in dissemination of success stories on effectively using funding from global health initiatives in health system development.

WHO Secretariat mechanisms are needed to: i. harvest tacit country knowledge before staff leave; ii. orient staff to health system development in the country; and iii. work more in teams and networks to reduce reliance on individuals.

WHO Secretariat mechanisms are needed to: maintain independence and evidence-base of advice; ensure staff are capable of being both a friend and a critic to countries; and have easier access for working with other sectors on social determinants of health.

D. REVIEW FINDINGS

Summary of findings

Lessons and implications for WHO

6. There are mixed messages about WHO support in coordination of development partners’ work.

WHO can put more effort into building countries’ capacity in their leadership and governance roles.

7. The activities requested by the Regional Committee for the Western Pacific in its resolutions endorsing the regional health system strategies do not appear to be systematically followed by the WHO Secretariat or Member States.

WHO Secretariat mechanisms are needed to ensure stronger and more candid feedback and accountability to the Regional Committee for the Western Pacific, specifically on the actions the Regional Committee requests of the WHO Secretariat.

4. Effective technical partnership between WHO Member States and Secretariat 1. Effective technical partnership needs all three spheres of knowledge as presented in Figure 2.

2. WHO is most efficient with technical knowledge and less so at documenting, synthesizing and sequencing its own health system work in countries.

Strengthen all three spheres of knowledge (Figure 2) for more effective and efficient technical partnership more relevant to countries, and with more sustainable impact.

Strengthen country stewardship of their health sectors.

Support country health systems for stronger preventive approaches and to use public health and primary care more effectively.

Support strong engagement by health ministries in other sectors, such as education and urban planning.

3. WHO agility is limited by its cumbersome and time-consuming procedures.

Enhance WHO agility and flexibility by adjusting structure, funding and procedures to better support staff in countries to seize windows of opportunities when they occur.

4. The WHO Secretariat is criticized for inadequate sharing of lessons learnt.

Bridging the “know–do gap”, an important purpose in technical partnership, is facilitated by sharing well-presented lessons. More of the health system team’s work could be dedicated specifically to this.

Support knowledge and learning networks for timely exchange between countries for building resilient health systems.

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GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

G. Statement from the high-level meeting The draft Summary Report was reviewed at a High-level Consultation in Manila in July 2013 attended by 25 representatives from 18 Member States, eight WHO country office health system staff, six members of the Steering Committee, the Review team and many other Secretariat staff.

This final report has been revised as suggested by the consultation.

In the final session of the three-day meeting, participants drafted and agreed the following statement: We the participants of this High-level Consultation have considered the draft Summary Report entitled Guiding Health Systems Development in the Western Pacific: Summary of a Review of the Use and Utility of Six regional Health System Strategies.

We note that this Summary Report is the first of its kind to be conducted by any WHO Region.

Based on our consideration of the draft Summary Report, we make the following conclusions and recommendations: 1. Countriesâ&#x20AC;&#x2122; own health and development strategies and plans focused on the health of their individual populations are of paramount importance.

2. Strategies are context dependent and therefore any global or regional strategy must be adapted to the context of each country.

3. The evidence base of policy options and technical information is dynamic, and the WHO Secretariat can play an important role in assisting countries in keeping abreast of the changes 4. Consideration should be given to whether and how the whole-of-systems approach could support countries in adapting global or regional strategies to specific country contexts.

5. The demographic, socioeconomic and epidemiological transitions currently taking place require that health systems engage more fully with all sectors that are relevant to health or have an impact on it, so that health is reflected in all policies.

6. These transitions, the concurrent changing health needs in this diverse Region and the pursuit of universal health coverage together require a more whole-of-system approach within Member States and also within the WHO Secretariat. However, it is acknowledged that for both, full adoption of this approach may be constrained by structure and funding.

7. Countries, in partnership with WHO, should strengthen their stewardship capacity for working with the non-state actors in moving towards national health and development objectives.

8. WHO should assist in building national capacity in health system strengthening and in helping countries to operationalize health system strategies.

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D. REVIEW FINDINGS

9. Advances in information and communication technologies offer Member States and WHO new opportunities for faster and more efficient exchange of lessons learnt.

10. WHO has an essential current and future role in promoting and supporting networked learning and knowledge management and exchange within and between countries and sub-regions, e.g. Pacific island countries and areas, the Association of Southeast Asian Nations (ASEAN) and the Mekong countries.

High-level Consultation on Health System Strategies Review Manila, 22â&#x20AC;&#x201C;24 July 2013

In the future, health system strategies will be more context specific, and guide on wider stakeholder engagement on social determinants of health. In the Pacific, they will provide more guidance on linkages with healthy island initiatives.

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If you want to go fast, go alone; if you want to go far, go together.

©Bibliothèque nationale de France

—Old African proverb

Caravan crossing the Silk Road. (detail of the map of Asia) The Catalan Atlas, Spain, Majorca 14th century.

Annexes Annex 1 is a short briefing paper developed at the beginning of the Review process to explain what the Review was about. Annexes 3 to 18 are excerpts from the technical documents listed in Annex 2, and which form the evidence base of this Summary Report and reflect the breadth, depth and detail of the Review exercise.

Country abbreviations used in Annexes Countries Cambodia China Fiji Lao People’s Democratic Republic Malaysia

abbreviations KHM CHN FJI LAO MYS

Countries Mongolia Papua New Guinea Philippines Solomon Islands Viet Nam

abbreviations MNG PNG PHL SLB VNM

Annexes Annex 1.

Annex 2.

Annex 3.

Annex 4.

Annex 5.

Annex 6.

Annex 7.

Annex 8.

Annex 9.

Annex 10.

Annex 11.

Annex 12.

Annex 13.

Annex 14.

Annex 15.

Annex 16.

Annex 17.

Annex 18.

Annex 19.

Review of Regional Health System Strategies Briefing Paper Health system strategies Review work and documents Context of developing regional health system strategies and frameworks Main goals, high-level objectives and strategic areas of action in each of the six regional health system strategies Quotes on UHC from national health plans of 10 Review countries Influence of WHO on health system policies or key events (motivation, development, implementation) reported by national Key Informant interviewees..

Focus of Western Pacific WHO Regional and country office health system activities

by WHO core functions Partial indication of country health system activities mapped against actions requested of Member States in World Health Assembly and Regional Committee Resolutions related to six regional health system strategies Partial indication of WHO country office health system activities mapped against activities requested of WHO in World Health Assembly and Regional Committee Resolutions related to the six regional health system strategies Summary of links between WPRO disease programme strategies and six regional health system strategies Summary of links between strategies of five development partners and concepts in six health system strategies Reference information on indicator fixed points used in Tables 1 and 2 in section D. Review Findings Status of 10 Review countries on essential medicines, 2011 baseline Status of 10 Review countries on human resources for health indicators, most recent data from 2004–2011 Status of nine Review countries on health financing indicators Status of 10 Review countries on indicators recommended in the Traditional Medicine Strategy, 2011 Status of 10 Review countries on health equity, available data from 1993–2011 Proportion of deaths in the 10 Review countries, 2010 Contributors to the Review process

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GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Annex 1. Review of Regional Health System Strategies Briefing Paper

Review of Regional Health System Strategies Six regional health system strategies under review Over recent years the Division for Health Sector Development, Six regional strategies and frameworks • Regional Framework for Action on Access to Essential Medicines in the Western Pacific 2011–2016 • Regional Strategy on Human Resources for Health 2006–2015 and Human Resources for Health Action Framework for the Western Pacific Region 2011–2015 • Health Financing Strategy for the Asia-Pacific Region 2010–2015 • Asia Pacific Strategy for Strengthening Health Laboratory Services 2010–2015 • Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care (2010) • Regional Strategy for Traditional Medicine in the Western Pacific Region 2011–2020

in consultation with Member States of the WHO Region for the Western Pacific, has produced six regional strategies and action frameworks related to health system. All the strategies have one common goal – to support the attainment of universal coverage and equity in health outcomes. The timeframes for most of the strategies extend to 2015, the deadline for the Millennium Development Goals.

