HEALTH SYSTEMS FOR ACCELERATING ACHIEVEMENT OF SDGS
Dear Colleagues,
This blog has not been released in this space for some time. This was due to upgrade work on our website which has now been completed. However, I have been writing the and publishing the blogs in the Africa Health Journal every two months and all the issues can be accessed in the Discussion Forum at www.achest.org.
Please read and feel free to comment as in the past.
The months leading to the end of the year 2016 saw a flurry of activity around positioning for the acceleration of the achievement of SDGs. At ACHEST we convened several meetings including a Regional Consultation of Think Tanks and Academic Institutions in September 2016 with support from IDRC of Canada and the 3rd African Health Systems Governance Network in October, 2016 supported by the USAID. In November, 2016, ACHEST participated at a meeting in Rio de Jenairo and at the Global summit on Health Systems Research in Vancouver. In December 2016, one of our colleagues was at another meeting on SDGs convened by the UN in Vienna while I attended two meetings in Geneva on Universal Health Coverage and a High Level Ministerial meeting on the UN Secretary General Commission on Health Employment and Economic Growth two other ACHEST colleagues were on mission to Nigeria to monitor migration of health workers.
So with all this activity, are we going where we want to go with special reference to rural and poor urban communities in developing countries? Are we on the most desirable track to get there with the SDGs at the earliest and “leaving no one behind” as the slogan says?
This is how I see it. Our first and most important job is to create the right climate of opinion that will enable the global and regional actors to support country health systems that leave no one behind. The future health system should be one that is “wellness-based as opposed to illness-based” systems of today.
Who will be the key players? First and foremost it is the individuals, the ordinary person everywhere together with their households and communities who should be empowered to own and take responsibility for maintaining their own health, which in most cases is inborn and self- regulated. The Internal environment of each person’s body is scientifically very carefully self-regulated creating a harmonious physiological balance that gives the feeling of wellness and wellbeing. It is the behavior of people as individuals’, households and communities that disorganize this “mileau interior” originally described by Frenchman Claude Barnard. We introduce substances into our bodies and treat our bodies in ways that disturb this well balanced internal environment resulting in the loss of wellness. The priority for action therefore needs to shift the flurry of activity around positioning for the acceleration of the achievement of SDGs to the level of individuals, the ordinary person everywhere together with their households and communities.
A wellness-based health system can only work if it is owned and driven by individuals in the way they live out their daily lives. It is therefore the most important duty of the health system to provide the population with information that creates a high level of health literacy and empowers people to possess and apply knowledge for making lifestyle choices that maintain well-being and health. This calls upon health system leaders in our countries to take advantage of the fast growing digital communication trends to provide the population with information that empowers people to make lifestyle choices that promote health and wellness in communities.
Empowering individuals to maintain wellness should create in the population a sense of ownership of the health system as was envisioned in the Alma Atta Declaration where one of the tenets was the ‘active participation of the people themselves”. Not only that, this should also empower the population to demand quality health services and to drop their own sweat in contributing to better performance of “their” health system. This is not only a realistic entry point for moving towards attainment of a right balance between the illness-based and wellness-based health services but in addition underscores the need to explore how best to promote and intensify active participation of populations in actions for health and well-being.
It is individuals who bring themselves together to create groups known as Civil Society Organizations (CSOs) Professional Associations, Trade Unions and even political parties. These institutions are the vehicles for ensuring that the visibility of the health agenda remains high, relevant and acceptable within context. These institutions need to be supported and decentralized as near the households as possible .
Another key player is the national governments. I heard African delegates in one of the December meetings in Geneva, lamenting the failure of the international community to create positive change in the performance of African health systems. My questions are: Where are the African governments and other African health leaders themselves in this equation? Why blame others and not ourselves? Where is the ownership and accountability? As I have written elsewhere in the past, we need to feel the pain and shame and cause sustainable African led change for ourselves.
Other critical players are Regional and sub-regional groups who can facilitate convening and joint learning, the International Health community including the UN Family and financial institutions who should all rethink their strategies to better support the approaches articulated here.
Finally, accelerating the achievement of SDGs will require intense intersectoral collaboration and from my experience working in and with government, this is not easy. To address this challenge, the Think Tank meeting in Kampala recommended that we should assemble evidence through locally contextualized multi-sector studies and tactfully use the data for advocating for integrated primary health systems. It appears this message is gaining momentum as I was delighted to hear Bill Gates talking about strengthening health delivery systems only last week. We still have a lot of work to create that right climate of opinion.
