Research on practical and effective governance of the health workforce is limited. This paper examines health system strengthening as it occurs in the intersection between the health workforce and governance by presenting a framework to examine health workforce issues related to eight governance principles: strategic vision, accountability, transparency, information, efficiency, equity/fairness, responsiveness and citizen voice and participation.
This study builds off of a literature review that informed the development of a framework that describes linkages and assigns indicators between governance and the health workforce. A qualitative analysis of Health System Assessment (HSA) data, a rapid indicator-based methodology that determines the key strengths and weaknesses of a health system using a set of internationally recognized indicators, was completed to determine how 20 low- and middle-income countries are operationalizing health governance to improve health workforce performance.
The 20 countries assessed showed mixed progress in implementing the eight governance principles. Strengths highlighted include increasing the transparency of financial flows from sources to providers by implementing and institutionalizing the National Health Accounts methodology; increasing responsiveness to population health needs by training new cadres of health workers to address shortages and deliver care to remote and rural populations; having structures in place to register and provide licensure to medical professionals upon entry into the public sector; and implementing pilot programs that apply financial and non-financial incentives as a means to increase efficiency. Common weaknesses emerging in the HSAs include difficulties with developing, implementing and evaluating health workforce policies that outline a strategic vision for the health workforce; implementing continuous licensure and regulation systems to hold health workers accountable after they enter the workforce; and making use of health information systems to acquire data from providers and deliver it to policymakers.
The breadth of challenges facing the health workforce requires strengthening health governance as well as human resource systems in order to effect change in the health system. Further research into the effectiveness of specific interventions that enhance the link between the health workforce and governance are warranted to determine approaches to strengthening the health system.
Health governance; Health workforce; Human resources for health; Health system strengthening; Human resource management
The delivery of primary health information to rural women is a considerable challenge for government and private sectors in rural India. This paper illustrates how by applying the proposed user centered framework dissemination of maternal health information to rural women can be improved. First, the paper presents baseline study to obtain existing knowledge level of women and design requirements for a Primary Health Information System (PHIS). Second, the paper presents a brief description of the PHIS system which was deployed in a village for sixteen months in rural India. Third, the paper explains longitudinal study conducted post intervention of PHIS to measure the impact of PHIS on the knowledge level and health behaviour of rural women in comparison to the baseline study. The results indicate that by following the proposed user centered approach to design the PHIS, a significant improvement in knowledge level of rural women and positive changes in health practices are achieved.
Policy makers in developing countries need to assess how public health programmes function across both public and private sectors. We propose an evaluation framework to assist in simultaneously tracking performance on efficiency, quality and access by the poor in family planning services. We apply this framework to field data from family planning programmes in Ethiopia and Pakistan, comparing (1) independent private sector providers; (2) social franchises of private providers; (3) non-government organization (NGO) providers; and (4) government providers on these three factors. Franchised private clinics have higher quality than non-franchised private clinics in both countries. In Pakistan, the costs per client and the proportion of poorest clients showed no differences between franchised and non-franchised private clinics, whereas in Ethiopia, franchised clinics had higher costs and fewer clients from the poorest quintile. Our results highlight that there are trade-offs between access, cost and quality of care that must be balanced as competing priorities. The relative programme performance of various service arrangements on each metric will be context specific.
Franchise; private sector; reproductive health; family planning; Ethiopia; Pakistan; equity; quality
The lack of effective leadership and governance in the health sector has remained a major challenge in Nigeria and contributes to the failure of health systems and poor development of human resources. In this cross-sectional intervention study, leadership and governance competencies of policy makers were enhanced through a training workshop, and an assessment was conducted of organizational activities designed to promote evidence-informed leadership and governance to improve human resources for health (HRH). The training workshop increased the understanding of policy makers with regard to leadership and governance factors that ensure the functionality of health systems and improve human resources development, including policy guidance, intelligence and oversight, collaboration and coalition building, regulation, system design and accountability. Findings indicated that systems for human resources development exist in all participants' organizations, but the functionality of these systems was suboptimal. More systematic and standardized processes are required to improve competencies of leadership and governance for better human resources development in low-income settings.
Policy implementation in the context of health systems is generally difficult and the Kenyan health sector situation is not an exception. In 2005, a new health sector strategic plan that outlines the vision and the policy direction of the health sector was launched and during the same year the health sector was allocated a substantial budget increment. On basis of these indications of a willingness to improve the health care system among policy makers, the objective of this study was to assess whether there was a change in policy implementation during 2005 in Kenya.
