<div class="title-block" style="border-bottom-color: #628bb3"><h1><img class="title-image" src="http://www.heart-resources.org/wp-content/themes/heart/images/health.svg">Health Systems</h1><div class="post-type-description"></div></div> – Health and Education Advice and Resource Team http://www.heart-resources.org Providing DFID staff and other development actors with health, education and nutrition knowledge and expertise from around the world Fri, 02 Mar 2018 13:10:49 +0000 en-US hourly 1 https://wordpress.org/?v=4.9.4 The free healthcare initiative in Sierra Leone: Evaluating a health system reform, 2010‐ 2015 http://www.heart-resources.org/doc_lib/free-healthcare-initiative-sierra-leone-evaluating-health-system-reform-2010%e2%80%90-2015/ http://www.heart-resources.org/doc_lib/free-healthcare-initiative-sierra-leone-evaluating-health-system-reform-2010%e2%80%90-2015/#respond Wed, 14 Feb 2018 13:16:29 +0000 http://www.heart-resources.org/?post_type=doc_lib&p=30308 Read more]]> This article presents the findings of a theory‐based evaluation of the Sierra Leone Free Health Care Initiative (FHCI), using mixed methods. Analytical approaches included time‐series analysis of national survey data to examine mortality and morbidity trends, as well as modelling of impact using the Lives Saved Tool and expenditure trend analysis.

We find that the FHCI responded to a clear need in Sierra Leone, was well designed to bring about needed changes in the health system to deliver services to the target beneficiaries, and did indeed bring funds and momentum to produce important systemic reforms. However, its ambition was also a risk, and weaknesses in implementation have been evident in a number of core areas, such as drugs supply.

We conclude that the FHCI was one important factor contributing to improvements in coverage and equity of coverage of essential services for mothers and children. Modelled cost‐effectiveness is high—in the region of US$ 420 to US$ 444 per life year saved. The findings suggest that even—or perhaps especially—in a weak health system, a reform‐like fee removal, if tackled in a systematic way, can bring about important health system gains that benefit vulnerable groups in particular.

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Social Health Protection in low- and middle-income countries: the practical challenges, a brief discussion paper http://www.heart-resources.org/assignment/social-health-protection-in-low-and-middle-income-countries/ http://www.heart-resources.org/assignment/social-health-protection-in-low-and-middle-income-countries/#respond Tue, 23 Jan 2018 17:30:24 +0000 http://www.heart-resources.org/?post_type=assignment&p=30315 Read more]]> A seminar organised by Oxford Policy Management in June 2017 brought together practitioners and policy makers to exchange insights on practical challenges for the implementation of social
health protection (SHP) programmes, and social health insurance (SHI) in particular. Kicked-off with a presentation of recent experiences from Bangladesh and Pakistan, the discussion touched
on a range of issues, including how to reach and incorporate the poor and non-poor in the informal sector, working with private providers and moving towards strategic purchasing.

There was agreement that SHI means far more than raising contributions, as it is sometimes construed, and reaches into deep health sector reforms. These require careful staging, sustained political commitment and a focus on good governance, but also a continued engagement with core principles of universal health coverage (UHC), primarily equity. Nevertheless, some of the implementation challenges faced today are not new. Investing further in the existing health system learning mechanisms, formal and informal, will be key to avoid repeating implementation failures of the past.

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Transition and Recovery of Nepal’s Health System: Project Completion Review http://www.heart-resources.org/assignment/transition-recovery-nepals-health-system-project-completion-review/ http://www.heart-resources.org/assignment/transition-recovery-nepals-health-system-project-completion-review/#respond Fri, 12 Jan 2018 17:00:09 +0000 http://www.heart-resources.org/?post_type=assignment&p=30289 Read more]]> This project completion review (PRC) provides details on the outputs, lessons and recommendations from the DFID funded programme ‘Transition and Recovery of Nepal’s Health System’ which came to a close in May 2017.

The aim of the programme was to provide technical assistance to support the recovery of Nepal’s damaged health services, across 31 districts affected by a series of catastrophic earthquakes and aftershocks in April-May 2015.

Overall, outcome and output indicator results demonstrate that the programme has been successful, though not all targets were achieved by the close of the programme.

