Thursday, 9 February 2012

KNOTS blogger

KNOTS blogger

USAID leadership in health systems

Posted: 16 Dec 2011 06:46 AM PST

Dr. Ariel Pablos-Méndez of the USAID Global Health Bureau celebrated health systems progress and outlined challenges that lay ahead, at a meeting of the D.C. Health Systems Board in mid-December.

Highlighting key achievements of USAID in improving global health, he noted, “since the founding of USAID by President Kennedy 50 years ago, child mortality has declined nearly 70 percent… over 50 million children lives were saved during the last twenty years alone.”

USAID's work on strengthening health systems has played a key part in these important changes. Dr Pablos-Méndez enumerated some of the many contributions that USAID has made across the six building blocks of effective health systems. For example, regarding health service delivery he noted that USAID strategy has focused on working with health markets to catalyze sustainable development, including social marketing and sustainable commercial health products, expanded private sector partnerships, new networks and social franchising. And in terms of health information management, USAID is developing the Human Resource Information System or iHRIS, a suite of three open-source databases to track health worker training, manage and deploy personnel, and provide long-term health workforce modeling and planning.

But Dr. Pablos-Méndez argued that the global health sector is now at an inflection point. The field is facing a rapid and complex shift in the environment. The disease profile in developing countries is changing to chronic, non-communicable diseases such as cancer and diabetes. And official development assistance is also changing. He observed that, “in the 1960s, such assistance represented 70 percent of the capital flows going into developing countries. But today, because of private sector growth and increased trade, domestic resources, remittances, and capital flows, it is just 13 percent - even as development budgets have continued to increase.” Former aid recipients are transitioning to donors. And there has been a slow demographic shift to aging populations, decreased fertility rates and urbanizing populations.

To respond to shifting epidemiology and economic transitions in developing countries, Dr. Pablos-Méndez called for flexibilityinnovation and collaboration.

In anticipation of these shifts, Dr. Pablos-Méndez explained that US Global Health Initiative (GHI) will focus its efforts towards strengthening systems, fostering ownership and encouraging leadership, including greater domestic investment in healthcare. Interventions will be integrated across health areas and will move from a disease model to serving the needs of a patient. Smoking, obesity and basic prevention will gain prominence, and health financing will become increasingly central to country plans.

To foster cross-border learning, the Health Systems Office of USAID will act as a hub of knowledge management on complex systems, service delivery, governance, financing, training and professional development. Additionally, GHI promises to streamline PEPFAR and encourage greater interagency collaboration for a more strategic health response to the challenges of our times.

Dr Sara Bennett from the Johns Hopkins Bloomberg School of Public Health, and the CEO of the Future Health Systems consortium – which sponsored the event – was impressed by the breadth of activities outlined by Dr. Pablos-Méndez. She said, “you’ve provided us with a range of fresh and extremely challenging ideas when we think about the implications of economic growth and the shift in balance in power between countries, as well as the emerging epidemiological transition. And you’ve asked us really to challenge ourselves to think about how we can strengthen health systems.”

She also highlighted the importance of the D.C. Health Systems Board (HSB) as a forum for such discussion. Originally established in 2008, the Health Systems Board aims to provide a forum in the Greater Capital Area for discussion and debate about current issues in health systems research and policies relevant to low and middle income countries. The Board’s discussions concern both research about health systems and current policy issues related to health systems. Events are coordinated by the various institutional members, with this particular event hosted by the Johns Hopkins School of Advanced International Studies (SAIS).

A full report and video of the event are available on the HSB website, where you can also register for the HSB events updates list for announcements of future events.