Budget allocations and actual expenditures compared to set policy objectives in the Kenyan health sector was studied. Three data sources were used: budget estimates, interviews with key stakeholders in the health sector and government and donor documentation.
Budget allocations and actual expenditures in part go against policy objectives. Failures to use a significant proportion of available funds, reallocation of funds between line items and weak procurements systems at the local level and delays in disbursement of funds at the central level create gaps between policy objectives and policy implementation. Some of the discrepancy seems to be due to a mismatch between responsibilities and capabilities at different levels of the system.
We found no evidence that the trend of weak policy implementation in the Kenyan health sector was reversed during 2005 but ongoing efforts towards hastening release of funds to the districts might help solving the issue of low absorption capacity at the district level. It is important, however, to work with clear definitions of roles and responsibilities and well-functioning communications between different levels of the system.
This paper reports on health inequalities awareness-raising workshops conducted with senior New Zealand health sector staff as part of the Government's goal of reducing inequalities in health, education, employment and housing.
The workshops were based on a multi-method needs assessment with senior staff in key health institutions. The workshops aimed to increase the knowledge and skills of health sector staff to act on, and advocate for, eliminating inequalities in health. They were practical, evidence-based, and action oriented and took a social approach to the causes of inequalities in health. The workshops used ethnicity as a case study and explored racism as a driver of inequalities. They focused on the role of institutionalized racism, or racism that is built into health sector institutions. Institutional theory provided a framework for participants to analyse how their institutions create and maintain inequalities and how they can act to change this.
Participants identified a range of institutional mechanisms that promote inequalities and a range of ways to address them including: undertaking further training, using Māori (the indigenous people) models of health in policy-making, increasing Māori participation and partnership in decision making, strengthening sector relationships with iwi (tribes), funding and supporting services provided 'by Māori for Māori', ensuring a strategic approach to intersectoral work, encouraging stronger community involvement in the work of the institution, requiring all evaluations to assess impact on inequalities, and requiring the sector to report on progress in addressing health inequalities. The workshops were rated highly by participants, who indicated increased commitment to tackle inequalities as a result of the training.
Government and sector leadership were critical to the success of the workshops and subsequent changes in policy and practice. The use of locally adapted equity tools, requiring participants to develop action plans, and using a case study to focus discussion were important to the success for the training. Using institutional theory was helpful in analysing how drivers of inequalities, such as racism, are built into health institutions. This New Zealand experience provides a model that may be applicable in other jurisdictions.
Most adolescents live in resource-constrained countries and their mental health has been less well recognised than other aspects of their health. The World Health Organization's 4-S Framework provides a structure for national initiatives to improve adolescent health through: gathering and using strategic information; developing evidence-informed policies; scaling up provision and use of health services; and strengthening linkages with other government sectors. The aim of this paper is to discuss how the findings of a recent systematic review of mental health problems in adolescents in resource-constrained settings might be applied using the 4-S Framework.
Analysis of the implications of the findings of a systematic search of the English-language literature for national strategies, policies, services and cross-sectoral linkages to improve the mental health of adolescents in resource-constrained settings.
Data are available for only 33/112 [29%] resource-constrained countries, but in all where data are available, non-psychotic mental health problems in adolescents are identifiable, prevalent and associated with reduced quality of life, impaired participation and compromised development. In the absence of evidence about effective interventions in these settings expert opinion is that a broad public policy response which addresses direct strategies for prevention, early intervention and treatment; health service and health workforce requirements; social inclusion of marginalised groups of adolescents; and specific education is required. Specific endorsed strategies include public education, parent education, training for teachers and primary healthcare workers, psycho-educational curricula, identification through periodic screening of the most vulnerable and referral for care, and the availability of counsellors or other identified trained staff members in schools from whom adolescents can seek assistance for personal, peer and family relationship problems.
The predominant endorsed action is not that dedicated mental health services for adolescents are required, but that mental health care should be integrated using cross-sectoral strategies into the communities in which adolescents live, the institutions they attend and the organisations in which they participate.
