Strengthening Health Systems to achieve Universal Health Coverage

International Health | Health Systems Strengthening: our experience

Strengthening Health Systems to achieve Universal Health Coverage Everyone has the right to affordable, accessible, good quality healthcare. Universal Health Coverage has the potential to provide this, but it depends on strong health systems.

Strengthening Health Systems to achieve Universal Health Coverage

Increasing coverage for all populations We have learnt that achieving Universal Health Coverage in most LMICs and fragile states must go hand in hand with reaching the unreached and most vulnerable citizens. This is essential as these population groups are often hard to define, locate or access, but may also benefit least from the interventions and financial safety nets which are aimed at them. We have many examples and success stories about reaching these population groups, not just through vertical interventions but by introducing innovations to existing health systems and social protection programmes.

In Somalia we act on behalf of the UK government as the Fund Manager for SHINE, the Supply Component of the Somalia Health and Nutrition Programme (2018 – 2021). Somalia is a hugely complicated, fragile environment, which continues to be severely conflict affected. Our efforts to improve service coverage involve contracting NGOs to deliver an essential health package and simultaneously working with the Somali health authorities to strengthen their capacity to coordinate, manage and plan those services.

Mott MacDonald is committed to the global effort to shift Universal Health Coverage into a higher gear.

We have more than 25 years on the front line of strengthening health systems in low- and middle-income countries. This gives us the edge in achieving effective, sustainable and far reaching change in resource poor and complex environments. We work closely with national and local governments, health practitioners, development partners and civil society, helping them to reach more people with good quality health services and move towards universal health coverage.

Our health systems approach means we address all the components of the system - from policy, planning, organisational structure and management systems to human resource performance, information systems and quality management at the service delivery level. Our practical approach to technical assistance is grounded in evidence of what works for a particular place and why. Learning from implementation and innovation is built into all our programmes, supplemented by our extensive experience in monitoring and evaluation.

In our experience, working on the supply side is not enough to achieve Universal Health Coverage and financial protection. In many of our projects we work closely with community groups to develop locally meaningful solutions through demand side interventions that foster improved health seeking behaviour.

We encourage national health policies and programmes that are country owned, aligned with nationally defined health priorities and sustainable. We also promote responsiveness and accountability of health policies, programmes and services to the populations that they are expected to serve.

Moreover, Mott MacDonald also provides technical assistance in the related sectors of nutrition, education, women’s empowerment, social protection, socio-economic development, water, sanitation and hygiene, and waste management. This gives us a holistic view of health development issues and enables us to mobilise additional specialist inputs.

We specialise in: Design Helping countries and development agencies design and shape health systems.

Delivery Supporting the delivery of health policies and programmes through long- and short-term technical assistance, capacity building and fund management.

Evaluation Promoting the critical assessment of what works and why, ensuing programmes are grounded in robust evidence.

Country ownership We understand how to respect and foster country ownership, working in close collaboration with Ministries of Health and other partners.

People suffering from neglected tropical diseases by definition tend to have particularly poor access to appropriate services. Our Ascend programme (2019 – 2022), funded by the UK government, focuses on those aspects of health systems in West and Central Africa that are essential for widespread sustainable control and elimination of NTDs. Support is tailored to each of the 13 countries according to their priority areas, but commonly focuses on prevention, detection, treatment and surveillance to reduce current disease burden and prevent disease resurgence. In addition, for those countries with the capacity to do so, one of our key strategies is to help them integrate NTD programmes within their domestic health systems.

Ascend is the successor to the UK aid-funded KalaCORE programme for control and elimination of Visceral Leishmaniasis (VL) (2012-2018) which we operated in Ethiopia, Sudan, South Sudan, Bangladesh, India and Nepal. In order to increase service coverage, we helped countries design programmes and establish VL treatment centres that targeted 128 million people. Our focus was on service delivery, vector control, access to effective treatment and piloting of innovative approaches. The programme completion review confirmed that it had successfully contributed to reducing the economic and health impact of VL in South Asia and East Africa. Two key metrics - duration of illness and time between onset of symptoms and getting treatment - were reduced in all countries in Asia and across genders. Case fatality rate regional targets were achieved, and Bangladesh and Nepal met the elimination of VL as a public health problem target.

In Pakistan, we ran a Technical Resource Facility (TRF+) with the governments of Punjab and Khyber Pakhtunkhwa (KP) (2014-2019), supported by UK funding. We focused on outcomes around RMNCH, working with the provincial governments to agree priorities, set targets, build capacity and improve public financial management (PFM). In addition to technical assistance, the use of performance monitoring ‘roadmaps’ helped both governments drive innovative and evidence-based solutions. Both provinces saw a significant increase in skilled birth attendance over the programme period from 53% to 71% in Punjab and from 48% to 67% in KP. This was achieved through intensive monitoring of key inputs e.g. availability of 24/7 specialist staff, plus PFM support to reduce budgetary bottlenecks to ensure timely flow of funds through the system. TRF+ was the successor to our first successful Technical Resource Facility Programme (2009 – 2015).

Under-nutrition affects a large number of Pakistani women and children, undermining progress in social and economic development. On behalf of the UK government we manage the £41 million Food Fortification Programme (2016-2021) widening efforts to reach more children and women of childbearing age with fortified food. We work with federal, provincial and local governments to develop, monitor and enforce food fortification regulations and standards. This is done in close partnership with the commercial food production sector – we work with them to build their capacity to carry out fortification in their factories and to develop their understanding and commitment to playing a role in the national fortification effort. To date, FFP has signed MOUs with 70% of the 1,100 flour mills and is working to address various market failures affecting wheat flour fortification rates. FFP also works with nearly all the 116 active oil/ghee refining mills, who are now successfully fortifying over 90% of their production.

In South Africa our efforts to widen service coverage for all populations have involved working beyond the health sector. As part of a consortium we delivered the USAID funded Government Capacity Building and Support (GCBS) programme (2013-2018) to enable the Department of Social Development to effectively target orphans, vulnerable children and youth affected by HIV. Our other extensive HIV work in South Africa informed our management of the UNAIDS’ Technical Support Facility for Eastern and Southern Africa (2005 – 2017) in which we provided quality technical support and capacity development services to strengthen the delivery of effective national AIDS programmes in 22 countries.

Improving the quality of essential health services Improving the quality of care requires a health systems approach that combines evidence-based service protocols, patient-centred service delivery, use of data to inform decision making and a continued focus on quality and performance management to foster competent and motivated staff. Mott MacDonald therefore approaches effectiveness and quality of care from various angles (organisational, technical, human resource development etc.)

Antimicrobial resistance (AMR) is a major threat to health systems around the world, but LMICs are particularly vulnerable to AMR due to limited access to appropriate antibiotics and to unknown, unreported levels of resistance of specific pathogens.

Both of these undermine health service outcomes but most LMICs lack the quantity and quality of data to address the problem. As the Management Agent for the Fleming Fund (2016-2021), we run a £235 million-pound global, regional and country grants programme aimed at strengthening capacity in 24 low and lower middle-income countries to help them address AMR through improved surveillance and reporting.

Other AMR work has been commissioned from us by the EBRD in Georgia (2018 – 2019) and Turkey (2019 – 2020) where we are assessing selected private-public partnership hospitals to help them improve their antibiotic stewardship an infection prevention and control practices, as well as carry out appropriate management of patients with resistant infections.

We have also worked with WHO on AMR, exploring options to increase investments in national action plans on antimicrobial resistance in low- and middle-income countries (2017).

In South Africa our Better Health Programme (2019 – 2024), funded by the UK Prosperity Fund, supports the South African government on its journey towards universal health coverage. Improving the quality of treatment and care for noncommunicable diseases (NCDs) is a particular focus: in addition to promoting a multisectoral response, integrating NCD data and surveillance and supporting civil society networks for patient empowerment and engagement, we are also strengthening health technology assessments. Some of the initiatives we support include the development of a systemwide quality improvement strategy, developing a framework for patient engagement on safety and quality, and helping the government scale up certification of both private and public facilities.

The Better Health Programme continues our long-term health systems strengthening involvement in South Africa since 2010.

The foundation of this is the strong relationship we built with the National Department of Health (NDoH) when we implemented the UK funded £37 million programme to Strengthen South Africa’s Response to HIV and Health (2010 – 2016). This had two strands, firstly helping NDoH reduce mother-to-child transmission of HIV from 13% to 3% over the course of those six years by increasing acess to early detection and treatment of HIV. Secondly, we helped NDoH to prepare for national health insurance by setting up a quality assurance system for providers, preparing the public primary care system to compete with the private sector and evaluating different purchasing models.

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NCDs are also the focus of our Strategic Health Partnership in Samoa (2015 – 2020). Although Samoa has relatively high government expenditure on health in comparison to other small island states in the Pacific, it still has NCDs as its highest cause of death. Funded by the Australian government, we work with the Samoan Ministry of Health and the Australian Queensland Department of Health to share knowledge, skills and experiences and work collaboratively to develop solutions to common issues.

Monitoring, Evaluation and Learning An important source of learning about strengthening country health systems and moving towards universal coverage is through the rigorous programme and impact evaluations that Mott MacDonald undertakes in a range of countries. The focus of many evaluation contracts has been on assessing the effectiveness and value for money of interventions aimed at reaching the unreached and the most vulnerable.

We are the independent evaluator for the Bill and Melinda Gates Foundation programme, Improving the quality and use of HIV data in Malawi (2015 – 2021). Our role is to generate lessons on how best to introduce new information technology into existing government systems. The intention is to encourage more frequent use of health data in routine decision-making at all levels, whilst understanding how and why decision-making has improved and establishing whether HIV service delivery has improved as a result. In addition, for the same donor, we are undertaking the External Evaluation of the Better Immunization Data Initiative (2014-2019) implemented by PATH in Tanzania and Zambia.

We have just finished Monitoring and Evaluating the Reproductive Maternal & Neonatal Health Innovation Fund for DFID Ethiopia (2014-2019). The fund aimed to improve the health outcomes of women, newborns and young people in the pastoral list regions of Ethiopia. As independent contractors to DFID we monitored the work of a wide range of sub-recipients and evaluated the programme as a whole.

In addition, we carried out value for money assessments and provided technical support for operational research.

Elsewhere in Africa we ran the UK funded Evidence for HIV Prevention in Southern Africa (EHPSA) programme (2014-2018), focusing on research around preventing HIV in adolescents, prisoners and LGBTI in South Africa, Malawi, Lesotho, Namibia, Swaziland and Zambia . Not only did this programme generate evidence to identify the most effective and efficient HIV prevention responses, but it also supported strategies to translate that evidence into action. This was important for the design of interventions to help targeted vulnerable populations – adolescents, prisoners and LGBTI – about whom research and programming efforts have been insufficient. Evidence generated by the programme had some notable impacts on policy and practice on HIV prevention in the region. For example, in Kenya, the Anza Mapema study on HIV services for MSM, including the provision of preexposure prophylaxis (PrEP), has informed the approval and implementation of PrEP as part of the national programme.