Issue #5 - The Cog In Health Systems - Global Health Magazine

Levers in a Working Health System Prescription for Systems Strengthening 15 The Road Not Taken: The Role of Transportation 09 12

Issue 05

WINTER 2010 $4.95 U.S.

the cog in

HEALTH SYSTEMS www.globalhealthmagazine.com

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spring 2010:

Goals and Metrics

summer 2010:

Health and Climate

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issue 05

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In this issue:

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09 the Levers in a Working Health System

15 Road Not Taken: The Role of Transportation

COVER STORY: health systems

6 Making Anatomy of a Pandemic 0 12 Leadership and Management 18 In-Country Supply Chains: The Weakest Link

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20 What Does ICT have to do With It?

stories online: C Health Worker Migration: Disease or Symptom?

C Tertiary Care for Health Care Development C Health Systems Strengthening - True or False?

C buzzwords or buzzkill?

C Empowering the Public Sector in Indonesia

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04 Causes of Death in China and India 05 Natural Disasters 05 Sexual Violence among Adolescent Girls www.globalhealthmagazine.com

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Issue 05

Global Health

letter

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from the editor

Executive Editor

Annmarie Christensen Managing Editor

Tina Flores

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Web

Winnie Mutch Liza Nanni Graphic Design

Shawn Braley

health systems To take up the challenge to address health systems is a little daunting, to say the least. The components are complex and numerous, and the breadth of work to be done enormous.

WHO’s building blocks of health systems strengthening are service delivery, health workforce, information, medical products, vaccines and technologies, financing, and leadership and governance. Alone, each piece is a challenging, but necessary component of a greater whole.

On the surface, it would seem that the key to improving health systems might be structures logistics, meeting supply and demand. But as this issue of GLOBAL HEALTH shows, at the core of health systems strengthening is people.

There is a need to foster a cadre of leaders across the globe to catalyze change. Building capacity on the ground to improve the flow of goods, services and information is a crucial component for most developing countries. Newer buildings, fancier equipment and access to information technology are not a panacea for all that ail these crumbling systems. They merely facilitate the work that needs to be done.

Also, perhaps most notably, the global health community needs to address the issues of health care workers – from training to compensation to migration. It has often been a lightning rod for great debate, but the topic of health workers is, perhaps, the most complicated and arguably the most important of all if any system is to be sustainable.

The Editors

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E-mail:

magazine@globalhealth.org Global Health Council Board of Directors

Susan Dentzer, chair, William Foege, MD, MPH,

chair-emeritus Valerie Nkamgang Bemo, MD, MPH Alvaro Bermejo, MD, MPH George F. Brown, MD, MPH Rev. Dr. Joan Brown Campbell Haile T. Debas, MD Julio Frenk, MD, PhD Michele Galen, MS, JD Gretchen Howard, MBA Hon. Jim Kolbe, MBA Joel Lamstein, SM Reeta Roy Jeffrey L. Sturchio, PhD,

President and CEO Global Health is published by the Global Health Council, a 501(c)(3) nonprofit membership organization that is funded through membership dues and grants from foundations, corporations, government agencies and private individuals. The opinions expressed in Global Health do not necessarily reflect the views of the Global Health Council, its funders or members.

Learn more about the Council at www.globalhealth.org

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issue 05

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online exclusives

go to www.globalhealthmagazine.com for further reading

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C The Blog Veena Siddharth and Dee Redwine on a peer-to-peer model of delivering contraceptives to rural youth in Ecuador.

C Field Notes

Empowering the Public Sector in Indonesia Laurel Lundstrom on a project that provides small grants to local organizations to reduce maternal and infant morbidity and mortality.

C Hot Escapes

Panama Jessica Mack explores Bocas del Toro, Panama.

C Dim Sum

A collection of book reviews, music picks, and other cultural forays.

© IPPF

Dr. Richard Love on the need for greater investment in global health research in breast cancer to make significant advances in battling the disease.

Ward Cates on ICPD+15, Kampala and the way forward for reproductive health.

© Laurel Lundstrom

C Going Viral

What’s the buzz on Twitter, YouTube, Facebook and other places online

© Jim Daniels/FHI www.globalhealthmagazine.com

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Global health statistics

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causes of deaths in china and india

China all deaths India Deaths per 100,000 persons

702 989

Communicable, maternal, perinatal, nutritional conditions

Infectious and parasitic disease (total) 39 197.3

Tuberculosis 20.8 34.8

STDs, excluding HIV 0 4.6

HIV/AIDS 3.3 34.4

Diarrheal diseases 8.3 43.5

Childhood-cluster diseases 1.6 27.4

Meningitis 0.6 5.1

Hepatitis B 1.5 2.2

Hepatitis C 0.6 0.9

Malaria 0 0.9 Respiratory infections 22.4 107 Maternal conditions 0.8 12.7

Perinatal conditions 20.9 72.6 Nutritional deficiencies 0.6 12.3 Noncommunicable diseases Malignant neoplasms Other neoplasms Diabetes mellitus Endocrine disorders Neuropsychiatric conditions Sense organ diseases Cardiovascular diseases Respiratory diseases Digestive diseases

Genitourinary diseases Skin diseases Musculoskeletal diseases Congenital anomalies

133.5 1.2 9.6 2.4 8 NA 230.5 110 27.9 10.7 NA 1 6.6

71 1.2 14.9 1.5 17.4 0.1 267.7 58.1 32.6 11.2 0.7 0.7 9.9

Injuries

Unintentional injuries 52.3 76.2

Intentional injuries 24 23.8 ISSUE 05 winter 2010

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Ma, S and Sood, N. 2008. A Comparison of the Health Systems in China and India. RAND Corporation. www.rand.org/pubs/occasional_papers/2008/ RAND_OP212.pdf (Accessed Jan. 2010)

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natural disasters* 2000-2009* Year Occurrences No. Affected Economic losses

(millions) (billions) 2000

413

173 46

2001

379

109 27

2002

422

660 52

2003

360

255 70

2004

354

162 136

2005

434

160 214

2006

401

122 34

2007

413

211 75

2008

349

216 190

2009

245

58 19 Click on the source at C www.globalhealthmagazine.com.