Large increases in health sector investment and policies favoring upgrading and expanding the public sector health network have prioritized maternal and child health in Mozambique and, over the past decade, Mozambique has achieved substantial improvements in maternal and child health indicators. Over this same period, the government of Mozambique has continued to decentralize the management of public sector resources to the district level, including in the health sector, with the aim of bringing decision-making and resources closer to service beneficiaries. Weak district level management capacity has hindered the decentralization process, and building this capacity is an important link to ensure that resources translate to improved service delivery and further improvements in population health. A consortium of the Ministry of Health, Health Alliance International, Eduardo Mondlane University, and the University of Washington are implementing a health systems strengthening model in Sofala Province, central Mozambique.
Description of implementation
The Mozambique Population Health Implementation and Training (PHIT) Partnership focuses on improving the quality of routine data and its use through appropriate tools to facilitate decision making by health system managers; strengthening management and planning capacity and funding district health plans; and building capacity for operations research to guide system-strengthening efforts. This seven-year effort covers all 13 districts and 146 health facilities in Sofala Province.
A quasi-experimental controlled time-series design will be used to assess the overall impact of the partnership strategy on under-5 mortality by examining changes in mortality pre- and post-implementation in Sofala Province compared with neighboring Manica Province. The evaluation will compare a broad range of input, process, output, and outcome variables to strengthen the plausibility that the partnership strategy led to health system improvements and subsequent population health impact.
The Mozambique PHIT Partnership expects to provide evidence on the effect of efforts to improve data quality coupled with the introduction of tools, training, and supervision to improve evidence-based decision making. This contribution to the knowledge base on what works to enhance health systems is highly replicable for rapid scale-up to other provinces in Mozambique, as well as other sub-Saharan African countries with limited resources and a commitment to comprehensive primary health care.
The extra demand imposed upon the Libyan health services during and after the Libyan revolution in 2011 led the ailing health systems to collapse. To start the planning process to re-engineer the health sector, the Libyan Ministry of Health in collaboration with the World Health Organisation (WHO) and other international experts in the field sponsored the National Health Systems Conference in Tripoli, Libya, between the 26th and the 30th of August 2012. The aim of this conference was to study how health systems function at the international arena and to facilitate a consultative process between 500 Libyan health experts in order to identify the problems within the Libyan health system and propose potential solutions. The scientific programme adopted the WHO health care system framework and used its six system building blocks: i) Health Governance; ii) Health Care Finance; iii) Health Service Delivery; iv) Human Resources for Health; v) Pharmaceuticals and Health Technology; and vi) Health Information System. The experts used a structured approach starting with clarifying the concepts, evaluating the current status of that health system block in Libya, thereby identifying the strengths, weaknesses, and major deficiencies. This article summarises the 500 health expert recommendations that seized the opportunity to map a modern health systems to take the Libyan health sector into the 21st century.
Libya; Health services; Health system; Conference
Strengthened national health systems are necessary for effective and sustained expansion of antiretroviral therapy (ART). ART and its supply chain management in Uganda are largely based on parallel and externally supported efforts. The question arises whether systems are being strengthened to sustain access to ART. This study applies systems thinking to assess supply chain management, the role of external support and whether investments create the needed synergies to strengthen health systems.
This study uses the WHO health systems framework and examines the issues of governance, financing, information, human resources and service delivery in relation to supply chain management of medicines and the technologies. It looks at links and causal chains between supply chain management for ART and the national supply system for essential drugs. It combines data from the literature and key informant interviews with observations at health service delivery level in a study district.
Current drug supply chain management in Uganda is characterized by parallel processes and information systems that result in poor quality and inefficiencies. Less than expected health system performance, stock outs and other shortages affect ART and primary care in general. Poor performance of supply chain management is amplified by weak conditions at all levels of the health system, including the areas of financing, governance, human resources and information. Governance issues include the lack to follow up initial policy intentions and a focus on narrow, short-term approaches.
The opportunity and need to use ART investments for an essential supply chain management and strengthened health system has not been exploited. By applying a systems perspective this work indicates the seriousness of missing system prerequisites. The findings suggest that root causes and capacities across the system have to be addressed synergistically to enable systems that can match and accommodate investments in disease-specific interventions. The multiplicity and complexity of existing challenges require a long-term and systems perspective essentially in contrast to the current short term and program-specific nature of external assistance.
