In this study, the authors captured common implementation experiences and lessons learned to understand core elements of successful health systems interventions in Ghana, Mozambique, Rwanda, Tanzania, and Zambia. Four major overarching lessons were highlighted. Variety and inclusiveness of concerned key players are necessary to address complex health system issues at all levels. A learning culture that promotes evidence creation and ability to efficiently adapt were key in order to meet changing contextual needs. Inclusion of strong implementation science tools and strategies allowed informed and measured learning processes and efficient dissemination of best practices. Five to seven years was the minimum time frame necessary to effectively implement complex health system strengthening interventions and generate the evidence base needed to advocate for sustainable change for the Population Health Implementation and Training partnership projects.
Equitable health services
Mental, neurological and substance use disorders contribute to a significant proportion of the world’s disease burden, including in low and middle income countries. In this study, the authors focused on the health systems required to support integration of mental health into primary health care (PHC) in Ethiopia, India, Nepal, Nigeria, South Africa and Uganda. A checklist guided by the World Health Organisation Assessment Instrument for Mental Health Systems was developed and was used for data collection in each of the six countries participating in the Emerging mental health systems in low and middle-income countries (Emerald) research consortium. The documents reviewed were from the following domains: mental health legislation, health policies/plans and relevant country health programs. Data were analysed using thematic content analysis. Three of the study countries (Ethiopia, Nepal, Nigeria, and Uganda) were working towards developing mental health legislation. South Africa and India were ahead of other countries, having enacted recent Mental Health Care Act in 2004 and 2016, respectively. Among all the 6 study countries, only Nepal, Nigeria and South Africa had a standalone mental health policy. However, other countries had related health policies where mental health was mentioned. The lack of fully fledged policies is likely to limit opportunities for resource mobilisation for the mental health sector and efforts to integrate mental health into PHC. Most countries were found to be allocating inadequate budgets from the health budget for mental health, with South Africa (5%) and Nepal (0.17%) were the countries with the highest and lowest proportions of health budgets spent on mental health, respectively. Other vital resources that support integration such as human resources and health facilities for mental health services were found to be inadequate in all the study countries. Monitoring and evaluation systems to support the integration of mental health into PHC in all the study countries were also inadequate. Integration of mental health into PHC will require addressing the resource limitations that have been identified in this study. There is a need for up to date mental health legislation and policies to engender commitment in allocating resources to mental health services.
Four new Cochrane EPOC overviews of reviews show reliable evidence on the effects of different ways of organising, financing, and governing health systems in low-income countries and identify important evidence gaps. Strengthening health systems in low-income countries is key to achieving universal health coverage and achieving the health-related Sustainable Development Goals. Achieving these goals requires informed decisions about health systems. A team of Cochrane researchers from Argentina, Chile, Norway, and South Africa prepared four overviews of the available evidence from up-to-date systematic reviews about the effects of health system arrangements in low-income countries. They included 124 systematic reviews in the four overviews. For each review, a user-friendly summary of key findings was produced (see http://supportsummaries.org/), enabling users to explore the overview findings in more depth. The summaries include over 480 key messages about the effects of health system arrangements in low-income countries.
Universal Health Coverage (UHC) is normally understood as ‘people being able to access curative, preventive and palliative health services without incurring financial hardship’. Yet this interpretation is only one part of the overall picture of health. To mitigate and prepare for such environmental and societal changes and the subsequent impact on health the authors suggest that there are at least three major ways in which health systems need to radically transform. Firstly, health systems across the world continue to be predominantly ‘sick care’ systems. Despite the success of immunization campaigns, the availability of contraceptive services and other preventive interventions, most investment is in healthcare facilities that provide primarily personal, curative health services. The World Health Organization estimates that low- and middle-income countries direct only 11-12 per cent of their total health spending towards preventive services. Secondly, animal and wildlife information systems vary enormously across countries in their objectives and structure but rarely interact with systems for tracking human health. This means that opportunities to identify dangerous viruses and diseases in the animal population before they crossover into humans are frequently missed. Thirdly, at the UN General Assembly (UNGA) the community of academics and activists concerned with non-communicable diseases were vocal, and rightly so. Such diseases now account for 41 out of the world’s 57 million deaths each year. The authors suggest that there is a need to move away from a narrow view of ‘sick care’ to one that prepares for and acknowledges present day complexities and challenges to achieve UHC.
In 2000, WHO published its first attempt to assess the performance of the world’s health systems in The World Health Report 2000. This report generated enormous interest but, in many ways, the scientific progress was overshadowed by the political debate related to the estimates of country-level performance and the associated league tables. Since then, the WHO European and Eastern Mediterranean Regional Offices have maintained health system observatories, with detailed descriptions of country systems. The considerable interest in measuring the performance of health systems worldwide is illustrated by the recent European Ministerial Conference on Health Systems, which culminated in the Tallinn Charter entitled Health systems for health and wealth. In developed countries, primary concerns include costs, quality of care, aging and chronic diseases. In developing countries, health system constraints have restricted progress towards the UN Millennium Development Goals.
In low-and-middle-income countries (LMICs), epidemiologic transition is taking place very rapidly from communicable diseases to non-communicable diseases (NCDs). NCD mortality rates are increasing faster and nearly 80% of NCDs deaths occur in LMICs, with human and economic costs, increasing treatment costs and losses to productivity. At the same time, the increasing penetration of mobile phone technology and the spread of cellular network and infrastructure have led to the introduction of the mHealth. While mHealth offers a promising approach in prevention and control of NCDs, it is unclear how ready health systems are to adopt it for this. The authors raise a number of factors which determine health systems readiness and response for adoption of mHealth technology including preparedness of healthcare institutions, availability of the resources, willingness of healthcare providers and communities. They discuss these factors and suggest that they be dealt up-front through constant effort to improve health systems response for NCDs.
Sub-Saharan Africa is undergoing health transition as increased globalisation and accompanying urbanisation are causing a double burden of communicable and non-communicable diseases. This study indicates that rates of communicable diseases such as HIV and AIDS, tuberculosis and malaria in Africa are the highest in the world and the impact of non-communicable diseases is also increasing. For example, age-standardized mortality from cardiovascular disease may be up to three times higher in some African than in some European countries. As the entry point into the health service for most people, primary care plays a key role in delivering communicable disease prevention and care interventions. This role could be extended to focus on non-communicable diseases as well, within the context of efforts to strengthen health systems by improving primary-care delivery. The study puts forward several policy proposals to improve the primary-care response to the problems posed by health transition. Governments should improve data on communicable and non-communicable diseases and implement a structured approach to the improved delivery of primary care. They should also focus on quality of clinical care, align the response to health transition with health system strengthening and capitalise on a favourable global policy environment.
Health workers of Parirenyatwa and Harare Central Hospital have issued a petition for urgent action to address the prevailing crisis in Zimbabwe’s public health system. Problems within public health institutions include a serious lack of medical supplies, functional equipment and drugs. Since all hospitals and clinics are closed, Zimbabweans that fall ill have no access to health care, given the high cost of private health care. Problems facing health workers include poor salaries (which should be paid in foreign currency, not Zim dollars), rising transport costs and bad working conditions. The continued failure to address the above issues has resulted in lack of services in public health institutions and health workers failing to come to work. The workers call upon the responsible authorities to take urgent steps to remedy the situation above in consultation with the health workers concerned.
The purpose of this paper was to assess the epidemiology of endemic health care-associated infection (HAI) in Africa. Three databases (PubMed, the Cochrane Library, and the WHO regional medical database for Africa) were searched, of which 19 articles were included in this study, and four abstracts of leading international infection control conferences were also included. The hospital-wide prevalence of HAI varied between 2.5% and 14.8%; in surgical wards, and the cumulative incidence ranged from 5.7% to 45.8%. The largest number of studies focused on surgical site infection, whose cumulative incidence ranged from 2.5% to 30.9%. Data on causative pathogens were available from a few studies only and highlighted the importance of Gram-negative rods, particularly in surgical site infection and ventilator-associated pneumonia. The authors note that limited information is available on the endemic burden of HAI in Africa, even though its frequency is much higher than in developed countries. There is an urgent need to identify and implement feasible and sustainable approaches to strengthen HAI prevention, surveillance and control in Africa.
This paper applied Tanahashi’s equity model to identify the perceived equity of health services by actors across the health system and at community level, following changes to the priority-setting process at sub-national levels post devolution in Kenya. The authors carried out a qualitative study between March 2015 and April 2016, involving 269 key informant and in-depth interviews from different levels of the health system in ten counties and 14 focus group discussions with community members in two of these counties. Qualitative data were analysed using the framework approach. Their findings revealed that devolution in Kenya has focused on improving the supply side of health services, by expanding the availability, geographic and financial accessibility of health services across many counties. However, there has been limited emphasis and investment in promoting the demand side, including restricted efforts to promote acceptability or use of services. Respondents perceived that the quality of health services has typically been neglected within priority-setting to date. The authors observe that achieving universal health coverage means that all aspects of equity need to be addressed, including quality, and that community health services can play a crucial role in this.