FHS Updates

BLOG: The mining boom: will residents of mineral rich countries benefit?

Fri, 17 Feb 2012 12:10:38 +0000

BY GERRY BLOOM, RESEARCH FELLOW, IDS

As part of my ongoing work investigating health markets and the role of non-state actors in provision of health services, I am involved in a project concerning the role of mining companies in supporting the provision of health services to their employees and the wider community in mineral rich countries. This provided me with the opportunity to participate in the Mining Indaba 2012 in Cape Town in early February. This is an annual event for managers of mining companies, financiers, officials of multi-lateral organisations and Ministers from many African countries. The meeting was an eye-opener.

I had not been sufficiently aware of the magnitude of the present boom in the demand for minerals, which seems to be associated with rapid economic growth in many low- and middle-income countries and the enormous investments being made in the infrastructure of many large cities.

I was impressed by the size of investments being made in a number of African countries. Several new finds will provide large revenue streams for many years. There was a lot of discussion of ‘resource nationalism’, stimulated by high mineral prices. There was a view that companies need to earn their ‘licence to operate’ over the many years needed to recoup the large investment in a new mine. This was seen to involve much more than ‘traditional’ investments in corporate social responsibility.

Mamphela Ramphele, who chairs the Board of Gold Fields, presented a vision of a partnership between large corporations, community social investment organisations and national and local governments aimed at solving major problems with the provision of education, delivery of health services and the development of communities where mines are located. She called on large mining companies to play a leadership role in helping governments address these problems, suggesting that they operate on a time frame longer than the usual political cycle.

The unspoken alternative, of course, was the possibility that calls to nationalise mines could gain political support and that mining companies from countries where demand for minerals is growing rapidly might be potential partners for joint ventures with governments.

The take home message from the Indaba is that we are in the midst of a major mining boom. If mining companies, governments and civil society organisations can create effective partnerships for development, many people living in mineral rich countries will benefit a great deal. Otherwise, we may be witnessing another turn in a boom and bust cycle that enriches few and leaves many more in poverty.

[EDITOR'S NOTE: This blog originally appeared on the IDS Globalisation and Development blog. See also the IDS Globalisation Team’s Business and Development seminar series. Three of the five seminars under last autumn’s theme ‘Conflicting Interests: How Businesses Operate in Areas of Conflict’ focused on mining.]

PUBLICATION: 卫生服务提供体系创新:公立医院法人化 (中文版)

Tue, 31 Jan 2012 16:59:50 +0000

《卫生服务提供体系创新:公立医院法人化》系世界银行经济学家对多个发达国家(地区)和发展中国家(地区)的公立医院改革进行研究的一项成果。《卫生服务提供体系创新:公立医院法人化》清晰地提出了公立医院的改革目的，阐述了其改革的理论基础，提出了分析、评价公立医院改革的基本框架。强调只有外部环境和内部治理的制度安排相互作用和协调一致，公立医院的改革才能成功。《卫生服务提供体系创新:公立医院法人化》利用原苏东地区和拉丁美洲地区的综述及九个国家(地区)案例研究的数据，对公立医院组织变革的全球经验进行了比较分析。作者通过系统、翔实的资料和深入的分析向读者展示了英国、新西兰、澳大利亚、中国香港、马来西亚、新加坡、突尼斯、印度尼西亚和厄瓜多尔等九个国家(地区)的公立医院改革的鲜活案例。《卫生服务提供体系创新:公立医院法人化》对公立医院改革的研究者和实践者大有裨益。

PUBLICATION: FHS Podcast 2: A visit to Kabul

Thu, 12 Jan 2012 13:12:10 +0000

In the second podcast from Future Health Systems, Jeff Knezovich visits the FHS Afghanistan team in Kabul to find out what sort of research they're currently undertaking, what challenges they face in attempting research in an insecure environment, and what it's like living and working in difficult security situations. He interviews Kojo, Melissa Roach and Anubhav Agarwal, who tell him about the community scorecard that FHS is in the process of piloting in several provinces in Afghanistan.