বাড়িতেই বেশি প্রসব, সুন্দরবনে বিধ্বস্ত শিশু-স্বাস্থ্য

Posted: 12 Dec 2011 11:28 PM PST

আনন্দবাজার পত্রিকা • সোমা মুখোপাধ্যায় • কলকাতা প্রতি তিনে এক জনের ফুসফুসে সংক্রমণ। প্রতি পাঁচে তিন জনের ওজন স্বাভাবিকের অনেক কম। পাঁচ বছরের কমবয়সীদের প্রায় ৬৫% গভীর অপুষ্টির শিকার। নিউমোনিয়া-ডায়েরিয়ায় মৃত্যুর হার ঊর্ধ্বমুখী। সুন্দরবনের ১৯টি প্রশাসনিক ব্লকেই শিশু-স্বাস্থ্যের এই ‘ভয়াবহ’ ছবি ধরা পড়েছে ব্রিটিশ সংস্থা ‘ডিপার্টমেন্ট ফর ইন্টারন্যাশনাল ডেভলপমেন্ট’ (সংক্ষেপে ডিএফআইডি)-এর সমীক্ষায়। গত পাঁচ বছর ধরে তারা সুন্দরবনের বিস্তীর্ণ এলাকা জুড়ে এই সমীক্ষা চালিয়েছে। যাতে স্পষ্ট, আয়লা-পরবর্তীকালে সেখানকার পরিস্থিতি আরও শোচনীয় হয়ে উঠেছে। সমস্যা যে সত্যিই গভীর, তা মেনে নিচ্ছে রাজ্যের স্বাস্থ্য দফতরও। স্বাস্থ্য-কর্তাদের ব্যাখ্যা: সুন্দরবনের স্বাস্থ্য পরিকাঠামো নিয়ে একটা সময় পর্যন্ত তেমন ভাবনা-চিন্তাই হয়নি। এখন শুরু হলেও প্রয়োজনের তুলনায় তা খুবই সামান্য। জাতীয় গ্রামীণ স্বাস্থ্য মিশনের রাজ্য অধিকর্তা দিলীপ ঘোষের কথায়, “ধাপে ধাপে বিভিন্ন পরিকল্পনা বাস্তবায়নের চেষ্টা চলছে।” বিস্তারিত >>

Health System Reform in Asia

Posted: 10 Dec 2011 05:25 PM PST

From 10-12 December, several researchers from the Future Health Systems consortium will be presenting at the Health System Reform in Asia conference hosted by Elsevier at Hong Kong University. Barun Kanjilal of IIHMR has summarized the proceedings in a recent blog 'Health dragons or health hydras? The challenges of regulation in Asian health systems'.

Over the last five years, FHS work in Asia has focused on:

  • Health markets and the role of informal providers: For many rural poor, informal providers are the first port of call when seeking health services, especially in Bangladesh and India. However, these providers have little training and often over-prescribe unnecessary – and occasionally harmful – medications to make a living. The FHS Bangladesh team has established a social franchise of informal providers called ShastyaSena, or Health Soldiers, to train the providers and to create a recognized brand of higher quality services.
  • Health financing for the poor: As a core health systems building block, FHS focuses on improving health financing mechanisms. In China, this involved research contributing to the merger of two insurance schemes, the New Rural Cooperative Medical Scheme (NCMS) and the Medical Financial Assistance Scheme (MFA). In Afghanistan, our research contributed to the removal of user fees to access health services.


In the future, we will be undertaking cutting edge research in Asia into:

  • Health service delivery innovations: Training informal providers has been an important but not sufficient intervention to improve rural health services. Establishing links to the formal sector is also key. FHS Bangladesh, in partnership with the Telemedicine Reference Centre, are exploring innovative mHealth approaches to delivering health services in hard-to-reach areas.
  • Unlocking community capabilities: In Afghanistan, health services are mainly contracted to NGO providers through the Basic Package of Health Services (BPHS). Overall these services have been improving since 2003, but communities have had little say in how they can be better tailored to meet their needs. FHS Afghanistan is piloting a community-based scorecard to encourage dialog and improve services.
  • Intervening in complex adaptive systems (CAS): One priority on China's health reform agenda is to build a national essential drug system that ensures the rational use and effective delivery of essential drugs. But different combinations of approaches are being trialled in different counties. In the Sundarbans, a range of stakeholders, including the government, NGOs and private sector (mainly informal) actors deliver health services in an uncoordinated manner. Working across countries we will use a CAS approach to plan better interventions and understand how this approach can be used more effectively in other contexts.
  • Understanding the links between climatic shocks, health and wellbeing: The Sundarbans are a geographically isolated delta region in West Bengal, India, which are highly susceptible to climate events. Cyclone Aila only left informal providers of health services in her wake when she passed through the area in 2009. We will explore how we can establish resilient and effective health systems in such adverse conditions.