The follow-up actions required following project closure are as follows:

  1. For DFID: in order to fast-track the mobilization of support in case of emergencies in disaster-prone countries, to consider the inclusion of an earmarked budget allocation to respond to disaster situations in all health sector operations. Such budget could be re-allocated before programme closure in case no emergencies arise.
  2. For DFID: given the familiarity and success of the combined Financial Aid and Technical Assistance aid modality in Nepal, both in the regular support to the health sector and the earthquake response programme, a similar aid modality should be considered for future disaster recovery and relief operations.
  3. For MoH and DFID: to limit the number and severity of permanent disabilities resulting from spinal cord injuries during future earthquakes, ensure that a public awareness campaign is launched on the safe transport and correct referral process of people possibly having injured their spinal cord. Such campaign should be targeted at the public, rescue workers, para-medical personnel and health workers. This action would also reduce the risks for people injured during other accidents, especially in road traffic accidents and accidents in the construction sector.
  4. For the TA team: to continue monitoring the progress and quality of the unfinished infrastructure work initiated under the programme.
  5. For MoH and DFID: to maximize the durability of the infrastructure financed under the programme, permanent as well as semi-permanent (the pre-fabricated structures), advocate with the National Planning Commission and the Ministry of Health for a reasonable budget in the Annual Work Plan and Budgets for maintenance.
  6. For DFID and TA team: to elaborate a module for the prevention of gender-based violence and physical abuse (e.g. awareness and anger management counselling) to be used in the immediate aftermath of possible future earthquakes or other disasters.
  7. For DFID and the TA team: in order to be able to again respond effectively in case of any future disaster, to engage with the government and other External Development Partners (EDPs) on changing disaster preparedness modalities as the devolution in Nepal evolves and changes in decision making, operational structures and procedures, and communications channels materialize. For instance, the role 
of the District Officer of Health may change under the upcoming provincial structure and support to her/his office may have to be re-directed to provincial and/or municipal structures.
  8. For MoH, DFID and External Development Partners: to build on progress made in mental health in terms of the institutional arrangement, treatment protocols and people trained in both the diagnosis and treatment of mental health problems and provide resources for its sustainability and scale-up.

Download the full report for further details.

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Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity. Workshop Report http://www.heart-resources.org/doc_lib/unpicking-power-politics-transformative-change-towards-accountability-health-equity-workshop-report/ http://www.heart-resources.org/doc_lib/unpicking-power-politics-transformative-change-towards-accountability-health-equity-workshop-report/#respond Tue, 10 Oct 2017 14:20:26 +0000 http://www.heart-resources.org/?post_type=doc_lib&p=30128 Read more]]> While ‘accountability’ has become an increasingly popular buzzword in health systems debates and health service delivery, it has multiple – and contested – meanings.

From 19-21 July 2017, Institute of Development Studies (IDS) brought together 80-plus activists, researchers, public health practitioners and policy makers to examine critically the forces that shape accountability in health systems, from local to global levels. Their partners in convening this workshop, as part of a new IDS programme on ‘Accountability for Health Equity’ were the Unequal Voices project, Future Health Systems, the Open Society Foundations, the Impact Initiative and Health Systems Global.

This is the workshop report for the event which is a record of the presentations and discussions that occurred over the course of these three days.

Read the related blog article by Erica Nelson for further insight into the Accountability for Health Equity workshop.

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Urban Health http://www.heart-resources.org/mmedia/urban-health/ http://www.heart-resources.org/mmedia/urban-health/#respond Tue, 29 Nov 2016 14:54:39 +0000 http://www.heart-resources.org/?post_type=mmedia&p=29705 Read more]]> Dr Helen Elsey is from the Nuffield Centre for International Health and Development, University of Leeds. In this HEART Talks she talks through the urban health HEART reading packs that she has put together with Dr Siddharth Agarwal from the Urban Health Resource Centre in India. The three reading packs are: A) Data and evidence, B) Improving population health – strategies for inter-sectoral action, and C) Interventions and pro-poor service provision.