VIDEO: USAID Leadership in Health Systems

futurehealthsys — Fri, 06 Jan 2012 12:31:23 +0000

	USAID Leadership in Health Systems Dr Ariel Pablos-Mendez, Assistant Administrator of the Global Health Bureau at USAID, presents his vision to shape USAID's Bureau for Global Health's programmatic efforts to accomplish sustainable, scalable and measurable impact on the lives of people in developing countries at a public event hosted by the DC Health Systems Board in conjunction with partners at Johns Hopkins School of Advanced International Studies (SAIS). The DC Health Systems Board is Health Systems Board, a Future Health Systems project, 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. Find out more at: sites.google.com	From: futurehealthsys Views: 45 0 ratings
	Time: 45:42	More in News & Politics

BLOG: Health dragons or health hydras? The challenges of regulation in Asian health systems

Mon, 19 Dec 2011 06:45:03 +0000

Dr Asha George of JHSPH discusses rural medical practitioners in India at HSRA

BY BARUN KANJILAL, IIHMR

Like most aspects of life in Asia, health systems have undergone massive changes in the last twenty years. And if we’ve seen some economic dragons, we’ve also seen some health dragons – with several countries posting impressive gains in health outcomes. For example, official figures indicate China has already achieved MDG 4 by reducing infant mortality rates from over 50 per 1000 live births in 1991 to under 14 in 2009, while under-five mortality has also dropped from 61 per 1000 live births in 1991 to just over 17 in 2009.

But ‘health dragons’ doesn’t quite capture the full picture. For the most part these changes have not been happening as a result of a controlled change process. Rather, they’ve been emerging from the diverse, unguided responses of some of the most populous countries in the world. This means they look more like another mythical creature: the many-headed hydra.

This was made very apparent at this year’s Health System Reform in Asia conference held from 10-12 December at Hong Kong University. Organised by Elsevier and their journal, Social Science and Medicine (be on the lookout for a special issue from the conference out in 2012), the conference brought together some of the biggest names in health systems in Asia. The organisers of the 2^nd Global Symposium on Health System Research, which will be held in November 2012 in Beijing, had a strong presence, for example.

As I presented at the conference, the story of the Indian health system is a good example of the health hydra. Following significant economic reforms in the 1990s, the private sector soon outstripped the public in terms of health service provision – not only in hard-to-reach rural areas, but even in major urban hubs. Utilisation of in-patient care by private providers, for instance, jumped from less than 40% in the late 80s to more than 60% in the last decade. And outpatient care has even higher private sector penetration at roughly 77% across the country.

Of course, when I say the ‘private sector’ the majority of those providers, especially in the outpatient care market, have little to no formal medical training. My colleague at JHSPH, Dr Asha George, presented a more detailed discussion of who these informal ‘rural medical providers’ are and why they play such an important role in the Indian health system. And indeed, the Future Health Systems consortium has a substantial body of work on the role of informal providers not just in Bangladesh and India, but also in Nigeria.

Our recent study of health care service provision in the Sundarbans of West Bengal paints an even messier picture. In addition to the publicly funded health clinics and hospitals and the raft of informal providers, the area is also serviced by an array of both local and international NGOs. Coupled with rapid advances in health technologies and pharmaceuticals – not to mention a fragile environment susceptible to frequent climate shocks, like Cyclone Aila which devastated the area in 2009 – it’s easy to understand how the system became so complex.

But this poses a significant challenge: how can we improve these systems, with all their perverse incentives, to better serve the poor? In other words, how can we better regulate these health markets?

One phrase that kept popping up throughout the conference was the idea of ‘command and control’ – that through strong government intervention we could make significant and intentional changes in the way these health systems worked. But there was an even larger group who suggested that, when working in complex adaptive systems, ‘command and control’ is inefficient. There are simply too many interconnections that we cannot understand, which lead to a variety of unintended consequences when we intervene in these systems.

Finding a model that works somewhere between ‘command and control’ and utter chaos was one of the challenges my colleague at IDS, Dr Gerry Bloom, put forward to the conference.

This led to a lot of discussion about ‘poly-centric governance models’, where the challenge of regulation doesn’t lie simply in the hands of the government. Rather, the argument goes, we must be working on all fronts: institutionalising professional bodies and standards to promote self-regulation in the private sector; establishing patient support groups – like the diabetes-related peer group MoPoTsyo in Cambodia – and improving their access to health information; and recognising non-traditional actors as part of the health system.

We tend to overlook the role that non-traditional actors, like social change entrepreneurs, the media and advertisers play in health markets. However, Dr Sachiko Ozawa’s presentation on trust in injections in Cambodia underscores this point. The average Cambodian receives six injections per year, usually because they think injections are more efficacious than other forms of treatment (e.g. oral tablets). This is such a firmly held belief that often patients will seek care outside of the formal sector (who usually deny inappropriate injections) to get what they want. Although her research didn’t delve too deeply into why there was such misplaced trust in injections, it might be at least in part due to substantial vaccination education campaigns from public health advocates. Working with media and advertisers will be an important part of improving knowledge here about appropriate use of injections.