What do you all think?
Wishing you all self-driven wellness in 2017 and beyond.
Francis.
Comments (19)
M. Rashad Massoud
Thank you very much for sharing this.
Kind regards, Rashad
Emile Rwamasirabo
It is good to hear from you after so long. I hope you and your family had an enjoyable end of the year festive season.
Individual own health "ownership" especially in least development countries is indeed a concept that requires to be well researched as it looks like it is the only way to ensure sustainability of our health systems. As you well say it, there is no short-cut to people knowing their own body, understanding how to protect it and how to share own resources to maintaining it. Off course governments have the prime responsibility to setup and support systems working together with all stakeholders; this works better when the people play fully their part. By the way African countries do not need much external resources to provide health education to their people and clean their environment. Again here the cost of health will always be a question on our agenda; what is the cost of health care and how is it covered and by who will cover it especially in Africa is still to some extent poorly understood. Africa and Africans need to own this issue as it is not only a social but has also important development, political and security dimensions. Governments have to setup conducive environment for individual peoples, community organizations, cooperatives, private sectors and state organizations to fairly share the cost of health in Africa.
African populations are capable to financially contribute to that collective effort provided the rules of the game are clear and transparency ensured; this is how you are able to control malaria, URTIs, medically assisted deliveries, etc. Their participation creates awareness and readiness to understand the role of prevention and early management of NCDs. In short, while the external support is important, Africa needs to "beleive" in its inner capacity to handle the fundamentals of its healthcare requirements.
Thank you again Francis for sharing your thoughts
E. Rwamasirabo, MD
Francis Omaswa
Thank you for your well thought response to this topic. My family had a peaceful holiday season and are back to normal work again.
Individual ownership and collective community and national accountability for population health is taking root in your country of Rwanda. You in Rwanda have a strong community spirit which is backed by the government and have as a result achieved an amazing over 90% health insurance. Rwanda achieved MDGs through collective action and strong political leadership.
I have heard some people say that Rwanda is too hard on the people and I have defended the approach taken by Rwanda. Societal discipline or indiscipline is a major determinant of health outcomes.
Can you pleased tell us more about your community approaches.
All the best for 2017.
Francis.
Francis Omaswa
Through the many things that we have done together over the years I have appreciated the depth of your grasp of the issues and your passion for health system reforms that give more responsibility to the population for maintaining and promoting their own health.
You have recently shared with me the work you are doing as Chair of the UK Parliament All Party Committee on Health. Could you please share some of this with this group either some documents or summarize the massage that your Committee is passing to the public in the UK.
All the best.
Francis.
"OKELLO, David O.
Good to hear from you, and Compliments of the Seasons.
I totally agree with your thoughts on ways to address health systems for accelerating achievements of SDGs. Focus must indeed be put on wellness-based health systems. This is precisely my pet talk with Ministers of Health, to encourage them to live to the aspiration of the name of the ministry they lead - which is Ministry of Health, suggesting that they should put more efforts on keeping the population healthy - through effective health promotion, helping communities and individuals deal with lifestyle choices that maintain well-being and health; as well as addressing issues of preventive medicine - as opposed to putting more attention to fighting ill health. After all, prevention is still cheaper than cure. As implicit in the SDGs, we should promote the concept of 'health in all sectors'.
If you allow, let me throw in yet another idea to your already rich menu of issues to chew. WHO defines health as a state of complete physical, mental and social well-being, and not merely the absence of disease or infirmity. While we may now have a critical mass of skills for dealing with physical and mental well-being, our systems are not well equipped to handle the concept of 'social well-being'. Are we clear about what sets of skills are needed to deal with 'social well-being', and how should we go about tracking it at individual level?
Your reference to the rural and urban poor is critical. Poverty is perhaps the single most important determinant of bad health. There is a vicious cycle between poverty and bad health. Until we can figure out ways of pulling our communities out of poverty, I am afraid no amount of individual empowerment with knowledge will make a difference. Today our countries are experiencing major youth population bulge, but will most likely not benefit from the demographic dividend because of unemployment headaches and rampant poverty. This is where the role of Government is key, to put in place incentives for creating wealth. The rural communities need guidance on how to use their land. We must reintroduce the concept of cash crops, and help farmers better deal with climate change.
Thank you.
