Geneva Health Forum Archive

Browse and download abstracts, posters, documents and videos from past editions of the GHF

Increasing Access to Surgical Services in Resource-constrained Settings

Author(s): J. von Schreeb*1, S. Luboga2, S. Macfarlane3, M. Kruk4
Affiliation(s): 1Division of International Health, Karoliniska Institute, Stockholm, Sweden, 2Department of surgery, Makere University, Kampala, Uganda, 3Global Health Sciences, University of California San Francisco, 4Health Management and Policy, University of Michigan, School of Public Health, Michigan, United States
Keywords: Surgery, district, hospitals, training

Surgical services provide important preventive and life-saving strategies. Contrary to prevailing opinion, essential surgical procedures can be provided in district hospitals at a cost per DALY equivalent to other well-accepted preventive procedures. An international group of health professionals met last year at the Rockefeller Foundation’s Bellagio Center to develop strategies to raise the profile of surgery and increase access in resource-constrained settings in Africa. The group agreed that the major limiting factor in providing access is the shortage of suitably skilled health workers at district hospitals. The presentation is compiled on behalf of the Bellagio Essential Surgery Group.


 The objectives of the presentation are to: 1) outline what is known about the unmet need for surgical services in Africa and gaps in our knowledge; 2) layout obstacles to access; 3) examine alternative strategies to increase appropriate workforce skills; and 4) call for wider partnerships to integrate surgery within primary healthcare and develop training strategies.


The results are based on a literature review conducted prior to the Bellagio Conference and a synthesis of experiences of participants from Eritrea, Ghana, Kenya, Mozambique, Southern Sudan, Sweden, Tanzania and Uganda, and USA. A significant burden of disease is attributable to surgical conditions in sub-Saharan Africa but that much more evidence needs to be generated in order to better target interventions. A major proportion of these conditions can be treated or prevented cost-effectively at the first referral level but that this will require investments in facility infrastructures and in the training of non-surgeons to perform basic life saving general and obstetrical surgery. Preventive and curative programmes to address basic surgical conditions could strengthen health systems in resource-constrained settings and every effort should be made to develop these programmes in an integrative manner. Preventive and curative surgical interventions are essential to health systems and should to be integrated into primary healthcare strategies.

Lessons learned:

More effort is required to raise the profile of surgery on national and international agendas. In the first instance, there is need for: 1) more research to fill gaps in knowledge; 2) demonstration models of provision of surgical services at district level; and 3) sharing, through partnerships, of country experience in training non-surgeons in basic surgical procedures.

Global Patients, Global Doctors: Lessons from the Health System of the Maritime Industry

Author(s): D. Lucero-Prisno1
Affiliation(s): 1IMHA, Tacloban City, Philippines
Keywords: Maritime health, health system, seafarers, global health

The maritime sector is a highly globalized industry with an international workforce of 1.5 million seafarers working on literally all waters of the world. As a risky profession (second only to commercial fishermen), seafarers are exposed to a multitude of occupational and health hazards. This equates to USD 135 million of compensation for personal injury from the P&I Clubs (insurance) every year, which is more than the claims for maritime pollution. As ships ply their routes, medical services all over the world are always at bay waiting for patient calls once needed. These highly organized services are specifically designed for the industry with medical services provided regardless of the nationality of neither the seafare nor the medical staff, the flag of the ship, nor the port of call.


To understand how health services are delivered and provided to the global seafarers. To understand the framework governing the scheme of health service provision beyond nationalities and borders. To deduce learning from this industry for other ‘global’ health systems. To assess the weaknesses, strengths and gaps of the maritime health system.


The workforce of maritime industry is composed of seafarers from different countries with a big percentage from East Asia and Eastern Europe. Filipinos comprise almost a third. These seafarers work on ships flagged under different countries with Liberia and Panama on top of the list. Globalization paved the way to this scheme despite real ownership in other countries. For every tour of duty of the seafarers, a medical examination is required in the home country of the seafarer. This screening identifies those who are fit to work. The countries where the ships are flagged accredit these clinics. Insurance companies support this screening to avoid health claims from those who have existing health problems. These companies have a separate accreditation scheme of all the clinics where seafarers can go in case they are afflicted with a malady while on board or on contract. They can easily approach health services at different ports without too much financial worry. These clinics and hospitals make claims from the representatives of the shipping or insurance companies within the area. Despite the lack of international standards, the maritime industry is able to carry out its task of taking care of the health and welfare of its workers; though maybe not to a perfect degree. The International Maritime Health Association (IMHA) is the only international organization of health professionals who have direct contacts with seafarers. They lead the initiative of developing an international medical standard for the seafaring sector so that services and diagnosis will be similar throughout the world. WHO accredits four Collaborating Centres on health of seafarers based in Germany, Denmark, Ukraine and Poland. They are clustered under occupational health. WHO, ILO and the IMO have some collaboration in the area of health of seafarers. The industry observes ‘self-regulation’ and maintains certain standards without too much intervention from nation-states.

