Document(s) 7 of 10

The way health systems are designed, managed and financed affects people's lives and livelihoods. The difference between a well-performing health system and one that is failing can be measured in death, disability, impoverishment, humiliation, and despair.
-- Gro Harlem Brundtland (WHO 2000)

The lowering of mortality rates and disease burden in Rufiji and Morogoro supports the initial premise that TEHIP set out to test. The burden of disease can be significantly lowered through relatively low-cost investments in strengthening health systems by providing incremental, decentralized, sector-wide health basket funding -- and a tool kit of practical management, planning, and priority-setting tools that assist an evidence-based approach. In other words, investing in health systems works.

What else have we learned? During several years of intensive research and fieldwork, the TEHIP team has observed many situations that we feel are instructive for health system development. This chapter lists a few critical lessons arising from that experience. All relate to the task of strengthening health systems and are organized under the thematic categories of general principles, people, information, infrastructure, and governance. These are
all crucial components to ensure the effective delivery of health care. Investing in these essential pillars of health care delivery will maximize any corollary gains achieved through the introduction of new drugs, treatments, and interventions.

General principles

A significant amount of new money needs to be dedicated to strengthening basic health systems in developing countries to allow the scaling-up of coverage of existing essential health interventions. Basic health services -- widely distributed but tightly integrated -- are the foundations upon which advances in health can be based.

Where possible, initiatives to improve health should take advantage of the synergies created by combining research and development functions into a mutually reinforcing, integrated system. Funding research and development activities simultaneously -- and encouraging researchers and development specialists to be aware of and involved in each other's specific areas of concern -- produces multiple benefits. Foremost among these is that important research findings can be acted upon quickly: there is no need to reapply for funding before the development stage can proceed. Also, development plans can benefit from continuous input from researchers: effectiveness can be monitored and improvements can be made as work proceeds. Finally, being linked to a concrete development agenda affords researchers greater credibility within communities. 

People

Investments must be made to increase and improve human resources to implement health services. IMCI, the Integrated Management of Childhood Illnesses -- a key expression of health reforms instituted in the districts -- illustrates how crucial training and retraining are to success. In addition, projected population growth, workforce attrition, and changing patterns of disease indicate that major and continuing investments in human resources will be crucial if Africa is to meet the coming challenges. For example, models published by Kurowski et al. (2003) predict that in a country like Tanzania, even with large increases in training capacity, the work force available for the health sector will decrease by up to 25% by the year 2015.

Coming at a time when most health problems are increasingly preventable, when health threats and strain on health services are also expected to increase, and when significant new resources for health are being mobilized, these work force statistics highlight the need for a major increase in human resources for health. New expenditures should include funding for initial training, retraining, and continuing education, as well as for the development of new curricula to address and update health workers' knowledge of new interventions and guidelines.

Infrastructure

Significant amounts of money must be made available for the "bricks and mortar" aspects of health care -- essential capital resources like community clinics, vehicles to transport providers and supplies to where they are needed, and information and communication technologies. The size of investments required will vary from country to country. While in Tanzania, a good network of health facilities was already in place (albeit, in various states of disrepair), such facilities may not exist in other countries.

Governance

Rather than depending on a series of remotely planned, disease- or intervention-specific programs, funding and implementation priorities must increasingly be based upon locally owned, evidence-based plans that aim to develop the health system, maximize health, and reduce inequities. Ministries of health, local government, and health system managers need to ensure that regulations and standards for quality of care and service delivery are adequately maintained.

Health-related project initiatives should be designed with an "exit strategy" in mind, so that local ownership and buy-in, sustainability, and momentum become factors that are likely to extend the influence of the project once the project managers have left. It is important to provide funding for the machinery -- such as the training of local-level professional trainers -- so that the benefits of a promising project will extend both nationally and internationally.

The benefits of health "observatories" must be recognized. It is here that current research can be assembled, packaged, and translated into accessible language so that governmental decision-makers in health are better equipped to do their jobs. Researchers cannot be expected to have the appropriate skills to disseminate their findings to politicians and government officials. That task requires another level of specialists who will function as intermediaries between the research community and the architects of the health system.

Information

To optimize the use of limited financial resources, health spending must respect and encourage local evidence-based priorities rather than the agendas of donors and "vertical" programs. As experience with decentralization proceeds, it is no longer appropriate for districts in developing countries to be compelled to design their local budgets and programs around the priorities of bilateral and multilateral agencies. Additionally, it is advantageous to avoid competitive situations that can arise between international donors. The sector-wide approach (SWAp) -- which pools international sectoral contributions to create a funding "basket" -- is one example of how competition can be avoided and cooperation encouraged.

Furthermore, the availability of data through sentinel population-based information systems provides a disincentive for the continuation of vertical, sometimes competitive agendas promoted by single organizations. Donors and funders sometimes promote vertical initiatives because this is the easier way of monitoring the impact of their program spending. However, Demographic Surveillance System data can provide a measure of accountability by demonstrating whether, cumulatively, international contributions have had an impact on mortality rates.

In countries not yet able to afford or manage functional vital event registration of births, deaths, and causes of death -- including most of sub-Saharan Africa -- there should be an alternative of at least two (one rural, one urban) sentinel or sample Demographic Surveillance Systems. These would function as minimum, cost-effective population, health, and poverty observatories. More such sentinels are needed in countries with greater diversity in health risk patterns. DSSs should also be employed with a view to the integrated use of several different streams of information (such as health status, poverty indicators, and equity indicators), all of which flow from sentinel DSS monitoring. These systems can provide an important share of the evidence base for local planners.

If health-intervention systems are to play their role effectively as instruments for improving health, they must be designed to support the decisions and actions of health personnel. They may also be part of an integrated poverty-monitoring system. Health workers also need access to population-based information and to practical information on how to manage health facilities. This points, for example, to an urgent need to develop new tools to help district planners understand health service access and coverage, and where and how it fails. It also points to the importance of assisting the health system to scale up once its technical and allocative deficiencies have been addressed. Information must be presented to managers and management teams in an easily understood fashion. Local-level managers have neither the time nor the luxury of sifting through large amounts of data to determine what information is of practical use to them. Presenting such data precisely and graphically will speak to these managers in ways that allow them to make better, evidence-based decisions.

Conclusion

As the accounts contained in this book have shown, TEHIP has been largely concerned with assisting decentralized health system managers address technical and allocative inefficiencies by increasing their access to new management skills and new forms of local evidence. More work is required, however.

In the medium term, the challenge is to strengthen and consolidate the indigenous structures capable of absorbing the hard-won lessons of the district health managers in Rufiji and Morogoro and "rolling out" the products and approaches that led to drastic reductions in mortality in those districts. This challenge is being addressed today, for instance, by a consultancy that has been set up to enable Tanzania's zonal training centres to train and motivate the personnel responsible for bringing those tools and approaches to the rest of Tanzania. "Scaling up," however, is difficult and time-consuming. It is important that we not become discouraged by the scope of this task and that the lessons that flow from the experience in Tanzania -- that systemic improvement of health care delivery can greatly reduce mortality -- not be discarded or forgotten.

Document(s) 7 of 10