Health Systems Strengthening

Health Systems Strengthening (HSS)

The Global Health Initiative (GHI) and its approach of integrating health programs with HIV & AIDS, malaria, tuberculosis, maternal, newborn, and child health, nutrition, and family planning and reproductive health is in line with the current approaches and health priorities of the Government of Malawi.

Malawi, with a population of slightly over 13 million people, has 83% of its people living in the rural hard to reach, underserved areas. The biggest health challenge facing the country is access to basic health services by the rural population. The problem of access to health services is multifaceted. For instance, family planning services are mostly facility-based, contributing to a low Contraceptive Prevalence Rate of 28% and high unmet family planning need of 28% (Malawi Demographic and Health Survey, 2004).

However, there is also a critical shortage of trained health service providers and availability of contraceptives is a logistical nightmare in Malawi. Making a routine mix of all contraceptives accessible to women of reproductive age regularly in rural communities can avert unwanted pregnancies and maternal deaths, and reduce high total fertility rate and infant mortality rate. Rural people walk long distances to seek health services, sometimes only to return without a service due to shortage of health personnel and stock-out of supplies.

Health Clinic in Southern Sudan

 

For the past week, we in Southern Sudan have crowded polling stations to vote on a referendum that, if passed, would declare Southern Sudan the world’s newest nation. Observers have declared the voting “broadly fair,” and the 60 percent voter turnout required for the vote to pass has been reached. We are optimistic that this referendum will bring us closer to a peaceful, prosperous future.

The mood in Juba (the capital city of Southern Sudan) is bright as we await the results of the polls, set to be announced February 1. But our government and people realize that secession will bring new challenges along with its opportunities. About 150,000 of our Southern Sudanese brothers and sisters have returned home in recent weeks and still more are expected. While we welcome them joyfully and are delighted to see extended families reunited, this great influx of people will put additional strain on a health system that already struggles to meet the needs of the people it serves.

Health Workers in Southern Sudan

A few weeks ago, I had the opportunity to visit Southern Sudan. For over five decades, Southern Sudan endured civil war, unrest, and several waves of forced displacement and refugees. The infrastructure of nearly every sector was mostly destroyed throughout the region. It is a classic fragile state situation.

Since the Comprehensive Peace Agreement was signed five years ago, the Government of Southern Sudan, donors, international organizations, nongovernmental organizations, private organizations, and, most importantly, health workers are coming together to rebuild a shattered health system.

Now the global community focuses attention on Southern Sudan as they prepare for a Referendum vote to decide if they will officially break away from Northern Sudan to become an independent state. The vote is scheduled to begin January 9, 2011.

At the First Global Symposium on Health Systems Research in Montreux, Switzerland in November, Dr. Yogesh Rajkotia, of USAID Rwanda, moderated a panel discussion noting that Performance-Based Financing (PBF) is an effective health systems strengthening strategy. The presentations were made on behalf of the Rwandan Ministry of Health with the guidance of Dr. Agnes Binagwaho, Permanent Secretary.

In 2000, Rwanda’s health system was perceived as weak: there were human resources shortages, especially in rural areas; poor quality of services; and a high morbidity/mortality rate of women and children. Since 2001, Rwanda has committed itself to better health and to pushing for achievement of the Millennium Development Goals (MDG) by 2015.

PBF is a powerful means for increasing the quantity and quality of health services by providing incentives to health providers to improve performance. A PBF program typically includes performance-based grants or contracts. Health clinics and their staff are rewarded for reaching or exceeding health indicators.

This blog post was co-written with Morsi Mansour. Joan and Morsi are leadership development specialists in MSH’s Center for Leadership and Management.

Students in Uganda participate in a leadership development program during their pre-service medical training.

How can we empower the front-line of health care managers and service providers in the developing world?

As the Leadership, Management and Sustainability Program completes five years, it is an important moment to sum up what we have learned about sustainability and to reflect on how local ownership of health improvement programs supports sustainability of health results.

Halida Akhter receiving the United Nations Population Award in 2006.

Bangladesh, which is situated in a resource poor setting with a population of over 150 million, faces the major health challenge of a high maternal mortality rate. In the 1970s, the maternal mortality rate was 700 deaths per 100,000, and now it is still at 320 per 100,000. Although Bangladesh has made progress in reducing its infant mortality, much progress needs to be made to reach the Millennium Development Goals for maternal mortality. Bangladesh will need more than five years to achieve the goals. The Global Health Initiative (GHI) will help address the major health challenges women face in Bangladesh. Bangladesh has successful models of collaboration and public-private partnerships to share with other countries.

There have been a collection of high-profile and well attended mobile health (mHealth) “summits” held around the world in the past few years, including last month’s second annual mHealth Summit in Washington, D.C. (headlined by Bill Gates and Ted Turner), but the really interesting conversations are happening on the African continent. While large providers in the “developed world” are talking about the need for business plans and analysis, the debate in Kenya and Nigeria and Ghana is on how country-based leadership can scale up proven programs, develop sustainability, and provide practical and integrated models for cooperation between the government, mobile service providers, the medical community and the private sector.

On this World AIDS Day, we reflect yet again on progress made toward global commitments to fight the HIV epidemic. According to UNAIDS, new infections have decreased this past year from 2.7 million to 2.6 million, but, 30 years into the epidemic, only 5.2 million people out of the estimated 15 million who need drugs have access to treatment. Stigma, discrimination and human rights violations against persons living with HIV still exist, even in countries with generalized epidemics.

Integrated HIV programming across the entire health system can minimize many of these barriers to HIV prevention, care and, treatment.

At this First Global Symposium on Health Systems Research there have been a number of concurrent sessions on how best to make the link between research and decision-making. How do we make research relevant and timely so that it can inform policy-making?

MSH served as a panelist on the panel “Health systems and national policy-making: Strengthening the Connection,” which provided good examples of studies from Nigeria and the Middle East and North Africa (MENA) Region that provided insight into this gap.

In Nigeria, a study focused on how the gap between policy makers and researchers could be bridged. How can research be made attractive so policy makers desire it? Through a cross-sectional survey, they set out to improve the skills of policy makers in evidence-informed policy making. A platform was created where the two met on neutral ground to develop the research agenda. What came out of this collaboration were five skill building workshops where pre/post data was collected. There was much participation and enthusiasm by both parties which culminated in six policy briefs to improve health systems operation in Nigeria.

Last year, the mHealth Alliance and the National Institute of Health (NIH) sponsored their first mobile health (mHealth) “Summit,” at the Ronald Reagan building in Washington, DC. The location was telling: it is the home of the US Agency for International Development (USAID). This year’s mHealth Summit has nearly doubled in size, moved its location to the Convention Center, and is being keynoted by Bill Gates and Ted Turner. It is safe to say that mHealth is certainly a topic de jour. The problem is that the big names---the global mobile phone network providers, manufacturers, pharma companies, and global consulting firms---are all jumping on the bandwagon, but they are late to the game. And the conversations in the plenary sessions highlight the fact that there’s a huge disconnect between the global companies and the on-the-ground implementers.

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