The world is urbanising. Globally, more people live in urban areas than in rural areas. By 2050, it is expected that 66% of the world’s population will be urbanites. Africa and Asia are urbanising the fastest. By 2050 56% will be urban in Africa and 64% in Asia. There are currently 28 mega-cities (i.e. with a population of 10 million or more). By 2030, the world is projected to have 41 mega-cities. However, the fastest growing urban areas are medium-sized cities and those with less than 1 million inhabitants located in Asia and Africa. UN-Habitat estimates the number of people living in slum conditions is now 863 million; growing from 760 million in 2000 and 650 million in 1990. Cities are at the forefront of ‘disease transition’ with malnutrition and obesity occurring simultaneously. Water and sanitation provision is grossly inadequate in urban slums. Tobacco consumption is a major concern among urban poor men, and increasingly women; a risk factor for both NCDs and TB. There are multi-sector influences on urban health.

Local governments are key to coordinating inter-sectoral action. Donors are increasingly working with local government to strengthen capacity to plan, manage services, link with sector ministries, enforce public health legislation and establish local level governance structures.

There is a need to coordinate health services between local government and health ministries. The urban public health service is woefully inadequate. There has been underinvestment due to years of the perceived ‘urban advantage’. Responsibilities for staff, their training, equipment/drugs, and facilities often fall between the Ministry of Health (MOH) and the Municipality. The poor are left with little option but to use meagre resources on private facilities resulting in high levels of catastrophic health expenditure. There are poor referral mechanisms due to the plethora of NGO and private providers. There is a need for monitoring and enforcement of quality standards among providers and pharmacies. Secondary care is insufficient with maternity hospitals not open all hours and weak services. Tertiary hospitals are overloaded and not easy to access for the poor.

Public Private Partnerships (PPPs)
There are challenges with different forms of PPPs, private for-profit and not-for profit forms. For-profit PPPs have no incentive to reach out to the urban poor. They are not keen to partner for outreach care which is the key to preventative healthcare and the most crucial for urban deprived communities. Non-profit agencies tend to have few resources. Bangladesh’s Urban Primary Healthcare Programme uses partnerships with NGOs, private clinics and government health centres to expand services to slum and vulnerable communities. There are still challenges with monitoring, quality, and referrals between providers which covered in some detail by in the reading packs.

Health promotion
Helping people remain healthy and not in need of health services is a fundamental goal of any urban health strategy. There is a lack of evidence on which health promotion approaches are likely to be effective in changing ‘lifestyle behaviours’ such as tobacco use, diet, and exercise among the urban poor. Encouraging waist measurement, desired diet, physical activity and mental wellbeing at community level; peer education approaches to nutrition, physical activity, and promoting optimal behaviours in schools have shown some success. Community healthworkers (CHWs) have been effective at changing behaviours in Bangladesh, India, and Ethiopia. CHW and slum women’s groups promoting peer-to-peer health promotion shows promise. Mass media through mobile phones, print, radio and television have wide audience reach in urban centres, but it is hard to compete in the cluttered media environment. Instant messaging for skilled birth attendants is more effective in urban areas. There has been increases in zinc treatment awareness following TV, radio, and newspaper media campaign in urban areas.

Water, sanitation and hygiene (WASH)
WASH needs to be promoted in households and schools to improve, health, nutrition and education. The three interventions of the WASH sector (hand-washing, food storage, garbage disposal) – depend on one another for full realisation of their benefits. For example most sanitation systems cannot function without water. School WASH impacts education outcomes, especially for girls. Menstrual hygiene and girl friendly toilets in schools affect school attendance of girls and reproductive tract infections. Hand-washing with soap and water and other personal hygiene practices have the potential to substantially reduce within household transmission of diarrhoea and improve nutrition. Promoting practices such as hand-washing with soap and water, and safe disposal of child faeces benefit health and nutrition and can be incorporated in a wide range of public health strategies at low cost.

Participatory neighbourhood mapping
Participatory mapping has been used in India to expand the reach of urban services. Slum women’s groups use hand drawn maps to ensure that no family is left out from municipal/NGO lists used for housing, sewage systems, toilets, and entitlements. They are also used to track access to health services eg. immunisation, antenatal care,  and delivery. The maps help identify recent migrants for linkage to services and entitlements. Gentle negotiation is occurring through collective petitions. Inclusive urbanisation requires disadvantaged communities to actively participate in governance.

Healthy places
Pressure from real estate developers, poor governance and corruption undermines local government’s role in controlling urban development to keep healthy places within the city. Access to green spaces reduces mental illness and has been shown to reduce inequities in cardio vascular disease and all-cause mortality in high income countries. Green spaces are rarely considered in controlled and uncontrolled expansion of urban areas. Urban agriculture can make an important contribution to household food security, especially in times of food crisis or food shortages. This needs support and regulation so food is grown in healthy environments.

Health and safe places for children
Urban poor women are more likely to work outside the home than other women in urban or rural settings. Working outside the home provides opportunities to improve income and increase self-esteem and gender equity. However, there is a lack of childcare and supervision for children. This could be solved with early childhood development opportunities. An NGO mobile crèche run day care centres in partnership with government’s National Creche scheme and with support funding agencies in India. Day care centres operate in coordination with builders and contractors near construction sites.

Transport and communications
10 billion trips are made every day in urban centres around the world. An increasing proportion of urban trips are using high carbon and energy-intensive private motorised vehicles. The urban poorest are disproportionately affected by key negative externalities generated by transport, including road accidents, air pollution and displacement when transport developments are occuring. Regulation to improve road safety can make a substantial difference to accidents. For example regulation of ‘matatus’ (mini-buses) in Kenya was introduced where drivers had to increase their driving and safety skills. This legislation resulted in a 73% reduction in accidents. Keeping cities compact, with opportunities for walking, cycling and public transport reduces emissions and support public health.

All of these issues and more are covered in the reading packs which point out key resources.

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Health responses to humanitarian crises http://www.heart-resources.org/mmedia/chris-lewis-presentation-health-responses-humanitarian-crises/ http://www.heart-resources.org/mmedia/chris-lewis-presentation-health-responses-humanitarian-crises/#respond Mon, 24 Oct 2016 17:29:53 +0000 http://www.heart-resources.org/?post_type=mmedia&p=29457 Read more]]> This HEART Talks is a presentation from a humanitarian health seminar held at DFID 29th July 2016. In the video below DFID health adviser Chris Lewis talks about two of the HEART reading packs. The first is Health Responses to Humanitarian Crises and the second is Humanitarian Overview From Principles to Coordination.

Humanitarian crises are important as they contribute to 60% of all preventable maternal deaths. They also contribute to 53% of under 5 deaths, as well as 45% of neonatal deaths. The most common causes of mortality in emergencies are pneumonia, diarrhoea and malaria. As well as the initial response  to a crisis, it is important to consider the long-term impacts. Water borne diseases tend to emerge a week or two after a crisis. Vector borne diseases emerge after one or two months. In the video, Chris summarises the impact of crises on health systems.

Different types of monitoring are required for different post-crisis periods. Chris outlines how the initial assessment should be carried out in the first 72 hours. In weeks one to two field assessments shout be carried, and from week three onwards more health specific assessments should be conducted. Details of health assessment methods for each health topic are available in the reading pack. Key response activities for different diseases and health areas are presented.

Chris states that it is important to be aware of the opportunities for health system reform. The end of a crisis may be an opportunity to implement effective reform. Chris outlines the principles and conventions that exist within humanitarian response, which one of the reading packs is about. There are 11 clusters in the humanitarian system to be aware of. They have different roles and responsibilities that are outlined in the pack.

WHO global health cluster update

A recent WHO global health cluster update describes areas of crisis response planning that still require attention. More thought must be given to coordination efforts across the different support mechanisms. Chris describes humanitarian response as a continuum from humanitarian relief to sustainable development. Humanitarian advisers must consider the opportunities to strengthen health systems after a crisis.

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Fiscal space analysis in Sierra Leone: the free health care initiative and universal health coverage http://www.heart-resources.org/assignment/fiscal-space-analysis-sierra-leone-free-health-care-initiative-universal-health-coverage/ http://www.heart-resources.org/assignment/fiscal-space-analysis-sierra-leone-free-health-care-initiative-universal-health-coverage/#respond Mon, 17 Oct 2016 09:49:07 +0000 http://www.heart-resources.org/?post_type=assignment&p=29448 Read more]]> This brief highlights how Sierra Leone can improve the sustainability of the free health care initiative (FHCI) financing, lower household out-of-pocket (OOP) payments on health care, and decrease its dependence on donors. A secondary analysis provides insights into how Sierra Leone could work towards achieving its longer-term health goal of Universal Health Coverage (UHC).

If Sierra Leone’s FHCI and UHC policies continue as they are, both areas will be increasingly underfunded within ten years. Neither the economy, nor the tax base, is projected to be strong enough to create the fiscal space to invest as needed in health if current policies are sustained. With a reprioritised focus on the FHCI financing policy, the resource gap can be closed.

