Marjan Pirard

Interactions between Global Health Initiatives and Country Health Systems: The Case of a Neglected Tropical Diseases Control Program in Mali

Background Recently, a number of Global Health Initiatives (GHI) have been created to address single disease issues in low-income countries, such as poliomyelitis, trachoma, neonatal tetanus, etc.. Empirical evidence on the effects of such GHIs on local health systems remains scarce. This paper explores positive and negative effects of the Integrated Neglected Tropical Disease (NTD) Control Initiative, consisting in mass preventive chemotherapy for five targeted NTDs, on Malis health system where it was first implemented in 2007. Methods and Findings Campaign processes and interactions with the health system were assessed through participant observation in two rural districts (8 health centres each). Information was complemented by interviews with key informants, website search and literature review. Preliminary results were validated during feedback sessions with Malian authorities from national, regional and district levels. We present positive and negative effects of the NTD campaign on the health system using the WHO framework of analysis based on six interrelated elements: health service delivery, health workforce, health information system, drug procurement system, financing and governance. At point of delivery, campaign-related workload severely interfered with routine care delivery which was cut down or totally interrupted during the campaign, as nurses were absent from their health centre for campaign-related activities. Only 2 of the 16 health centres, characterized by a qualified, stable and motivated workforce, were able to keep routine services running and to use the campaign as an opportunity for quality improvement. Increased workload was compensated by allowances, which significantly improved staff income, but also contributed to divert attention away from core routine activities. While the campaign increased the availability of NTD drugs at country level, parallel systems for drug supply and evaluation requested extra efforts burdening local health systems. The campaign budget barely financed institutional strengthening. Finally, though the initiative rested at least partially on national structures, pressures to absorb donated drugs and reach short-term coverage results contributed to distract energies away from other priorities, including overall health systems strengthening. Conclusions Our study indicates that positive synergies between disease specific interventions and nontargeted health services are more likely to occur in robust health services and systems. Disease-specific interventions implemented as parallel activities in fragile health services may further weaken their responsiveness to community needs, especially when several GHIs operate simultaneously. Health system strengthening will not result from the sum of selective global interventions but requires a comprehensive approach.

Positive spill-over effects of ART scale up on wider health systems development: evidence from Ethiopia and Malawi

BackgroundGlobal health initiatives have enabled the scale up of antiretroviral treatment (ART) over recent years. The impact of HIV-specific funds and programmes on non-HIV-related health services and health systems in genera has been debated extensively. Drawing on evidence from Malawi and Ethiopia, this article analyses the effects of ART scale-up interventions on human resources policies, service delivery and general health outcomes, and explores how synergies can be maximized.MethodsData from Malawi and Ethiopia were compiled between 2004 and 2009 and between 2005 and 2009, respectively. We developed a conceptual health systems framework for the analysis. We used the major changes in human resources policies as an entry point to explore the wider health systems changes.ResultsIn both countries, the need for an HIV response triggered an overhaul of human resources policies. As a result, the health workforce at health facility and community level was reinforced. The impact of this human resources trend was felt beyond the scale up of ART services; it also contributed to an overall increase in functional health facilities providing curative, mother and child health, and ART services. In addition to a significant increase in ART coverage, we observed a remarkable rise in user rates of non-HIV health services and an improvement in overall health outcomes.ConclusionsInterventions aimed at the expansion of ART services and improvement of long-term retention of patients in ART care can have positive spill-over effects on the health system. The responses of Malawi and Ethiopia to their human resources crises was exceptional in many respects, and some of the lessons learnt can be useful in other contexts. The case studies show the feasibility of obtaining improved health outcomes beyond HIV through scaled-up ART interventions when these are part of a long-term, system-wide health plan supported by all decision makers and funders.

Neglected tropical disease (NTD) control in health systems: the interface between programmes and general health services.

Disease control programmes are an intrinsic part of health systems. Neglected tropical disease (NTD) control is a clear case in point. While there is a growing consensus that NTD control and health services are linked, with important mutual impacts, little is known of what actually happens at the interface between the two entities. Here, we review the rationale, viewpoints and experiences of NTD control programmes regarding general health services, and vice versa, and compare their respective arguments. We discuss the interactions and interface between disease control and health systems, and present possible scenarios for health system strengthening by NTD- and other disease-specific programmes. Focusing on countries in sub-Saharan Africa, we suggest a number of principles that could pave the way for fruitful discussions and development of synergies.

An experience in training international health professionals in people-centred care: the imperative of bridging health and social perspectives

Introduction/Problem statement : Providing quality health care remains a challenge in many low and middle-income countries. The challenges are two-fold: quality of care is often narrowly defined in biomedical terms or technical effectiveness and, health care delivery systems are fragmented in poorly connected subsystems such as preventive and curative care, primary care and disease control programs, health and social care. Additionally, health care providers, health managers and policy makers are mostly trained within a biomedical health framework and often lack experience with people-centred and integrated care. Description /Aim of the intervention : The Institute of Tropical Medicine in Antwerp, Belgium, attempts to address this training gap in its international one-year Master in Public Health programme (1). Every year about forty experienced health professionals from Africa, Asia, Latin America and Europe are taught concepts and models pertaining to the analysis, planning, organization and evaluation of local health systems and their interactions with social services in the four-week course component on “Local Health Systems”. This course endorses people-centred and integrated health and social care as cornerstones of quality health care and aims to enable its participants to understand the strengths and weaknesses of dominant biomedical paradigms and to develop a more holistic vision on health care. Students are expected to use comprehensive models for the analysis of (local) health systems and the organization of health services. To reach these learning outcomes the course uses methods for adult learning that emphasize a participatory approach. The diversity of the participants, in terms of professional experience and academic background, constitutes a unique and rich opportunity for meaningful exchanges and experiential learning. The concepts and models on people-centred and integrated health and social care are taught through different learning activities such as interactive lectures, critical reading of scientific papers and real life case studies introduced by a Belgian general practitioner. In parallel, students are coached in a personal assignment in which they analyse the quality of health care in a local health system in their own or a known context. In this application participants are expected to gain further insights and develop a set of analytical skills from the exchange with their peers, coaches and lecturers. Beyond classroom learning, participants are also given the chance to observe the process of people-centred care in first-line health services and to interview key stakeholders such as doctors, nurses, social workers and psychologists in various Belgian municipalities. This study visit also includes the Public Centres of Social Welfare and other frontline social services. The objective of the visit is to illustrate the complementarity of the health and social sub-sectors in ensuring global and integrated health care. Participants are made aware of the need to go beyond exclusive biomedical answers to adequately address the problems people present with at general practice level. The participants are assessed in several activities: first, they present and discuss their personal analysis of a known local health system with peers and staff; after the study visits they share their analysis of the quality of care and the contribution of the social welfare system to people-centred health system; and finally the participants identify lessons from the Belgian situation that are relevant to their own local health systems and share these reflections in individual blogs. The presentations in the seminars and the blog writing exercise facilitate meaningful interactions amongst participants whilst enhancing their communication skills. Findings/Highlights : Following the training, most participants understand the comprehensive and systemic characteristics of people-centred and integrated health care; as well as the importance of including the social sector when organizing health services at local level. Interesting statements obtained from feedback sessions and blogs are: _“ I experienced a shift in the way I think about the organization of health services to provide quality health care”_,“From the site visit […] I think there are four important elements that promote PCC (people-centred care): sufficient time, qualified personnel, privacy and looking beyond the bio-medical aspects (e.g. social security issues and system barriers) of a patient’s suffering ….” Conclusions : Adequate public health training that broadens the vision on quality of care and allows the development of comprehensive analytical skills can contribute reducing barriers to implementing people-centred and integrated health care. Although the findings obtained during this course are useful, more research is required to define the most desirable skills mix that public health professionals and caregivers should possess.