Buzzwords or Buzzkill?
01/26/2010
Can new interest in health system strengthening lead to meaningful change?
Health system strengthening. Integrated programming. Comprehensive global health policy.
The key words of health systems are quickly becoming part of the global health vernacular from the Washington beltway to the shores of Lake Geneva. But for community care-givers 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 care-givers - 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.
Across the wide ranging, complex field of improving health outcomes in developing countries, it can be extremely difficult to devise a donor strategy to strengthen the underlying health system across sectors, which includes everything from the new emergency department in Dar es Salaam to the bikes in rural Zambia. But that is exactly what some of the world's leading donors are attempting through a number of new initiatives launched this year.
In May, the U.S. committed to a six-year, $63 billion Global Health Initiative that adopts a "more integrated approach to fighting diseases, improving health and strengthening health systems." That same month at the 62nd World Health Assembly in Geneva, health ministers adopted a resolution on primary health care that encourages the "development, integration and implementation of vertical programs, including disease-specific programs, in the context of integrated primary health care." The Taskforce on Innovative International Financing for Health Systems - created by British Prime Minister Gordon Brown and World Bank President Robert Zoellick in 2008 to help strengthen health systems in the world's 49 poorest countries - announced $5.3 billion in additional commitments in September to bolster health services for women and children.
As these initiatives attempt to inject more flexibility and integration into donor financing for global health, the lessons learned by people on the ground in Zambia and Tanzania - which have received major support by the United States and other donors - provide some insight on the challenges and opportunities.
Reaching Rural Populations
The professional lives of a medical professor in Zambian capital of Lusaka and a taxi driver in a small town along the route to safari hotspots in Tanzania intersect at one the critical points any health systems initiative must include: innovative mechanisms for reaching rural populations with services and information.
About a decade ago, Dr. Mary Ngoma, an associate professor of pediatrics and child health at the University of Zambia, recognized significantly lower childhood immunization rates in some of the country's rural provinces compared with the national average - a common occurrence in many countries. According to Ngoma, mid-level district health managers went years without getting proper basic immunization training, but she was rejected for a private grant to fill the gap in health ministry trainings.
Flash forward to this year - the gap still great - and Ngoma is finally able to do something about it because of $200,000 from the Merck Vaccine Network Africa (MVN-A) and the Merck Company Foundation. MVN-A is running similar programs in Kenya, Mali and Uganda, partnering research institutions those countries with universities in the United States and United Kingdom to provide these trainings of both mid-level managers and "national trainers" - an attempt to provide the oft-mentioned donor requirement: sustainability.
The need for sustainability also brought Sikoyo and his taxi into the health sector. A group called Minnesota International Health Volunteers came into Sikoyo's district - Karatu, Tanzania - with a flexible U.S. Agency for International Development child survival grant that also addresses related issues critical to child survival, including maternal health and malaria.
In an attempt to address lack of access to transport and information among the rural population, the Minnesota volunteers started the Men Active in Sustaining Health Action (MAISHA) driver program, which trains taxi drivers to convey health messages, assist in emergency transport in clients and distribute condoms. Many men like Sikoyo were happy to participate in the program, but it does not come without hardship. They often are transporting clients in critical condition (Sikoyo told of a recent trip to pick up an HIV-positive woman who was suffering from an opportunistic infection who died en route to the clinic), and sometimes their clients do not pay a fare and fuel costs are not subsidized.
MIHV-Tanzania Country Director Jolene Mullins said the driver program is one of the their attempts to provide community ownership over issues not normally covered by a health system but, according to Mullins, are absolutely vital to its success.
Integrating a New Workforce
At an overcrowded clinic outside Lusaka where pregnant women sit on concrete benches all day in hopes of being seen, to the rural villages where community health workers make the rounds, a clear message for the new cadre of donor initiatives: many more health workers are needed and they need additional training. Some disease-specific funding streams such as the President's Emergency Plan for AIDS Relief (PEPFAR) now have requirements for training additional health workers - a welcome sign for managers on the ground in Zambia and Tanzania.
With a dearth of health workers, programs are often addressing needs by training community volunteers on issues that paid workers do not have time for - such as nutrition counseling, distribution of malaria nets and prevention of childhood illnesses. Catherine Mukuka, director of the Infant and Young Child Nutrition (IYCN) program in Zambia for PATH, said that task-shifting nutrition counseling to volunteers who could travel throughout the community was a necessity but added that it can only be successful with a strong monitoring and evaluation program.
Global health officials are trying to grapple with exactly how to monitor and evaluate the often vague concepts of flexibility and integration for the lawmakers authorizing funding. For Dr. Rowland Swai, manager of Tanzania's National AIDS Control Council, the answer is simple: work in tandem with country partners to fill the biggest gaps.
Swai said that through the years he has seen donors and philanthropists come in and build luxurious facilities - that does not address the most critical needs and fails to strengthen the health system. The Abbot Fund's work in Tanzania, Swai said, should be looked at as a model for similar programs to follow.
Abbot came into Tanzania looking to improve the country's response to HIV/AIDS. Swai and other officials told them they were already getting funding to supply drugs and what is needed, and needed a major injection into improving the facilities at the regional health centers and national hospital. With new labs online or on the way at all 23 regional facilities, and a transformed Muhimbili National Hospital, Swai said Abbot's investments have gone a long way in building sustainability to Tanzania's health sector.
As major government programs look to get into the business of filling health system gaps, Tanzanian and Zambian workers across the spectrum of health issues argued for greater investment in health systems - what exactly that means remains to be seen.
Vince Blaser, a freelance writer, was formerly part of the communications team at the Global Health Council.
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