David Okello
WR/Zimbabwe
Mr okong Pio
I also wish to add my observations to the rich synthesis already assembled.
Legal challenges might not be of Primary importance but in Uganda, I have observed the following and I think this could be one of the critical issues to give "The Ministry of Health the necessary Clout"?
The Ministry of Health derives its mandate from the Constitution of the Republic of Uganda 1995, largely from national Objectives and Directive Principles of State Policy, under Social and economic objectives.
For health it is under Objective number XX. It states that " The State shall take all practical measures to ensure the provision of basic medical services to the population". The word "Health" is used for the first time in the Constitution under Objective number XXII Food Security and nutrition: (c) "Encourgae and promote proper nutrition through mass education and other appropriate means in order to build a healthy state". The objective number XXI is about Clean and safe water.
It might be inforamtive to look at how the Objective on Education was crafted:
Objective number; XVIII Educational objectives and they are listed as:
(i) The State shall promote free and compulsory basic education
(ii) The State shall take appropriate measures to afford every citizen equal opportunity to atatin the highest eduactional standard possible.
(iii) Individuals, religious bodies and other non governmental organizations shall be free to found and operate eduactional institutions if they comply with general eduactional policy of the country and maitain national standards.
It is well recognised Health and Education are fundamental SOCIAL issues for development. I am concerned that it seems ours (Our sector) is a Ministry of Medical Services? it appears the mandate of the Ministry is constricted??? I have also observed that in EAC ....the Constitution of Kenya explicitly mentions Health in relation to the mandate of the Ministry..
I have in the past at different fora e.g during vetting for my present position and before the Parliament Committee of Health articulated these observations in regard to the Constitutional provisions and pehaps a need for amendments...?
Is this a smoking gun??/
Emile Rwamasirabo
Thank you for your feedback.
Rwanda has relied heavily in post-genocide (1994) on traditional community mechanisms to resolve issues (justice, poverty reduction and wealth creation, financial services access, mutual health insurance, etc.). Government back-up consists mostly of helping setting up the right institutional/regulatory framework, decentralized financial support, etc.
Transparency and accountability is one of the toughest aspect that HAS to be ensured if this approach is to bear fruits; money raised from the communities for health insurance or other self-help projects may look like an easy target by officials and other stakeholders; this is where government has to be uncompromising and make sure those individuals are brought to book. There is no alternative to that in my opinion. The government action in that aspect has sometime been criticized as being too harsh.
In the case of mutual health insurance, about 80% of the Rwanda population financially contribute into the insurance; the money raised may not cover the whole health bill but it pays for drugs and consumables at health center and to some extent at district hospital levels (this includes ambulance to pick patients from health center to district hospital); about 20% are too poor to afford the contribution and their fee is paid by government and others such as development partners and levy on commercial insurances). This has really had an impact on maternal and infant mortality that dropped considerably.
Rwanda government puts a lot of resources in community development through a decentralization approach with targets and performance contracts at all levels (imihigo: traditional individual/group public pronouncement of projected targets to be achieved). This is definitely a political choice with regards to leadership style and development model.
What I have personally learnt, Francis, is that there are lots of innovative traditional resources in our African communities that quite often we, the elites, do not value; in Rwanda we learnt that reality when the country was on its knees with nobody to turn to in 1994; I can see the relevance of all this especially with the rise of non communicable diseases on the continent; we are yet to know what is going to be the cost of healthcare provision to counter the NCDs on the continent; what is the potential of community mobilization in the prevention of diabetes and hypertension?; what is the potential of African pharmacopoeia and traditional medicine as we are facing this challenge?; how much resources African countries are prepared to invest in research for that purpose?
Please always keep us posted on those fundamental issues that we need to address
Best regrds
Emile Rwamasirabo, MD
Kigali, RWANDA
Mr okong Pio
Thank you for the subject matter and starting off the discussion.You have presented well synthesised issues and some of the possible solutions. One of the challenges is knowing where Goverbnments and citizens ought to start.
In a number of countries, there are also legal challenges which may constitute bottlenecks in implementing health mandates, which is a cardinal role of Government.
In Uganda, I have made the following observation which has persisted since the promulgation of the 1995 Constitution and I think impacts on the "Clout of the Ministry of Health" with regard to WELLNESS.