This Review will examine the extent to which the health system strategies and action frameworks are effective in supporting countries to achieve universal coverage. Findings will be presented at the 64th Regional Committee Meeting in 2013.

Review objectives The Review will identify where progress has been made, where it has been slow, and why. Member States will be able to appraise their individual and collective progress on strengthening health

system and use the evidence for decisions in their countries and for future guidance to the WHO Secretariat.

1. Review implementation of key policies and programs related to the six regional health system strategies by countries, WHO and partners 2. Assess the usefulness of the six WPRO health system strategies to countries, WHO and partners 3. Identify gaps and future needs to inform appropriate WPRO health system development approaches 4. Identify major lessons learned regarding WHO support to health system

Key issues: • • • • • •

Equity Services Efficiency Quality Safety Financial protection

development Three dimensions of the Review a. Identify inputs by WHO, countries and partners Qualitative review of progress on selected actions in each of the strategies and related RCM resolutions. b. Establish trends on indicators Data for the past 15–20 years on key health system performance and health outcome indicators to see country and regional trends. Where possible, data disaggregated by social stratifiers will be used to appraise health equity. c. Assess utility and identify lessons learned Contribution and usefulness of the WHO strategies to country actions, processes and health outcomes. The focus will be on ways to enhance future health system work in support of universal coverage and health equity.

Timeframe Data collection and analysis will be completed by May 2013. Findings will be presented at the 64th Regional

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Committee Meeting 2013.

ANNEXES

Annex 2. Health System Strategies Review work and documents The following Technical Documents have been produced during the course of the Review. They report the methods and findings of individual Review elements. The numbers are used to cite these Technical Documents in this Summary Report Technical Documents

Number

WHO Western Pacific Region Health System Strategies Review initiation document

TD1

Summary of WHA and Western Pacific RCM resolutions on health system development; actions for Member States (2004–2011)

TD2

Summary of WHA and Western Pacific RCM resolutions on health system development; actions for WHO Secretariat (2004–2011)

TD3

Content analysis of six current WHO Western Pacific regional health system strategies

TD4

Analysis of national health policies and plans of 10 Review countries against six WHO Western Pacific regional health system strategies

TD5

Comparison of Western Pacific regional disease programme strategies with Western Pacific regional health system strategies

TD6

Comparison of Western Pacific regional health system strategies with development partner strategies

TD7

Key events in 10 Review countries that significantly impacted on their health system development and functioning (1990–2011)

TD8

Summary of health system assessment in four Review countries

TD9

Analysis of health system performance indicators for 10 Review countries

TD10

Data on health system performance indicators for 10 Review countries 1994–2012

TD10

Proportion of deaths in the 10 Review countries, 2010

TD11

Review of disaggregation in published national health statistics of eight Review countries 2000–2012

TD12

Overview of eight development partners’ health system work in the Western Pacific Region 2004-June 2012

TD13

Desk review of WHO Western Pacific Regional Office health system work (2004–2012)

TD14

Submission by six WHO Western Pacific country offices of their health system work

TD15

Summary of Western Pacific regional and country office health system activities by WHO’s six core functions

TD16

Summary of key informant interviews in eight Review countries, 2013

TD17

Summary of key Informant Interviews with eight development partner agencies, 2013

TD18

Summary of five WHO Western Pacific staff interviews on policy dialogue experiences, 2012

TD19

Future issues on health system, Don Matheson 2013

TD20

61

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Annex 3. Context of developing regional health system strategies and frameworks Context Existing WHO global Regional health system strategy strategies 

Traditional Medicines Strategy 2002–2010 Essential Medicines Strategy 2004 Health Financing Strategy 2006–2010

Human Resource for Health Strategy 2006

Other WHO global documents

Demand from countries

Innovation

2000–2003

Guide to develop national drug policy, 2001; World Medicines Situation, 2004

Persistent problem of insufficient access to medicines

Embedding drug policy in the overall health care system

No

WHR 2000: HS improving performance; CMEH 2002 *

Assistance with access and poverty, and low investment in health

Emphasis on universal coverage

No

Nursing and Midwifery Strategic Directions 2002–2010; WHR 2006: Working Together

HR crisis – need for effective strategies on health workforce production and retention

2002–2005

Laboratory services Need to reduce critical cross-cutting fragmentation and progress support integral to on MDGs health system; Indicators

Laboratory Strategy 2010–2015

No

Health Financing Strategy 2010–2015

No

WHR 2010: Health Care Financing and UHC

Universal coverage; Indicators with targets;

No

Everybody’s Business 2007; WHR 2008: PHC Now More Than Ever

Brings together health systems and PHC – not done elsewhere;

2009 – no end date

Nursing and Midwifery Strategic Directions 2011–2020; 2010 Code of Practice

Health Systems based on the Values of PHC 2010

Human Resources for Health Framework 2011

Need operational perspective Need to control international recruitment

Essential Medicines Framework 2011

2004–2007 2008–2013

World Medicines Situation, Move from policy to action 2007

Traditional Medicines Strategy 2011–2020

Not current

Extensive use of Traditional Medicine; challenges with quality, safety, efficacy

WHR = World Health Report;

UHC = Universal health coverage;

Indicators Traffic light presentation of indicators Indicators

PHC = Primary Health Care;

WHA = World Health Assembly; HS = Health System; * Commission on Macroeconomics and Health 2002.

This table is table 2 in the Content analysis of six current WHO Western Pacific regional health system strategies (See Technical Document 4 in Annex 2 of this report).

62

ANNEXES

Annex 4. Main goals, high-level objectives and strategic areas of action in each of the six regional health system strategies Western Pacific Regional Strategy for Health Systems Based on the Values of Primary Health Care (2010) Core values Equity Social justice Universality People-centeredness Community protection Participation Scientific soundness Personal responsibility Self-determination Self-reliance Six Health System Building Blocks • leadership and governance • health care financing • health workforce • medical products and technologies • information and research • service delivery

Four goals of a health system • health, both absolute across the entire population and equity across socioeconomic groups • social and financial risk protection in health • responsiveness and people-centeredness • efficiency

Health Financing Strategy for the Asia-Pacific Region (2010–2015) Four target indicators (1) out-of-pocket spending should not exceed 30%–40% of total health expenditure; (2) total health expenditure should be at least 4%–5% of the gross domestic product; (3) over 90% of the population is covered by prepayment and risk pooling schemes; and (4) close to 100% coverage of vulnerable populations with social assistance and safety-net programmes.