Lessons learned:

The health system of the maritime industry is an interesting model of a responsive and effective global health system beyond the consideration of the nationalities of neither the patients nor the health providers and without considering national borders. Though this study does not claim for it to be a perfect global health system, it has many characteristics that are worth emulating. Its well-organized structure allows easy access for its clients to quality health services. The major strength of the system is its strong health-financing scheme that is backed by a rich maritime industry. Quality and access are assured because of the good compensation given to the health providers. Keeping maritime workers healthy is imperative because they literally run 90% of the global trade.

Improving Access to Healthcare Services through Leadership Development and Organisational Effectiveness: A Case study of Jharkhand state in India

Author(s): A. Kumar*1, K. Nayar2
Affiliation(s): 1Department of Rural Development, Xavier Institute of Social Service, Ranchi, 2Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
Keywords: Health, access, health services delivery

Health status of population is one of the significant indicators of social and economic well being. Despite the government policy, programmes, effort and planning to improve the health services and make it accessible to all, we are not able to achieve those in last 60 years knowing the challenges and problems. Recognising this, the Government of India launched National Rural Health Mission (NRHM) in 2005 to expand the coverage of public health services. It also envisaged for developing infrastructure and enhancing the capacity of its people for the expansion of health services. But despite these efforts by the government to improve the health services and make it more accessible to poor, Jharkhand as one of the poorer states in India, continue to share a number of characteristics such as high infant mortality, low immunization of children and expectant mothers, high mortality due to infectious and contagious diseases, and high maternal mortality. These coupled with poor access to healthcare facilities and high costs of treatment by households have made all achievements in health sector look insignificant in the state.


Considering the challenges in strengthening the public health services and political economic conditions, the explanation of bad performance in terms of health access and services, the paper highlights and recommend a model and mechanism focusing leadership development and organisational effectiveness to improve health services delivery and access involving civil societies, local bodies and appropriateness of Public-Private-Partnership model in strengthening access of health services.


Major factors and hindrances behind access to health services are due to lack of leadership, team building, developing systems, non existing inter-sectoral linkages between different stake holders and involvement of local bodies.

Lessons learned:

Existence of services in terms of structure will never insure its utilization to fullest unless until there is proper channel between different stake holders which can link people to these services.

Working in Partnership to Improve Child Survival: Red Cross Support to the Ministry of Health During the Mali Integrated Campaign

Author(s): M. M. Erskine1, D. Adama*2, J. Peat1, O. I. Toure3
Affiliation(s): 1Health and Care Department, International Federation of Red Cross and Red Crescent Societies, Geneva, Switzerland, 2Governance Committee, Mali Red Cross Society, 3Ministry of Health, Bamako, Mali

Child survival, Mali, Ministry of Health, Red Cross, integration, vaccination, malaria, civil society, partnership


In 2007, the Malian Ministry of Health worked with its financial and technical partners to plan and implement one of the largest child survival campaigns to date. The Mali Child Survival campaign targeted over 2.8 million children under the age of five throughout the country. In one week, children received vaccination against measles and polio, supplementation with vitamin A, deworming treatment and long-lasting insecticide treated nets for malaria prevention. Together, the integrated package addresses a number of diseases that contribute to a high disease burden among African children.  A central part of the campaign planning was the communications and social mobilization strategy, to ensure that all segments of society were informed and motivated to promote and participate in the activities. One organization that played an important role was the Mali Red Cross Society, which trained 2,500 volunteers in six regions of the country. The partnership between the Malian Ministry of Health and the Malian Red Cross is an example of how civil society organizations can play a supportive role to improve healthcare delivery. The Malian Red Cross continues to play this auxiliary role for community- and household-based promotion of routine health services to work towards sustaining the high coverage rates attained during the integrated campaign.