The most effective domestic financing mechanism is government spending, whether purely budgetary or health insurance allocations. The continuation of external donor support is essential to continue to deliver FHCI and UHC services in an effective manner throughout the country. The government needs to improve Public Financial Management (PFM) in the health sector in order to increase the confidence of donors.


For other reports in this series on Sierra Leone’s Free Health Care Initiative, see:

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Monitoring and evaluation in Sierra Leone’s health sector http://www.heart-resources.org/assignment/monitoring-evaluation-sierra-leones-health-sector/ http://www.heart-resources.org/assignment/monitoring-evaluation-sierra-leones-health-sector/#respond Mon, 17 Oct 2016 09:43:59 +0000 http://www.heart-resources.org/?post_type=assignment&p=29444 Read more]]> As part of the review of Sierra Leone’s Free Health Care Initiative (FHCI), researchers assessed its monitoring and evaluation (M&E) system, strengths and weaknesses, and the changes that took place as a result of the FHCI.

This brief notes that a strong M&E system is crucial to help improve performance and achieve results. Several key points were identified as part of the review to strengthen health sector M&E processes. These include: consulting key data users to clarify what information should be collected and how frequently, and using this as the basis to develop a new M&E strategy; improving the quality and coherence of the various health data sources, especially for maternal mortality; increasing the publication and dissemination of health data analysis in user-friendly formats; strengthening the demand for and use of health information particularly through health sector reviews and accountability processes.

For other reports in this series on Sierra Leone’s Free Health Care Initiative, see:

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The free health care initiative (FHCI) in Sierra Leone: real gains for mothers and young children http://www.heart-resources.org/assignment/free-health-care-initiative-fhci-sierra-leone-real-gains-mothers-young-children/ http://www.heart-resources.org/assignment/free-health-care-initiative-fhci-sierra-leone-real-gains-mothers-young-children/#respond Mon, 17 Oct 2016 09:38:23 +0000 http://www.heart-resources.org/?post_type=assignment&p=29439 Read more]]> In 2010, the Free Health Care Initiative (FHCI) abolished health user fees for pregnant women, lactating mothers and children under five. This was a response to very high mortality and morbidity levels among mothers and children and reports that financial costs were a major barrier to health service uptake and use by these groups.

This brief highlights that FHCI triggered some real gains in the health system such as revitalised structures for sector governance; increased staffing; and better systems for staff management and pay, and for getting funds to the facilities. New monitoring and evaluation systems were introduced and facility audits conducted; infrastructure improved from a very weak starting point; and a communication campaign was initiated with resulting high population awareness.

Further, more financial resources led to a prioritisation of maternal and child health programmes and to some degree a switch from household to donor spending. Household spending as a proportion of total health expenditure went from 83 per cent in 2007 to 62 per cent in 2013. Donor funding went from a low of 12 per cent in 2007 to a high of 32 per cent in 2013.


For other reports in this series on Sierra Leone’s Free Health Care Initiative, see:

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Sierra Leone’s free health care initiative: financing implications http://www.heart-resources.org/assignment/sierra-leones-free-health-care-initiative-financing-implications/ http://www.heart-resources.org/assignment/sierra-leones-free-health-care-initiative-financing-implications/#respond Mon, 17 Oct 2016 09:33:22 +0000 http://www.heart-resources.org/?post_type=assignment&p=29436 Read more]]> In 2010, the Government of Sierra Leone (GoSL) took steps towards establishing the Free Health Care Initiative (FHCI). At its core, this was the removal of user fees (on drugs and consultations) for pregnant women, lactating mothers and children under five.

This brief is based on an independent review of FHCI completed in 2016, which looked at financing changes following the initiative’s launch, and focuses on the pre-Ebola outbreak years (2010-2013). It outlines how financing flows changed, and highlights some of the major strengths and weaknesses in resourcing the initiative.

In putting forth several recommendations, the brief notes, that the government should prepare a health financing strategy which outlines: a plan for future donor expenditure; a plan for increasing pre-financed domestic expenditure on health; a plan for improving the efficiency of existing expenditure on health; and a set of solutions that help align and coordinate government and donor funding.


For other reports in this series on Sierra Leone’s Free Health Care Initiative, see:

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