Regional Strategy on Human Resources for Health (2006–2015) updated in 2010 by Human Resources for Health, Action Framework for the Western Pacific Region (2011–2015) Three Key result areas (KRA) KRA 1: Health workforce response to population health needs KRA 2: Health workforce education and continuing and competence KRA 3: Health workforce deployment, management and retention KRA 4: Health workforce governance and partnerships for sustained contributions to improved health outcomes.

Asia Pacific Strategies for Strengthening Health Laboratory Services 2010–2015 Seven key strategic elements 1. Establish a coherent national framework for laboratory services.

2. Finance laboratory services in a sustainable manner.

3. Build capacity for laboratory services.

4. Assure the quality of health laboratory services.

5. Promote the rational use of laboratory services.

6. Improve laboratory safety.

7. Support research and ethics in laboratory settings.

Regional Framework for Action on Access to Essential Medicines in the Western Pacific (2011–2016) Strategic action areas National medicines policy and medicines regulation; medicines procurement and supply system; substandard and counterfeit medicines; adequate financing and affordable prices; intellectual property rights and international trade agreements

Regional Strategy for Traditional Medicine in the Western Pacific Region (2011–2020) Five key strategic objectives 1. to include traditional medicine in the national health system; 2. to promote safe and effective use of traditional medicine; 3. to increase access to safe and effective traditional medicine; 4. to promote protection and sustainable use of traditional medicine resources; and 5. to strengthen cooperation in generating and sharing traditional medicine knowledge and skills.

This table is Annex 2 in the Content analysis of six current WHO Western Pacific regional health system strategies (See Technical Document 4 in Annex 2 of this report).

63

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Annex 5. Quotes on UHC from national health plans of 10 Review countries The Review examined the national health plans of the 10 participating countries for explicit or implicit references to universal health coverage – the uniting goal of the health system strategies.

It found that all ten contained such references to UHC principles including access to quality services, equity, safety and financial protection.

Cambodia: “The day-to-day activities of health managers and staff… should be guided by… social health protection, especially for the poor and vulnerable groups [and] client-focused approach to health service delivery.” Health Strategic Plan 2008–2015, Ministry of Health.

China: “The implementation of the five priority reform programmes aims at effectively solving the problem of ‘difficult and costly access to health care services’.... efforts will be made to improve the service quality of public health care institutions and to meet the demand of the people to have ‘convenient and affordable access to health care services’.” Implementation Plan for the Recent Priorities of the Health Care System Reform 2009–2011, Ministry of Health (translation).

Fiji: “The Strategic Plan has been developed [so that] communities [will] have access to effective, efficient and quality clinical health care and rehabilitation services…Government has recognized the need to strengthen health care services and through the Peoples Charter has made a commitment to have an annual increase to the health budget.” Strategic Plan 2011–2015: Shaping Fiji’s Health, Ministry of Health.

Lao People’s Democratic Republic: “We have to…implement health strategy by giving priority to prevention and health promotion and at the same time, by giving importance to good quality in treatment and universal health service coverage.” The Seventh Five-Year Health Sector Development Plan 2011–2015 Ministry of Health. (Provisional Non-Official Translation).

Malaysia: “Health sector development key result area – Health sector transformation towards a more efficient and effective health system in ensuring universal access to health care.” Country Health Plan 2011–2015: 1 Care for 1 Malaysia, Ministry of Health.

Mongolia: “The mission of the Ministry of Health is the commitment to contribute to poverty alleviation and socio-economic development by ensuring the delivery of quality health care that is equitable, user -friendly, evidence-based and sector-wide, to improve the health status of all the people of Mongolia… especially to the poor and to areas in greatest need.” Health Sector Strategic Master Plan 2006–2015, Ministry of Health.

Papua New Guinea: “The National Health Plan 2011–2020 [is a] demonstration of our commitment to strengthen primary health care for all, and improve service delivery for the rural majority and urban disadvantaged.” National Health Plan 2011–2020: Transforming our health system towards Health Vision 2020, Ministry of Health.

Philippines: “Inequity is a pervasive problem in our country… We are now pursuing the goal of… universal health care to overcome inequities in our health system and delivery better health outcomes.” National Objectives for Health 2011–2016, Department of Health.

64

ANNEXES

Solomon Islands: “Universality – All residents of the country must be entitled to the health services provided by the nation’s health sector on uniform terms and conditions…the recent increase in funding for the health sector has been dramatic…. Both as a percentage of GDP and the percentage of government total revenues the allocations to health are high for a country… relative to countries of similar socio-economic levels.” National Health Strategic Plan 2011–2015, Ministry of Health and Medical Services.

Viet Nam: “To promote preventive medicine and primary health care in the new situation, assuring people access to quality basic health services.” Five-Year Health Sector Development Plan 2011–2015, Ministry of Health.

This is part of Analysis of national health policies and plans of 10 Review countries against six WHO Weston Pacific regional health system strategies (See Technical Document 5 in Annex 2 of this report).

65

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Annex 6. Influence of WHO on health system policies or key events (motivation, development or implementation) reported by national Key Informant Interviewees During the semi-structured key informant interviews in eight Review countries, interviewees were asked to select key events or policies that they considered to have had significant influence on health system development. Their views were sought on whether WHO was involved or of influence in the chosen events or policies at three stages: the catalyst or motivation for the event or policy; its subsequent development; its implementation.

In the third column of the table, diamonds represent the number of events or policies discussed by interviewees in eight event or policy areas. In subsequent columns the diamonds represent WHO involvement or influence at each of the three stages of the events and policies as perceived and reported by the interviewees.

Health policy or event area KHM CHN National Health LAO Plans, general MYS health system policy, Primary PHL Health Care, quality PNG & safety SLB VNM LAO MYS Medicines / health PHL technologies PNG VNM KHM Human Resources LAO for Health VNM Laboratories VNM KHM CHN LAO Financing PHL PNG VNM PHL Traditional medicines VNM Health information KHM / research MYS LAO Reproductive / PHL Maternal & Child SLB Health VNM

Number of policies/events discussed by interviewees

Number of policies/events for Number of policies/events for Number of policies/events for which WHO was mentioned as which WHO was mentioned in which WHO was mentioned in catalyst or motivation development implementation













































 































 







































































 















































  



This is Table 1 in Summary of key informant interviews in 8 Review countries (See Technical Document 17 in Annex 2 of this report).

66

4.5%

4. Assessment of health sector and monitoring health system performance and monitoring implementation of national health plans 5. Institutional capacity-building at national level 6. Research 7. L - National health policies, strategies and plans 8. Policy dialogue on Health Care Financing, Human Resources, Health Information System, Essential Medicines and Technologies, Laboratories, Traditional Medicine 9. Information and monitoring indicators 10. L - Development partner coordination 11. Institutional capacity-building at sub-sector level for Health Care Financing, Human Resources, Health Information System, Essential Medicines and Technologies, Laboratories, Traditional Medicine 12. Institutional capacity building at sub-national level (community, district, province) 13. L-Multisectoral approaches

11.6% 10.3% 5.2% 4.5% 2% 1.9% 1.3% 0.6% 0.6% 0%

4. Assessment of health sector and monitoring health system performance and monitoring implementation of national health plans

5. Institutional capacity-building at national level

6. Policy dialogue on HCF, HRH, HIS, EMT, Laboratories, TRM

7. Norms and standards

8. Information and monitoring indicators

9. Research

10. L-Development partner coordination

11. 11. Institutional capacity building at sub-sector level for Health Care Financing, Human Resources, Health Information System, Essential Medicines and Technologies, Laboratories, Traditional Medicine

12. L-Multisectoral approaches

13. Institutional capacity-building at sub-national level (community, district, province)

Leadership and advocacy, and health worker capacity-building are high on both lists.