The objectives of the Integrated Child Survival campaign in Mali were to reach more than 95% of children with measles vaccination and more than 80% of children with all other interventions. Additional objectives included ensuring adequate social mobilization to persuade caretakers of the importance of the campaign, undertaking micro-planning for logistics and management of all campaign supplies and implementing an effective system for monitoring and supervision during the week of activities. The campaign will be evaluated in late January/early February using PDA technology.


Results for this presentation are divided into two components, one related to process and the other related to impact. In terms of process, a strong collaboration and cooperation existed amongst partners, with the Ministry of Health leading and coordinating all activities. Strong relationships with civil society organizations, including the Mali Red Cross, allowed for successful mobilization of parents and organization of sites for the child survival campaign. The role of the Red Cross as a civil society organization is highlighted here to emphasize the need for community-based volunteers to ensure that the most vulnerable, and the most resistant, households receive these necessary interventions. In terms of impact, data were collected daily during the seven days of campaign activities and information was relayed from the health centre level to the national level through telephones, computers and radios. The results of the campaign indicate that all objectives set at the outset of the campaign were not only reached but also exceeded. A cluster survey, using PDA technology, will be used to confirm the daily tally results from health facilities with household level data regarding under fives and their participation in the campaign.

Lessons learned:

The Mali Integrated Child Survival campaign was an enormous undertaking for the country. The importance of partnership, at both international and national levels, is highlighted as a major reason for the success of the initiative. Within the vast country, the contribution of community-based organizations is central, as demonstrated by the role of the Red Cross in mobilizing caretakers before, during and after the campaign. The importance of ongoing messaging to parents to ensure that health facilities are accessed for routine vaccination services, and to contribute to positive behaviour change at the household and community level, are retained as major lessons for sustaining achievements.

The Zimbabwean Experience with Primary Healthcare in the Period 1981-2000: Which Factors Shaped this Success Story?


B. Criel*1, P. Bossyns2, T. Hoeree1, J. Macq3, B. Vander Plaetse4, A. Van Geldermalsen5, E. Mabiza6, G. Mhlanga6, C. Tshuma7, A. Chimusoro8


1Department of Public Health, Institute of Tropical Medicine, Antwerp, 2Medical Department, Belgian Technical Cooperation, 3School of Public Health, Free University of Brussels, Brussels, Belgium, 4Health Section, Alafa project, Maseru, Lesotho, 5Health Services Support Programme, 6Department of Public Health, Ministry of Health & Child Welfare, Harare, 7Provincial Medical Office, Ministry of Health & Child Welfare, Bindura, 8Provincial Medical Office, Ministry of Health & Child Welfare, Gweru, Zimbabwe

Keywords: Primary healthcare, district health systems, strengthening health systems, Zimbabwe

Zimbabwe succeeded, after its independence in 1981, in dramatically transforming its health system. During the 80s and 90s, the Zimbabwean health services gradually evolved into one of the best performing systems of Sub-Saharan Africa.


We believe that the Zimbabwe experience constitutes a major learning opportunity for our understanding of how to organize Primary Health Care (PHC). We analyse the factors, both internal and external to the health system, which contributed to the success at the time. The current crisis in the health sector does not necessarily invalidate lessons from the past.


We distinguish between factors internal and external to the health system.

Internal factors:

1 – A clear operational model on how to organize PHC based on the development of integrated district health systems with networks of decentralized health centres staffed by small teams of versatile health workers, supported by district hospitals acting as back-up facilities for patients in need of more specialized nursing and medical care. Specific disease-control activities were largely integrated in the district health care delivery system.
2 – Multidisciplinary district health teams (doctors, nurses, health administrators, environmental workers, pharmacists) heading the district health services system and operating in a managerial environment with room for local decision-making and resource allocation.
3 – Significant support from provincial health teams for the district teams. The availability of true specialized care at the level of provincial hospitals and the existence of functional referral systems enhanced the health system’s overall credibility.
4 – Well-trained frontline health workers operating in a culture of rationalization of diagnostic and therapeutic behaviour and quality control.