The Ministry derives its Mandate from the Constitution of the Republic of Uganda 1995 from the "National Objectives and Directive Principles of State Policy, under Social and Economic objectives"
In the Constitution, The Ministry of Health derives its mandate from objective No. XX which satates " The State shall take all practical measures to ensure the provision of basic medical services to the population". Can this empower the Ministry to deliver on SDG Goal 3? It appears to me that the way this objective is stated is constrictive. The Ministry then has to shop around from other sectors to have meaningful contribution to WELLNESS.
Examples, Objectives:
XXI Clean and safe water.....under another ministry
XXII Food Security and nutrition...also under another ministry..... BUT it is in this objective that there is reference in the Constitution for the first time about "Health" to quote (c) "Encourage and promote proper nutrition through mass education and other appropriate means in order to build a healthy state".
I am not proposing that the Ministry should take over all these and other related HEALTH issues but rather suggest that objective XX can be improved to strenghten the clout of the Ministry to demand for appropriate resources and implement a broader mandate than what is stated in XX.
It is informative to look at the framing of the Education Objectives (NOT EDUCATION OBJECTIVE)
XVII Educational Objectives......which are narrated as follows
(i) The State shall promote free and compulsory basic education
(ii) The State shall take appropriate measures to afford every citizen equal opportunity to attain the highest educational standard possible
(iii) Individuals, religious bodies and non governmental organizations shall be free to found and operate educational institutions if they comply with general eduactional policy of the country and maintain national standards.
In East Africa, I think it s only the constitution of Kenya that explicitly mentions HEALTH in relation to the mandate of the Ministry....directly FACILITATING ADDRESSING WELLNESS?
I have in the past articulated my concerns (at several FORA) that the current mandate of the Ministry in Uganda seems to be too constricted and boxed to Disease and Medical services and ought to be reviewed...may be a Constitutional review...?
COULD THIS LEGAL FRAMEWORK be a smoking gun and bottleneck to attainment of WELLNESS?
Miriam Were
I thank Francis for writing this piece. And I do agree with him that what happens at the individual level is very important.
However, it is virtually impossible to aim at individually dealing with each of the billions of individuals on planet earth for purposes of empowering them. It is as equally impossible as it would be to aim at universal literacy by aiming on getting to every individual to get them to read!. That is why there are schools so that one teacher can address many.
So it seems to me that what we need to emphasize is that for accelerating achievement of SDGs, National Health Systems need to have a clearly articulated Community Level Health Services component. In this approach, a group of households is the focus. Over and above them being empowered, social networks emerge through which the empowering process become sustainable. It is really essential that the world--and especially African Governments-- are inspired to take up this approach. We have seen what can be achieved by the achievements of those countries where the Heads of State have taken this on as the way to improvement of health and thus to development of their people. We have the examples of Ethiopia and Rwanda as a big population country and a small population country where they have achieved what was deemed impossible through the Community Health Approach. As it always happens, the Community Health Approach addresses the social determinants of health such as water, food and poverty to name a few. What approach would be better than this for Africa's acceleration towards achieving Sustainable Development Goals?
Yes, let us get to the 700 or 800 million Africans but let us do it through National Health Systems that have a clearly articulated Community Health Approach, Let every nation on the continent formally recognize and establish within its National Health System Community Health Services and give it the priority and attention it needs.
HAPPY NEW YEAR, 2017, EVERYONE! This is the year for our continent to accelerate achievement of SDGs through the contribution of National Health Systems with clearly articulated Community level health Services!!.
Miriam K. Were..
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Prof. Miriam Khamadi Were EBS, IOM
BA (William Penn), Dip. Ed (Makerere), MB ChB (Nbi), MPH, Dr PH (John Hopkins),
Chancellor, Moi University
Sam Okuonzi
Thank you for this topic and for such a robust response. Let me wish you all the best for the new year 2017. Prof Omaswa's central question seems to be whether we are on the right path to achieve SDGs. With a flurry of high level meetings on SDGs focusing on UHC, governance etc, the signs are that we are searching for effective ways of implementing SDGs. These are only goals, without any strategic plan or enforcement mechanism. Their implementation rests solely on political will of our leaders. I witnessed first-hand, at the UNGA at NY, the presentation of country reports on MDGs in Sept 2014, which paved way for the launch of SDGs in Sept/Oct 2015. I can say with certainty that in most cases there was lack of seriousness among leaders about MDGs and the successor SDGs. There were exceptional cases of high commitment and achievement but these were exceptional. Rwanda was one of those exceptions.
