Responses from Featured Experts
Question 1: (Bangladesh)
I am interested to know the ideal steps of designing and setting up a Maternal & Child Health related primary health care programme, tagging it to existing Water & Sanitation projects in remote hard to reach villages, and creating a functional linkage with secondary and tertiary health facilities for referral of patients. I also need to write a project proposal on this. How would you suggest I begin?
Tarry Asoka Response:
From the brief note you have provided of the project site, it appears that you should be looking at helping to develop a programme that is designed according to the special needs and circumstances of the area it intends to serve. In doing so it would be proper to identify how people are already coping with meeting their needs for health services and broader health-related issues including water and sanitation, food, housing and so on. Specifically, find out the constraints they are facing in meeting these needs. Start by designing the project to relieve these constraints. Then add on other initiatives as the people begin to have confidence in what the project can deliver. All the way, identify ‘community-resources’ – people, materials and, if possible, money - that can be used to undertake project activities. This is actually the ‘ownership’ factor that has been very elusive in many projects.
Question 2:
Health system functions have often been defined from a largely supplier perspective, ignoring the role that communities play in health system processes and indeed in achieving the intended outcomes. Do we have examples of developing countries where the full functionality of the health systems that exclude communities has been achieved? I am also interested to know the HSAN experts’ perspective on the community role in health systems strengthening.
Tarry Asoka Response:
Clearly, it would be difficult to achieve any meaningful progress in developing a functional health system where communities have been excluded. Defining health systems from a supplier perspective is a major carry-over of the traditional thinking of health services to mean hospitals, clinics, doctors, nurses and so on. Issues of responsiveness, accountability and appropriateness of services, which are equally necessary and can lead to effective demand for health services, have been left unattended. No doubt, there has been dismal performance of health systems in many developing countries despite over three decades of health sector reforms. I am not aware of any country where a functional health system has been put in place with the exclusion of the communities. Development after all is about ‘people’. In other words, the people are ‘the means’, ‘the agents’ and ‘the ends’ of development. Anything short of that is fraud.
Question 3: (Ghana)
How do you identify the poor so as to offer the protection for them in an environment where there is stigma of being seen or known as poor?
Tarry Asoka Response:
I quite agree with you that many poor people do not want to be ‘patronized’ despite their economic status, and thus do not readily identify themselves as such. However, such persons are usually well known within their communities. By using existing social support structures such as age-group organisations, women’s groups, religious bodies especially places of worship such as churches and mosques, and community-based mutual associations set up for other reasons – it is possible to identify those who could be offered a safety net for healthcare expenses. In this day and age, there are also many NGOs who are working with communities on a whole lot of issues. These organisations are usually able to work with social protection initiatives to extend services to the poor.
In addition, if services provided are used by all irrespective of social class, the poor do not see themselves as receiving inferior quality of care because of their inability to pay. Therefore issues that lead to stigmatization of the poor or any other group for that matter must be effectively managed, in order to remove other barriers apart from finance that prevent the poor and other vulnerable groups from accessing vital health services.
Question 4: (Belgium)
We are planning an investigation project in Latin America that aims to improve access to and quality of reproductive health care services for adolescents.
We want to study the outcome of a intervention package: 1) a vouchers system giving access to adolescents from poor areas to Family planning services and STI diagnosis/treatment for free 2) consciousness-raising of adolescents through peer activities 3) interventions at primary health centers to make them more youth friendly.
In your experience, what is the added value of a voucher system to improve access to health care services? Do you have knowledge about such experiments?
Tarry Asoka Response:
A Voucher Scheme or System refers to providing a voucher, usually a ‘token’ in form of a receipt or ticket to targeted population (as in your case adolescents from poor areas), which entitles them to access vital healthcare services free at the point of use. Rather than using cash to pay for services, voucher holders use this instrument that has been pre-paid by a third-party in exchange for the services.
In practice, vouchers are generally used for increasing the utilization of specific services such as insecticide treated bednets (ITNs), ante-natal care, and as in your situation – family planning services and STI diagnosis/treatment. The real value of vouchers is to stimulate demand for these high impact services, which in turn leads to improved health status for the targeted population. The removal of financial barriers through vouchers can also guarantee a minimum level of service delivery package to poor or vulnerable persons.
Uses of vouchers to improve the utilization of ITNs have been reported in Uganda and Tanzania with significant degree of success. Some Projects in South-East Asia focusing on your area of interest (similar target groups and services) have also recorded similar level of success. However, the major drawbacks noted from the experience of these projects both in Asia and Africa include: forging of vouchers, difficulty in identifying the poor in the context of limited poverty data, and resource intensity to continuously distribute vouchers to appropriate persons.
