WHAT CAN BE DONE: HEALTH SYSTEM DEVELOPMENT
For countries facing a crisis in child health and survival, low health system capacity and lack of funding for health-system development are serious macro-level constraints that can limit the impact of strengthening community partnerships, the continuum of care and developing health systems to achieve specific results. Efforts to save children’s lives will therefore require countries to not only to look into the potential for expanding health interventions but also to address the constraints and obstacles that might hinder advances. It is also advisable that countries include the following measures for the development of health systems in their strategic health plans:
- Identify and remove health-system bottlenecks: ‘Bottlenecks’ to health-service delivery can occur at all levels of a health system. Obstacles can arise, for example, at the level of communities and households, where, for instance, demand for health services may be low; at the level of facilities and outreach, which may be limited by a poor supply of affordable drugs and high attrition rates among community health workers; and at the highest levels of government that set and implement health policies. Community partnerships can play a role in removing some bottlenecks by enhancing contact between community health workers and services and the households and communities that are lacking essential health interventions. Facility-based care and outreach initiatives will be required both to support community health workers and to provide services for those health interventions that require more specialized assistance. At the policy-making level, sound leadership, advocacy, technical assistance and global health partnerships can help to address bottlenecks.
- Monitor progress and problems in coverage: Regular monitoring, feedback and adaptation of programmes on the basis of evaluation and evidence are vital components of a well functioning health system. Measurements of the health-based Millennium Development Goals (MDGs) depend on such instruments as Demographic and Health Surveys (DHS) and Multiple Indicator Cluster Surveys (MICS), whose frequency is being increased from every five years to every three years in order to better evaluate progress towards the goals. In addition, national, subnational and community-based monitoring processes are essential tools in the analysis of progress and problems encountered in scaling up interventions.
- Phase in intervention packages and health-system strengthening: A phased approach to health service delivery allows countries to put in place an initial package of interventions that can then be expanded over time depending on the capacity and condition of their health systems. In sub-Saharan Africa, the World Health Organization, the World Bank, and UNICEF, at the invitation of the African Union, have jointly developed a strategic framework to support African countries in their efforts to achieve MDG 4. Phase one would provide a minimum package of high impact, low-cost interventions including components such as antimalaria interventions, nutrition, HIV and AIDS prevention and treatment and the Integrated Management of Neonatal and Childhood Illnesses (IMNCI), along with stronger support to outreach services and community partnerships. The second phase would comprise an expanded package that includes further neonatal and maternal interventions, improved water supplies and adequate sanitation through national policies and the mobilization of additional funding. The final phase would introduce and scale up innovative interventions, such as rotavirus and pneumococcal vaccines (to protect against diarrhoeal diseases and pneumonia), and enhance the supply of and demand for this maximum package. In the context of the Strategic Framework, the following cofinancing scenario is proposed: In all three phases, almost half of the additional funding to scale up the minimum package would come from national budgets, including budget support, with 15 per cent coming from out-of-pocket expenditures, and one third from the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFTAM), UNICEF, the World Bank, WHO and other donors.
- Address the human resource crisis in health care:. Several developing countries are facing a health worker crisis; addressing this crisis in sub-Saharan Africa alone will require an unprecedented surge in staffing levels in the coming decade. Almost 860,000 additional workers are estimated to be needed to scale up health-care provision to the level required to meet the health-related MDGs in that region, more than half of them community health and nutrition promoters. Efforts are already under way to expand the number of community health workers in many developing countries, as well as to create incentive packages that will decrease attrition rates. Evidence suggests that multiple incentive packages – often combining small monetary incentives or ‘in kind’ payments with a strong emphasis on community recognition and supervision, as well as personal growth and development opportunities – tend to have a significant effect on reducing attrition rates among community health workers. In Guatemala, for example, supervised community health workers had attrition rates two to three times lower than those who were unsupervised, because their link with outside experts gave them a higher status.
- Strengthen health systems at the district level: The decentralization of health systems and an increasing focus on the district level can be seen as an effective vehicle for delivering primary health care to marginalized children and families at the community level. But decentralization is not without risks: It can have unintended consequences, such as deepening inequalities based on poverty, gender, language and ethnicity already existing in communities. Furthermore, even where decentralization efforts have been successful, experience suggests that transforming an administrative district into a functional health system takes time. Nevertheless, the experience of decentralization during the past decade has shown that, on balance, health districts remain a rational way for governments to roll out primary health care through networks of health centres, family practices or equivalent decentralized structures, backed by referral hospitals. Where districts have become stable and viable structures, they have demonstrated notable results, even in situations of complex emergency, as in the Democratic Republic of the Congo and Guinea. Similarly, Mali has broadened its health-centre networks and services for mothers and children. In countries where decentralization has been accompanied by reforms of public administration, there has been significant progress within a few years. Examples include Mozambique, Rwanda and Uganda, all countries that suffered many years of conflict and economic collapse but have since made significant progress in reforming government institutions and performance, including their health systems.
Finally, especially in the case of Africa, efforts to improve harmonization of aid and to scale up activities have increasingly focused on utilizing the health-related MDGs and other indicators as the benchmark to strengthen the health system. The emphasis on such outcomes aims to create synergy between the outcomes and inputs. This means that developing a country’s health system is framed as part of the process of achieving the goals, not distinct from them.
Health systems development for outcomes
A ‘health systems development for outcomes’ approach to health-service delivery defies the longstanding dichotomy between ‘vertical’ approaches to achieve outcomes and ‘horizontal’ approaches to strengthen systems, arguing that both aims can be realized by adapting health systems to achieve results. It also recognizes that optimal child survival, growth and development are more likely to be achieved and sustained if preventive measures are available to future mothers (i.e., adolescent girls and young women) before their children are born and if they benefit from a continuum of care for maternal, newborn and child health.
The strategic framework also analyses bottlenecks in the health systems of 16 African countries and suggests the potential impact on the MDGs of removing these bottlenecks country by country. Based on this framework, more than 10 countries in Africa are currently revising plans such as Poverty Reduction Strategy Papers, health-sector development plans, sector-wide approaches and medium-term expenditure frameworks to strengthen health systems with the aim of concrete health outcomes for mothers and children.