The UN Convention on the Rights of Persons with Disabilities, in Australia, acts as a philosophical and moral statement and framework guiding integrated and strategic policy across the nation. Broad policy agreement has been reached by governments, and both the government and non-government sectors are developing strategies for implementation or evaluation. There is however a need for a more integrated approach to disability policy and information, reflecting all three components of the Italian project:
• legislation and a high level philosophical framework and policy guide;
• a technical framework that can underpin specific policies and programs aiming to achieve the major goals; and ,
• a language and set of tools, relating to both the above, that provide infrastructure for assessment methods and information systems.
The International Classification of Functioning, Disability and Health (ICF) is the ideal tool to support the latter two components, consistent with the UN Convention. While the ICF has been used as the basis for national data standards, in population surveys and in the national data collection on disability support services, there is considerable scope for greater use of it, including using all domains of the Activities and Participation and the Environmental Factors component for policy, information and service provision, to advance a disability-inclusive society. Information available from the income support system and from generic services could be enhanced by reference to the ICF components. It would be of significant national value in Australia, especially as a ‘continuum of care’ is desired, if consistency of concepts and information were expanded across health and social welfare sectors. It would then be possible to obtain consistent data from health, aged care, disability and community services systems about key aspects of health and functioning, building a consolidated picture of access and experience across these sectors. Without attention to all three components of the Italian project and continuing effort to meet the challenges identified in this paper, it will not be possible to determine whether the goals of Australia’s National Disability Agreement or the ambitions of the Convention are achieved.
Understanding Health systems have now become the priority focus of researchers and policy makers, who have progressively moved away from a project-centred perspectives. The new tendency is to facilitate a convergence between health system developers and disease-specific programme managers in terms of both thinking and action, and to reconcile both approaches: one focusing on integrated health systems and improving the health status of the population and the other aiming at improving access to health care. Eye care interventions particularly in developing countries have generally been vertically implemented (e.g. trachoma, cataract surgeries) often with parallel organizational structures or specialised disease specific services. With the emergence of health system strengthening in health strategies and in the service delivery of interventions there is a need to clarify and examine inputs in terms governance, financing and management. This present paper aims to clarify key concepts in health system strengthening and describe the various components of the framework as applied in eye care interventions.
Global eye health; health interventions; health systems; systems thinking
The increasing mobility of the population and frequent changes in healthcare coverage, in both the government and private sectors, require integration of medical records not only longitudinally, but also across a variety of healthcare providers. Early in 1998, the federal government decided to solve this problem by constructing a framework for access to medical records by all of the government’s health care facilities, called the Government Computer-Based Patient Record (GCPR). The government consortium chose a proposal by Litton PRC, a partnership of 11 companies with complementary areas of expertise. The framework is based on open systems, which use publicly available standards, and includes a Master Patient Information Locator that allows access to medical information from remote facilities, based on creating a unique identifier for each and every individual patient. PRC will use the Digital Imaging and Communications in Medicine (DICOM) imaging standard for radiology, supplemented by Health Level Seven (HL7).
Enhancing the adaptive capacity of individuals, communities, institutions and nations is pivotal to protecting and improving human health and well-being in the face of systemic social inequity plus dangerous climate change. However, research on the determinants of adaptive capacity in relation to health, particularly concerning the role of governance, is in its infancy. This paper highlights the intersections between global health, climate change and governance. It presents an overview of these key concerns, their relation to each other, and the potential that a greater understanding of governance may present opportunities to strengthen policy and action responses to the health effects of climate change. Important parallels between addressing health inequities and sustainable development practices in the face of global environmental change are also highlighted. We propose that governance can be investigated through two key lenses within the earth system governance theoretical framework; agency and architecture. These two governance concepts can be evaluated using methods of social network research and policy analysis using case studies and is the subject of further research.
global health; climate change; adaptive capacity; equity; governance; decision-making
Governance and leadership in health development are critically important for the achievement of the health Millennium Development Goals (MDGs) and other national health goals. Those two factors might explain why many countries in Africa are not on track to attain the health MDGs by 2015. This paper debates the meaning of 'governance in health development', reviews briefly existing governance frameworks, proposes a modified framework on health development governance (HDG), and develops a HDG index.
We argue that unlike 'leadership in health development', 'governance in health development' is the sole prerogative of the Government through the Ministry of Health, which can choose to delegate (but not abrogate) some of the governance tasks. The general governance domains of the UNDP and the World Bank are very pertinent but not sufficient for assessment of health development governance. The WHO six domains of governance do not include effective external partnerships for health, equity in health development, efficiency in resource allocation and use, ethical practises in health research and service provision, and macroeconomic and political stability. The framework for assessing health systems governance developed by Siddiqi et al also does not include macroeconomic and political stability as a separate principle. The Siddiqi et al framework does not propose a way of scoring the various governance domains to facilitate aggregation, inter-country comparisons and health development governance tracking over time.
This paper argues for a broader health development governance framework because other sectors that assure human rights to education, employment, food, housing, political participation, and security combined have greater impact on health development than the health systems. It also suggests some amendments to Siddigi et al's framework to make it more relevant to the broader concept of 'governance in health development' and to the WHO African Region context.
A strong case for broader health development governance framework has been made. A health development governance index with 10 functions and 42 sub-functions has been proposed to facilitate inter-country comparisons. Potential sources of data for estimating HDGI have been suggested. The Governance indices for individual sub-functions can aid policy-makers to establish the sources of weak health governance and subsequently develop appropriate interventions for ameliorating the situation.
There is overwhelming scientific evidence that human activities have changed and will continue to change the climate of the Earth. Eco-environmental health, which refers to the interdependencies between ecological systems and population health and well-being, is likely to be significantly influenced by climate change. The aim of this study was to examine perceptions from government stakeholders and other relevant specialists about the threat of climate change, their capacity to deal with it, and how to develop and implement a framework for assessing vulnerability of eco-environmental health to climate change.
Two focus groups were conducted in Brisbane, Australia with representatives from relevant government agencies, non-governmental organisations, and the industry sector (n = 15) involved in the discussions. The participants were specialists on climate change and public health from governmental agencies, industry, and non-governmental organisations in South-East Queensland.
The specialists perceived climate change to be a threat to eco-environmental health and had substantial knowledge about possible implications and impacts. A range of different methods for assessing vulnerability were suggested by the participants and the complexity of assessment when dealing with multiple hazards was acknowledged. Identified factors influencing vulnerability were perceived to be of a social, physical and/or economic nature. They included population growth, the ageing population with associated declines in general health and changes in the vulnerability of particular geographical areas due to for example, increased coastal development, and financial stress. Education, inter-sectoral collaboration, emergency management (e.g. development of early warning systems), and social networks were all emphasised as a basis for adapting to climate change. To develop a framework, different approaches were discussed for assessing eco-environmental health vulnerability, including literature reviews to examine the components of vulnerability such as natural hazard risk and exposure and to investigate already existing frameworks for assessing vulnerability.
The study has addressed some important questions in regard to government stakeholders and other specialists' views on the threat of climate change and its potential impacts on eco-environmental health. These findings may have implications in climate change and public health decision-making.
Government actors have an important role to play in creating healthy public policies and supportive environments to facilitate access to safe, affordable, nutritious food. The purpose of this research was to examine Waterloo Region (Ontario, Canada) as a case study for “what works” with respect to facilitating access to healthy, local food through regional food system policy making. Policy and planning approaches were explored through multi-sectoral perspectives of: (a) the development and adoption of food policies as part of the comprehensive planning process; (b) barriers to food system planning; and (c) the role and motivation of the Region’s public health and planning departments in food system policy making. Forty-seven in-depth interviews with decision makers, experts in public health and planning, and local food system stakeholders provided rich insight into strategic government actions, as well as the local and historical context within which food system policies were developed. Grounded theory methods were used to identify key overarching themes including: “strategic positioning”, “partnerships” and “knowledge transfer” and related sub-themes (“aligned agendas”, “issue framing”, “visioning” and “legitimacy”). A conceptual framework to illustrate the process and features of food system policy making is presented and can be used as a starting point to engage multi-sectoral stakeholders in plans and actions to facilitate access to healthy food.
food policy; community food security; public health; government; land use planning; food access
Over the past decade, development assistance for health (DAH) in Uganda has increased dramatically, surpassing the government’s own expenditures on health. Yet primary health care and other priorities identified in Uganda’s health sector strategic plan remain underfunded.
Using data available from the Creditor Reporting System (CRS), National Health Accounts (NHA), and government financial reports, we examined trends in how donors channel DAH and the extent to which DAH is aligned with sector priorities. The study follows the flow of DAH from the donor to the implementing organization, specifying the modality used for disbursing funds and categorizing funds based on program area or support function.