* Biological disasters excluded. * Until November, 2009.

Source: EM -DAT: The OFDA/CRED International Disaster Database www.emdat.be/sites/default/files/Press_Release_Copenhagen.pdf

physical and/or sexual intimate-partner violence and non-partner sexual violence among adolecent girls 15-19 Percentage Serbia and montenegro brazil province tanzania province namibia city samoa thailand province peru province bangladesh province ethiopia province 0

C see source for full analysis.

Source: Tremin, M and Levine, R. 2009. Start with a Girl: A New Agenda for Global Health. Center for Global Development. www.cgdev.org/content/publications/detail/1422899/ (Accessed Jan. 2010) Click on the source at C www.globalhealthmagazine.com.

10

20

30

40

50

Intimate partner physical and sexual violence in last 12 months Non-partner sexual violence since age 15 www.globalhealthmagazine.com

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The Making of the PBS Documentary: Anatomy of a Pandemic By larry klein

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When novel H1N1 was beginning its global trek toward pandemic status in late spring 2009, we approached PBS about producing a special that would attempt to look at the pandemic from the point-of-view of those on the front lines of the effort to slow infection rates and treat those already sick.

We decided on this approach because this would be a documentary requiring months to complete. We knew we could not compete with the news of the day (the networks and cable providers would certainly do that).

But we could be like imbedded journalists for this war – examining the outbreak from the ground up and through the eyes of those our society entrusts with our very lives and well-being. The Corporation for Public Broadcasting funded the project and we were off … sort of.

The main focus of the program remained our guiding principle throughout: Is the country’s public health and health-care infrastructure prepared enough and capable enough to take on a major flu outbreak?

But in order for our battlefront approach to work, we would need to win the trust of local health officials and hospital authorities, who would have to consent to our filming inside the planning-and-response meetings and emergency rooms and Intensive Care Units where the real action would be taking place. This was a lot to ask as we would be shooting highly sensitive situations where the pressures on public health and medical professionals could become intense. And in the hospitals, we would need to respect patients’ rights and wishes.

We, nonetheless, were able to persuade public health and hospital authorities in Seattle and Boston to let us in. We chose these cities in large part because of contrasts: older Eastern city with urban poor and top

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Photos courtesy of Production Group Inc.

flight medical community versus newer West Coast city with wider affluence and another strong medical community. Since we knew the vaccine would be a hotbutton topic, the fact that the Seattle area boasts a large anti-vaccine community and Boston a highly compliant one presented another attractive reason for the two choices.

By mid-September, permissions were lined up and then we waited … and waited. The outbreak hit the South in the early fall but took weeks to appear in the communities we had prepped. As the news reports shouted about flu dorms, school closings and hospitals with tents in parking lots, we began to feel the pressure: could this outbreak pass us by? As the clock ticked, we began filming secondary targets, such as random vaccine clinics, and we produced those before the pandemic sequence in Boston. But it was now the middle of October, our Dec. 14 airdate loomed, and we had very little in the can of what we originally set out to do.

Larry Klein is the producer, director and writer of Anatomy of a Pandemic.

He won an Emmy Award in 2006 for the PBS show, Rx for Survival: A Global Health Challenge.

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Fortunately, we held fast and the outbreak finally struck Boston. We filmed at a furious pace over the next several weeks, realizing that if we truly wanted a groundup view, we would have to jettison Seattle. There was no time left to do both cities comprehensively. Boston, like most regions, ended up handling this flu pretty well. The disease remained mild enough so the resources put in place, such as supplies of Tamiflu and the administrative efforts to deal with the surge of cases, worked. In some areas, things were stretched but not broken. Had the flu been more virulent, it was also clear that regardless of how well Boston or the even the CDC had prepared, we might not have done nearly as well. And this became the overall conclusion of the program.

There is also the fact that pandemics like this one often come in waves. So although it looks like things may be slowing down right now, the outbreak could pick up steam for another round in the late winter or even the spring.

We would have liked to film longer. A new flu virus can change over the course of a large outbreak – becoming more or less virulent – and the disease can also come in waves. As new infections slowed in December, some experts began declaring the outbreak over while others warned of a re-emerging outbreak. There were also

reports of increased virulence in places like the Ukraine and more and more instances of Tamiflu resistance through endemic regions. And the vaccine continued to be late arriving. So we wanted to see things through to the end. But the film was tied to a December airdate. So we stopped filming in November to edit and complete Dr. Anne Schuchat, the Director of the CDC National Center for Immunization and Respiratory Diseases, at the Centers for Disease Control and Prevention in Atlanta

GH

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A new flu virus can change over the course of a large outbreak – becoming more or less virulent – and the disease can also come in waves.

the program. It felt like we were ending the story in the middle of Act Two, but hopefully we did a good job of meeting our original goals and that people understand that the U.S. and rest of the world really does need to devote far more resources to combat influenza for we may not be as lucky the next time.

There is also the fact that pandemics like this one often come in waves. So although it looks like things may

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be slowing down right now, the outbreak could pick up steam for another round in the late winter or even the spring. But we knew that at some point we had an airdate to meet and that we would need to report on the status of the pandemic “before” we knew all the answers. That can be a bit frustrating for documentary productions (as opposed to news). But as one of our experts said: “If anyone tells you they know what will happen with this pandemic, don’t believe them.” GH —

Anatomy of a Pandemic companion site, with experts interviews, lesson plans and H1N1 news: www.pbs.org/newshour/pandemic/?cc=1234

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by nellie bristol

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Where are the Levers in a Working Health System?

The word “system” conjures up an image of a rational, organized, well-planned operation where cause equals effect and everyone knows ahead of time what the outcome will be. Health systems, however, defy that concept.

They tend to be more akin to living organisms: amorphous, evolving, reactive. They reflect a country’s history, political and social structure, and character as much as they do its health needs.

As an example, the United Kingdom’s National Health Service grew out of the devastation of health infrastructure caused by World War II. Free-marketloving Americans embrace the most private-sectororiented system of any developed country while communist Cuba successfully supports cradle-to-grave care for all.

