Welcome to our course on Understanding and Strengthening Health Systems for Global Health. During the course we will provide you with an overview of the main elements or building blocks of a health system based on the World Health Organization’s guidance. You will have the opportunity to explore four main areas of health systems in global health with particular reference to low and middle income countries. The first area focuses on understanding health service organizations, the challenges. Our second module looks at WHO’s six major building blocks or health systems components with particular reference to primary health care and the need for community participation in planning, delivery and assessment of these systems components. in our third module we examine the specific systems component of human resource development and capacity building. The fourth area consists of health policy making and advocacy with stakeholders. This course is geared toward learners who are already involved in managing health and development programs on the ground in low and middle income countries or who are preparing for such a management role. The main lectures will span a four-week period with approximately 2-4 hours of viewing learning materials per week. We have one peer graded essay wherein you will use skills in ‘organizational’ diagnosis to better understand a challenge in an organization where you are or have worked. There are also quizzes. We hope you will engage with your fellow learners in discussion forums to learn from each other.
Organizational Change (Part 2)
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From the course by Johns Hopkins University
Understanding and Strengthening Health Systems
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From the lesson
Understanding Organizations and How They Change
Health Systems are human organizations. Organizations have structure, purpose and membership. To remain “Healthy” an organization must adapt to its environment, whether that be funding and policy changes or expectations of its clients. In this module we will focus on diagnosing factors related to the health of organizations and consider strategies to help organizations adapt.
Meet the Instructors
William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
There are some sections in your course notes about village health workers.
At this point, it's important to comment that
they themselves are an example of second order change.
It's a new delivery mechanism,
it's not just a substitution it's a new way of going about it by
making sure that medications and knowledge and skills are in the community,
that the person who provides these services are accountable to the community.
So they are definitely a new type of provider.
This sets up a new relationship between the community and the health system.
New forms of supervision and partnership are required.
It's not that the village health worker is just an extension of the health center,
and the health workers go out and give them orders and collect their returns.
But since the village health workers chosen by,
supported by the community,
they are really an extension of the community leadership and
the health workers need to work with them as partners.
Because again the village health worker representing the type of
communication in the adoption model called homophilis
communication where people of similar backgrounds communicate best.
The idea of observational learning by other people within the environment,
as a way of enhancing self efficacy for
new health skills in social learning theory is exemplified by village health workers,
a number of our social network theory.
So the idea of this type of health delivery system does require new relationship,
new partnership between the health system and the community.
Village health workers and this type of
health care delivery are a new form of economic support for health.
The village health workers,
together with the community committees raise their own money,
stock their own drug boxes as can be seen in the next picture.
And this means that people in the community have a new way of accessing care.
If they are 20 or 30 miles from the town center from the district headquarters,
they're not going to run down at the middle of the night that their child has fever.
They may have before tried to save
some medicine from the last time the child was sick and it may have expired.
They may have gotten some concoctions from the local market.
They may have bought some drugs from
someone peddling them on a motorcycle going through town.
But this is not acceptable.
The village health worker concept in primary healthcare means that quality,
although simple but quality care is available.
So this is like a second order of change,
and brings about a whole new way of delivering healthcare to people.
Next, we will look at the issue of health systems reform.
This is another word as we said for changes in the health system.
Four different types or situations under which reform occur have been observed.
In one setting, the health system is a responder to changes in the broader environment.
There may be changes in the style of government,
as is happening in many countries particularly in Africa.
There is a change from military dictatorships,
or one party rule to multi-party democracy.
These changes require changes in the health system,
as was observed in Nigeria in particular where I've worked during the military rule.
The soldiers, the officers were not
technical experts in the areas of health, agriculture etc.,
and they often left the health sector and these other sectors and
ministries be run by top level administers,
the top level administrators.
Systems were not accountable to
anyone and were very much under internal political pressure.
In the era of democracy all government systems need to be responsive to the public.
People are much more outspoken.
Changes in economic patterns, growth, inflation,
recessions have implications for
health sector reform may bring about changes in terms of financial policies,
sources of funding, access to funds,
types of services that are available.
An example in your class notes comes from the Gambia,
and in this particular case when funds were devoted to primary healthcare,
where there were adequate frontline health workers
posted to health facilities where drugs were available,
child mortality decreased during economic hard times in the past couple of years.
The quality of these services has decreased.
Staffing patterns, availability of drugs,
and child mortality has increased.
So the health system is responding to changes in the broader environment.
This kind of change may be fundamental affecting all areas of government not just health.
Another position that the health system may find itself in is that of resisting,
or adjusting day by day firefighting operation to handle problems,
no perceived need particular motive for change.
Simply trying to make the best of the situation.
The goals in this particular case are specific to
the health sector trying to ensure supplies of drugs where they've run out,
trying to reallocate staff where people have resigned.
This may be incremental change certainly not fundamental change.
In fact very little change may actually occur in the way things are being run.
A third type of change puts the health system in the role of reformer.
There may be an external impetus such as the coming of democracy,
or there may be a perceived need from inside,
that has started the process of contemplation and planning to reform the system.
In this particular case though,
the reforming system tries to develop specific goals for health,
often multiple goals in terms of child survival,
maternal health, care of the elderly.
Change is fundamental and sustained.
Finally, as is seen in many conditions such as the recent floods in Mozambique,
civil wars in Angola,
and Democratic Republic of Congo,
health systems may have collapsed under natural or human disasters.
In the situation of post conflict or post disaster,
there is basic instability or insecurity goals for the health system
are quite specific in terms of health in terms
of maintaining the system the basic services and staff.
It's a question of rebuilding rather than starting something new.
Recently, the World Health Organization in collaboration with many other donor agencies,
and international groups and agencies has launched the Roll Back Malaria program.
Roll Back Malaria is attempting to focus attention, political will,
and resources on existing and affordable health technologies to
control malaria to reduce the burden of malaria disease in endemic countries,
and starting in particular with those in Africa.
Simple technologies such as an insecticide treated bed nets,
prompt treatment of children with malaria,
and appropriate malaria prophylaxis for pregnant women.
WHO recognizes that these simple technologies
cannot be implemented unless the health system itself is healthy and functional.
Therefore plans made with regional bodies and
particularly with national governments in Africa to implement Roll Back Malaria,
focused in large extent,
to large extent on health systems reform.
Prompt treatment, and appropriate treatment of childhood fevers cannot
occur unless there is a guaranteed supply of antimalarial drugs in the community.
Generally. If antimalarial drugs are not there are
probably other basic drugs for treating respiratory illnesses,
supplies for managing diarrheal illness,
other childhood problems are probably not there either.
So unless the drug supply and management treatment protocols
have been reformed generally in the health system,
it's unlikely that malaria can be addressed either.
Similarly, if the general health system does not have the capacity for outreach,
does not have staff who are trained to organize communities,
there is no way that they can promote
the distribution and use of insecticide treated bed nets.
So clearly the Roll Back Malaria Programme recognizes that improvements in
services to control malaria will not
be effective if the overall health system does not reform.
Finally, it's important to look at the role of
non-governmental organizations in health and development.
In recent years, there has been much emphasis on looking at the non-governmental sector.
As we mentioned with the program in Lagos,
it was organized by the Basics Project of USAID.
It was incumbent upon the organization
to look directly to the private sector and leave the government
behind because of the government being put on the blacklist by USAID,
by the State Department,
for political suppression and drug trade.
And therefore, the organization had to consider
local community based organizations and NGOs.
We also gave examples of how USAID is involving NGOs such as World Vision,
Africare in child survival programs.
One of the reasons NGOs are receiving much attention is that they are able to innovate.
They are often relatively smaller,
they lack disabling bureaucracies,
and they are able to try new ideas,
work in new settings.
Also, NGOs represent civil society and they are in
a much better position to look into the needs of minority groups.
NGOs in countries often reflect community needs and interests.
They are able to do so and lobby much more than along state government bureaucracy.
This does not mean that NGOs are perfect.
When effort was being made to establish West African Youth Initiative,
an idea of providing reproductive health education
through peer education in Nigeria and Ghana,
staff from an NGO in Washington went to Nigeria and worked with a nationwide NGO there to
try to identify community based youth serving
organizations who could take up the role of community education for youth.
They found more than 400 groups that called themselves NGOs,
and the joke was that even a bicycle repairman and his wife called themselves an NGO.
NGOs have been springing up in Nigeria and
other developing countries because it's recognized
that many funders want to work with the private sector.
And one has to be careful to distinguish those NGOs that are working,
that have created themselves simply to be
a moneymaking venture and those that are responding to a real community need.
Again, as we said, organizations in
the very beginning are created in response to their environment.
And one of these responses could be that donor money is available for the NGOs.
Another response could be,
as you'll see in a case study that the end of this chapter,
an organization that responded to
the reproductive health needs of women and youth in particular in Nigerian communities.
Just like large health systems,
NGOs themselves may reform the process of innovation,
also means that they change from time to time,
adding new programs, increasing staff,
responding to different community needs.
The final two slides show us that NGOs,
particularly based in the US and Europe,
do receive a lot of scrutiny much more than the bicycle repairman and his wife.
Before people donate money,
they want to know what it's going for.
And these two slides show flyers that are sent
out by two NGOs to show how they use their money
to convince individual contributors that
their involvement would be beneficial, effective, efficient.
As we said NGOs represent civil society and in that sense can bring in quite a lot of
resources and not be dependent on one source and influenced by that particular source.
So, in summary, we have different kinds of organizations involved in health.
The local clinic and its staff being part of a larger district health department.
We have large health systems or ministries of health.
We have international agencies such as
the African Program for Onchocerciasis which involves UNDP,
World Bank, UNICEF, WHO, various contributors.
We have non-governmental organizations involved in
health: The Carter Center, Doctors Without Borders.
And these systems are composed of individual people who have their own goals and needs.
Organizations like these were created in response to a need in the environment,
but they also change because the environment changes,
either their supply of resources that they need to run
the organization changes or
the response of the people who consume the services and products changes.
Therefore, it's not adequate for us in public health simply to be concerned
about changes in behavior of individuals and families in the community.
We also need to understand what influences change in the organizations where we work,
and how we can bring about positive change
through a proper organizational diagnosis to make
our own organizations more effective and responsive to the needs of the community.
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