External factors: 1 – Strong national political (and financial) commitment towards social sectors in general, and the health sector in particular. The rights-based approach of the Alma Ata philosophy found fertile soil in the postrevolution period.
2 – Support from the international donor community, including the provision of expatriate health workers integrated in the Zimbabwean public service system.
3 – Good basic transport and communication infrastructure inherited from the Rhodesia regime.
4 – Presence of economic development (commercial farming, tourism) in the 80s and early 90s.
5 – A bureaucratic but functional State apparatus: fulfilment of its normative role, payments of decent salaries to civil servants, punitive action in case of professional misconduct of health workers, etc.
Lessons learned:

In the case of Zimbabwe, in the period 1981-2000, a conjunction of elements, both internal and external to the health sector, led to an environment conducive to the development of equitable and effective PHC systems. With the increased attention for the strengthening of low-income countries’ health systems, the Zimbabwe experience provides a valuable source of inspiration.

Patients on the Move

Author(s): M. M. Kingma1
Affiliation(s): 1International Council of Nurses, Geneva, Switzerland
Key messages:

1 – Globalisation is affecting the health sector - expanding the health services provider market as well as the health professional labour market.
2 – Health tourism tends to introduce or facilitate the growth of the private sector health industry. This may result in intranational tensions and competing vested interests.
3 – Health tourism needs to be monitored and evaluated in terms of population access to care, service stan- dards, and local labour conditions.

Summary (max 100 words):

The international migration of health professionals has increasingly been on the political agenda, especially in the context of widespread shortages of employed care providers. Globalisation is a reality and recognised characteristic of today’s world. Health systems are faced with the challenge of increasing demands on their services and a relative decrease in funding. Privatisation in the health sector is increasing, including in areas known as health tourism – patients seeking care outside their country of residence. Health facilities are being established providing medical and surgical interventions, as well as health promotion services (e.g. massage, relaxation therapy) essentially for foreign patients. While recognised as an income generating initiative in many cases, the introduction of health tourism may distort the public/private mix within the national economy, increase the intranational “migration” of health professionals from the public to the private sector, influence educational and practice standards, challenge professional regulatory bodies, place new demands on health insurance systems and create wide disparities among the pay and working conditions on offer locally. Health tourism may also help retain health professionals by providing better employment and professional development opportunities, improve working conditions, advance health care, harmonize standards of service delivery, and disseminate evidence-based practice.

Conclusion (max 400 words):

Health tourism is on the increase and predicted to be a growth industry in the years to come. Its introduction influences aspects far beyond health care, including the national economy, education, regulation, access to and quality of public sector services, insurance companies’ sustainability, the tourist industry and people’s expectations. Health tourism needs to be monitored and evaluated as a social phenomenon as well as studied in terms of impact on the accessibility and quality of care, patient outcomes, labour market and health personnel behaviours.

The State of Global Mental Health Services

Author(s): B. Saraceno 1
Affiliation(s): 1WHO, Geneva, Switzerland
Key messages:

1 – Mental, neurological, and substance use (MNS) disorders are prevalent in all regions of the world and are major contributors to morbidity and premature mortality.
2 – The resources that have been provided to tackle the huge burden of MNS disorders are insufficient, inequitably distributed, and inefficiently used and this generates a serious treatment gap.
3 – Success in implementation of the programme rests, first and foremost, on political commitment at the highest level.

Summary (max 100 words):

Mental, neurological, and substance use (MNS) disorders are prevalent in all regions of the world and are major contributors to morbidity and premature mortality. The stigma and violations of human rights directed towards people with these disorders compounds the problem. The resources that have been provided to tackle the huge burden of MNS disorders are insufficient, inequitably distributed, and inefficiently used, which leads to a treatment gap of more than 75% in many countries with low and lower middle incomes. The World Health Organization (WHO) has recognized the need for action to reduce the burden, and to enhance the capacity of Member States to respond to this growing challenge. The objectives of the WHO’s programme are to reinforce the commitment of all stakeholders to increase the allocation of financial and human resources for care of MNS disorders and to achieve higher coverage with key interventions especially in the countries with low and lower middle incomes. The Programme attempts to deliver an integrated package of interventions, and takes into account existing and possible barriers for scaling up care. Priority conditions were identified on the basis that they represented a high burden (in terms of mortality, morbidity, and disability); caused large economic costs; or were associated with violations of human rights. These priority conditions are depression, schizophrenia and other psychotic disorders, suicide, epilepsy, dementia, disorders due to use of alcohol, disorders due to use of illicit drugs, and mental disorders in children. The obstacles that hinder the widespread implementation of these interventions must also be considered, together with the options that are available to deal with these. Success in implementation of the programme rests, first and foremost, on political commitment at the highest level. One way to begin to achieve this is to establish a core group of key stakeholders who have multidisciplinary expertise to guide the process. Assessment of needs and resources by use of a situation analysis can help to understand of the needs related to MNS disorders and the relevant health care, and thus to guide effective prioritization and phasing of interventions and strengthening of their implementation. Development of a policy and legislative infrastructure will be important to address MNS disorders and to promote and protect the human rights of people with these disorders. Decisions will need to be made as to how best to deliver the chosen interventions at health facility, community, and household levels to ensure high quality and equitable coverage.