Norms and standards are more significant for CO (13%) than RO (4.5%).

Multisectoral approaches are very low for both RO and CO (confirmed by DP KIIs) and inadequate for future work.

DP coordination seems fairly low on the CO list, (may not be fully recorded), both country and DP KIIs indicate potential/need

•

•

•

•

for a stronger role by WHO, or supporting MoH to take that role.

Overall the order of the two lists is quite similar except for NHPSP and norms/standards.

•

analysis of scale, cost and HR input might give a different picture.

Comments: Summary is on number of activities only and one activity may not be defined consistently across offices and units –

6.2%

3. Leadership and advocacy

12.9%

3. Health worker capacity-building

Greens – capacity-building, •

Blues – information and monitoring Mauve – norms and standards Grey – research

• • •

technical support

Yellow – policy dialogue

leadership

Brown to orange – various forms of •

•

Colour codes for WHO core functions:

0.5%

1.1%

3.4%

3.9%

4.1%

6.6%

7.4%

9.2%

9.3%

13.2%

2. Norms and standards

21.9%

2. Leadership and Advocacy

30.6%

% of activities (N=937)

1. Health worker capacity-building

Eight country offices’ HS work 2008–2012

27.7%

% of activities (N=155)

1. L-National health policies, strategies and plans

Regional Office DHS 2008 - 2012

Annex 7. Focus of Western Pacific WHO Regional and Country Office health system activities by WHO core functions

ANNEXES

67

68

6 (35%)

4 (24%)

5

6

4

5

5

MYS

MNG

PHL

PNG

VTN

1 (6%)

Health Systems based on the values of Primary Health Care (HS-PHC)

3

3

1

13

4

11

3

2

12

Total number of MS activities

2 (6%)

2 (6%)

1 (3%)

8 (23%)

2 (6%)

6 (17%)

2 (6%)

2 (6%)

8 (23%)

Resolution actions covered

Total number Resolution actions on Human Resources: 35

2

3

3

Total number of MS activities

1 (6%)

0

2 (11%)

0

0

2 (11%)

0

0

0

Resolution actions covered

Total number of Resolution actions on HS-PHC Values: 18

Note: it has not been possible to do a comprehensive mapping

3 (18%)

2 (12%)

4 (24%)

6 (35%)

3

17

FJI

LAO

2 (12%)

5

3 (18%)

Resolution actions covered

CHN

Total number of MS activities

Total number of Resolution actions on Health Care Financing: 17

7

>50% 15–49% <15%

Human Resources

Essential Medicines and Technologies

8

5

1

9

10

13

3

1

0

Total number of MS activities

1 (50%)

1 (50%)

1 (50%)

1 (50%)

1 (50%)

1 (50%)

1 (50%)

1 (50%)

0

Resolution actions covered

Total number of Resolution actions on Essential Medicines and Technologies: 2

WPR/RC55.R4 (2004): Regional Strategy for WPR/RC35.R4 (1984), WPR/RC39.R9 (1988), WPR/RC59.R4 (2008); WHA62.12 (2009); WPR/ Improving Access to Essential Medicines in the WHA58.33 (2005), WPR/RC56.R6 (2005), WPR/ WHA57.19 (2004), WHA58.17 (2005), WHA59.23 RC61.R2 (2010); WHA64.8 (2011): Health System Western Pacific 2005–2010, Regional Framework RC60.R3 (2009), WHA64.9 (2011) (2006), WHA59.27 (2006), WPR/RC57.R7 (2006), Strengthening and Primary Health Care for Action on Access to Essential Medicines in the WHA 64.6 (2011), WHA64.7 (2011) Western Pacific 2011–2016

Health Care Financing

KHM

Resolutions

1

5

0

3

0

1

1

0

0

Total number of MS activities

1 (17%)

4 (67%)

0

2 (33%)

0

1 (17%)

1 (17%)

0

0

Resolution actions covered

Total number of Resolution actions on Laboratory Services: 6

WPR/RC60.R6 (2009): Asia Pacific Strategy for Strengthening Health Laboratory Services 2010–2015

Laboratory Services

Annex 8. Partial indication of country health system activities mapped against actions requested of Member States in World Health Assembly and Regional Committee Resolutions related to six regional health system strategies

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

18

5

14

25

3

1

4

CHN

FJI

LAO

MNG

PHL

PNG

VTN

Total number of WHO CO activities

Health Systems based on the values of Primary Health Care (HS-PHC)

67

19

7

20

8

13

23

21

Total number of WHO CO activities

15 (33%)

7 (15%)

4 (9%)

11 (24%)

4 (9%)

5 (11%)

11 (24%)

11 (24%)

Resolution actions covered

Total number Resolution actions on Human Resources: 46

66

4

0

21

5

2

0

0

Total number of WHO CO activities

12 (60%)

4 (20%)

0

7 (35%)

4 (20%)

2 (10%)

0

0

Resolution actions covered

Total number of Resolution actions on HS-PHC Values: 20

Note: it has not been possible to do a comprehensive mapping

4 (27%)

1 (15%)

3 (20%)

8 (53%)

7 (47%)

3 (20%)

4 (27%)

7 (47%)

Resolution actions covered

Total number of Resolution actions on Health Care Financing: 15

14

>50% 15–50% <15%

Human Resources

Essential Medicines and Technologies

80

17

8

59

6

12

34

115

Total number of WHO CO activities

2 (100%)

1 (50%)

1 (50%)

2 (100%)

1 (50%)

1 (50%)

2 (100%)

2 (100%)

Resolution actions covered

Total number of Resolution actions on Essential Medicines and Technologies: 2

WPR/RC55.R4 (2004): Regional Strategy for WPR/RC35.R4 (1984), WPR/RC39.R9 (1988), WPR/RC59.R4 (2008); WHA62.12 (2009); WPR/ Improving Access to Essential Medicines in the WHA58.33 (2005), WPR/RC56.R6 (2005), WPR/ WHA57.19 (2004), WHA58.17 (2005), WHA59.23 RC61.R2 (2010); WHA64.8 (2011): Health System Western Pacific 2005–2010, Regional Framework RC60.R3 (2009), WHA64.9 (2011) (2006), WHA59.27 (2006), WPR/RC57.R7 (2006), Strengthening and Primary Health Care for Action on Access to Essential Medicines in the WHA 64.6 (2011), WHA64.7 (2011) Western Pacific 2011–2016

Health Care Financing

KHM

Resolutions

7

11

2

18

5

10

1

2

Total number of WHO CO activities

3 (43%)

3 (43%)

2 (29%)

2 (29%)

2 (29%)

3 (43%)

1 (14%)

1 (14%)

Resolution actions covered

Total number of Resolution actions on Laboratory Services: 7

WPR/RC60.R6 (2009): Asia Pacific Strategy for Strengthening Health Laboratory Services 2010–2015

Laboratory Services

Annex 9. Partial indication of WHO country office health system activities mapped against activities requested of WHO in World Health Assembly and Regional Committee Resolutions related to the six regional health system strategies