They say that the best way to fight fire is with fire. Perhaps this ‘poly-centric governance structure’ is attempting just that – fighting hydra with hydra. I would expect to be hearing much more about what this model might look like in different Asian contexts in the near future.

NEWS: USAID leadership in health systems

Fri, 16 Dec 2011 14:46:00 +0000

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 flexibility, innovation 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.

PUBLICATION: Building Informed Trust: Injection Practices in Cambodia

Fri, 16 Dec 2011 06:09:05 +0000

Dr Sachiko Ozawa from JHSPH presents recent findings from a study on trust in health systems and injection rates in Cambodia to the Health System Reform in Asia conference in Hong Kong in December 2012. She notes that the average Cambodian receives six injections/year, and that trained medical practitioners often feel pressure to give shots and IVs as patients will often turn to informal providers if they don't.

PUBLICATION: Regulatory challenges associated with the rapid spread of health markets

Wed, 14 Dec 2011 06:18:46 +0000

Dr Barun Kanjilal of IIHMR gives an overview of the regulatory challenges associated with the rapid spread of health markets in India to the Health System Reform in Asia conference held in Hong Kong in early December 2011. He notes in particular the important role that informal providers have played in delivering health services in the wake of government reforms.

PUBLICATION: Understanding informal markets: The roles and perspectives of RMPs in West Bengal and Karnataka, India

Tue, 13 Dec 2011 09:20:29 +0000

Dr Asha George of JHSPH presents work on the role of informal health care providers in India at the Health System Reform in Asia conference held in December 2011 in Hong Kong. She compares West Bengal and Karnataka -- two states with very different health profiles -- providing both qualitative and quantitative insights into how and why the poor use poorly trained rural medical practitioners as their first port of call when accessing health services.

NEWS: বাড়িতেই বেশি প্রসব, সুন্দরবনে বিধ্বস্ত শিশু-স্বাস্থ্য

Tue, 13 Dec 2011 07:28:01 +0000

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 >>

PUBLICATION: Building institutions for health and health systems in contexts of rapid change

Sun, 11 Dec 2011 15:32:51 +0000

Dr Gerald Bloom from IDS presents in a plenary session at the Health Systems Reform in Asia conference in Hong Kong on 11 December 2011. He focuses on the need to consider the complex mixed health systems when setting an evaluation research agenda.

NEWS: Health System Reform in Asia

Sun, 11 Dec 2011 01:25:31 +0000

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

Meeting new regulatory challenges: Markets, information and citizen, 10 Dec., 16:30-18:00, Rayson Huang Theatre
- Dr Barun Kanjilal - Regulatory Challenges Associated With The Rapid Spread Of Health Markets
Building institutions for health and health systems in contexts of rapid change, 11 Dec., 09:00-10:30, Rayson Huang Theatre
- Dr Gerry Bloom - Building Institutions For Health And Health Systems In Contexts Of Rapid Change
Strategies for improving the performance of poorly regulated health markets, 11 Dec., 13:30-15:10, Rayson Huang Theatre
- Dr Asha George: Understanding Informal Markets - The Roles And Perspectives Of RMPs In West Bengal And Karnataka, India
- Dr Sachiko Ozawa - Building Informed Trust: Injection Practices In Cambodia

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

Posters

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.

NEWS: Seven African Universities set Health Systems Research Capacity Agenda

Wed, 07 Dec 2011 12:24:13 +0000

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).

PUBLICATION: Removing user fees for basic health services: a pilot study and national roll-out in Afghanistan

Wed, 07 Dec 2011 06:19:26 +0000

Steinhardt, L., I. Aman, I. Pakzad, B. Kumar, L Singh and D. Peters (2011) Removing user fees for basic health services: a pilot study and national roll-out in Afghanistan. Health Policy Plan. (2011) 26 (suppl 2): ii92-ii103. doi: 10.1093/heapol/czr069

Abstract

Background User fees for primary care tend to suppress utilization, and many countries are experimenting with fee removal. Studies show that additional inputs are needed after removing fees, although well-documented experiences are lacking. This study presents data on the effects of fee removal on facility quality and utilization in Afghanistan, based on a pilot experiment and subsequent nationwide ban on fees.

Methods Data on utilization and observed structural and perceived overall quality of health care were compared from before-and-after facility assessments, patient exit interviews and catchment area household surveys from eight facilities where fees were removed and 14 facilities where fee levels remained constant, as part of a larger health financing pilot study from 2005 to 2007. After a national user fee ban was instituted in 2008, health facility administrative data were analysed to assess subsequent changes in utilization and quality.