In spite of the quirks and eccentricities inherent in each country’s health system, or maybe because of them, the World Health Organization (WHO) attempts to

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Six Building Blocks of Health Systems Strengthening Service delivery Health workforce Information Medical products Vaccines and technologies Financing Leadership and governance (stewardship)

rationalize systems through the development of norms and definitions. It defines a health system as “all the activities whose primary purpose is to promote, restore or maintain health.” The definition is meant to include not only health services, but also factors that contribute to overall health promotion, including health education and relevant social structures.

More specific to health services, WHO delineates six “building blocks” essential to system function: service delivery; health workforce; information; medical products, vaccines and technologies; financing; and leadership and governance. Not only is each individual element needed to ensure adequate access to health services, but so are the connections between them, according to Badara Samb, advisor to the assistant director-general, health systems and services at the WHO.

Mark Pauly, University of Pennsylvania Wharton School professor of health management, agrees.

“Countries usually pick a system that fits their special circumstances, so it’s hard to generalize,” he says. “I tend to be relatively non-judgmental about systems just because, for one, they’re hard to transplant and, for another thing, there is at least, we hope, a kind of dynamic that sort of fits the nature of their problems and also the nature of what their people want.”

The country-specific nature of health systems, Pauly argues, makes comparisons of costs and outcomes difficult. “And, of course, on the outcome side, there are other things that affect health other than the health-care system and you can’t perfectly control for them,” he adds. Ultimately, he says, “A higher standard of living is probably the best way to improve health.”

The U.S. Agency for International Development (USAID) has worked with countries on health system strengthening for 30 years. It looks at all aspects of a system, including availability of facilities, transportation options, compatibility of a facility’s hours with local living conditions, and whether it’s possible to offer services in the community. It tries to react to the degree possible to factors such as mobility and cultural norms of the population. For example, if the movement of women is restricted, it tries to take services as close to them as possible, even to their doorstep, if feasible.

It also looks at quality of services, which can depend on the status of facilities and equipment, and staff training and knowledge, but also can depend on factors such as availability of electricity and clean water.

William Hsiao, Harvard School of Public Health economist, says the building blocks really are more descriptive of health system inputs and that more research is needed into the strategies and organization that make a system function effectively. “In terms of what makes a system work well or not work well, we really don’t know too much yet,” he says.

Barbara Stilwell, director of human resources for health and health systems strengthening at IntraHealth International, a global health systems consultant, emphasizes the importance of equity. “A strong health system would be able to provide the same health service to somebody in a remote rural area as it would to somebody in the center of the city,” she says.

Achieving equitable access and many other elements of a good health system requires good governance, she adds. Systems must not only be able to support quality facilities, but provide qualified personnel and provide them with good management and supervision. Good governance also requires a minister of health, who can make a strong case for health care as part of the national budget, Stilwell says. Health spending as a percentage of GDP globally ranges from 1.7 percent in Equatorial Guinea to a projected 17.6 percent in 2009 in the U.S.

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Nellie Bristol is a freelance journalist, specializing in health policy.

“You cannot take one from the other,” he says. “But to make a system is to make them work in harmony toward improvement of a delivery system that allows people access to services.”

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Expanding knowledge and access are crucial roles of health systems and increasingly are on the agenda as the global health community shifts its focus to health strengthening as a major development topic.

Better information about health consequences also leads to improvements. WHO points out that enemies of good health in urban areas, including pollution and lack of sanitation, had more profound effects in early 19th century London and Paris then than they do in developing metropolises today. “On one hand, increased knowledge of how diseases are caused and transmitted has led to valiant efforts to reduce contamination, control disease vectors, and educate the population to take care of itself,” according to the World Health Report 2000. “On the other hand, even very poor urban dwellers now have better access to effective personal health care [such as vaccines] than much of the rural population ...”

Expanding knowledge and access are crucial roles of health systems and increasingly are on the agenda as the global health community shifts its focus to health strengthening as a major development topic. Disease specific programs, like the Global Fund to Fight AIDS, Tuberculosis and Malaria, the GAVI Alliance and the President’s Emergency Plan for AIDS Relief, added health systems growth to their portfolios in recent years in an attempt to address total capacity.

The move is necessary as vertical programs are stymied in attempts to expand access by a lack of health-care workers in the hardest hit countries: the health workforce building block is inadequate. More attention is now being paid to personnel deficiencies and effective

workforce management. Systems strengthening could receive another major boost as the World Bank, WHO, GAVI and the Global Fund develop a joint health systems platform using aid effectiveness principles.

Recommended by the High Level Taskforce on Innovative International Financing for Health Systems, the goal is to develop a standardized process for the major grant-making organizations to reduce the strain on countries applying for financial help.

Harvard’s Hsiao says the trick is to integrate vertical programs into existing systems in a way that complements and enhances them rather than robbing them of scarce resources. Each country must develop an overall financial plan, he says, and vertical programs must be tweaked to fit into them. But, Hsiao says, changing the mindset of some advocates and programs has been difficult. “It’s not easy to change organizations’ focus and priorities and so it takes time to do that,” he says.

Even with greater standardization at the donor level, implementing system changes still must develop out of the countries they are intended to serve. “The country should be in the driving seat for many reasons,” said WHO’s Samb. “And we really need to make sure that the driver is in command and we’re not talking about a diplomatic car where …the one who is in the back of the car is really in command.” GH —

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By joseph dwyer and sara wilhelmsen

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Leadership Management: The New Prescription for Health Systems Strengthening?

A broken health system is a silent killer. People get sicker and die in disproportionate numbers just as they do during an epidemic. Yet the culprit is not lack of knowledge. Nor is it always a shortage of funds.

Technically and medically, we know what to do to reduce illness and save lives. But what is sorely amiss is the dearth of knowledge and skill to manage these very complicated health systems. Dr. William H. Foege sums up the issue as “global health waits expectantly for management to match its science.”

Simply put, global health initiatives must recognize the critical need for investing in the leadership and management skills of those running health systems.

Doing so is a key step in getting countries back on track

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toward making progress on the ambitious Millennium Development Goals (MDGs). More important, it is essential if countries are to meet the health needs of their own populations and ensure the sustainability of long-term health interventions.

Linking leadership and management Building the management and leadership capacity of health care managers and practitioners is an important step in improving service delivery. When leadership and management are strengthened, the rewards for the health system are high.