During the conference, we will be participating in a number of panels, presentations and posters, many of which are available as audio 'slidecats' on the FHS website (see links below).

Plenaries, sub-plenaries and symposia

Additional presentations

  • A semi-professional workforce in a growing market: The implications for health care regulation, X. Pei, 10 Dec., 11:30-11:50, Rayson Huang Theatre
  • Trust matters: Villagers’ trust in providers and insurers and their demand for community-based health insurance in Cambodia, S. Ozawa and D.G. Walker, 10 Dec., 14:10-14:30, Meng Wah Complex T5
  • Food safety regulation in the context of rapid change: The case of melamine contamination of milk in China, Y. Xiao and G. Bloom, 10 Dec., 14:10-14:30, Meng Wah Complex T4
  • Coming home: The return of migrant workers with work injury in Hubei & Sichuan, C. Chen, S. Ding, H. Lucas & G. Bloom, 11 Dec. 16:30-16:50, Meng Wah Complex T4


  • How donors add value to private sector health care in Myanmar: Tracking the flow of funds in a social franchise, D. Bishai et al., 11 Dec.
  • Evaluating the costs & sustainability of improved vaccination coverage in slums in Dhaka, Bangladesh, K. Hayford et al., 11 Dec.

Seven African Universities set Health Systems Research Capacity Agenda

Posted: 07 Dec 2011 04:24 AM PST

Dr Eric Mafutu from Kinshasa University presents findings from the capacity self-assessment

By Kakaire Ayub Kirunda

With support from the Future Health Systems (FHS) consortium, seven schools of public health (SPHs) in East and Central Africa have embarked on a five-year project to strengthen their capacity to undertake high quality, policy relevant health systems research (HSR).

During a three-day regional meeting in the Kenyan capital of Nairobi, the schools from Uganda, Kenya, Tanzania, Rwanda, D. R. Congo, and Ethiopia presented findings from capacity self-assessments, from which seven thematic areas of collaboration emerged.

Among the seven thematic areas that emerged from the schools’ self-assessments include: funding availability and resource mobilization, faculty development for HSR, database and library resources for HSR and support for and coordination of HSR activities. Others are setting national HSR priorities, knowledge translation and communication, and developing HSR curricula.

The schools are under the umbrella of the Higher Education Alliance for Leadership through Health  (HEALTH Alliance). In addition to the Africa Hub, the Alliance also coordinates other programs, like the One Health initiative and also supports the deans of the SPHs to convene, discuss, and resolve common management issues.

Speaking of the self-assessment findings, the HEALTH Alliance Director Prof. William Bazeyo said the information generated was vital for HSR planning in the respective countries, yet governments did not have it.

“If you work on these findings and synthesized them into position papers or policy briefings and give them to the right people at the right time, they can be useful,” said Prof. Bazeyo, who is also dean of the Makerere University School of Public Health, which hosts the HEALTH Alliance.

Officiating at the meeting, the Deputy Vice Chancellor of Moi University Prof. Bob Weshitemi observed that the kind of health systems research that the seven schools intend to focus on should have an ultimate goal of benefiting communities and improving their livelihoods.

But for that to happen, according to Prof. Weshitemi, the kind of research to be conducted should be the type that goes beyond helping researchers get promotions.

“We should ask ourselves if we are doing research that is relevant. Sometimes the answer is yes. Sometimes it is no,” said Prof. Weshitemi. “We should focus more on research that drives the development agenda. In Kenya, the national council for science and technology has embarked on a process to identify key relevant research for the country.”

And while the HEALTH Alliance member countries can achieve these, “funding needs to be increased,” according to Prof.  Weshitemi.