Results The pilot study analysis indicated that observed and perceived quality increased across facilities but did not differ by fee removal status. Difference-in-difference analysis showed that utilization at facilities previously charging both service and drug fees increased by 400% more after fee removal, prompting additional inputs from service providers, compared with facilities that previously only charged service fees or had no change in fees (P = 0.001). Following the national fee ban, visits for curative care increased significantly (P< 0.001), but institutional deliveries did not. Services typically free before the ban—immunization and antenatal care—had immediate increases in utilization but these were not sustained.

Conclusion Both pilot and nationwide data indicated that curative care utilization increased following fee removal, without differential changes in quality. Concerns raised by non-governmental organizations, health workers and community leaders over the effects of lost revenue and increased utilization require continued effort to raise revenues, monitor health worker and patient perceptions, and carefully manage health facility performance.

PUBLICATION: Targeting accuracy and impact of a community-identified waiver card scheme for primary care user fees in Afghanistan

Tue, 06 Dec 2011 17:53:36 +0000

User fees are a known common barrier to using health services, particularly among the poor. When fees are present, many facilities have waiver systems for poor patients to exempt them from paying. Targeting waivers to patients who need them most has been a challenge, especially in fragile states, where relevant data are limited and trust in institutions is low. An analysis of the asset index of beneficiaries indicated that although targeting was progressive, significant leakage and high levels of under-coverage occurred; 42% of cards were used by people in the wealthiest three quintiles, and only 19% of people in the poorest quintile received a card. Households with waiver cards reported higher rates of care-seeking for recent illnesses compared to those without cards (p = 0.02).

PUBLICATION: Association between health workforce capacity and quality of care for children under five in Afghanistan

Thu, 01 Dec 2011 11:29:00 +0000

This presentation by Dr Anbrasi Edward at the 28th ISQua conference in Hong Kong was informed by a study to determine the association between health workforce capacity and quality of care in primary care facilities providing a basic package of health services (BPHS) in Afghanistan.

BLOG: CHMI highlights five emerging models for health service delivery and financing

Wed, 30 Nov 2011 14:43:58 +0000

BY ROSE REIS, CENTER FOR HEALTH MARKET INNOVATIONS

New approaches to improve health access and quality being pioneered by Future Health Systems

6000 Ugandan women die every year from preventable pregnancy and childbirth related complications. If women could only deliver under skilled care, about 80 percent of these deaths could be prevented. Enter Future Health System’s Safe Deliveries initiative: The program offers vouchers for transport and maternal services as well as training for health workers and provision of essential equipment, drugs and supplies. Its impact? The number of facility deliveries more than tripled during the pilot phase.

Vouchers are an example of a ‘health market innovation,’ a program that harnesses the private sector in low- and middle-income countries to deliver better health and financial protection for the poor. While many governments promise well-functioning, state-run public health systems, what often happens is much more chaotic and less centrally managed, with patients seeking care from a plethora of providers, including drug shops, village doctors, non-governmental organization (NGO) clinics, private hospitals, as well as government clinics.

Health market innovations help health systems improve quality, access, affordability and efficiency in transactions between patients and providers, promoting better health with less financial risk, especially for the poorest and most vulnerable. In 2010, the Center for Health Market Innovations (CHMI) was launched to serve as a global information source on these programs and policies—implemented by governments, NGOs, social entrepreneurs or private companies—that have the potential to improve the way health markets operate.

With eight partners based in 16 countries, CHMI has identified more than 1000 programs in 108 countries—including several programs FHS studies. These programs work to:

Better organize fragmented providers
Mobilize funds and create financing mechanisms to provide purchasing power to the poor
Set quality standards and monitor provider performance
Educate consumers and providers to ensure that appropriate care is both demanded and provided
Enhance quality and efficiency through standardized operational processes and innovative information technologies

In its 2011 Annual Highlights Report, CHMI identified five innovative emerging models that show promise, and may ultimately improve the performance of health markets in low- and middle-income countries.

1. Low-cost, high-quality retail pharmacies

Small family-owned drug shops line the streets of cities and villages across low- and middle-income countries. Unfortunately the quality of their offerings is equally all over the map, with many shops offering counterfeit drugs that don’t work and can be toxic. Professionalized pharmacy chains and franchise networks proliferating in Asia may improve drug quality and operational efficiency to keep prices low. In the Philippines, Botika ng Bayan and Generics Pharmacy are two popular franchise networks that have seen success. Similarly, in India, the pharmacy chain MedPlus originated in tech-hub Hyderabad and has since spread nationally.