Conclusion (max 400 words):

Successful scaling up is the joint responsibility of governments, health professionals, civil society, communities, and families, with support from the international community. An urgent commitment is needed from all partners to respond to this urgent public health need.

Lessons learned:

Adequate human resources will be needed to deliver the intervention package. Most countries with low and middle incomes do not assign adequate financial resources for care of MNS disorders. Resources for delivery of services for these disorders can be mobilized from various sources – e.g. by attempts to increase the proportion allocated to these conditions in national health budgets; by reallocation of funds from other activities; and from external funding, such as that provided through developmental aid, bilateral and multilateral agencies, and foundations.

Public Health Capacity-Building and Web 2.0 – the Peoples-uni

Author(s): R. F. Heller1
Affiliation(s): 1Peoples-uni, Edinburgh, United Kingdom
Key messages:

1 – There is a wealth of educational resource freely available on the Internet, but to be really useful it needs to be set in the context of an educational programme.
2 – Peoples-uni helps to build Public Health capacity in low- to middle-income countries, using volunteers to develop and deliver modules and courses which use Open Educational Resources, and which are of much lower cost than courses offered by universities.
3 – The experience of the Peoples-uni so far, suggests that this model of capacity-building has considerable potential, even if there are difficulties in realising the full potential of the concept of Web 2.0.

Summary (max 100 words):

The Peoples-uni ( aims to help build Public Health capacity in low- to middle-income countries (LMIC). It is based on the existence of high quality, online Open Educational Resources (OER) freely available through the Internet. Use of OER and volunteer staff allows costs to be kept to those that can be met by the target audience. A group of nearly 70 volunteers are helping develop course modules, covering major Public Health problems and the foundation sciences of Public Health, leading to certificate and diploma awards to be offered by the UK Society of Public Health. A single course module covering Maternal Mortality, aimed at Public Health professionals, was piloted with 38 health professionals from 8 countries, using the open source educational platform, Moodle. An evaluation revealed that gaining knowledge and skills were rated as more important than academic credit, and the academic value of the course was judged excellent or good by the majority of the respondents, with a majority also reporting that this module was relevant to their job or career and that they would enrol in more course modules. In the spirit of Web 2.0, we have invited the students to recommend the topics of future course modules and to join in the course development and delivery, although most students so far have found it difficult to go beyond the role of the traditional student. We wish to be responsive to the real capacity-building needs of the communities in LMICs, and to ensure that the education is appropriately localised. For this purpose, and to ensure that we add value to local LMIC organisations, we seek to engage partners and collaborators in these countries.

Conclusion (max 400 words):

Peoples-uni is an Internet-based educational initiative, using Open Educational Resources, to assist with Public Health capacity-building in LMICs. A pilot course module was well received, and an international faculty has come together to develop and offer courses to the certificate and diploma level. Collaboration and participation between teachers and students, and with organisations in LMICs, are key goals.

Lessons learned:

On-line education, taking advantage of Open Educational Resources and volunteers, has considerable potential to contribute to capacity-building in low- to middle-income countries. Taking full advantage of the possibilities of Web 2.0 is difficult in the educational arena.

