Health Systems Strengthening

Millions of people around the world die each year from preventable diseases because they cannot access affordable health care. Developing countries often struggle with insufficient resources and they face numerous challenges trying to strengthen weak health systems. A strong health system working well at all levels, from the household to the community to health facilities to national authorities, can provide effective services to improve the health of the people they serve.

Health financing is the critical foundation for strengthening health systems and ultimately for achieving health impact. Health financing is the starting point – money is the fuel to start and keep a strong health system running. Health financing includes generating funds, distributing those funds, ensuring effective and efficiency use of funds, and protecting the poor from the financial hardship of accessing health services. Without financial resources and proper management of these resources, health workers, health facilities, and medicines would not exist. In difficult economic times, generating those resources seems an insurmountable task. Yet some countries are showing how it can be done.

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.

Prior to January 12, 2010, Management Sciences for Health’s Leadership, Management and Sustainability Program was working with Haiti’s Ministry of Public Health and Population to build capacity in several areas:  family planning and reproductive health; commodity management and security; coordinating HIV & AIDS awareness and community mobilization activities; and leadership development.

But after the terrible earthquake of one year ago, we who normally promote leadership in the health sector were faced with our own leadership challenges:  how to continue to lead and manage our program effectively during an ongoing crisis, and most importantly, how to ensure continued help to those who rely on LMS support. Our immediate priority:  dealing with the collapse and destruction of our office.  For months, we worked out of large tent constructed next to the LMS warehouse, a reminder everyday that many of those we were serving had been forced to move into temporary shelters.  

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.

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.

Fragile states such as Afghanistan, the Democratic Republic of Congo, Haiti, Liberia, and Southern Sudan have among the worst health statistics – especially for women and children.  For political, economic, security and other reasons they can be extremely challenging work environments. Despite this, I have been deeply inspired to see what local health leaders have achieved when they have created strong partnerships among government, donors,  non-governmental organizations and where possible the private sector.  The charismatic former minister of health from Afghanistan, the  medical director of an urban clinic in northern Haiti, and the director of Torit hospital in Southern Sudan stand out as examples of local leadership in action under circumstances that would immobilize many of us.

In fragile states, constraints on governments often prevent them from simultaneously building their stewardship role and immediately expanding service delivery. Supporting the Ministry of Health to establish a basic package of health services, train local organizations to implement those services, and provide incentives (such as through performance-based financing) is critical to success. Additionally, the goal should be to move from many plans and actors across districts to one health plan with committed partners. 

Part three of the blog series: Spotlight on Global Health Initiative Plus Countries

Health Financing is Helping Rebuild Rwanda’s Health Sector

It's been over 15 years since the Rwandan genocide; few would know of the tremendous successes in health that the country has experienced. Rwanda has made good progress towards meeting the Millennium Development Goals since they were identified. These impressive achievements are due to an increase in essential health interventions and the implementation of new health financing mechanisms.

The Health Minister’s Conference for member countries of The East, Central and Southern Africa Health Community (ECSA HC) was opened by the Minister of Health, Zimbabwe in Harare on October 25. The theme, "Moving from Knowledge to Action: Harnessing Evidence to Transform Healthcare" is very relevant to the mission of Management Sciences for Health (MSH).

I’ll highlight two sessions from the first day that support the evolving global health field and the work of MSH.

 

The Global Health Initiative (GHI), with its plans for integrated programs across the spectrum of infectious diseases, maternal and child health, family planning and health systems, seems like it was designed specifically to meet Guatemala’s challenges.

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