here is a growing recognition that the global health agenda needs to shift from an emphasis on disease-specific approaches to strengthening of health systems, including dealing with social, environmental, and economic determinants through multisectoral responses. A review and analysis of data on strengthening health sector reform and health systems was conducted. Attention was paid to the goal of health and interactions between health sector reforms and the functions of health systems. The authors explored how these interactions contribute toward delivery of health services, equity, financial protection, and improved health. they found that health sector reforms cannot be developed from a single global or regional policy formula. Any reform will depend on the country's history, values and culture, and the population's expectations. Some of the emerging ingredients that need to be explored are infusion of a health systems agenda; development of a comprehensive policy package for health sector reforms; improving alignment of planning and coordination; use of reliable data; engaging 'street level' policy implementers; strengthening governance and leadership; and allowing a holistic and developmental approach to reforms.
Equitable health services
This paper argues that the global health agenda tends to privilege short-term global interests at the expense of long-term capacity building within national and community health systems. The Health Systems Strengthening (HSS) movement needs to focus on developing the capacity of local organisations and the institutions that influence how such organisations interact with local and international stakeholders. While institutions can enable organisations, they too often apply requirements to follow paths that can stifle learning and development. Global health actors have recognised the importance of supporting local organisations in HSS activities. However, this recognition has yet to translate adequately into actual policies to influence funding and practice. While there is not a single approach to HSS that can be uniformly applied to all contexts, several messages emerge from the experience of successful health systems presented in this paper using case studies through a complex adaptive systems lens. Two key messages deserve special attention: the need for donors and recipient organisations to work as equal partners, and the need for strong and diffuse leadership in low-income countries. An increasingly dynamic and interdependent post-Millennium Development Goals (post-MDG) world requires new ways of working to improve global health, underpinned by a complex adaptive systems lens and approaches that build local organisational capacity.
Medicine availability is improving in sub-Saharan Africa for palliative care services. There is a need to develop strong and sustainable pharmaceutical systems to enhance the proper management of palliative care medicines, some of which are controlled. One approach to addressing these needs is the use of mobile technology to support data capture, storage and retrieval. Utilizing mobile technology in healthcare (mHealth) has recently been highlighted as an approach to enhancing palliative care services but development is at an early stage. An electronic application was implemented as part of palliative care services at two settings in Uganda; a rural hospital and an urban hospice. Measures of the completeness of data capture, time efficiency of activities and medicines stock and waste management were taken pre- and post-implementation to identify changes to practice arising from the introduction of the application. Improvements in all measures were identified at both sites. The application supported the registration and management of 455 patients and a total of 565 consultations. Improvements in both time efficiency and medicines management were noted. Time taken to collect and report pharmaceuticals data was reduced from 7 days to 30 min and 10 days to 1 h at the urban hospice and rural hospital respectively. Stock expiration reduced from 3 to 0.5 % at the urban hospice and from 58 to 0 % at the rural hospital. Additional observations relating to the use of the application across the two sites are reported. A mHealth approach adopted in this study was shown to improve existing processes for patient record management, pharmacy forecasting and supply planning, procurement, and distribution of essential health commodities for palliative care services. An important next step will be to identify where and how such mHealth approaches can be implemented more widely to improve pharmaceutical systems for palliative care services in resource limited settings.
Although progress has been made in strengthening laboratory capacity to support programmes such as poliomyelitis eradication, HIV prevention and control, and measles elimination, this study notes that challenges remain. These include the lack of national policy and strategy for laboratory services, insufficient funding, inadequately trained laboratory staff, weak laboratory infrastructure, old or inadequately serviced equipment, lack of essential reagents and consumables, and limited quality assurance and control protocols. Laboratories are usually given low priority and recognition in most national health delivery systems. The study identifies the main challenge as the need to develop a comprehensive national laboratory policy that addresses the above issues. Other recommendations include improving laboratory leadership, strengthening the laboratory supply and distribution system, improving monitoring, providing adequate training for staff, strengthening information systems and putting in place effective monitoring and evaluation systems.