New Ways to Achieve Primary Healthcare in India: A Critical Review of National Rural Health Mission

Author(s): K. R. Nayar*1
Affiliation(s): 1Centre of Social Medicine and Community Health, Jawaharlal Nehru University, New Delhi, India
Keywords: Primary healthcare, health services system, India

The idea of a health ‘worker’ from the community is not a new one; from a public health point of view, it may be an ideal vehicle for another development in the field. But it failed miserably in the case of the Community Health Guide/Volunteer (CHV) scheme due to several reasons. The most serious problem with the CHV scheme was the selection process; it was misused to distribute political patronage and even close relatives of panchayat leaders were selected. The training was extremely limited but in the course of time, most of the CHVs became quacks. A programme meant to give ‘people’s health in people’s hands’ ended up as mere quackery. It is against this background that the government introduced the National Rural Health Mission (NRHM) which includes a women’s community health volunteer called Accredited Social Health Activist (ASHA).


This paper critically reviews the National Rural Health Mission from a public health perspective as well as based on the ideals of Primary Health Care (PHC).


The key strategies of the Rural Health Mission include: ensuring intra- and inter-sectoral convergence, strengthening public health infrastructure, increasing community ownership, creating a village level cadre of health workers, fostering public-private partnerships, emphasizing quality services and enhanced programme management inputs.. Community participation will be enhanced by giving functional responsibilities and powers to the panchayati raj (local self-government) institutions, apart from creating a cadre of voluntary accredited social health activists, and a drug and contraceptive depot at the village. The mission will also use management experts, Chartered Accountants, Business management specialists and GIS specialists for its management units.
We find that the utter neglect of primary care and primary healthcare institutions has influenced the utilization of health services and contributed to the worsening epidemiological profile in the country in recent years. In the present form, the proposed mission adds to the confusion about the approach to healthcare in the country. Cost-effective interventions such as the rational distribution of financial and medical resources, including drugs, effective manpower distribution and primary healthcare approaches, should be part of the vision.

Lessons learned:

This paper recommends that a vision that gives primacy or rather credibility to the vast network of health institutions that the country has built over years is needed. Strengthening the sub-centres and equipping the government’s own health workers (instead of adding posts) would be epidemiologically and economically more effective. States should be allowed to define their own priorities and plan programmes. At present the public health scenario is extremely nebulous and the differential pattern across states is so glaring that it does not allow the imposition of pan-Indian solutions.  Apart from this, there is also a need to equip and enable elected representatives at the village and block level for handling health issues. Presently, health programmes are beyond the reach of people who are supposed to govern under the decentralised form of government as these are often considered technical subjects. There is a need to remove the confusion among representatives and officials at the panchayat (local self-government) level about the roles and responsibilities around health services. This paper concludes that initiatives such as the rural health mission would greatly benefit if it follows the vision of those that scripted India’s health service system based on an integrated and unified approach as against the selective interventions being proposed in recent years.

Local Planning: An Experience of a Primary Care Centre in Florianópolis, Brazil

Author(s): C. M. S. Moutihno, Jr1
Affiliation(s): 1Public Health Department, Municipal Health, Florianópolis, Brazil
Keywords: Primary Care, health planning, Family Health Strategy

The project of health planning at the Primary Health Center Lagoa da Conceição, in Florianópolis (Brazil) emerged as a need to change a model of care assistance, based on the spontaneous demand and a limited scope in the practice of health (passive attitude) for a model of Family Health Strategy, with shares epidemiological data on a defined territory and organizes a supply of services, expanding the community’s access to health services (pro-active attitude). The planning tool enabled changes on the organization for the work process in the primary care of the Family Health Teams (FHT).


The indicators available have been raised using SIAB (Information System in Primary Attention), SIM (Information System in Mortality), SINASC (Information System of Births), and HIPERDIA (Information System of hypertensive and diabetic people). There were used the following indicators:
1– Medical care / team resolution: consultations pop / year, the average time, total resolution, average visits / family.
2– Women/Children: exclusive breastfeeding, pregnant beginning the 1st quarter, pregnant medical/nursery care in the month, pregnant <20 years, low weight at birth, pregnant with more than 4 and 7 consultations in the prenatal, procedures Papanicolau / pop fem.
3– Hypertensive/ Diabetic people: lifting risk of disease DAC in 10 years, using of Framingham Score.
The objectives were:
1– Work with a common goal for the actors involved in the planning (FHT); stimulate work as a team
2– Develop the diagnosis of the current situation, with survey data; study of the data and dynamics of monitoring / update-dynamic planning
3– Improve health indicators of the population.

Lessons learned: