The health systems’ movement has all the positive energy of an activist cause, but still lacks a cohesive narrative

I maybe preaching to the choir when I say this, but this week’s Third Global Symposium on Health Systems Research is a clear indication of something special in the history of global health movements.

Other global health causes – and I’m talking as a 15-year veteran of the field here – follow one of only a few distinct trajectories. They may start off as a neglected issue that through persistence, passion and persuasion by committed advocates slowly gains the necessary international attention to set off the domino effect – HIV and malaria are cases in point here.

Perhaps, like many of the neglected tropical diseases, the advocates and passion are there, but when they get to the international level they are somehow still side-lined, never quite winning the battle of political priority against other, more eye-catching, issues.

Or, worse, they never really get the international attention in the first place – or at least not the kind that leads to actual health improvements (think leprosy, mental health, maternal mortality).

However, the health systems movements bucks all these trends. Why? The key differentiating factor is the very fact that it is not a global health cause per se. Instead, health systems strengthening is the catch-all solution to global health problems that has been independently arrived at by multiple stakeholders at all levels of the policy-financing-research-implementation chain.

Health systems strengthening is now a clear political, academic and international priority simply because it makes so much sense – economically, rationally, and emotionally – to so many people.

However, what seems like an advantage can also be a risk. The trouble with several different constituencies all arriving at the same solution is that they all have their own definition of what that solution actually is. And this lack of a cohesive narrative about health systems is as clear at HSR2014 as the energy and smiling faces are.

The problem is, while policy makers, donors, international organisations and researchers may be using the same words and talking about similar topics, the language, culture and contextual framework of each of this constituencies remains starkly different.

The result is that policy makers are still not really using evidence in their decisions; donors are not really investing in evidence generation or reporting, or promoting evidence-informed programme design; and researchers are still not really answering the questions that decision-makers – whether in government, donor agencies, international organisations, or implementation partners – need answers for.

If we, as health systems enthusiasts, continue on this road of applying our own definitions to the problem and its solutions – and allowing others to do the same – we will be missing a huge and unique opportunity to capitalise on the convergence of interests and priorities that the health systems movement represents right now.

Importantly, Health Systems Global and their very impressive team of local conference organisers and facilitators have created the very conditions for solving this problem, as well as highlighting it, by bringing all relevant stakeholders together in the same place. And infusing the gathering with such enthusiasm for change.

Delegates from all constituencies now need to take up the challenge. If you are a researcher, why not strike up a conversation with an implementing partner organisation like MSH? If you are a policy maker or a health service manager, why not go and ask the London School of Hygiene and Tropical Medicine how you can work together? And for the World Bank, WHO and other international organisations – why not try to promote collaboration between policymakers, researchers and implementers, rather that reinforcing the divisions between them?

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PRESS RELEASE: SA national health data overestimates immunisation coverage rates by up to 6 times

FOR IMMEDIATE RELEASE: TUESDAY 30th SEPTEMBER 2014, 00h00 CAPE TOWN

CAPE TOWN – Inaccurate data on South Africa’s national health information system means that the national database shows numbers up to 6 times higher than are recorded in corresponding facility registers, a new study published in the October issue of Strengthening Health Systems reveals.

The study, which involved authors from the Eastern Cape Department of Health and the University of Alberta, Canada, investigated the accuracy of nationally reported immunisation rates for children younger than 1 year in Eastern Cape Province, as reported on South Africa’s national health database – the District Health Information System.

By visiting a selection of facilities and counting numbers of children immunised as listed in facility records, then comparing these numbers with the database figures, the team calculated error rates for the data from each facility and sub-district. They then conducted a series of interviews with staff and district managers to find out why the data was not being managed correctly.

“We knew from an initial review of the national data that there were problems with the figures because five sub-districts reported that they had immunised more than 100% of the children in their catchment area – which is, of course, impossible,” explains lead-author Anne-Marie Jamin, University of Alberta, Canada, who supported the Eastern Cape Department of Health to investigate the issue.

“When we compared the database numbers with records at the facilities, we found surprisingly large differences between the national data and the records at facility level. One facility reported a 358% coverage rate when they had only recorded immunising 1.4% of the local children,” says Jamin.

According to authors, these findings show how the data management system is struggling to provide health managers and policy makers with the crucial information they need to do their jobs properly.

“If you looked at the reported figures alone, without knowing the error rates, you would think that the Province is doing really well on immunisation. What we found was that feasible-sounding district and provincial averages may actually be obscuring a significant problem, not only with data but also with the underlying public health campaign to expand immunisation,” explains Jamin. “Knowing more accurately where the problem areas are would help the Province target its work much more effectively.”

The authors recommend that the better training about data management processes in line with the national policy on health management information, better communication between programmes that deal with child health and improved systems for procuring registers for facilities could address the identified issues.

Notes for editors

1. The referenced paper is: A-M Jamin, B Kaposhi, D Schopflocher, N Mqoqi. Strengthening health systems through improving the reliability of health information: an evaluation of the expanded programme on immunisation data management in Eastern Cape, South Africa. Strengthen Health Sys 2014 epub ahead of print DOI:10.7196/SHS.10.
2. This paper is being published to coincide with the Third Global Symposium on Health Systems Research in Cape Town, South Africa, Sept 30-Oct 3.
3. PDF copies of the paper can be obtained from the journal office: shs@hmpg.co.za
4. Strengthening Health Systems is a new international peer-reviewed open access journal that aims to publish articles that support evidence-informed policy changes to improve health system function and health outcomes. It is published by the Health and Medical Publishing Group (www.hmpg.co.za), publishers for the South African Medical Association, and is supported by the United States’ President’s Emergency Plan for AIDS Relief through an award to the Foundation for Professional Development, South Africa (www.foundation.co.za).

CONTACTS

Study lead author: Anne-Marie Jamin – ajamin@ualberta.ca, +254 (0)704 968 870

Strengthening Health Systems: Hannah Kikaya – hannah.kikaya@hmpg.co.za, +27 791 525 406

Strengthening Health Systems @ #HSR2014

We have arrived in Cape Town, South Africa, ready to join in the conversation at the Third Global Symposium on Health Systems Research – on how we can best use existing knowledge and focus our collective efforts towards strengthening health systems in ways that reduce barriers to access and inequities in service provision.

In honor of this landmark event – held in the shadow of the accelerating Ebola epidemic in West Africa which has exposed the true fragility of health systems in the face of severe health threats – Strengthening Health Systems is today publishing two articles that speak to the central themes of the conference, and to key issues the health systems community continues to grapple with:

1. MSH President Jonathan Quick and colleagues write in an editorial that the “people-centered” approach, around which the conference is based, is inextricably linked to the movement towards universal health coverage, so that neither goal can be achieved without achievement of the other.

2. In an article that evaluates the accuracy of immunisation data on South Africa’s national health information system, Anne-Marie Jamin (University of Alberta, Canada) and colleagues from the Eastern Cape Department of Health, South Africa, find that database figures are up to 6 times higher than the corresponding figures in facility registers, signalling severe problems with data management in the province. The authors warn that without a data management system that can be relied upon to convey accurate data, policy makers and health managers are unable to make informed decisions about health programmes and priorities.

For the full text of these and other articles published in Strengthening Health Systems, please visit our website and online submission system – now live! www.shsjournal.org

Quick JD, Canavan CR, Jay J. People-centered health systems for UHC. Strengthen Health Sys 2014 epub ahead of print DOI:10.7196/SHS.9

Jamin A-M, Kaposhi B, Schopflocher D, Mqoqi N. Strengthening health systems through improved reliability of health information: An evaluation of the expanded programme on immunization data management in Eastern Cape, South Africa. Strengthen Health Sys 2014 epub ahead of print: DOI:10.7196/SHS.10

Ebola shows that epidemic preparedness is about public health education as much as outbreak control

As WHO has acknowledged many times in the past, in outbreak situations information is often the only effective disease-control intervention. But if it is administered too late, in the wrong way, or without a foundation of trust, it may not work at all.

For this reason, health system resilience and public health preparedness should be considered one and the same. Preparedness must not be limited to the technical aspects of disease surveillance, drug and vaccine stockpiling, or border controls. Real disease control starts with public health education. And deep trust built over time.

There is an unspoken social contract that underlies public health: professionals provide reliable advice, and individuals make (mostly) reasonable choices, while accepting a certain amount of coercion to avoid severe health threats. But this pact is fragile. And wholly dependent on people’s confidence in their advisors. Individuals that comprise populations at risk must believe that the advice they receive is for their own – or the population’s – benefit, otherwise no instruction, no matter how important, will be heeded.

It has become starkly clear in this Ebola epidemic what can happened when there is no trust. Rumours carry more weight that evidence. And professionals – with all their technical knowledge – are powerless to stop disease. Public health education should not just be an after-thought. It is the very cornerstone of health system resilience.

 

Scalability – not generalizability – of findings is what distinguishes truly valuable health systems research

It may be stating the obvious to say it, but health systems are context-specific. Every country’s system is a hotch-potch of features. Some created by deliberate decisions; some stop gap-turned-permanent solutions; and many organic arrangements that have grown to fill gaps, with interesting arrays of unintended effects.

These systems usually have similar goals – to deliver effective, impactful health care equitably and accessibly – but the ways those goals are achieved are necessarily idiosyncratic. More often than not, it is the approach to implementation that determines eventual outcomes, rather than the intervention itself.

For these reasons, research that focuses on finding the “right” way to organise a health system by comparing settings is intellectually interesting but not necessarily directly useful for policy or programme design. There are many lessons that can be learnt by looking at the experiences of countries with common features, but aiming for generalizable conclusions often means finding the lowest common denominator – and losing much of the context-specific information that is crucial in determining results in the process.