Strengthening the evidence-policy interface is a well-recognized health system challenge in both the developed and developing world. According to this paper, brokerage inherent in hospital-to-hospital partnerships can boost relationships between ‘evidence’ and ‘policy’ communities and move developing countries towards evidence-based patient safety policy. In particular, the authors use the experience of a global hospital partnership programme focused on patient safety in the African Region to explore how hospital partnerships can be instrumental in advancing responsive decision-making, and the translation of patient safety evidence into health policy and planning. A co-developed approach to evidence-policy strengthening with seven components is described, with reflections from early implementation. The rapidly expanding field of towards evidence-based patient safety policy calls shared learning across continents, the authors conclude, in keeping with the principles and spirit of health systems development in a globalised world.
This field study investigated the potential stress-reducing effects of exposure to real or artificial nature on patients in a hospital waiting room. Additionally, it was investigated whether perceived attractiveness of the room could explain these effects. In this between-patients experimental design, patients were exposed to one of the following: real plants, posters of plants, or no nature (control). These conditions were alternately applied to two waiting rooms. The subjects consisted of 457 patients (60% female and 40% male) who were scheduled for various health services, such as echocardiogram and x-ray. Patients exposed to real plants, as well as patients exposed to posters of plants, report lower levels of experienced stress compared to the control condition. Further analyses show that these small but significant effects of exposure to nature are partially mediated by the perceived attractiveness of the waiting room. In conclusion, natural elements in hospital environments have the potential to reduce patients' feelings of stress. By increasing the attractiveness of the waiting room by adding either real plants or posters of plants, hospitals can create a pleasant atmosphere that positively influences patients' well-being.
This study had three aims: to measure agreement between nine structured approaches for diagnosing childhood tuberculosis; to quantify differences in the number of tuberculosis cases diagnosed with the different approaches, and to determine the distribution of cases in different categories of diagnostic certainty. It investigated 1,445 children aged less than two during a vaccine trial held in a rural South African community from 2001 to 2006. Clinical, radiological and microbiological data were collected prospectively. Tuberculosis case status was determined using each of the nine diagnostic approaches. Tuberculosis case frequency ranged from 6.9% to 89.2%. Significant differences in case frequency occurred in 34 of the 36 pair-wise comparisons between structured diagnostic approaches. There was only slight agreement between structured approaches for the screening and diagnosis of childhood tuberculosis and high variability between them in terms of case yield. Diagnostic systems that yield similarly low case frequencies may be identifying different subpopulations of children. The study findings do not support the routine clinical use of structured approaches for the definitive diagnosis of childhood tuberculosis, although high-yielding systems may be useful screening tools.
According to this report, 4.4 million children and 265,000 mothers die in sub-Saharan Africa every year, which amounts to half of the world's maternal, newborn and child deaths. It identifies the five biggest challenges for maternal, newborn and child health in sub-Saharan Africa as pregnancy and childbirth complications, newborn illness, childhood infections, malnutrition, and HIV and AIDS. Many scientifically proven health interventions are available for maternal, newborn, and child health such as medicines, immunisations, insecticide-treated bed nets, and equipment for emergency obstetric care. Yet many African governments are currently underutilising existing scientific knowledge to save women's and children's lives. The report recommends a scientific approach based on local epidemiological and coverage data that will prioritise the highest impact and most appropriate interventions in a given context. Although most countries in sub-Saharan Africa are behind in achieving the Millennium Development Goals (MDGs) for maternal and child health by 2015, progress in several low-income countries demonstrates that the MDGs could still be attained through immediate strategic investments in selected evidence-based interventions and targeted health systems strengthening.
Strengthening health systems is a key challenge to improving the delivery of cost-effective interventions in primary health care (PHC) and achieving the vision of the Alma-Ata Declaration. This overview summarises the evidence from systematic reviews of health systems arrangements and implementation strategies, with a particular focus on evidence relevant to PHC in such settings. Although evidence is sparse, there are several promising health systems arrangements and implementation strategies for strengthening primary health care. However, their introduction must be accompanied by rigorous evaluations. The evidence base needs urgently to be strengthened, synthesised, and taken into account in policy and practice, particularly for the benefit of those who have been excluded from the health care advances of recent decades.
The authors of this article argue that surgery can and should be recognised as an important global health intervention. To achieve this goal, they emphasise that it is critical to improve the local surgical capacity in low- and middle-income countries. While the accomplishment of this goal will not be easy it is certainly possible, especially when doctors join forces with providers and policy-makers that set the direction of a public health movement that has seen a dramatic change and increase in its authority over the past decade. The authors call on the World Health Organisation to exercise its leadership in advancing the status of surgical care in global health by organising action plans to meet unmet surgical burdens.