In the case of Uganda, the assessment of MDGs (the final report is now published and can be googled on the internet) was less than satisfactory. There were 17 key targets / indicators to assess progress in MDGs in Uganda. Only 6 targets were met (halving the number of people living on less than a dollar a day, universal access to ARVs, halting and reversing the incidence of malaria, achieving debt sustainability, access to drugs, and access to new technologies). 9 targets were not met (on employment, hunger, completion of primary education, elimination of gender disparity in primary and secondary schools, child and maternal mortality, and increasing access to clean water) and 2 indicators had no data or targets (reducing biodiversity and improving the lives of slum dwellers). The most interesting part of the Ugandan MDGs report was the lessons learnt. Among others, that: 1) MDGs tackled symptoms but not the actual drivers of development, which are: good governance, people participation, government capacity, and economic growth; 2) MDGs were narrow; Uganda needs a wide transformational agenda through innovation and public feedback; and 3) MDGs distracted and delayed government's shift to its core plans for economic growth, wealth creation, and structural transformation.
It is still unclear to me how SDGs can be implemented in countries like Uganda. One way is to bring out strongly in the national annual plans the aspects that relate to SDGs. This will require a lot of lobbying and advocacy. Indeed, a new draft SDG strategy for Uganda that I have seen shows that SDGs will be implemented within the National Strategic Plan II 2015 -2020 and subsequent strategic plans, under the overall framework of Uganda Vision 2040. But it is a tug of war - of pushing and pulling, between addressing "symptoms" and "core agenda". Fortunately, most elements of the SDGs are embedded in the plans. Even so, by 2030, we will be happy and lucky to make a modest progress in SDGs.
Regarding the empowerment of individuals and families to take health decisions and actions, this is indeed a good strategy. This is particularly so through public health education and legislation. But it is not enough. Determinants of more that 80% of health in a home are bestowed by the government and the health system through public education, legislation, inspection, facilitation, or provision. Look at the 11 basic social determinants that "make" health at home: safe water, good hygiene and sanitation, household income, small family-size, food and nutrition, UPE, local participation in decision-making, female education, political priority for health, UHC and healthy life-styles (concerning seatbelts, alcohol, smoking, regular exercise, animal fat, sugar, salt, regular medical checks, among others). No single individual or family or community can create such a package without a key role played by the national government. To lobby, even to pressure governments to play their rightful role in creating and sustaining health must therefore be maintained.
I admire Africa leaders who stand their ground to achieve what is good for their country. Rwanda comes to mind. Ethiopia too. Even Ghana. And I agree that leaders who look for all solutions to their national problems from the international community must do more to innovate locally. But today, the reality is that no country is an island, not even the US. We are all interdependent. The current circus at the WDF between China and the US about globalism and isolationism, demonstrates just who sees where the world is headed. Sorry to US under Donald Trump and to Britain with its Brexit. The truth is that the world is becoming one global economy through a rapidly encompassing globalization. The current phase of globalization is to integrate (absorb is the right word) the underdeveloped economies like those in Africa into the mainstream global economy. The rules of the global economy are written by the west and increasingly by China and Russia. The idea is to create a globally integrated free-market system, with no trade barriers, using market-enabling institutions to accumulate wealth from around the world. And presumably to modernize the world to be like the west. The current globalization has widened, deepened and accelerated human interconnectedness. All world systems are being integrated and have become increasingly complex. Production, financing, trade, investment, and labour are being integrated and accelerated by the rapidly evolving information technology to form one complex system. Not long from today, international governance is going to be more important than national governments. If not already so. What is critical for this globalization in health is health security (not SDGs) because of the rapid human movement around the world. So, the lukewarm response by leaders to SDGs is explainable, but not excusable.
Behind this huge drive to globalize is an enormous idle "capital" or wealth waiting to be invested, sitting in the west. This wealth must be invested in developing countries where there are still many huge investment opportunities. If not invested, the wealth will lose value. Social media is currently trending the story of just 8 individuals whose net worth is equivalent to that of half of the entire human population (ie of 3.5billion people). The wealth must be invested in our countries on their terms, not our terms. So, I can understand the helplessness of some African leaders. They are mere custodians, sometimes spectators, whilst the true rulers are outside. This is the reality of our generation and age.