The most policy-useful research is that which seeks to identify ideas and innovations with the potential to bring profound change if implemented on a large scale – and then delves deeper to understand why those ideas worked the way they did, in the place they did.

The science of systems, of real-world settings, is not so much about the what – the technical details of a policy change intervention – but about the how – what conditions led to success and how can they be replicated. Knowing which lessons and best practices can be effectively translated and scaled up – scalability – is the most valuable knowledge policymakers and programme designers can build on.

Health systems research should be to policy makers what medical research is to doctors. Unfortunately, it is not

Policy makers are the doctors of health systems. They are the ones who, when faced with difficult diagnoses – such as inequalities in service access, human resource shortages, poor health outcomes, emerging diseases – select the interventions they believe will restore the patient’s (system’s) health, and oversee adherence to treatment (implementation). They are the individuals and collectives with the power to influence health on a population level. And the power to limit the opportunities of entire countries with poor decisions and inadequate service planning.

Unfortunately for policy makers, however, they are not in the privileged position of today’s doctors, with a vast array of well-researched treatments for the myriad common diseases that burden their patients. The policy makers’ toolkit is limited to the blunt instruments of budgeting, national goal setting, and guideline development. Diagnoses are equally unsubtle: high burdens of disease, low life expectancy, and catastrophic health expenditure, to name just a few.

Systems’ “medicine” is languishing in a time akin to the era when doctors could do nothing for their patients but barbaric surgeries, blood-letting, and doling out reassuring words. If health systems are going to deliver on the population health benefits that should result from medical innovations and advances, this has to change.

Health systems research has much potential to be the science that policy makers depend on to inform their professional decision-making, just as medical science is to doctors. Unfortunately, however, the field does not currently fill this need. But maybe it should.

West African health workers are the true Ebola experts. They should document their knowledge

Ebola scares everyone.[1] But one thing we know for sure is this: the next Ebola outbreak is not going to be in the USA, or Switzerland, or the UK. It will be in DR Congo, South Sudan, or Gabon. What the doctors, nurses and health managers in those places – the front line defence against this terrifying disease – need to know is not the genetic makeup of the organism or the likelihood of vaccines they will never afford. They need to know what to do when funerals spread infections. When witchcraft is being blamed by communities. When patients refuse to stay in hospitals. When the disease is spreading in the kind of marketplaces and city conditions that only African countries share. And what to do when foreigners are too scared to come and help.

The doctors, nurses and health service managers in Liberia, Sierra Leone, Guinea and others will – when this awful crisis is finally over – have much valuable knowledge that others can, and desperately need to, learn from. We must all support them to document and publish it so that when this disease rears its head again, in the deep dark rainforests and crowded bustling cities of Africa, we, in this continent, are prepared with the real practical preparatory information that can help stop the disease in its tracks – and comfort the rest of the world.

The Health Knowledge Gap – and how to fill it

There is a knowledge gap in health. A big one. And this gap is what prevents our knowledge about disease and how to treat it from achieving its potential impact on health burdens. Let’s take an example. Tuberculosis. This bacterial scourge has been destroying lives for centuries and has now won the dubious accolade of number one killer in South Africa[1] – quite a feat in such a multi-burdened nation. Globally, 8.6 million people got TB last year, and 1.3 million died (25% of these deaths can be blamed on HIV).[2]

We have known about the bacterium and how it causes illness since Nobel Laureate Robert Koch’s history-making lecture[3] in 1882, in which he demonstrated a staining technique that made the organism visible for the first time. Effective drugs have been available since the 1940s – the first discovery was streptomycin, then a sleuth of new discoveries through the 1950s and 60s led to the combination regimens still used today.[4] So if both disease knowledge and treatments are available, why is TB still a global emergency? That is the health knowledge gap. We simply do not know how to use our health knowledge to achieve the maximum benefits of medical innovations.

The health knowledge gap is about health systems. And health care delivery. How to organise the infrastructure, human resources and operational aspects of health services so that sick people can reap the full benefits of available treatments, and that healthy people can benefit from our knowledge of diseases to avoid them. There are lots of examples of what works and what does not, but systems are not studied in the same systematic way that diseases and medicines are. As a result, there is very little evidence – in the scientific meaning of the word – to help governments decide how to organise and reform their health systems to improve the health of their populations.

Strengthening Health Systems has been set up with the aim of addressing this knowledge gap. By helping to capture the knowledge that exists in the minds of practitioners and documenting it so that others can learn; by forging links between academics, policy makers and implementers to ensure that research targets policy and implementation-relevant questions; and by creating a strong, relevant evidence base that policy makers, programme designers and funding organisations can draw on to make better, more informed decisions. We hope you will join us in supporting this cause.

Further reading: Kikaya H. Can there really be a ‘science’ of health systems? Strengthen Health Sys 2014; 1(1): 3 SHS EDITORIAL