Xiaolin Wei Response:
I fully agree with Tarry that it is important to recognise the drawbacks of the travel incentive programmes. I led a recent evaluation of one of the Fidelis projects in China which provided travel incentives to the poor to promote tuberculosis services. However, the project did not succeed its goals because it lacked two key operational tools:
- How to evaluate the economic situation of farmers and how to identify the poor;
- How to publicise the information (travel incentives/ vouchers) to the farmers.
Also, you have to consider what your target population, adolescents in your case, thinks are their barriers to access the STI services. Money/vouchers will help, but it can not help everything. The incentive has to be considered with other wider problems that the adolescents are facing to access STI service in their daily life.
For the reference of the Fidelis evaluation, one article is to be published in the October issue of the Journal of International Union Against TB and Lung Disease. Another qualitative paper has been accepted by Health Policy and is under review.
Question 5: (Nigeria)
Two decades ago, the world embraced the Alma Ata Declaration and the concept of primary health care (PHC) as a system that will guarantee equitable distribution of health resources for the provision of quality services to the population. The noble dreams of "health for all by year xxxx" have been elusive, and now we are in hot pursuit of the MDGs and hope to erase the health development gaps in 2015. How do we ensure that the health system yields the expected health dividends to the average member of each society? Is it not time we start seeing health as a 'business' venture whose return on investment translates to a healthy society? Would it not be better if we incorporate the concepts of 'performance management' and ' continuous quality improvement' into our health systems rather than depend on vertically-initiated global health initiatives whose targets are not so real?
Tarry Asoka Response:
The argument between health as a basic right of every citizen to be guaranteed by governments versus health as a personal responsibility is still an unending debate. But central to both sides of the divide is the issue of funding the health systems of the world. It is a matter of ‘the rich also cry” as it is about ‘the poor struggling to survive”. Healthcare is both capital and labour intensive. And thus requires loads of investments on a continuous basis. The main reason why many health systems have failed to deliver the expected health dividends to the average citizen is the lack of investments in real terms by those societies, to match the health needs of their populations. Apart from the lack of resources, the effective and efficient management of what is available is another problem.
I assume that the call for seeing health as ‘business venture’ refers to using a ‘business approach’ in the management of health enterprises rather than using a ‘business model’ as the basis of running health systems. If my first assumption is true - then yes - using an outcome based approach in managing the health system is the best option as far as focusing on delivering results is concerned. This also ties very well with the use of modern management tools such as performance management and continuous quality improvement as a means of ensuring sustainable systems. However, there may be a need to review the question if it is about looking at health from a business outlook where ‘the bottom line’ is all that matters. Although this can be defined in terms other than economic profit to include – reduced morbidity and mortality, improved quality of life, and increased life expectancy. What really matters is to adopt what can be of real value and applying same to solve difficult problems in similar contexts.
Nonetheless, we are aware that in many countries especially the developing ones, many people are already voting with their money in terms of where they spend their health dollars – public or private. With health expenditures significantly skewed in favour of the private sector, policies have been developed to redefine the role of the public sector. Rather than continue to compete with the private sector to provide health goods and services that can be better delivered by the private sector, the public sector in many countries is being encouraged to focus on stewardship of the entire health sector, which includes issues of priority setting, coordination, standardization, regulation and the likes. Extending from this role re-definition is the issue of public-private partnership (PPP) where collaboration between the two sectors is expected to create value greater than the sum of the individual components. This helps to cancel the effects of both market and government failures as well as mobilize additional resources, but ensuring that overall health sector goals are achieved.
Finally, let me quickly add a note on Global Initiatives (GIs). Many of these initiatives have been proposed following the failure of health systems in many countries to deliver even the very basic of health services to their populations. While GIs have been purported as potential sources of new investments for health systems, they have failed to deliver on this promise. This is because all of them have been designed as ‘projects’ focusing on outputs related to their areas of concern. Where health system strengthening is mentioned, it is mere a rhetoric. However, opportunities still exist where the huge resources available to say Malaria or Tuberculosis (Tb) can be used to getting a whole system working again in a given country. This can be done through constructive linkages with the entire service delivery chain. After all a microscopist trained by either Tb or Malaria Programme under the Global Fund, would not only attend to Malaria or Tb patients, but would be available to examine the urine of pregnant mothers as well.