2. Affordable Primary Care Clinic Chains

These chains—often for-profit—are set up to standardize quality and give low-income people more care options. Many chains operate in urban areas where large volumes can help them keep prices down. Inspired by the U.S. drug store chain CVS and its Minute Clinics, Saúde 10 opened in 2011 in Rio de Janeiro, Brazil. In Nairobi, LiveWell's main clinic provides consultation, diagnosis, and treatment for a wide range of illnesses, while qualified clinical officers and registered nurses run satellite clinics.

3. Vouchers

Vouchers—distributed for free as with FHS’s Safe Deliveries project in Uganda, or sold for a small fee, as with Kenya’s Output Based Aid Voucher Program—increase access to key health services by allowing low-income people to “purchase” (through demand-side donor or government subsidies) a specific package of services from approved clinics which often include both public and private facilities. Private maternity clinics have been able to expand their services and extend their customer base to poorer clients as a result.

4. Telemedicine

In many countries doctors and specialists cluster in urban areas leaving rural areas underserved. Telemedicine shows promise in bridging the rural-urban health divide. In one example of how this model works, World Health Partners is a promising not-for-profit chain using technology that allows doctors in urban areas to monitor vital signs, diagnose illnesses, and recommend treatment for patients in India’s rural north.

5. Health Hotlines

Health hotlines provide basic health information and connections to available health services. HealthLine — run by Dhaka’s Telemedicine Reference Center, an FHS partner — connects providers and patients in Bangladesh through a mobile phone based hotline number (789) to a call center manned by licensed physicians that provide medical consultations 24/7. MeraDoctor is a for-profit health line just launched in Mumbai. Popular throughout South Asia, these well-utilized businesses may soon be replicated in East Africa.

These models offer promising solutions to key health system challenges, but the question remains: do they really work in the long term? What programs are actually improving quality, affordability, and access? We look forward to working with Future Health Systems and other partners to collect and share better evidence, and then promote the scale-up and replication of high-impact programs.

NEWS: FHS to participate in STEPS Centre summer school

Sat, 26 Nov 2011 13:44:57 +0000

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.

BLOG: M4P Hub Conference proceedings series: Making informal health providers work better for the poor

Tue, 22 Nov 2011 17:30:04 +0000

EDITORS NOTE: This blog is a repost from the M4P Hub Conference news.

BY DR GERALD BLOOM, INSTITUTE OF DEVELOPMENT STUDIES

My presentation at the M4P Hub Conference reflects work by several members of the Future Health Systems Consortium on the implications of the rapid spread of markets for health-related goods and services. These markets are complex with a variety of sellers of health related goods in terms of ownership, mission, reputation and relationship to the regulatory system. Poor people frequently use providers in unorganised markets. Studies in Nigeria and Bangladesh found that more than half of people seeking treatment for malaria in the former used a patent medicine vendor and sixty-five percent of people who visited a health provider in a rural district in the latter went to an informal village doctor. In both cases there were serious problems with safety, effectiveness and cost. The behaviour of informal providers of drugs and health services is influenced by their source of knowledge (formal training, informal apprenticeships, advertising, marketing by drug wholesalers and so forth), financial incentives (including profits from selling drugs and commissions from drug wholesalers) and strategies to build and maintain their reputation. In both countries, interventions sought to convince informal providers to pay more attention to the quality of drugs and appropriateness of prescriptions through training and the involvement of trade associations and local government leaders in measures to monitor their performance and build their reputation. Governments and other stakeholders need to find effective ways to engage with pervasive health markets to protect the interests of the poor.

The following lessons should be taken into account:

Interventions should be based on an analysis of the market system including the drug distribution network and the growing role of knowledge intermediaries, such as mobile telephone companies.
Effective interventions are likely to involve partnerships between organisations with different agendas and different capacities.
ustainable interventions need to include realistic business models for informal providers and for other intervention partners.
Politics and interests strongly influence outcomes when going to scale and effective strategic leadership is needed.

Dr Bloom describes the response at the conference: “There was a lot of discussion about whether the special characteristics of the health sector mean that the M4P approach is not applicable to it. We discussed how unregulated markets for health-related goods and services can expose individuals to risk from dangerous or ineffective treatment and also lead to the emergence of diseases that are resistant to the available drugs. We also discussed the many ways that health markets are similar to markets in other sectors. We agreed that the design and implementation of interventions to improve the performance of health markets needs to combine expertise in health and health systems with expertise in engaging with markets. There was some discussion of the difficulties in combining these approaches. However, there was general agreement on both the magnitude of the health problems in many low income countries and the degree to which health markets have spread in them. We concluded that it is time for serious work to develop practical approaches for improving the performance of health markets in meeting the needs of the poor”.

NEWS: Making health markets work for the poor

Wed, 09 Nov 2011 20:05:15 +0000

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.