In Brazil, for example, the Secretariat of Health of Ceará mandates that public servants receive leadership training to apply for management positions.

Joseph Dwyer is the director of the Leadership, Management & Sustainability Program at Management Sciences for Health (MSH). Sara Wilhelmsen is a senior program officer in MSH’s Center for Leadership & Management.

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This process has broken the mold of just promoting people, prepared or not, to leadership positions. The improvement in health results was significant, illustrating the link between transparency, governance and health outcomes. In one municipality, infant mortality dropped from 26 to 11 deaths per 1,000, while the percentage of women receiving pre-natal care increased from just over 50 percent to 80 percent. Overall, 70 percent of the 25 municipalities that participated in the leadership development process were able to reduce their infant mortality – some by as much as 50 percent.

In order to establish a link between the strengthening of management and leadership practices and the strengthening of health systems overall, as was seen in Brazil, those working in the health sector at all levels – governmental, institutional, academic and other – must commit themselves to the monitoring and evaluation of data that validates this connection.

leaders and managers are the foundation to achieve both Kenya’s National Vision 2030 and the MDGs for health. This had led to a systematic, intensified reform process and new policies requiring leadership and management development for those entering the health sector.

It is this kind of country ownership and action paired with investment by the global community that shows the potential to produce more effective health systems.

Countries have a responsibility to develop and support policies that address health leadership and management at all levels and in all aspects of the health system.

Although performance planning and evaluation systems and performance-based financing mechanisms are gaining popularity as ways of holding managers accountable for results, measuring the impact of leadership and management has been a major challenge. A breakthrough related to this challenge has been a change in thinking from seeing improved leadership and management as a means to an end, not an end unto itself. True measurement of leadership and management capacity can be undertaken when those working in health systems have the expertise and capabilities to clearly identify their challenges, mobilize resources, select meaningful indicators, and measure results.

When we look at health leaders and managers as a critical part of the workforce and plan for them accordingly, we will go beyond the skills of medical practitioners to the skills of planning, motivation, procurement systems, and accountability for results (including monitoring and evaluation) that are fundamental in making a health system effective.

Investing in Leadership and Management High-level efforts by the U.S. Agency for International Development (USAID), the World Health Organization (WHO), the Rockefeller and Gates Foundations, and others have shed light on the importance of investing in leaders to strengthen global health systems. WHO’s three-country study of South Africa, Togo and Uganda provides insight into the challenges faced by health managers. Fortunately, many are acknowledging the need for change and taking action. At the country level, the ministries of health in Kenya recognize that effective

Opposite: Hospital staff at the Nandi East District Hospital in Kenya consult in passing. Above: A health worker in Afghanistan examining some of his documented challenges. Photos courtesy of MSH. www.globalhealthmagazine.com

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It has been well-documented that poor leadership and management result in low staff morale, high staff turnover, and unacceptable levels of vacancy, all of which waste financial and human resources.

A health-care worker in Afghanistan during a leadership development seminar.

Donors have an accountability to ensure their approach will influence positive change and deliver results.

What does building leadership and management capacity look like?

Government mandates such as Kenya’s, and regional resolutions for improving leadership and management such as the one drafted at the East, Central and Southern Africa Health Minister’s Conference in 2009, are one approach to building leadership and management capacity. Integrating a focus on these areas into the earliest stage of a health worker’s career – while they are still preparing to join the field – is another.

Four universities in Nicaragua have been taking this pre-service approach over the past few years. Another method is offering those tasked with leadership and management responsibilities professional development opportunities, such as ADRA International’s Professional Leadership Institute, which offers in-service trainings once a year to health sector workers in Africa, Asia and Latin America.

In order to understand the benefits of building capacity through these approaches, perhaps it is best to start with what happens in the health system when people lack these skills. It has been well-documented that poor leadership and management result in low staff morale, high staff turnover, and unacceptable levels of vacancy, all of which waste financial and human resources. More recently, it has also been documented that a shortage of doctors, nurses and allied health professionals does, in turn, lead to higher maternal and child mortality.

One example of how investment in leadership and management can make a difference in even the most challenging of circumstances comes from Afghanistan.

There, the ministry of public health works to strengthen the leadership and management of the central and provincial levels by making managers more aware of their role as stewards of the health system. Under a program supported by USAID, more than 1,800 health professionals throughout 13 provinces have been reached, with gratifying results. These managers have been able to increase vaccination coverage and access to family planning services, resulting in improved child and maternal health. The most significant improvements: an increase of almost 70 percent in health facility births and a 28 percent increase in family planning consultations.

These examples show how all levels of the health sector recognize the great need for leadership and management as well as illustrate that models for practical preparation do exist.

Conclusion We potentially face billions of dollars in wasted resources if the people who drive the health system have not been prepared with the management and leadership skills to take proven medical programs and practices to scale. The evidence for the critical role of leadership and management in closing the gap between what is known about public health problems and what is done to solve them is clear. Policies that support leadership and management at every level of every initiative, organization, government agency, hospital and university to prevent needless deaths are needed and the time is now. If we are going to make a difference in global health, we must invest in leadership and management. GH —

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By Ngwarati mashonga

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The Road Not Taken The Role of Transportation in Global Health Systems

Without the correct maintenance ambulances will break down before the end of their mechanical life span, becoming an expensive wasted resource.

Photos courtesy of Riders for Health

British Prime Minister Gordon Brown pledged in September 2009 to a fund that would provide free health care to 10 million people in some of the world’s poorest countries. This is an impressive ambition, and removing fees would undoubtedly remove one of the barriers that prevent people accessing health care. However, if a health worker could not travel to families in a rural village, it makes little difference how free treatment is.

Lack of reliable transportation currently constrains the performance of health delivery organisations across

Ngwarati Mashonga is operations director at Riders for Health.

Africa. It is, of course, not the only constraint to access but it is a fundamental problem. Yet, without addressing these issues, overcoming the other constraints will still not result in the complete health-care coverage that could play a key role in the development of Africa.

The missing link Transportation is so often the missing link in health-care programs across Africa. By improving their transport capabilities, organizations can increase the number, distribution and retention of health workers. With access to reliable transport, the amount of time that health workers are able to spend in the field or at the community level increases.