ANNEXES

69

70

7 objectives Yes / Yes

"4 strategic areas 24 specific strategies" Yes / Yes

**

(Roll Back Malaria)

This is a global strategy

Malaria

Reproductive Health NCD

(IHR)

Emerging Diseases *

(Global)

HIV

**

"5 objectives 5 objectives 5 components 6 objectives 8 focus areas" 3 objectives Yes / Yes Yes/No No / Yes No/No Yes / No

Tuberculosis

5 priority areas Yes/No

Alcohol

5 objectives Yes / Yes

Neglected Tropical D

Mental Health Dengue

**

"3 goals 5 objectives 6 approaches" 6 objectives Yes / Yes No/No Yes / Yes

STIs

"8 key areas for actions" No / Yes

(Global)

Polio

Green means health system components are identified as goals, objectives and actions points in WHO. *The International Health Regulations (IHR) are legal requirements for all countries “to protect against, control and provide a public health response to the international spread of disease….” IHR indicators are presented in separate publications. ** The importance of disaggregated data is emphasized in the respective strategic documents

“HIV = A Strategy to halt and reverse the HIV epidemic among people who inject drugs (Asia and the Pacific) 2010–2015” Vaccine = Global Immunization Vision and Strategy 2006–2015 Alcohol = Regional Plan of Action for the reduction of alcohol-related harm in the Western Pacific (2009–2014) “Malaria = Regional Action Plan for Malaria Control and Elimination in the Western Pacific 2010–2015” Neglected Tropical D = Regional Action Plan for Neglected Tropical Disease in the Western Pacific 2012–2016 Tuberculosis = Regional Strategy to Stop Tuberculosis in the Western Pacific 2011–2015 STIs = Regional Strategic Action Plan for the Prevention and Control of Sexually Transmitted Infections 2008–2012 Reproductive Health = Regional Framework for Reproductive Health in the Western Pacific 2013 Mental Health = Regional Strategy for Mental Health (2002) NCD = Western Pacific Regional Action Plam for Noncommunicable diseases: A Region free of avoidable NCD deaths and disability Dengue = Dengue Strategic Plan for the Asia Pacific Region 2008–2015 Emerging Diseases = Asia Pacific Strategy for emerging diseases 2010 Polio = Polio Regional Strategic Plan 2008–2012 This table is table 1 in the Comparison of Western Pacific regional disease programme strategies with Western Pacific regional health system strategies (See Techinical Doucment 6 in Annex 2 of this report).

List of indicators / targets Governance & Leadership Political Commitment Communication & social mobilization Strengthen policy and guidelines National programme management Coordination & Partnership Service Delivery Service management & integration / Logistics Treatment and diagnosis Service quality and patient safety Health Care Financing Adequate and sustainable financing Links to national plans / costing / MTEF Human Resource for Health health workforce strategic response health workforce education and training health workforce management health workforce leadership and partnership Medical Products, Vaccines and Technology Medicines in essential medicine list Immunization Laboratory Health Information Monitoring & Evaluation Surveillance / Outbreak preparedness Research and technology Knowledge Management Information System / Database Equity, Gender and Human Right Universal and equitable access Advocates targeting vulnerable groups Attendtion to human right and gender issues

List of goals or objectives

Outlines a global / regional overall goal

Existance of global strategy

Regional Goal

Vaccine

Annex 10. Summary of links between WPRO disease programme strategies and six regional health system strategies

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

ANNEXES

Annex 11. Summary of links between strategies of five development partners and concepts in six health system strategies Scope, duration

UNICEF1 Global, 2006–2015

World Bank2 Global, 2007 to present

ADB3 Asia Pacific, 2008–2020

JICA4 Global, 2010–2015

USAID5 Global, 2012–2016

Health system strengthening Health care financing Human resources for health Essential medicines Laboratory Service delivery Governance Health information system and research Primary health care Universal health coverage Traditional medicine Equity Gender Human rights Other references to WHO Coordination and collaboration with WHO

* Green indicates inclusion of future directions related to general concepts of health system building blocks and related principles. For Primary Health Care, USAID mentions its mission and approach for locally-adopted solutions. UNICEF mentions “universal coverage” in the context of filling gaps to access. For equity, gender and/ or human rights, reference to the term is needed.

1

UNICEF (2006). UNICEF joint health and nutrition strategy for 2006–2015. E/ICEF/2006/8. United Nations Economic and Social Council, United Nations Children’s Fund Executive Board, First regular session 2006.

The World Bank (2007). Healthy Development: The World Bank Strategy for Health, Nutrition, and Population Results.

2

ADB (2008). Strategy 2020 – The Long-Term Strategic Framework of the Asian Development Bank 2008–2020.

Asian Development Bank.

3

JICA (2010). JICA’s Operation in Health Sector – Present and Future. Japan International Cooperation Agency.

4

5

USAID (2012). USAID’s Global Health Strategic Framework – Better Health for Development FY 2012 – FY 2016.

United States Agency for International Development

This table is table 1 in the Comparison of Western Pacific regional health system strategies with development partner strategies (See Technical Document 7 in Annex 2 of this report).

71

72 100 100

Antenatal care coverage (1+ visit) (% of pregnant women)

Antenatal care coverage (4+ visits) (% of pregnant women)

90

Children <5 years with ARI symptoms taken to a health facility (%) Children <5 years with diarrhoea receiving ORT (%) Vitamin A supplementation among children <5 years (%)

Children <5 years sleeping under ITN (%)

20 21 22 23

27

26 80 70

Cervical cancer screening: women 20–64 years (%)

80

TB case detection rate (% of estimated cases)

ARV coverage among people with advanced HIV infection (%)

70 70 70

Contraceptive prevalence (% of women 15–49 years)

19

24

100

DPT3 immunization coverage** (% of infants 12–23 months)

18 70

100

Skilled attendance at birth (% of live births)*

17

16 16

85

TB treatment success rate (% of cases)

12

95

Average availability of 14 selected essential medicines (public) 3

5

General government health expenditure on health as % of GDP

Median price ratio for tracer medicines

500

Reference point

Total health expenditure (THE) per capita at exchange rate

Indicator

10

9

2

1

No

0

30

20

0

30 30 0

30

50

25

25

25

70

17.5

10

1

40

Poor

70

100

80

90

100 100 100

80

100

100

100

100

95

1

95

5

500

Better

Reference point based on the EM strategy is below 3x world market reference price. CHN and MYS are below 2x. Better in this Review is set at below world market reference price.(1) Global Tuberculosis Report based on previous WHA resolution sets global target at 85%. KHM and CHN have reached 95%. Hence, better is set at 95%.

Average from OECD countries is 99% while from 20 Asian countries is 85%.

Reference point and better are set at 100%.

MYS and MNG have reached 100%.

Hence, better is set at 100%.

Average from OECD countries is 99% while from 20 Asian countries is 78%.

MYS and MNG have reached 100%.

Hence, better is set at 100%.

Average from OECD countries is 95% while from 22 Asian countries is 92%.

CHN and FJI have reached 99%.

Reference point of 70% is based on OECD average of 73% & Asia-20 average of 69%. CHN has reached 84.6%.

Better is set at 80%.

MNG has reached 87%. Hence, better is set at 100%.

