How can global health professionals gain a better understanding of what works and what doesn’t?
While health systems can often seem like inflexible and monolithic entities that are complex and difficult to change, breaking these systems down into their constituent parts and analyzing the factors that make each part or cog in the system turn can help us create better health solutions.
While the Millennium Development Goals have focused the world’s attention and triggered global action, by the 2015 deadline many of the goals are still unlikely to be met. Moreover, opportunities to seize upon the synergies that arise across sectors and within the health system have been missed.
For this reason, we believe that health professionals need to reconsider the way in which we prioritize, design and implement interventions that affect the lives of some of the most marginalized populations.
At the Overseas Development Institute, our development progress research on health seeks to bridge gaps in knowledge and examine factors that drive progress in health. We do so by exploring countries that have shown progress — often against the odds. While the outcome we sought to measure was that of health, the drivers identified as supporting progress in health span different sectors as well as levels of implementation — levels that also often interact.
For example, we examined how education played a role in Cambodia’s battle against neglected tropical diseases, why infrastructure matters to child and maternal health in Mozambique, and what impact community volunteers have had on treating NTDs in Sierra Leone.
Lessons from these case studies can then hopefully be taken across to other countries, while being mindful to adapt generic recommendations to specific country contexts and realities. On paper, the suggestions may seem blindingly obvious but — in practice — our findings suggest they can help address many barriers to progress.
There are three key findings to highlight here:
1. Genuine political buy-in is the bedrock of health progress
The fact that a decision-maker’s commitment to investing in health provision and reform makes a big impact on health outcomes, is to a large extent project management 101. However, the real difference this factor can make in terms of health is remarkable. It explains why one of the world’s poorest countries, Sierra Leone, is a West African leader in the fight against NTDs — indeed, the country has a history of politicians trained in tropical medicine that have established the frameworks and sought the necessary funds to tackle many of these devastating diseases.
The presence of a voice at the national level — where policies are developed, priorities identified, financial resources planned and relationships developed — creates the framework from which all actions will flow. For example, when the Nepali government prioritized maternal health in the late 1980s, verbal commitments were followed with a range of policy documents and priority programs emphasizing institutional delivery care and an increased number of facilities providing emergency obstetric care.
A core group of midlevel health ministry officials — who had worked as public health experts and medics, with first-hand experience of the country’s dire birthing conditions — spearheaded research around the issues of maternal mortality. These efforts were reinforced by pressure from civil society groups and health experts, who together ensured the provision of basic health services remained a priority.
2. Collaboration at implementation level can boost sustainability and effectiveness
The growing demand for cross-sector collaboration certainly needs to be met, but there are also advantages that can be gained from better collaboration across project levels. At the implementation level policies are actioned, resources are allocated, and intra and inter-sectoral dynamics come into play.
For example, in 2004 Cambodia became the first country to reach the World Health Organization target in treating soil transmitted helminths — or intestinal worms — in schools, a full six years ahead of schedule. While this progress was made possible through a nationwide school deworming campaign, high-level commitment created the necessary buy-in for the country’s ministries of health and education to work collaboratively on its implementation.
Through commitment at the highest levels, Cambodia’s school curriculum was adapted to explicitly include STH as a health education subject. The nationwide campaign sees schools provide the infrastructure and carry out deworming interventions. Twice per year, school teachers take on the additional role of drug administrators across all 24 provinces in Cambodia. The success of the campaign suggests national-level support can be translated into effective implementation that delivers increased access and scale-up.
3. Community power can create huge impact
We need to give genuine consideration to the level at which services are actually delivered. Community involvement is a well-known strategy to implement programs in a resource-constrained setting. Not only does involving communities extend access to many services and allow often marginalized communities to access services, but it also creates ownership, fosters inclusion, and leads to sustainability and a sense of empowerment.
The scale of the impact that community drug distributors — or CDDs — have had in Sierra Leone, for example, illustrates the impact that can be made by communities. Some 29,000 CDDs distribute NTD drugs to their local communities, covering in excess of 14,400 villages. As a result, this volunteer “army” has been able to reach remote areas of the country that are beyond the reach of most formal health providers.
The fight against NTDs is a collective effort, but the international guidelines, support from global partners and drug donations would be wasted without those at the “sharp end” of the fight, walking throughout their communities to distribute the drugs and convince their peers of the positive impact they can have in their lives.
There are no “cookie-cutter” solutions to the immensely knotted and complex health challenges that must be remedied. The political economies of the countries we study vary immensely, as the wide range of factors that have shaped outcomes in health illustrate. Yet the messiness of the problem offers many solutions — if we stop treating health systems as if they operate in a vacuum, we might stand a better chance of being able not only to more effectively address the challenges, but to grasp the opportunities that enable us to improve the broader wellbeing of citizens.
Will a rethink by global health professionals on how to prioritize, design and implement interventions deliver positive impacts for the marginalized populations they serve? Have your say and share your experiences below.
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