Strengthening health systems
April 3, 2013
As the world observes World Health Day on April 7, IDRC asked researchers:
What does it take to strengthen health systems?
The quotes below represent a range of views on this important issue. The opinions expressed reflect those of the speaker, and not necessarily those of the International Development Research Centre.
Courage and political will
It takes political will to propose and implement health projects to strengthen health systems … and courage to base them on evidence.
Amina Abubakar Former Permanent Secretary, Ministry of Health
Bauchi State, Nigeria
During her time as Permanent Secretary in the Bauchi Ministry of Health, Abubakar served as both a researcher and advocate for the Nigeria Evidence-based Health System Initiative (NEHSI), a partnership between the Government of Nigeria, IDRC, and the Canadian International Development Agency. NEHSI’s goal: to strengthen health information systems and support health institutions to make better use of local evidence to plan, budget, and deliver services, particularly for pregnant women. As part of their efforts on maternal health care, NEHSI and the Bauchi State government are piloting a surveillance system that uses mobile technology to help community health workers assess maternal health risks and make better, more informed decisions about care. Abubakar continues to advocate the evidence-based approach of NEHSI in her current role with the Federal Capital Territory in Abuja. Photo: Panos/A. Trayler-Smith
The health of mothers and their children depends on the status of women.
Creativity and audacity
The first step is to understand that health systems are complex social entities. Then one needs to be creative, participatory, and audacious to implement interventions suitable to specific contexts.
Walter Flores Centro de Estudios para la Equidad y Gobernanza en los Sistemas de Salud
With the support of IDRC, Flores and a coalition led by Centro de Estudios para la Equidad y Gobernanza en los Sistemas de Salud (CEGSS) have explored how power is exercised in Guatemala’s health system. In six rural areas, they engaged indigenous community-based organizations in assessing needs and barriers; in devising plans to increase access; and in monitoring the follow-through in services provided. The result: communities gained improved health services, hours of service were extended, more staff was hired, and health workers who provided inferior treatment were sanctioned. The approach developed by these communities with CEGSS is now being adapted for other municipalities.
Photo: CEGSS/ P. Prachanronarong
A citizen’s health council in Guatemala discusses the legal framework for their right to health.
Quality of care
Bricks and clicks are important because decent infrastructure and effective information management systems are essential.
But most important of all are people … Instead of addressing poor motivation and low morale, we end up providing incentives to health personnel to do the work they have been hired to do without paying enough attention to the quality of care they deliver.
Gita Sen Indian Institute of Management-Bangalore
With IDRC support, Sen has been investigating the underlying causes of maternal illness and death in India, where routine patterns of deprivation and abuse are often hidden. To ensure evidence informs health policy and practice, her research team is also working with state officials to improve maternal health services, creating village-level support groups and district-level advocacy for safe motherhood, and building overall awareness on maternal rights and safety. Photo: Indian Institute of Management Bangalore In rural Karnataka, a mother and newborn child are confined to a dark and poorly ventilated room. Research and advocacy efforts are building awareness on maternal rights and safety.
It takes values-based leaders, throughout the health system, who are willing to take risks, learn through practice, and nurture relationships with others in the system.
Lucy Gilson Health Economics Unit, University of Cape Town
With support from IDRC, Gilson and colleagues at the University of Cape Town and University of the Western Cape are managing a fellowship and research program that seeks to build the field of health policy and health systems research across Africa. The combination of fellowships along with research activities aims to strengthen and sustain equitable health systems.
Photo: IDRC/R. Lord
The performance of a well-conducted orchestra is always soothing, with every last musician contributing to the outcome. Similarly, a harmonious health system brings a sense of peace, joy, and security within the community.
Shariq Khoja The Aga Khan University
With the support of IDRC, Khoja led a 12-country research network – PAN Asian Collaboration for Evidence-based eHealth Adoption and Application (PANACeA) – which supported collaborative research to generate evidence on eHealth and its influence on health outcomes. A project within the network in Indonesia, Pakistan, and the Philippines examined the effectiveness of using mobile phone-based text messages to influence maternal health behaviours. In the Philippines, health centres using this system experienced an increase of 20% in facility-based deliveries and a 4% change in breastfeeding practices.
Photo: Panos/GMB Akash
Focus on evidence
There is no blueprint and simply no vaccine for many conditions. So why undermine the systems everyone depends on to address targets and goals set externally? This focuses national and international resources on the targets rather than local needs. We need to develop local abilities to generate and socialize evidence, enabling plans and priorities to be based on the local context.
Neil Andersson Centro de Investigación de Enfermedades Tropicales (CIET)
Andersson leads several major components of the Nigeria Evidence-based Health System Initiative (NEHSI), a partnership between the Government of Nigeria, IDRC, and the Canadian International Development Agency. NEHSI’s goal is to strengthen health information systems and support health institutions make better use of local evidence to plan, budget, and deliver services, particularly for pregnant women. As part of their efforts on maternal health care, NEHSI and the Bauchi State government are piloting a surveillance system that uses mobile technology to help community health workers assess maternal health risks and make better, more informed decisions about care.
Using technology, NEHSI collects vital health information on the doorsteps of Nigerian families. Here, a health extension worker captures and relays information on the health of a mother and her infant. With an inexpensive smartphone, she can identify high risk cases for immediate follow up. The device also pinpoints her location.
Innovating beyond technology
Innovation across the health systems spectrum is not limited to technology. Often a combination of innovation in processes, technologies, and partnerships is necessary to bring about systemic change.