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Top: With systems of reliable maintenance, the right vehicles should never break down, no matter how tough the terrain. Right: An outreach clinic for infant health in the Gambia. Services like this are only possible with reliable transportation

Despite the obvious benefits of reliable vehicles for delivering health care, there is still an overwhelming tendency of them to break down in Africa after a very short proportion of their intended mechanical life. This is due to a widespread misunderstanding of the precise needs and nature of vehicles in hostile conditions and harsh terrain, allied to an acute and extremely damaging shortage of vehicle maintenance infrastructure in Africa.

Development agencies and the ministries with whom they work often misunderstand or critically underestimate the funding needed to run a vehicle for its natural lifespan and/or do not have the necessary immediate funding or the appropriate techniques required. The upshot of this is that precious resources are wasted and health-care goals are not reached.

One of the key problems African governments face is that they are often ill-equipped to be ‘intelligent’ purchasers from the private sector. This can lead to the buying-in of poor service at a high cost. In-house management is unsatisfactory as the competence or capacity for specialist vehicle maintenance in hostile conditions is not available.

Similarly, for many other NGOs, vehicle management is not a core competency and yet the vehicles are vital to meet their goals. High costs, unreasonable ‘down time,’ and often the loss of relatively new vehicles through negligence is a common consequence, and has a negative outcome on the health of the people served, especially those most isolated. It also has negative impact on the agencies’ and governments’ abilities to retain and motivate health workers, a factor widely known to weaken health systems still further.

Organizations working in global health and those responsible for – or linked to – health systems have responded to the need for transport for the delivery

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of health care in a range of ways, such as purchasing expensive vehicles without attending to management and maintenance; trying to strengthen the fleet management capacity within the ministry of health; and, contracting out to the for-profit sector.

These alternative methods have not proved successful.

In these circumstances, governments and agencies should not be afraid to use the expertise of organizations whose sole purpose is fleet management.

There is absolutely no reason why vehicles should break down in Africa. If the appropriate vehicles have been selected by buyers, performing the regular maintenance programmes recommended by the manufacturers will ensure that the vehicle never breaks down during its mechanical lifespan. Yet, if vehicles are not managed correctly – from both the technical and the usage points of view – they will fail. And that has nothing to do with the harshness of the conditions. Unmanaged, they would fail just as quickly in Washington, London or Melbourne as they will in Banjul, Maseru or Harare. And, as in the developed world, a broken vehicle is far more expensive to repair, than it is to service it regularly and replace parts before they fail.

Over 20 years, Riders for Health has been developing systems of routine outreach maintenance, reliable systems for the ordering and delivery of replacements parts, and a network of workshops. There is a forceful case for Riders not-for-profit fleet management model.

There are a few other pockets of good maintenance in isolated cases in Africa but they are not replicable or sustainable and so far it is only Riders that has developed a comprehensive system capable of meeting the widespread need.

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Saving money as well as lives By consolidating the running of all of an organization’s or department’s vehicles into a single fleet, it will not only ensure the availability of the right vehicles where they are needed, the organisation will also make substantial cost savings.

First, by combining their fleet into a single budget line, costs can be clearly identified rather than being scattered and hidden. Second, by ensuring that vehicle fleets are standardized and include as few different makes and models of vehicles as possible, the organization can save money. By not purchasing vehicles in an ad hoc and uncoordinated manner, buying replacement parts is easier, quicker and the organization benefits from economies of scale. But to make the right choices it requires an intelligent purchaser. The wrong purchase of a large fleet would be a huge, and costly mistake.

These benefits can be seen in the Gambia. In 2009, the ministry of health signed an agreement which saw Riders own and manage the entire fleet of outreach vehicles for the ministry. This public-private program, run on a not-for-profit basis, allows both parties to concentrate firmly on their core-competency. It means that the health service knows that it will have reliable transport, allowing it to set its goals with conviction, and the savings made from better purchasing, and from removing the costs associated with unexpected vehicle breakdowns can be better targeted at health-care delivery.

Accurate testing = effective treatment It is not just delivering medication, or providing emergency treatment that requires reliable transport.

In November 2009, the World Health Organization changed its advice on antiretorviral drugs, suggesting that people should have access to them earlier to improve their effectiveness. But knowing that people need antiretrovirals is dependent on knowing they are HIV positive, and as soon as possible. In so much of Africa, timely and accurate sample testing is impossible because, without transport, the samples never reach the laboratory in the first place.

If it takes six weeks for the samples to reach the laboratory, how long will it take for the results to arrive back at the clinic? Without testing, those that could benefit from treatment will never be identified. The hundreds-of-billions of dollars that are spent in the world’s leading universities and research centers are

being wasted because the results of their research do not reach those that will benefit.

In Lesotho, Riders has launched a program of sample couriers. With a network of motorcycle couriers, Riders can ensure that turnaround time for samples is consistently within one week. This is a comprehensive sample courier service, which supports the decentralization of the health service, strengthening local health-care provision. And because samples can be transported in temperature-controlled, shock-proof containers, when they do arrive at the laboratory, they are suitable for testing.

Riders for Health is now expanding this program into Zambia, where the scattered population and poor infrastructure means that a reliable testing program is almost impossible. Other countries in Africa, which are planning nationwide testing schemes, are now planning to build systems of reliable transportation, based on intelligent vehicle purchasing, reliable maintenance, and thorough training, into their programs before they get under way.

Any program for delivering health care in Africa must incorporate the systems of transport which will make them possible. It must have established networks of workshops and outreach technicians to provide monthly services on every vehicle, and we have a logistics system that means technicians have replacement parts when they need them.

A profound benefit Ambitious and noble targets set by governments or institutions are important, but they must be matched by a commitment to strengthening systems of reliable transport for health-care systems.

A broken vehicle not only means that communities will go without health care, it is also a senseless waste of valuable resources. A waste that could be prevented.

There is not a single country in Africa that would not profoundly benefit from reliable transport. Ministries of health would be able to reach everyone, no matter where they live. National immunisation campaigns and disease eradication targets would actually be met. Children would become healthier. Education would improve.