Despite efforts to improve alignment through the formation of a sector-wide approach (SWAp) for health in 1999 and the creation of a fund to pool resources for identified priorities, increasingly DAH is provided as short-term, project-based support for disease-specific initiatives, in particular HIV/AIDS.
These findings highlight the need to better align external resources with country priorities and refocus attention on longer-term sector-wide objectives.
Foreign aid; International cooperation; Health policy; Health financing; Sector-wide approach; Paris declaration
While reaching consensus on future plans to address current global health challenges is far from easy, there is broad agreement that reductionist approaches that suggest a limited set of targeted interventions to improve health around the world are inadequate. We argue that a comprehensive systems perspective should guide health practice, education, research and policy. We propose key ‘systems thinking’ tools and strategies that have the potential for transformational change in health systems. Three overarching themes span these tools and strategies: collaboration across disciplines, sectors and organizations; ongoing, iterative learning; and transformational leadership. The proposed tools and strategies in this paper can be applied, in varying degrees, to every organization within health systems, from families and communities to national ministries of health. While our categorization is necessarily incomplete, this initial effort will provide a valuable contribution to the health systems strengthening debate, as the need for a more systemic, rigorous perspective in health has never been greater.
Health systems strengthening; systems thinking; global health
The Department of Health in Western Australia identified access to, and daily consumption of recommended amounts of fruit and vegetables, as priority health determinants. The numerous factors that influence supply and consumption of fruit and vegetables indicated that a comprehensive approach would be required.
A government and non-government sector steering group was set up to select priority interventions using the National Public Health Partnership's Framework for Implementing Public Health Strategies. This structured framework was used for developing strategies to improve fruit and vegetable consumption and supply, and to identify implementation priorities.
After one year a desktop audit of progress on framework interventions was undertaken.
The structured framework led to a plan for defined actions, partners, costs, and performance indicators for strategies to improve fruit and vegetable consumption and supply. Lead agency custodians for management of the selected interventions were identified.
After one year there was significant progress in the implementation of a number of the high-ranking interventions. The exception was interventions that provide the infrastructure support such as research and development capacity, information systems.
A structured framework and stakeholder participation assisted in developing a fruit and vegetable implementation strategy. Engagement and commitment of influential and diverse stakeholders is needed, not just for program support, but particularly in the areas of food and nutrition policy development and providing the infrastructure support required. Further work is required to develop performance outcomes and cost effectiveness measures for many of the strategies that have been proposed to address portfolio objectives.
In the debate on 'Third options' for health care delivery in low- and middle-income countries it is proposed that self-help should play a larger role. Self-help is expected to contribute towards improving population health outcomes and reducing government health care expenditure. We review scope and limitations of self-help groups in Europe and South Asia and assess their potential role in health care within the context of health sector reform.
Self-help groups are voluntary unions of peers, formed for mutual assistance in accomplishing a health-related purpose. In Europe, self-help groups developed out of dissatisfaction with a de-personalised health care system. They successfully complement existing social and health services but cannot be instrumentalized to improve health outcomes while reducing health expenditure.
In South Asia, with its hierarchical society, instrumental approaches towards self-help prevail in Non-governmental Organizations and government. The utility of this approach is limited as self-help groups are unlikely to be sustainable and effective when steered from outside. Self-help groups are typical for individualistic societies with developed health care systems – they are less suitable for hierarchical societies with unmet demand for regulated health care. We conclude that self-help groups can help to achieve some degree of synergy between health care providers and users but cannot be prescribed to partially replace government health services in low-income countries, thereby reducing health care expenditure and ensuring equity in health care.
Self-help; Health Sector Reforms; Health care provision; South Asia; Health care organization
Systems for planning are a critical component of the infrastructure for public health. Both in Australia and internationally there is growing interest in how planning processes might best be strengthened to improve health outcomes for communities. In Australia the delivery of public health varies across states, and mandated municipal public health planning is being introduced or considered in a number of jurisdictions. In 1988 the Victorian State government enacted legislation that made it mandatory for each local government to produce a Municipal Public Health Plan, offering us a 20-year experience to consider.
In-depth interviews were undertaken with those involved in public health planning at the local government level, as part of a larger study on local public health infrastructure and capacity. From these interviews four significant themes emerge. Firstly, there is general agreement that the Victorian framework of mandatory public health planning has led to improvements in systems for planning. However, there is some debate about the degree of that improvement. Secondly, there is considerable variation in the way in which councils approach planning and the priority they attach to the process. Thirdly, there is concern that the focus is on producing a plan rather than on implementing the plan. Finally, some tension over priorities is evident. Those responsible for developing Municipal Public Health Plans express frustration over the difficulty of having issues they believe are important addressed through the MPHP process.
There are criticisms of Victoria's system for public health planning at the local government level. Some of these issues may be specific to the arrangement in Victoria, others are problems encountered in public health planning generally. In Victoria where the delivery structure for public health is diverse, a system of mandatory planning has created a minimum standard. The implementation of the framework was slow and factors in the broader political environment had a significant impact. Work done in recent years to support the process appears to have led to improvements. There are lessons for other states as they embark upon mandated public health plans.
In the past decade the sector-wide approach (SWAp) model has been promoted by donors and adopted by governments in several countries. The purpose of this study is to look at how partners involved in the health SWAp in Bangladesh define ownership and coordination, in their daily work and to analyse the possible implications of these definitions.
The study object was a process of decision-making in the Government of Bangladesh in 2003. Information was collected through participant observations, interviews and document review.
During the study period the Government of Bangladesh decided to reverse a decision to unify the two wings of the Ministry of Health and Family Welfare. The decision led to disagreements with development partners, which had serious implications for cooperation between key actors in the Bangladesh health sector leading to deteriorated relationships and suspension of donor funds. The donor community in itself was also in disagreement which led to inconsistencies in the dialogue between the development partners and the Government of Bangladesh.
The case shows that main actors in the Bangladesh health SWAp interpret ownership and coordination, fundamental aspects of SWAp, differently. As long as work ran smoothly, the different definitions did not create any problems, but when disagreements arose they became an obstacle. It is concluded that partners in development should devote more effort to their working relationships and that responsibilities within a SWAp need to be more clearly delineated.
Despite the mounting attention for health systems and health systems theories, there is a persisting lack of consensus on their conceptualisation and strengthening. This paper contributes to structuring the debate, presenting landmarks in the development of health systems thinking against the backdrop of the policy context and its dominant actors. We argue that frameworks on health systems are products of their time, emerging from specific discourses. They are purposive, not neutrally descriptive, and are shaped by the agendas of their authors.
The evolution of thinking over time does not reflect a progressive accumulation of insights. Instead, theories and frameworks seem to develop in reaction to one another, partly in line with prevailing paradigms and partly as a response to the very different needs of their developers. The reform perspective considering health systems as projects to be engineered is fundamentally different from the organic view that considers a health system as a mirror of society. The co-existence of health systems and disease-focused approaches indicates that different frameworks are complementary but not synthetic.
The contestation of theories and methods for health systems relates almost exclusively to low income countries. At the global level, health system strengthening is largely narrowed down to its instrumental dimension, whereby well-targeted and specific interventions are supposed to strengthen health services and systems or, more selectively, specific core functions essential to programmes. This is in contrast to a broader conceptualization of health systems as social institutions.
Health systems theories and frameworks frame health, health systems and policies in particular political and public health paradigms. While there is a clear trend to try to understand the complexity of and dynamic relationships between elements of health systems, there is also a demand to provide frameworks that distinguish between health system interventions, and that allow mapping with a view of analysing their returns. The choice for a particular health system model to guide discussions and work should fit the purpose. The understanding of the underlying rationale of a chosen model facilitates an open dialogue about purpose and strategy.
Health systems; Health systems strengthening; Donor policies; Global health governance
The new agenda for Public Health in India includes the epidemiological transition, demographical transition, environmental changes and social determinants of health. Based on the principles outlined at Alma-Ata in 1978, there is an urgent call for revitalizing primary health care in order to meet these challenges. The role of the government in influencing population health is not limited within the health sector but also by various sectors outside the health systems. This article is a literature review of the existing government machinery for public health needs in India, its success, limitations and future scope. Health system strengthening, human resource development and capacity building and regulation in public health are important areas within the health sector. Contribution to health of a population also derives from social determinants of health like living conditions, nutrition, safe drinking water, sanitation, education, early child development and social security measures. Population stabilization, gender mainstreaming and empowerment, reducing the impact of climate change and disasters on health, improving community participation and governance issues are other important areas for action. Making public health a shared value across the various sectors is a politically challenging strategy, but such collective action is crucial.
Health sector; intersectoral issues; public health; role of government