Sania Nishtar Heartfile
The founder of Heartfile, Nishtar and her team have developed an innovative model of health financing that aims to help ordinary Pakistanis absorb health shocks – the birth of a child, an accident, a serious illness – that are driving them into poverty. With the support of IDRC, Heartfile is seeking to strengthen primary health care and social protection for Pakistan’s most vulnerable. Photo: DFID/R. Watkins
A doctor with the International Medical Corps examines a woman patient at a mobile health clinic in Pakistan.
Critical mass is not just about the numbers. It’s about people with the necessary disciplines, perceptions, capacities, and consciousness to act.
Rene Loewenson Training and Research Support Centre (TARSC)
Loewenson coordinates the EQUINET secretariat, a long-standing network in East and Southern Africa that works with communities and with regional and national decision-makers to promote health equity. EQUINET spearheaded the Equity Watch report series, which tracks regional progress on health equity. Country reports, undertaken by governments and technical and civil society organizations in Mozambique, Tanzania, Uganda, Zambia, and Zimbabwe, analyzed 25 markers of progress within and beyond the health sector to improve equity. With this increased focus, health ministers of the East, Central, and Southern African Health Community resolved in 2010 to strengthen their monitoring of health inequities.
Photo: Regional Equity Watch
Innovation is making the blocks of the health system dance. It is a process, sometimes radical and disruptive, that results in improved health and economic sustainability for countries.
Hassan Mshinda Tanzania Commission for Science and Technology
Mshinda was one of five Southern-based commissioners who received IDRC support to ensure that developing world voices would be reflected in a United Nations commission struck to address the lack of affordable and effective treatment, tools, and medical supplies for addressing maternal and child health. Published in 2012, the Report of the UN Commission on Life-Saving Commodities for Women and Children endorsed 13 life-saving products that it calculates could save more than 6 million lives if widely accessed and properly used. Photo: IDRC/P. Bennett
Rufiji district; Nyamisate village; women and children at clinic. Mshinda was also part of the Tanzania Essential Health Interventions (TEHIP) project, supported by the Government of Tanzania, IDRC, and the Canadian International Development Agency which showed that strategic investments in health budgets reduced child mortality by 40% in Tanzania in the 1990s.
Putting neglected problems on the table Many problems that occur in the day-to-day functioning of health systems are not usually put on the table. However, many health program failures are due to these problems, among them the actual practices of health personnel, the precise means of organizing care, and the implementation of health policies in the field. We call these the neglected problems of health systems.
Jean-Pierre Olivier de Sardan Laboratoire d’études et de recherche sur les dynamiques sociales et le développement local
de Sardan has led IDRC-supported research by Niger’s Laboratoire d'études et de recherches sur les dynamiques sociales et le développement local (LASDEL), which analyzed government efforts in Burkina Faso, Mali, and Niger to increase access to health care by removing user fees. LASDEL is now leading a new five-year research and training effort that will focus on issues crucial to maternal and child health, such as norms of practice among midwives, and the treatment of women who have experienced interrupted pregnancies. The aim is to inform public debate and mobilize policymakers, training institutions, and unions on systemic issues which stand in the way of healthcare reforms.
Researchers interview a mother who has brought her child to a health clinic in Ibohamane, Niger.
Systems integration is coherence, access, responsiveness, comprehensiveness, and respect at the interface between systems, community, and citizen.
Uta Lehmann School of Public Health, University of the Western Cape
With the support of IDRC, Lehmann has studied the role of nurses in South Africa who are working on the front-lines of health-care delivery, their burden of responsibility, and their limited opportunities to influence policy. She examined how nurses could be trained and empowered to be instrumental in the delivery of anti-retroviral drugs and other basic services to those living with HIV/AIDS.
Photo: IDRC/P. Bennett
Using a systems approach
Everything is linked and nothing is isolated. One aspect of the system affects multiple aspects. In turn these affect the first in a loop-like manner. Using a systems approach involves leadership as well as intersectoral participation. A clear example in financing methods is the use of both benefit and financing incidence.
John Ataguba Health Economics Unit, University of Cape Town
South Africa With support from IDRC, Ataguba has conducted research as part of the Strategies for Health Insurance for Equity in Less Developed Countries (SHIELD), which analyzed health financing inequities in Ghana, South Africa, and Tanzania. SHIELD research determined that low-income countries should look more closely at various forms of indirect taxation as mechanisms to finance health system and that financial barriers to service access must be addressed if universal health coverage is to become a reality.
Photo: Consortium for Research on Equitable Health Systems/ B. Geach Queue outside a South African health clinic.
Equity, the soul of health care systems
Equity is the soul of all of our work – our research, teaching, and policy work is driven by the desire to ensure that the needs of the most vulnerable are given priority and are met. The principle of fairness also permeates our work and our interactions with everyone touched by our work.
Diane McIntyre Health Economics Unit, University of Cape Town
With support from IDRC, McIntyre has led research as part of the Strategies for Health Insurance for Equity in Less Developed Countries (SHIELD), a research partnership which analyzed health financing inequities in Ghana, South Africa, and Tanzania. SHIELD research determined that low-income countries should look more closely at various forms of indirect taxation as mechanisms to finance health system and that financial barriers to service access must be addressed if universal health coverage is to become a reality.
Photo: IDRC/R. Lord Research shows that taxation can be a progressive means of financing health coverage in low-income countries.