Very interesting discourse by Dr Okello and Dr Crisp: If health is equal to well-being then the ministries of health cannot handle health/well-being alone. In fact MOH would be a misnomer. What is the critical component of well-being that MOH is about, which no other sector has an overlap over? Of course it is to deal with diseases! The ministry of well-being, if it existed, would be a super ministry. In Uganda that would be the Office of the Prime minister, which coordinates all ministries. All ministries /sectors will argue that their goal is to promote the well-being of citizens. Where does that leave MOH if health is not just the absence of diseases but a "well-being"? Appropriately, the MOH should be called the Ministry for Disease Prevention and Treatment.
On Dr Crisp's "modern societies market unhealthy lifestyles", that is increasingly so. I co-authored an article in the Lancet of Jan 2, 2016 titled: "Coca-Cola's multi-faceted threat to global public health" where we (the authors) required Coca-cola company to desist from putting up huge adverts in schools under pretext of providing school sign-posts. Coco-cola in Africa is a highly sugared drink, a major contributing factor to diabetes. In the West there are plenty of such direct and indirect adverts for unhealthy foods and other products.
I really feel the passion of Prof Pius Okong's lamentation that good health is a constitutional /legal matter. But, as you know, this is only good for argument. If only just 30% of Uganda's laws were adhered to, Uganda would be a wonderful country. But the realities on the ground are different and are defined and driven by political priorities and available resources. I applaud Prof Were's proposal that community level approach be used to address a multitude of social determinants of health to advance the implementation of SDGs. Just to add that this must be supported by the national government, anchored in policy and strategic plan; and the level of the community in question should be linked to the administrative /local government/political structures. Some SDGs or their elements will need to be tackled mainly at a higher level: e.g decent work, economic growth, industry, climate change, peace and justice, and global partnership.
Regards, Sam
Dr Sam A Okuonzi, MD, PhD
Public Health Consultant/ Former Memeber of Parliament
C A Samkange
1. A Shona (one of the major indigenous languages in Zimbabwe) proverb that translates to "when a fish rots, it starts with the head"
2. A Scottish proverb that says "the behaviours of a child is a reflection of its mentor"
How can we ask our patients and our communities to take responsibility for their health and well-being when we, the leaders in healthcare provision expect donors to define our health needs and take responsibility for funding our services?
Any meaningful change in African Health Care will only begin with us: attitudes and behaviour.
C A Samkange
University of Zimbabwe College fo Health Sciences
Emile Rwamasirabo
E. Rwamasirabo, MD
Francis Omaswa
Thank you for your contribution. Can you or anyone else please suggest how to achieve the change we are calling for?:
"Any meaningful change in African Health Care will only begin with
us: attitudes and behaviour".
Francis.
Peter Eriki
Thanks for putting up this blog which has stimulated such a rich and very informative discussions. Further more it is so timely as the world has just gone through the !st year milestone since the SDGs came into being. I do concur with most comments raised by various contributors
In addition I wish to make reference to Integrated people-centred services which were regarded as a key feature of resilient and responsive health systems. This theme emerged strongly during debates at the Fourth Global Symposium on Health Systems Research in Vancouver, Canada on 14-18 November, in which two of us from ACHEST actively participated in. The theme of the symposium was "Resilient and responsive health systems for a changing world" and it was evident that resilient and responsive health systems are those which provide integrated, people-centred services and have a focus on primary health care as the frontline of routine services and outbreak response. Resilient health systems were recognized as operating from the end-users and patients back, and not from the organisation forwards.
Current discussion of resilience in the health sector is characterised by a focus on sudden shocks, such as disease outbreaks; but beyond sudden shocks, organisations and systems face ongoing strain of multiple factors.
Research has shown that district health managers routinely face structural and policy instability, such as: changes in governance structures, payment delays and abrupt and imposed policy directives. They also work with unstable authority delegations, manage unpredictable staff and address changing patient and community expectations. These stresses typically occur at the same time, in the same system, impacting on the same set of people. The devastating outbreak of Ebola in west africa remains fresh in our minds.
Everyday resilience is the ability of health systems to continue to deliver services in the face of constant
challenge and strain.
Recently, USAID and partners have developed tools whjch are being used to guide their work on health system strengthening (HSS), Some of them which are being valued include the key elements and processes of a health system, including: the workers, the money, the commodities, and the service facilities focusing on measuring service facilities using several methodologies, including the concept of SERVICE READINESS.
Dr Peter Eriki Direcor Health Systems (ACHEST)
KELLEY, Edward Talbott
Though I am reluctant to jump in with such an august group, I can only second Peter's point that the global movement on integrated, people centred health services is for me – as someone involved in health systems for many years – the true game changer we are seeing and the crucial link between these too often separate discussions on health systems strengthening and global health security. Whether it is in safe, high quality primary care which also serves as the front line in outbreaks or building community engagement efforts as the backbone of district health systems and emergency response and community disease detection, this is the true new agenda. We have spent significant time at WHO and in other forums working with countries on the financing reforms for UHC. For me now, the true innovation will be the joined up policy and practice changes in health workforces and service delivery models to deliver this people centred agenda.
The two documents adopted at WHA last year for us say it well, HWF 2030 and the Framework on Integrated People Centred Health Services. Getting political support for this agenda is the real gap we see at the moment, though.
Dr. Edward Kelley
Director
Service Delivery and Safety
World Health Organization
Emile Rwamasirabo
I totally agree that health is an integral concept at all levels from local all the way to global dimension; what is heartening today though in Africa is the inability of most African countries to take care of their own people's needs. It is true that health has a cost but also quality health care has benefits for all; it is also true that health systems strengthening can not be seen in isolation from overall countries' governance, socioeconomic development performance, people's participation, etc.
Over the years there have been evidence that initiatives from below can be very successful but they become short lived when they are not integrated in a broader national framework that support local community to sustain their efforts. Intellectual input and research are needed to bring proposals on the basis of data from below of what works and how can governments, professionals, partners and private sector support a sustainable system. We need to develop models that fit our specific environment and that encompass all aspects including capacity to finance and manage; prevention and management of both communicable and non communicable diseases.
Experience from Rwanda shows that the commitment of the state to provide strong support to local initiatives and integrate them into national policies and policy implementation "from local communities perceptive" (actually responding to people's demand with relevant key performance indicators and monitoring mechanisms) has brought a shift in the way government ministries, donor agencies allocate their financial support. Money invested in health system produce expected results indeed. Our role is really to own that research agenda and be committed to model development while of course we have a wider perspective. This is the best way health academics and professionals can fully play their part on the path to development.
I hope these few lines are clear enough to contribute to the ongoing debate
Best regards
Emile Rwamasirabo, MD
Kigali, RWANDA
Francis Omaswa
Very Good to hear from you and thank you for joining this conversation. We all participate as equals and we value your participation from our WHO and particularly as a leader in the organization.
Peter's intervention and your response has provided with us with a reminder that there are decisions and resolutions that we make but whose implementation we do not follow up as effectively as we should. The Resolutions that you quote are very important examples.
Peter and I have both worked inside WHO and I do not recall emphasis being placed on implementation arrangements for the many resolutions that the WHA or Regional Committees make. What is normal is to ask for a report back but not to embed implementation arrangements into the resolutions. If this had been done in the case of the resolution on "People-Centered Health Services" our conversation now might be different.
Have I missed some thing? Could you or anyone else please comment on this particular point on "implementation arrangements for WHO Resolutions?
All the best.
Francis.
KELLEY, Edward Talbott
You are very right that this is a very typical gap in the WHO governance approach. However, for us working on these two important documents, there are specific calls to action for both the Framework on Integrated People Centred Health Services and for the Health Workforce agenda. In the former, we are working across the organization on a set of policy briefs, consensus indictors and tools. On the latter, as you know, the action plan for the High Level Commission gives a five year set of action areas on which WHO, ILO, OECD and other stakeholders will work with member states to advance the agenda. Clearly, more needs to be done at country level, but at least this is a start I think. I am happy to circulate for those of you who have not seen all of these documents the items discussed if of interest to any individual.
Thanks for the comments Francis and for letting me add to this very rich discussion.
Dr. Edward Kelley
Director
Service Delivery and Safety
World Health Organization
Francis Omaswa
Your information is correct. I am aware of the five year action plan for the Health Workforce following the report of the Commission. I am less familiar with the action documents on the Framework on Integrated People Centered Health Services. I suggest you post the link or attach copies to of the documents to this correspondence. These documents do exist but very few of us know where or how to find them.
It will then be incumbent on each and everyone of us to take action to implement or cause implementation of the agreed actions wherever we are. One of the attitude changes called for by Chris Samkange in ability and willingness to search and act on what is already known.
Francis.