Economies would grow.

A lack of transport infrastructure, or a failure of vehicles, is no longer an excuse for a program to fail in Africa. The solution has been developed, tested and proven. GH —

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By prashant yadav

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In-Country Supply Chains: The Weakest Link in the Health System Figure 1 : A simplified schematic of a supply chain from the manufacturer to the end-patients.

Manufactures

global supply chain

in-country supply chain

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Global Demand Supply Planning ■ Pooled Procurement ■ Price Negotiation ■ Shipment Coordination

Great progress has been made in recent years in developing new medicines, vaccines and other technological interventions to improve health throughout the world.

Increased financing from multilateral, bilateral and private donors has resulted in these new drugs and vaccines being available to end patients in low-income countries, where affordability remains a serious issue. Many global health managers now realize that promoting health and reducing the burden of disease requires action across the health system, including vast improvements in the supply chain for distribution of medicines and other health commodities.

The need for better in-country supply chains is no simple matter; the inefficiency and ineffectiveness of the incountry supply chains is often staggering.

Many large multilateral donors, such as the Global Fund to fight AIDS, TB and Malaria and GAVI, have begun to acknowledge that the overwhelming lack of supply chain infrastructure and management capacity in recipient countries poses a key challenge to their ability to spend their resources effectively.

Many innovations have occurred at the global flow architecture for products, financing and information in this supply chain (See Figure 1). For instance, donors have started to explore pooled procurement as a means to address weak in-country procurement capacity and reduce disparity in prices; pledge guarantees and

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Forecasting Procurement Warehousing Distribution to Clinics

end patients

market-driven bridge-financing mechanisms are being piloted to counter against uncertainties in financial flows; coordination between multiple stakeholders and better information flow from countries is leading to more accurate forecasts; and, regional distribution hubs are cutting down the time and cost of flow of products from the manufacturers to the countries.

Some argue that a key reason for poor availability of drugs at the service delivery point is on account of poor financial and operational management, which leads to delays in purchasing drugs and does not ensure that sufficient quantities are in the pipeline. However, in my opinion, the weakest link in the chain now is the incountry distribution system. The costs of ignoring this ingegral part of the health system can be extremely high.

A key reason for the poor performance of the in-country supply distribution system is the lack of an institutional and governance framework on how to organize incountry distribution. When it comes to health-care provision, OECD countries have a varying mix from private to public with many shades in between. However, the distribution of pharmaceuticals to hospitals and retail point of dispensing is invariably carried by the private sector in almost all OECD countries. On the other hand, very few developing country governments and other global health stakeholders have begun to accept that pharmaceutical distribution is not necessarily a public sector role.

Prashant Yadav is professor of supply chain management at MIT-Zaragoza International Logistics program in Spain.

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Average availability of medicines between 2001 and 2007 in the public sector in countries surveyed across all regions was only 34.9 percent.

United Nations. 2008. Millennium Development Goal 8, Delivering on the Global Partnership for Achieving the Millennium Development Goals. MDG Gap Task Force.

Most African governments still choose a distribution model, where a publicly run central medical store distributes drugs to clinics using a government-owned transport fleet. In such a model, the managers of government-owned central medical stores confront severe challenges in improving operational performance.

They often have difficulty hiring people with business experience and skills because of poor wages and incentive systems in the public sector and often lack the ability to remove incompetent workers.

Distribution models such as decentralized medical stores, quasi-private or private drug-distribution systems offer several advantages over fully public distribution systems but are rarely implemented. A few countries, such as Zambia, have established para-statal drug distribution entities and have contracted out the operational management of such entities to private third-party companies. Some countries, such as Ghana, have decentralized their distribution by allowing districts to purchase drugs and supplies from private-sector suppliers, creating competition for the publicly run central medical store.

Admittedly, many of these models have not yielded their promised successes, but implementation weaknesses should not be seen as weaknesses in the distribution model itself. Admittedly, it is not a one-size-fits-all problem. Not all countries can outsource medicine distribution to the private sector because in many countries there is no capacity in the private sector to carry out this role. In other instances, the regulatory and contracting capacity in the government is so poor that monitoring and ensuring the quality of the distribution will be a challenge.

Within publicly owned and operated drug distribution systems, a large number of countries have a threetiered distribution system with product flowing from a central medical store to district or regional stores and then to the clinics. The most challenging part of such distribution systems (often called “last mile logistics”) is making deliveries to small clinics and health centers that are remote and have poor road access. In such instances, the clinic and health center staff themselves

travel to the district or regional medical store to receive their drug supplies using their own means of transport, such as cars, motorbikes etc., in the process taking away extremely crucial health-care worker time from the primary health system. When there is a system to distribute from the districts to the clinics, there is often a shortage of staff at the health centers that are trained to carry out the tasks of stock-keeping, ordering and requisitioning. Poor last mile logistics imply lack of consumption data from the service dispensing point which should be the backbone of all planning in the upstream system.

Estimates of supply chain costs vary from 13 percent of product cost in Ghana to 44 percent of the value of the bed nets for a bed net delivery project in Liberia.

Sarley, D, Allain, L and Akkihal, A. 2009. Estimating the Global InCountry Supply Chain Costs of Meeting the MDGs by 2015. USAID DELIVER PROJECT.

Here it is worthwhile to note that organizations, such as Coca-Cola, which are known to have high distribution reach and efficiency, use a more decentralized distribution model in Africa. In developed countries, their distribution model works on the principle of delivering large amounts of product via trucks or smaller vehicles to retail outlets. However, acknowledging the challenges of road infrastructure and smaller retail markets in Africa, they use a distribution method that relies on manual distribution, utilizing methods such as bicycles, boats and pushcarts to distribute small quantities of product to a range of small dispensing outlets. Their model is similar to community health workers traveling to small villages with drug and health commodity supplies with the difference being that owners of Coca-Cola manual distribution centers have a financial incentive to ensure timely and adequate replenishment at each of the retail points.

With the recent explosion of inexpensive information technology such as mobile phones, a range of new options to organize last mile distribution and collect information about clinic level consumption have become available. However, while mobile phone technology will clearly act as an enabler and catalyst of innovative distribution models at the last mile, it alone cannot achieve much unless the institutional and governance structure in the public sector creates the right incentives for better last mile distribution and investments are made to train field staff on better quantification and replenishment planning. GH —

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By dykki settle

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Greater than the Sum Technology and Health Systems Strengthening

While not a panacea for all that ail health systems, information technology is a key component to health system strengthening. Photo courtesy of IntraHealth

WHO defines six building blocks of a health system: service delivery, health workforce, information, commodities (products, vaccines and technologies), financing and leadership/governance. The health systems approach puts the emphasis not just on the components of the health system, but the relationships within and between the building blocks. Core to health systems strengthening (HSS) is the idea that none of these building blocks can stand alone, all are necessary for better health outcomes. Changes in one area have repercussions elsewhere. Improvements in one area can’t be achieved without contributions in another.

Information and communication technology (ICT) has a powerful role to play in illuminating these relationships, mitigating unexpected negative impacts to the health system, and maximizing positive ones. ICT can be most powerful in the essential role of health systems surveillance, supporting efforts to monitor and measure the strength of health systems and the success of HSS activities.

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Dykki Settle is the director of health Informatics for IntraHealth International, and leads the health workforce surveillance team for the CapacityPlus project.

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Health systems strengthening must be attentive, iterative and responsive to change. This can only be achieved through routine surveillance of health and health systems.

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Enterprise architecture is a systems engineering approach to define reusable blueprints for information flow based on business processes. These blueprints can be used by countries and communities to help plan their health system strengthening activities.

The concept and discipline of health surveillance, well established and explored by the disease surveillance community, is taking advantage of the growing availability and support of ICT in low-resource environments to monitor and respond to all aspects of health.

human resources for health (HRH), and a variety of other component systems. The comprehensive nature of the CHeSS approach creates an opportunity for deeper development of specialized health systems surveillance systems within and between the six building blocks.

Health surveillance begins with routine systems to measure the problems and the relative success of solutions, reaching beyond the health system itself to the broader determinants of health. Closing the Gap in a Generation, the final report of the WHO’s Commission on Social Determinants of Health, calls for countries and global organizations to establish national and global health equity surveillance systems. These systems will routinely collect, collate and disseminate information on health, health inequities and health determinants in a coherent fashion.

For example, within the complex domain of HRH and human resource information systems (HRIS), emerging approaches to develop the science and methodologies of workforce surveillance – defined by as the routine, dynamic and systematic collection and analysis of HRH data for the provision of rigorous evidence and information which leads to action – provide an excellent example of the power of linking data from the six building blocks to generate a comprehensive surveillance model on system components, health outcomes and health equity.

The routine surveillance of health systems is a necessary counterpart to health equity surveillance. In October 2008, WHO convened a meeting of technical partners in Bellagio, Italy to develop a plan for a global initiative to strengthen country health system surveillance (CHeSS).

The goal of the initiative is to improve the availability, quality and use of health system data to inform country health sector reviews and planning processes and strengthen assessments of health systems performance.

The initiative will be planned and implemented in line with the principles of the International Health Partnership (IHP+) common evaluation framework, which, in turn, is based on the Paris Declaration on aid effectiveness.

Health worker performance and retention is affected by all aspects of the health system. Reasonable workload and expectations, availability of medical supplies, clean water and power, proximity of health facilities to urban areas and major roads, availability of health information, supportive supervision and leadership, and of course, timely compensation are all essential contributors to health worker motivation and the successful delivery of health services. Using effective and well planned ICT, information from all six building blocks can be brought together to provide dashboards, maps, and other tools that will help policy and decision makers proactively identify and respond to health worker retention and performance challenges.

Country health system surveillance will draw data from a wide variety of routine information systems for the six building blocks. These include logistics and facility information systems for health commodities, health management information systems for service delivery,

These approaches apply across all sectors of health care. A report from Cordaid on strengthening human resources for health for faith-based organizations (FBOs) highlights the use of geographic information systems

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(GIS) by Tanzania’s Christian Social Services Commission (CSSC) to address a variety of FBO health workforce issues. Efforts such as this lay the foundation for health workforce surveillance at the country level.

Effective understanding of health inequities and the health systems that must sustainably address them cannot be accomplished without strong technology support. Efforts by private, public and non-profit sectors alike are closing the gaps in ICT infrastructure, local technology skills, and national ICT policies and support in regions and countries around the world. These increasing information resources will only be effective for addressing health challenges if they are used by the health community. Improving our understanding of the complex interrelationships of community, national and global health through a systems approach and proven surveillance methodologies will accelerate our efforts to reach the MDGs and achieve the collective vision of better health for all.

Recently, the global health informatics community, under the leadership of the Health Metrics Network, WHO, Rockefeller, Canada’s International Development Research Centre (IDRC) and others has begun to embrace and corral the complex interrelationships of the different health system building blocks through a discipline called enterprise architecture. Enterprise architecture is a systems engineering approach to define reusable blueprints for information flow based on business processes. These blueprints can be used by countries and communities to help plan their health system strengthening activities, ensuring a proactive design that will take the necessary information flows and system relationships into account. The architecture framework and process also provide a common language and set of tools to support south-to-south sharing and regional development of system blueprints.

system. Rwanda’s eHealth coordinator, Dr. Richard Gakuba, is working with WHO, the Health Metrics Network and a wide variety of international partners to develop and implement the plan through an enterprise architecture approach.

Enterprise architecture has implications beyond ICT implementation, however. The same approaches used to develop information systems can be used to better plan and strengthen the health system as a whole. Ethiopia is in the implementation stages of a multi-year, healthsector-wide, business process re-engineering activity that promises to realize significant gains in efficiency and effectiveness. This work applies many of the principles of enterprise architecture to health system design and reform and may serve as a model for other countries and global organizations embarking on health system strengthening efforts.

Finally, ICT for health systems strengthening does not exist in a vacuum. It exists within broader country efforts to strengthen ICT infrastructure and resources for the community. A recent article in the UK’s Independent highlights how the village of Macha in Zambia, two hours from the nearest paved road, is getting connected to the Internet by the UK charity Computer Aid and its local partner LinkNet. The local hospital, malaria research center, and nurse training center are all tied in to the community network and nurses are taking advantage of the new connectivity right alongside local farmers and community leaders. Placing the health system in the context of the community it serves helps provide the most successful and sustainable results.

Last September, Rwanda’s Ministry of Health unveiled a $32 million plan to make health-care services delivery effective through ICT. The funding will support district health centers, develop community-based information systems and computerize the national health-care

Getting to Maybe: How the World is Changed provides an excellent overview of complexity theory, systems dynamics and how they relate to social innovation, along with many examples from global health and international development. As the largest collective social innovation effort with the most important potential outcomes, the global health community has the most to gain and offer from a greater understanding the complex dynamics of our work. GH

Campbell, J and Settle, D. 2010. Taking Forward Action on Human Resources for Health in Ethiopia, Kenya, Mozambique and Zambia: Synthesis and Measures of Success. www.intrahealth.org/assets/uploaded/ resources_10/TFA_HRH_Synthesis_alt.pdf

Stansfield, S, Orobaton, N, Lubinski, D, Uggowitzer, S, and Mwanyika, H. The Case for a National Health Information System Architecture: A Missing Link to Guiding National Development and Implementation. www.who.int/ healthmetrics/tools/1HMN_Architecture_for_National_HIS_20080620.pdf

IHP+ Results. October 2008. Global Initiative to Strengthen Country Health Systems Surveillance (CHeSS). Italy. http://tinyurl.com/CHeSS-Bellagio

Learn more and link to all the sources on www.globalhealthmagazine.com

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online exclusives

By michael clemens

By vince blaser

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C health worker migration:

Disease or symptom?

Do health workers who leave developing countries, and the organizations that hire them, cause death?

To believe that, you would need to believe two things.

C Buzzwords or Buzzkill?

Health system strengthening. Integrated programming. Comprehensive global health policy.

First, you would need to believe that migration is an important cause of health worker shortages ...

Second, you would need to believe that health worker shortages at the national level are an important cause of death ...

The migration of health workers is a symptom rather than a disease. The disease that causes this symptom is often the very poor working conditions that these professionals face at home, relative to the excellent conditions that their rich-country colleagues take for granted. If our interest is in building the capacity of developing-country health systems to prevent suffering and death, we should move away from thinking of migration as the problem. Seeing migration as the problem leads us to “solutions” that involve stopping migration itself, forgetting that migration is merely a choice of where to live, a choice that very few of us would accept losing without our consent. Building up developing country health systems means asking health workers what they would need in order to stay and what they would need to be effective, as well as reconsidering the incentives created by current public systems of health-worker training and employment. In short, it means thinking of health workers less as human resources and more as human beings.

Read more at www.globalhealthmagazine.com.

The key words of health systems are quickly becoming part of the global health vernacular. But for community caregivers at a small village in Zambia’s Kapululwe region, the “buzz” could have real meaning for Batuke Walusiku. As deputy director of RAPIDS, one of the largest community health worker training programs in Zambia, Walusiku has become convinced that major progress on strengthening health care in her country cannot be achieved without properly tracking the work of caregivers – from taking clients on bicycles to the clinic, to advising them on HIV/AIDS prevention.

One week later in the sprawling commercial capital of Dar es Salaam, Tanzania, Dr. Kenneth Lema also hears the buzz as he takes a stroll through a construction site at the Muhimbili National Hospital.

The site now houses a new emergency department at the national referral hospital, and Lema’s organization, the Abbot Fund, has staked a major investment in its success.

Read more at www.globalhealthmagazine.com.

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By gerardine Luongo

By catherine connor

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C Tertiary Care for Long-Term Health Care Development

C Health Systems Strengthening - True or False?

… The global health community (governments, NGOs and individual advocates) continues to fail, and fail dramatically, to frame and pursue strategies for long-term health systems development. We continue to implement short-sighted, disease-specific approach to health-care aid that will save some lives but its greatest achievement will be to ease our collective conscience.

True or False? Health systems can’t be measured. We don’t know what works to strengthen health systems. Strengthening health systems will be a money pit, an expensive, open-ended investment that won’t show measurable results.

Primary care is one component of a comprehensive system of care. But it is just that, one component. It is arguably less expensive than secondary or tertiary care; if done well, it should have tremendous, positive impact on a large percent of the population. And, if developed in isolation from or in lieu of a comprehensive health-care system, it will not be able to sustain itself.

Health system strengthening is red hot and referenced in PEPFAR II, Obama’s Global Health Initiative, WHO’s “Everybody’s Business,” the World Bank’s new Health, Population, and Nutrition Strategy, and USAID’s Report to Congress. But the stampede to health systems still leaves key questions in the dust for many stakeholders.

Read more at www.globalhealthmagazine.com.

Read more at www.globalhealthmagazine.com.

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online exclusives Photos by Margaret Aguirre/International Medical Corps

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C global health council

members rush to help haiti

Global Health Council members are marshalling their forces enmasse to come to the aid of Haiti during this time of immense suffering after the devastating January earthquake.

The Council is the source of information of what is happening on the ground through its frontline blogs at www.globalhealthmagazine.com and its monitoring of news and places to donate at www.globalhealth.org.

If you have blogs from Haiti or photos or news to share, please contact Tina Flores at tflores@globalhealth.org

C online exclusives C E. Marilyn Lowney of the small Haitian Health Foundation says they are assessing damage and preparing for refugees C Margaret Aguirre of the International Medical Corps blogs about their work at the hotel-turned-hospital in Port-au-Prince C Jeff Jordan of the Catholic Medical Mission Board, which has been in Haiti since 1912, blogs about the coming health challenges C Save the Children’s Ian Rodgers reports on the situation in Port-au-Prince: “...When we spoke to children and families, it was clear that people are very much in shock. We saw a lot of people still crying.

There were so many distressed people - some of them were wailing, trying to find loved ones under debris and rubble. I’ve worked in a lot of disaster areas all over the world – and it was incredibly eerie to see so many people in shock.”

C CARE staff’s eyewitness accounts from the field: “... one of the biggest disasters, people are desperate for help.”

More frontline accounts from Haiti at www.globalhealthmagazine.com www.globalhealthmagazine.com

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