VNM has reached 94.7%. Hence, better is set at 100%.

In line with the above two indicators Global target of 75% disease reduction can only be achieved through 100% of children sleeping under ITN. MVP Reference point and better at 90%.

Standard for universal access to ARV therapy is 80%.

Hence, reference point and better are set at 80%.

Reference point set at 80% after consultation with STB unit.

FJI has reached 92%. Better is set at 100%.

Latin American cancer screening in the past three years is 40.3%- 68.3%; past 12 months is 15.3% to 72.2%. Coverage in European countries ranges from 10% to 93% using different criteria. Reference point and better are set at 80%.

Based on the EM strategy

Based on 5–6% target in the Health Care Financing strategy

MYS has reached US$ 346 per capita at exchange rate. Hence, reference point and better set at 500.

How the better point was arrived at

WHO IARC (2005). IARC Handbooks of Cancer Prevention Vol 10. International Agency for Research on Cancer. Pp. 125, 134.

WHO and OECD (2012). Health at a Glance Asia/Pacific 2012.

WHO (2012). Global Tuberculosis Report.

WHO (2012). Regional Framework for Action on Access to Essential Medicines in the Western Pacific (2011–2016).

WHO (2009). Health Financing Strategy for the Asia Pacific Region (2010–2015).

WHO (2012). Regional Framework for Action on Access to Essential Medicines in the Western Pacific (2011–2016).

References

Annex 12. Reference information on indicator fixed points used in Tables 1 and 2 in section D. Review Findings

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

10

Adolescent fertility rate for women 15–19 years (per 1000) 20

0

HIV prevalence among 15–49 years old (%)

Out-of-pocket as % of total health expenditure (THE)

19

11

Maternal mortality ratio per 100 000 live births

TB prevalence in population (per 100 000)

5

Under 5 mortality rate per 1000 live births

70

Condom use in adults 15–49 with more than 1 sexual partner (%) 80 80

80

Infants exclusively breastfed for the first 6 months of life (%)

Life expectancy at birth (years) (male) Life expectancy at birth (years) (female)

5

Low birth weight among newborns (%)

60

100

1

500

200

65

60 60

40

15

25

30 30 50

60

10 100 100 5

Overweight adults aged 20+ (BMI≥25) (%) (female)

Population using improved drinking-water sources (%) Population using improved sanitation facilities (%) Children aged <5 years who are stunted (%)

60

10

20

10

0

20

10

5

80 80

70

80

5

100 100 5

10

10

0

10

10

0

0

Better

Based on 20–30% target from the Health Care Financing strategy.

Average from 20 Asian countries is 2.4 while MYS has the lowest value of 0.45. Reference point and better are set at 0 Average from 16 Asian countries for males and females is 21% while VNM has reached 10.1%.

Hence, reference point and better are set at 10%.

OECD average is 98%; Asia-19 average is 89%. MYS 100%.

Hence, reference point and better are set at 100%.

MCN unit advised reference point at 5%.

OECD average is 6.7% while Asia-18 average is 13%. CHN has reached 3%.

MCN unit advised reference point at 5%.

MCN unit advised reference point at 70% while KHM and SLB have reached 74%. Reference point and better are set at 80%.

VNM is the only country with information at 58%.

Reference point and better are set at 70%.

OECD average is 79.8 years while Asia-22 is 72.2.

Reference point and better are set at 80 years.

OECD average is 5 per 1000 live births while Asia-20 is 32.

Reference point and better are set at 5.

OECD average is 11 per 100 000 while Asia-20 is 125.

Better is set at 10. LAO at 470. Poor is set at 200 OECD average is 19 per 100 000 hence better is set at 20.

KHM at 817 is an outlier. Poor is set at 500 Asia-18 average is 0.13% while OECD average is 0.19%. MNG and PHL have values <0.1%. Reference point and better set at 0.

CHN has a value of 6. MCN unit suggested 10 as reference point. Better is set in the same value.

Prevalence for WPR low and middle income countries is 17%. Better is set at 10%.

OECD values for males and females are available while CHN and MYS have female smoking rates of 2%.

Hence, reference point and better are set at 0.

How the better point was arrived at

This table is Annex 2 in Analysis of health system performance indicators for 10 Review countries (See Technical Document 10 in Annex 2 of this report)

*The proportion of live births attended by skilled health personnel. **Diphtheria, pertussis and tetanus toxoid immunization

46

43 45

42

39 40

38 38

36 37

35

32 33 34

30 31 31

50 10

17

Prevalence of raised BP among adults aged ≥25 years (%) (female)

50

0

17

Prevalence of raised BP among adults aged ≥25 years (%) (male)

60

60

Poor

Alcohol consumption among ≥15 years (litres of pure alcohol/person/ year) Overweight adults aged 20+ (BMI≥25) (%) (male)

0

Tobacco use: adults aged 15+ (%) (female)

28 29 29

0

Tobacco use: adults aged 15+ (%) (male)

28

Reference point

Indicator

No

WHO (2009). Health Financing Strategy for the Asia Pacific Region (2010–2015).

WHO and OECD (2012). Health at a Glance Asia/Pacific 2012.

Trends in Maternal Mortality from 1990 to 2010 by WHO, UNICEF, UNFPA and the World Bank.

WHO and OECD (2012). Health at a Glance Asia/Pacific 2012.

Pfizer (2011). The Global Burden of Noncommunicable Diseases. Population studies. P. 7.

WHO and OECD (2012). Health at a Glance Asia/Pacific 2012.

References

ANNEXES

73

74 No

No Yes

44.76

Public expenditure (including public health/social insurance) on pharmaceuticals as % of total pharmaceutical expenditure.

Out-of-pocket expenditure as % of total health expenditure.*

Does a public health service, public health insurance, social insurance or other sickness fund provide partial or full coverage for medicines that are on the EML for outpatients (write % of coverage and % reimbursement)?

Does a public health service, public health insurance, social insurance or other sickness fund provide partial or full coverage for medicines that are on the EML for inpatients (write % of coverage and % reimbursement)?

Is revenue from the sale of medicines used to pay the salaries or supplement the income of public health personnel in the same facility?

7

8

9

10

56.9

21.0

53.31 39.7

22.4

3.0

100 34.8

37.96

42.5

41.7

62.81

8.8

55

39.7

27.4

59

11.7

51.4

6

17.6

10.9

15.8

148

1.75 44

Total pharmaceutical expenditure as a % of total health expenditure.

21

25

5

19

35

Total pharmaceutical expenditure per capita –PPP$ (public and private).

1.48

55.9

35.4

47

17.15

55.7

60%

50.9

27.6

10.4

54.6

53.3

4

6

26.5

>70%

<30%

>25% and <15%

Yes, but phasing out

Partial

Partial

50%-70%

30%-50%

20%-25%

80–95% 3–5 x world market reference price

<80%

80–95%

80–95%

Every 2 yrs or more

> 2 years

> 5 years

Needs improving

>95%

>95%

>95%

Annual

< 2 years

< 5 years

Good

No

Full

Full

<50%

>50%

15%-20%

Baseline and 2015

< 3 x world market reference price

Guide to the traffic lights

> 5 x world market reference price

<80%

<80%

Public procurement prices for selected medicines in comparison to international reference price. (higher by how many times).

20

55.9

3

75

86.7

15.4

Availability of 30 essential medicines (public and private sector) (%).

43.8

80

77.3

25

Availability of 30 essential medicines (private sector, %).

74.8

98

Availability of 30 essential medicines (public sector, %).

2

No

Action is needed

No

PHL * VNM*

c. NMP implementation regularly monitored/assessed (how often monitored in years).

PNG*

MNG*

No

MYS*

b. NMP implementation plan exists. Write the year of the most recent revision.

CHN*

SLB

a. NMP official document exists. Write the year of the most recent revision.

LAO

Medicines policy and implementation mechanism in place.

FJI

KHM

1

Policy and Access

Indicator

Annex 13. Status of 10 Review countries on essential medicines, 2011 baseline

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

99 99

a. Average number of medicines prescribed per patient (outpatient).

b. % of patients in outpatient public health care facilities receiving antibiotics.

c. % of medicines in outpatient public health care facilities that are prescribed by INN (generic) name.

d. % of medicines prescribed in outpatient public health care facilities that are in the EML.

% of prescriptions complying with the standard treatment guidelines.

A national programme or committee (involving government, civil society and professional bodies) exists to monitor and promote rational use of medicines.

17

18

76.58

72.8

56.54

2.8

100

100

18

37

2.3

100

14.3

3

77.7

68.2

46.7

2

93.1

86.8

63.3

2

3.6

40.8

28.1

49.2

No

<50%

<70%

<50%

>20%

>3

No

> 3 years

Government only

50%-80%

70%-90%

50%-80%

10%-20%

2.5–3

> 5 years ago

3 years

Yes, government & partners

>80%

>90%

>80%

<10%

<2.5

< 5 years ago

< 3 years

No

Yes

Yes

< 5 years

Good

*”Out-of-pocket expenditure as % of total health expenditure” indicator above is listed as “Private out-of-pocket expenditure as % of total health expenditure” in the Regional Framework for Action on Access to Essential Medicines in the Western Pacific (2011–2016). Data source for this indicator: Global Health Expenditure Database 2011, http://apps.who.int/nha/database/DataExplorerRegime.aspx.

Note: Information from the following countries is not verified: China, Malaysia, Mongolia, PNG, the Philippines and Viet Nam. Results are 2011 baseline through 2013 survey by Essential Medicines This table is included in the companion Excel file of Analysis of health system performance indicators for 10 Review countries (See Technical Document 10 in Annex 2 of this report)

55

A survey on rational use of medicines has been conducted. Write the year of the survey.

16 2.5

EML updated in the last three years.

15

Rational selection and use

Licensed pharmacies but not drug sellers

Yes, licensed pharmacies and drug sellers

Antibiotics are dispensed over the counter without a prescription.

Partially

> 5 years

Needs improving

14

Action is needed

Guide to the traffic lights

Partially

PHL * VNM*

No

PNG*

Legal provisions exist requiring manufacturers, wholesalers, distributors and dispensers to be licensed.

MNG*

13

MYS*

No

CHN*

Legal provisions exist permitting inspectors to inspect premises where pharmaceutical activities are performed.

SLB

12

LAO

No

FJI

Has an assessment of the medicines regulatory system has been conducted in the last five years?

KHM

11

Quality assurance

Indicator

ANNEXES

75

76 CHN

FJI

LAO

This table is included in the companion Excel file of Analysis of health system performance indicators for 10 Review countries (See Technical Document 10 in Annex 2 of this report)

Source of data: Country Health Information Profiles 2012 and Human Resources country profiles. *These indicators are mainly to be maintained at national level for decision making and policy implementation.

Key result area 1: Health workforce strategic response to evolving and unmet population health and health service needs.

Existence of Human Resources plan Yes ?

Yes Yes Health workers (D+N+M)/10,000 12 11.6 Doctors/10,000 2.5 15.2 3.8 2.3 Nurses/10,000 6.5 16.8 20.3 9.3 Midwives/10,000 3 Health workers (D+N+M) in rural areas (%) 22 Key result area 2: Health workforce education, training and continuing competence.

No. Doctors graduated 134 435870 35 53 No. Nurses graduated 710 130426 191 No. Midwives graduated 801 No. Pharmacist graduated 131 40863 % Health professional graduates employed 12 months after graduation* Existence of national competency examination by category/cadre Yes No % of graduates by category/cadre passing the competency examination (on first attempt)* Key result area 3: Health workforce utilization, management and retention.

Existence of quality assurance mechanisms* Performance appraisal system in place* % Births attended by trained health professionals (skilled attendance at birth - % of live births) 71 97.8 99.8 18.5 Vacant post/Total vacant post by geographical location (urban vs. rural)* Total number of recruited to rural areas* Key result area 4: Health workforce governance leadership and partnerships for sustained contributions to improved population health outcomes Existence of Human Resources partnerships and networks addressing workforce efficiency and effectiveness* Existence of national policies addressing conditions at work* Existence of national policies addressing quality, including infection control* Existence of up-to-date Human Resources databases Yes Yes

KHM

Yes

99.8

98.6

40

49 135 64 25

2639 766 219 169 Yes

Yes 6 0.6 5 0.4 18

PNG

Yes 64.4 28.3 33.5 2.6

MNG

No

45.6 12.5 25.5 7.6

MYS

Yes

340

62.2

Yes

1732 79149 6332 1558

Yes 70.5 11.4 42.6 16.5

PHL

Yes

97.8

Yes

5 63 17 6

developing 19.5 2 17.5

SLB

97

1583

7897 1710

?

19.6 7.2 9.3 3.1

VNM

Annex 14. Status of 10 Review countries on human resources for health indicators, most recent data from 2004â&#x20AC;&#x201C;2011

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Note: Change 2002 to 2003 in Mongolia was due to change in survey methodology. Of the countries featured in the Review, total health expenditure per capita has increased generally.

These graphs are included in the companion Excel file of Analysis of health system performance indicators for 10 Review countries (See Technical Document 10 in Annex 2 of this report)

Annex 15. Status of nine Review countries on health financing indicators

ANNEXES

77

78 − -

√ √ √ √

− √

- a national plan/programme

- a Review and monitoring system

- information systems

- lead government agency/office

− − -

√ √ √ √ √ √ √

− − √ − −

- national regulation and registration system for products

- national pharmacovigilance system

- standards for the scope of practice, training, licensing and registration for providers

- organization of professional groups

- training programmes for Western health professionals in traditional medicine

- national medicinal plants monographs

- education programmes for consumers

−

√ √

√ −

- programme for educating indigenous groups

- a national research institution or centres of excellence

- national standards for classification of terminologies

This table is included in the companion Excel file of Analysis of health system performance indicators for 10 Review countries (See Technical Document 10 in Annex 2 of this report)

-

√ -

-

- conservation and cultivation programme

-

−

√

−

- controls for advertising traditional medicine products and services

Existence and support of:

-

√

−

- insurance coverage for products and practices of traditional medicine with established safety and efficacy

Existence and implementation of:

−

√

−

√

- programmes to build and strengthen national GACP, GMP, GLP, GCP and GSP

Existence and implementation of:

−

√

√

- national regulations

√ -

√

√

- a national policy

FJI

CHN

KHM

Existence and implementation of:

Traditional Medicine Country Level Indicators

−

√

-

−

−

-

−

−

−

-

-

−

−

-

√

√

−

√

√

√

LAO

√

√

−

√

− -

√

-

√

-

√

−

√

−

−

-

-

-

−

−

−

-

−

−

-

− √

−

-

√

-

−

√

-

√

PNG

√

−

√

−

−

√

−

√

MNG

√

√

√

√

√

-

√

√

√

√

√

√

−

√

√

√

√

MYS

-

√

-

−

-

√

-

√

−

√

√

−

√

√

√

-

√

√

√

√

PHL

−

-

-

−

-

−

−

-

−

−

-

-

-

-

-

-

-

-

-

-

SLB

√

√

-

√

√

√

√

√

-

√

√

√

√

Partial

√

-

−

√

√

√

VNM

Annex 16. Status of 10 Review countries on indicators recommended in the Traditional Medicine Strategy, 2011

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Annex 17. Status of 10 Review countries on health equity, available data from 1993â&#x20AC;&#x201C;2011 (WPRO HIIP and World Bank)

ANNEXES

79

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

80

These graphs are included in the companion Excel file of Analysis of health system performance indicators for 10 Review countries (See Technical Document 10 in Annex 2 of this report)

ANNEXES

81

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Annex 18. Causes of deaths in the 10 Review countries, 2010 The following graphs summarize the proportion of deaths in 2010 for the 10 countries covered by the WHO Review of six Western Pacific regional health system strategies. The diseases are grouped according to their main categories â&#x20AC;&#x201C; communicable diseases (shades of red), noncommunicable diseases (shades of blue) and injuries (shades of green). The area of the boxes refers to the proportion (per cent) relative to the total number of deaths. All data are based on the Institute for Health Metrics and Evaluation downloaded 14 June 2013 from: http://www.healthmetricsandevaluation.org Guide for disease categories used in graphs: Cancer = Neoplasms Cardio & Circ = Cardiovascular and circulatory diseases Chronic Resp = Chronic respiratory diseases Cirrhosis = Cirrhosis of the liver Diarr+LRI+Oth = Diarrhoea, lower respiratory infections, meningitis and other common infectious diseases Digestive = Digestive diseases (except cirrhosis) DUBE = Diabetes, urogenital, blood and endocrine diseases HIV+TB = HIV/AIDS and tuberculosis Intent Inj = Self-harm and interpersonal violence

Maternal = Maternal disorders MSK = Musculoskeletal disorders Mental = Mental and behavioural disorders Neonatal = Neonatal disorders Neuro = Neurological disorders NTD+Malaria = Neglected tropical diseases & malaria Nutr Def = Nutritional disorders Oth NCD = Other noncommunicable diseases Oth Comm = Other communicable, maternal, neonatal, and nutritional disorders Transport = Transport injuries Unintent Inj = Unintentional injuries other than transport injuries

Causes of deaths in Cambodia, both sexes, all ages, 2010

Causes of deaths in China, both sexes, all ages, 2010

Causes of deaths in Fiji, both sexes, all ages, 2010

Causes of deaths in Lao PDR, both sexes, all ages, 2010

82

ANNEXES

Causes of deaths in Malaysia, both sexes, all ages, 2010

Causes of deaths in Mongolia, both sexes, all ages, 2010

Causes of deaths in PNG, both sexes, all ages, 2010

Causes of deaths in the Philippines, both sexes, all ages, 2010

Causes of deaths in Solomon Islands, both sexes, all ages, 2010

Causes of deaths in Viet Nam, both sexes, all ages, 2010

83

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

Annex 19. Contributors to the Review process Review Team Ms Laura Hawken Dr Brian Buckley Dr Lester Geroy Mr Daniel Sekeun Yu Steering Committee Dr Graham Roberts Dr Benedict David Dr Veasnaskiry Lo Dr Henk Bekedam Dr Noordin Noorliza Dr Don Matheson Dr David Lee Chin Dr Dennis Ross-Degnan Dr Hilary Standing Mr Bob Williams DHS Team Leaders Dr Klara Tisocki Dr Budi Santoso Dr Xu Ke Dr Dorjsuren Bayarsaikhan Dr Fethiye Gedik Mr Sjoerd Postma Mr Mark Landry WPRO Division Representatives Dr Gabit Ismailov Dr Zhao Pengfei Dr Cherian Varghese WPRO Country Office Staff Dr Rasul Baghirov Dr Jaana Marianna Trias Mr Martin Taylor Dr Jun Gao Dr Erdenechimeg Enkhee Dr Paulinus Sikosana Ms Lucille Nievera Dr Clement Malau Dr Jacob Kool Dr Socorro Escalante WHO Interns Ms Sarah Sy Ms Emma Bestall Ms Carolyn Hunter Mr Joe Chow Dr Vincent Khor Mr Thomas Gaddsden Ms Safiyah Salim Ms Flavia Calisti

84

Country Australia Ireland Philippines Republic of Korea Country Australia Cambodia Egypt Malaysia New Zealand United States of America United Kingdom Unit Essential Medicines and Health Technologies Health Care Financing Human Resources for Health Health Services Development Health Information, Evidence and Research Division Health Security and Emergencies Combating Communicable Diseases Building Healthy Communities and Population Country Cambodia China Lao PDR Mongolia Papua New Guinea Philippines Fiji Vanuatu Viet Nam Country Canada South Africa United States of America Hong Kong Malaysia Australia Singapore Italy

ANNEXES

Member States Representatives Dr Rahman Said Ms Noraini Manap Dr Sia Ai Tee Dr Chen Ningshan Mr Arvind Kumar Dr Mitushiro Ushio Ms Wiriki Tooma Dr Ko Duk Yung Dr Bounkong Syhavong Dr Bounfeng Phoummalaysith Dato Dr Maimunah Hamid Dr Rozita Halina Binti Tun Hussein Ms Mungun Tuya Dr Jean-Paul Grangeon Ms Charlotte Deny Dr Yuriko Bechesrrak Dr Paison Dakulala Dr Madeleine Valera Dr Leao Talalelei Tuitama Ms Palanitina Tupuimatagi Toelupe Dr Siale Akauola Dr Vohor Serge Dr Santos Wari Prof Le Quang Cuong Mr Khuong Anh Tuan Local Researchers Mr Poch Lath Mr Chen Mean China Policy Dr Wu Qunhong Ms Ilisapeci Kubuabola Mr Andrew Darcy Ms Walaiporn Patcharanarumol Dr Hong Anh Chu Dr Ahmed Awaisu Institute of Health Systems Research Ms Laura Davison Ms Margaret Anere Dr Sarah Bales Mr Ton Luong Chinh Editors Mr Thomson Prentice Mr Marc Lerner Mr Alexander Pascual

Country Brunei Darussalam China Fiji Japan Kiribati Republic of Korea Lao People's Democratic Republic Malaysia Mongolia New Caledonia New Zealand Palau Papua New Guinea Philippines Samoa Tonga Vanuatu Viet Nam Country Cambodia China Solomon Islands Lao People's Democratic Republic Malaysia Papua New Guinea Viet Nam Country France United States of America Philippines

In addition, there were numerous key informants and other WHO staff.

Everyoneâ&#x20AC;&#x2122;s contributions and participation have been critical to the report and are highly appreciated.

85

GUIDING HEALTH SYSTEMS DEVELOPMENT IN THE WESTERN PACIFIC

86

ANNEXES

87