The Chief Executive Officer of FHS, Dr. Sara Bennett, pledged modest annual support to the Africa Hub over the next five years. She commended the schools for the work done over the last one year that has generated a lot of evidence that will guide HSR capacity strengthening activities over the next five years.

The schools are now drawing annual work plans and have initiated new drives for additional funding to be in position to implement the immense work under the identified in the seven thematic areas.

In addition to Makerere University and Moi University, the other schools of public health under the Alliance are found at Nairobi University (Kenya), National University of Rwanda, Jimma University (Ethiopia), Kinshasa University (DR Congo) and Muhimbili University of Health and Allied Sciences (Tanzania).

FHS to participate in STEPS Centre summer school

Posted: 26 Nov 2011 05:44 AM PST

This week, the ESRC Social, Technological and Environmental Pathways to Sustainability Centre (STEPS Centre) at the University of Sussex announced a major two-week international summer school on Pathways to Sustainability. Involving innovative forms of teaching and interaction, including an international team of leading researchers in this field, the Summer School will be held from 14 - 25 May 2012.

Focusing on the self-reinforcing and path-dependent interactions of social, technological and environmental systems – and informed by an analysis of the way different kinds of power help shape the social framing of knowledges, the STEPS Centre has developed a unique ‘pathways approach’ to research and policy engagement. Drawing on innovation and development theory, science and technology and policy studies, ecological economics, decision analysis and political ecology, the Summer School will explore and apply the associated array of cross- disciplinary concepts, analytical frameworks, empirical methods and policy strategies.

FHS members Dr Gerry Bloom and Jeff Knezovich will participate in the summer school, convening sessions examining sustainable pathways for establishing more effective health systems in complex environments as well as strategies for communication and engagement.

Interested in attending? Applications are invited from highly-motivated doctoral and postdoctoral researchers or those with equivalent experience, working in fields around development studies, science and technology studies, innovation and policy studies, and across agricultural, health, water or energy issues. There is a premium on interdisciplinary approaches and on interests and orientations that converge with work of the STEPS Centre. Numbers are limited, so recruitment will be by refereed selection. Successful applicants will pay no fees. But participants must cover their own travel and accommodation.

Making health markets work for the poor

Posted: 09 Nov 2011 12:05 PM PST

From 7-9 November 2011, the M4P Hub hosted a conference in Brighton, UK, on making markets work for poor people. It was a key opportunity to discuss and promote the M4P approach, which effectively maps the public, private and non-governmental systems that comprise a sector within a country.

Dr Gerry Bloom from FHS participated in the conference focusing on health markets in developing countries. His presentation gave an overview of work from FHS partners in Bangladesh and Nigeria of the role of informal providers in health markets.

Although he noted the tension in the health sector between working through public systems and engaging health markets, he pointed out that many poor use the private sector as their first point of call when accessing health services. For example, our research in Bangladesh shows that 65% of people who visit a health provider visit private 'village doctors'. In Nigeria, more than half of those studied obtained treatment for malaria through private providers.

Of course, working with these informal providers had risks. Even after training, in Bangladesh village doctors still gave inappropriate and occasionally harmful prescriptions. But while Dr Bloom urged caution, he doesn't think this means we should not engage with the private sector and informal providers. On the contrary, he also pointed out that building capacity of the public sector carried its own set of risks. Rather, he suggested that we need to be aware of these strong incentives and work to improve the business model so that these private providers have the appropriate incentives to provide accurate care.


Considering 'complex adaptive systems'

Posted: 03 Oct 2011 07:35 AM PDT

In the second phase of Future Health Systems, Professor David Peters at JHSPH has begun collaborating on a stream of work on ‘complex adaptive systems’. Complex adaptive systems (CAS) are described as such because, in addition to being comprised of many interacting components and agents, they have the capability to self-organize, adapt or learn from experience – what are sometimes known as emergent properties. Most social, biological and economic systems can be considered CAS, including health systems.

Today FHS have launched its complex adaptive systems theme page with a wide range of products that begin to explain our approach to CAS and why we think it’s such an important topic to consider.


Journal article:









Speaker of Ugandan Parliament Praises FHS

Posted: 24 Aug 2011 01:23 AM PDT

(L-R) Dr Elizabeth Ekirapa- Kiracho, Rt Hon. Rebecca Kadaga and Ms Veronica Kadogo Babirye

By Kakaire Ayub Kirunda

Having a meeting with a speaker of parliament is no small feat, especially at a time when the national assembly is busy discussing the 2011/2012 budget. But the Uganda FHS team last week (August 15) managed to have an hour with Speaker the Rt. Hon. Rebecca Kadaga at her offices in Kampala.

The timing could not have been better, coming hot on the heels of Parliament refusing to pass the Ministry of Health’s budget, due to diversion of some of the funds meant for maternal health to work workshops and seminars.

The four-person team from the Makerere University School of Public Health was led by Dr Elizabeth Ekirapa-Kiracho, who briefed the speaker about FHS -- especially on the Safe Deliveries Project and the upcoming second phase of FHS work. Buyende District Woman Member of Parliament, Ms Veronica Kadogo Babirye, whose district is a beneficiary of the project, coordinated the meeting.

Dr Ekirapa told the Speaker that the Safe Deliveries project, which has been implemented in four districts in Eastern Uganda, has seen an upsurge in women delivering in health facilities unlike before the intervention.

She hastened to add that the project was funded through development partners, and that project sustainability was an issue. She noted that more research was needed to find more effective ways for communities, using locally available resources, to contribute to such interventions. This, she explained, was going to be the focus of the second phase of Future Health Systems in Uganda, which starts in October 2011.

Speaker Kadaga, a strong maternal health advocate commended the team for the research saying the meeting was timely because as Parliament was scrutinizing ministerial policy statements.

“This is good work and we shall share it with members of the Network of African Women Ministers and Parliamentarians. We are currently handling budgets are certainly this information is helpful,” she said further asking the research team to avail her office with a detailed cost-benefit analysis. The speaker’s office has since been furnished with the additional information.

The speaker said effective delivery of services in the country was being affected by implementation that is not based on evidence.

Following the success of the Safe Deliveries Project, the second phase of FHS Uganda will focus on developing on a more sustainable mechanism of financing and managing the project so that the gains can be sustained.


Leading Indian newspaper takes note: 50% children in Sunderbans malnourished

Posted: 12 Aug 2011 12:39 AM PDT

Following a report issued by FHS India, the Stateman, one of India's oldest English language newspapers reported on the dire health situation facing both children and adults in remote parts of the Sundarbans. According to the article:

About half of the children in the Sunderbans, about 52 per cent, were either stunted or suffering from chronic malnutrition. The proportion of chronically malnutritioned children was higher than both the state [of West Bengal] and the national percentage of 45 and 48 per cent, respectively, implying that in the Sunderbans, a comparatively higher proportion of the children are growing up with serious nutritional retardation.

The article also notes higher incidence of fever and diarrhoea among children, and chronic diseases like heart disease and arthritis among adults.


Role of the private sector in health markets

Posted: 27 Jul 2011 03:49 PM PDT

Many researchers from Future Health Systems saw their hard work come to fruition with the publication of a special supplement of Health Policy and Planning entitled 'Role of the private sector in health markets'. The supplement was launched at the 8th World Congress on Health Economics in Toronto, Canda in early July.

As the supplement's editor, Birger Foresberg, explains in a Center for Health Market Innovations blog:

"The eight papers in the supplement provide an important contribution to coherent frameworks for analyzing and developing health systems in different contexts in low- and middle-income countries. There is a growing acknowledgment that health system development for improved health and health care must include private actors. Researchers are gradually filling the gaps in knowledge necessary for this inclusion. These articles illustrate that private health sector research has moved beyond classifying and counting providers and users into assessment of mechanisms for harnessing the private sector and identifying conditions for their successful application.

FHS authors contributed three of the eight articles in the supplement: