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Health Insurance for Rural Population – the Re-Organisation of Community Health Funds in Tanzania.

Author(s) Manfred Stoermer1, Manoris Meshack2, Ralf Radermacher3, Fiona Chilunda4, Yann Gelister5
Affiliation(s) 1Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Basel, Switzerland, 2Health Promotion and System Strengthening Project, Swiss Tropical and Public Health Institute, Dodoma, Tanzania, 3Micro Insurance Academy, Micro Insurance Academy, Bonn, Germany, 4Health Promotion and System Strengthening Project, Swiss Tropical and Public Health Institute, Dodoma,Tanzania, 5Micro Insurance Academy, Micro Insurance Academy, Bonn, Germany.
Country - ies of focus Tanzania
Relevant to the conference tracks Advocacy and Communication
Summary Community Health Funds (CHF) in Tanzania face problems in design, enrolment, servicing, and sustainability. Since 2011 the Swiss Government funded “Health Promotion and System Strengthening Project”, HPSS, has undertaken a re-design of the CHF in the 7 districts of Dodoma Region. The “CHF Iliyoboreshwa” (improved CHF) displays a purchaser-provider split, a strong Insurance Management Information System (IMIS), active enrolment at village level, portability of membership, and cross-district reimbursement. After one year of operation (August 2013), the “new CHF” has enrolled 408,000 persons, equivalent to 20% of the population, which is well above the national average of 7.9% of the previous CHF system.
What challenges does your project address and why is it of importance? Community Health Funds (CHF) in Tanzania aims at building a risk pooling mechanism for rural populations and informal sector communities. Implementing the “Health Promotion and System Strengthening” (HPSS) project, the Swiss Tropical and Public Health Institute (Swiss TPH) and their partner organisation Micro Insurance Academy (MIA) carried out an analysis which revealed structural problems with respect to design, enrolment, servicing, and sustainability. On request of the Ministry of Health and Social Welfare (MoHSW) the Swiss Agency for Development and Cooperation (SDC) supports the development of structural changes for CHF within the HPSS project.
CHF design problems arise from the a lack of separation between purchaser and provider roles, the CHF being operated by the District Medical Office. CHF coordinators work part-time, and benefit packages are inappropriate. The lack of a data management system results in data being not readily available for monitoring purposes, re-enrolment, or claiming of “matching funds”. Passive enrolment at health facilities is a weak enrolment mechanism. Problems of servicing include the missing linkage between provision of health care and reimbursement. Funds are spent at a district level regardless of the services provided by health facilities.
How have you addressed these challenges? Do you see a solution? The HPSS project has systematically addressed the problems identified by developing a re-organised Community Health Fund, the “CHF Iliyoboreshwa” (“Improved CHF). This model is being implemented in the 7 district and municipal councils of Dodoma Region since 2012.
The core of the re-design is the new Insurance Management Information System (IMIS) which provides the Community Health Funds with a comprehensive solution for data management, including membership enrolment through mobile phone technology, contribution management, claims processing and payment, as well as member feedback collection.
The IT system allows online and offline operation. Each family member is now getting their own CHF card, when it used to be one card per family, and this individual card allows easier access to health services. One of the major problems up to now has been the limitation of access to only one health facility in the home place of members. With the new system this limitation is overcome. The new CHF card can be used in any public health facility across the districts of Dodoma Region, including hospitals. Each health facility attached to the CHF network received a smart phone which is readily available in Tanzania and is able to connect to the data base to instantly download member photos from the IT system for easy identification of the member.
The same mobile phones are also used to enrol people into the CHF by taking their photo and uploading them to the IMIS database. This also works in rural areas with limited internet access through backup provisions for offline data management. Enrolment Officers are now placed at the community level to enrol members in a quick and easy procedure using the CHF phone. The new system also allows health facilities a fast and simple processing of the claims they submit after treating CHF patients. This is expected to strengthen the financial capacities of the health services. The new CHF system, once further tested and proven to be effective in Dodoma Region, is designed in a way that it can easily be rolled out nationwide, with the central server already being in place. The investment into developing the CHF Iliyoboreshwa is therefore hoped to benefit not only Dodoma Region, but the whole population of Tanzania.
How do you know whether you have made a difference? The re-organized CHF is a scheme operated fully by the Local Government Authorities themselves. The CHF offices are in place, and all cadres involved in the system have been trained. More than 600 Enrolment Officers have been identified by the communities and are enrolling CHF members against a moderate commission.
At the end of August 2013, after barely one year of operation, the “CHF Iliyoboreshwa” (together with remaining “old members” of the previous system”) had enrolled 68,027 households out of 347,265 households in Dodoma Region. Approximately 400,000 persons are now covered with health insurance, out of a population of 2,000,000. After not even a year of operation, the new health insurance system already reaches a coverage of approximately 20%, far above the national average of 7.9% with the “previous” CHF system, with some districts standing out with as much as 33%. This is a remarkable success already, and enrolment figures are still increasing.
Further, the members of the re-organized CHF now have access to each of the 250 health facilities being presently associated to the CHF network. Access to hospital level health care has become possible for the CHF members, even outside their home district. Cross-district reimbursement of claims directly to health facilities has been introduced, and for the first time health facilities start seeing tangible benefits for treating CHF members.
Have you or the project mobilized others and if so, who, why and how? The development of the reformed CHF “CHF Iliyoboreshwa” has been undertaken in close coordination and cooperation with the Government of Tanzania both at national as well as at regional and district / municipal level, and important stakeholders have been involved. The development of the “Insurance Management Information System” (IMIS), for instance, has been accompanied by a technical advisory group composed of the MoHSW, the Prime Minister's Office, Regional Administration and Local Government (PMO-RALG), and the National Health Insurance Fund (NHIF). The project activities are governed by a Regional Advisory Board chaired by the Regional Administrative Secretary (RAS), with the highest level representation of the district and municipal councils. The reforms are very actively pursued by the district and municipal councils responsible for the CHF structures, while the HPSS project limits itself to the provision of technical advice and expertise.
When your donor funding runs out how will your idea continue to live? The health insurance structures developed with support of the HPSS project are fully integrated in the structures of the Local Government Authorities. A “CHF Board” answerable to the district / municipal council oversees the operations of the CHF Iliyoboreshwa. The CHF office is staffed by personnel fully paid by the district / municipal council. The central CHF server will shortly be transferred to the premises of the Prime Minister's Office, Regional Administration and Local Government (PMO-RALG), who will take charge of operating the IT system on behalf of the district / municipal councils, as they do with other software (e.g. accounting software EPICOR). The central server is technically fully prepared to add on any further district and municipality in Tanzania depending on the decisions of the government. A decision on possible roll-out of the CHF Iliyoboreshwa is presently being discussed in the Ministry of Health and Social Welfare and in the “Interministerial Steering Committee” for the preparation of the new health financing strategy.

mAmbulance: An innovative intervention to reduce maternal deaths in rural Uganda

Author(s) Alakananda Mohanty
Affiliation(s) 1Healthcare, Kissito Healthcare, Inc., Roanoke, United States.
Country - ies of focus Uganda
Relevant to the conference tracks Health Systems
Summary Achieving the fifth Millennium Development Goal (MDG5) by reducing maternal deaths remains a significant challenge in Uganda. Uganda has a high Maternal Mortality Ratio (MMR) of 438/100,000 live births with the life-risk of 1 in 27 women dying in pregnancy. One of the many underlying factors that contribute to high MMR in the country is delay in reaching an emergency obstetric care (EmOC) facility. Evidence indicates that access to appropriate health care, including timely referrals to EmOC services, can significantly reduce maternal deaths.
Background Ensuring timely access to quality EmOC for women with obstetric complications are increasingly recognized as priority interventions needed to reduce maternal deaths. To reach EmOC services, one of the vital factors is the availability and accessibility of suitable and affordable transport. Delay in accessing and receiving EmOC is a major predisposing factor for maternal deaths in rural Manafwa and Mbale districts in Uganda. The high prevalence of maternal illnesses, and other emergency obstetric complications suffered by women in these two districts have been linked to their poor access to emergency obstetric services. Earlier studies indicate that motorcycle ambulances reduce the delay in referring women with obstetric complications where health centers have no access to other transport or means of communication. In order to reduce the referral delays in Manafwa and Mbale districts, Kissito Healthcare International partnered with PONT (UK based charity) to implement a pilot project where five specially designed eRanger motorcycle ambulances were stationed at 5 remote health centers for transporting obstetric emergencies to the health facilities.
Objectives The objective of the project was to assess referral time, acceptability, and feasibility of motorcycle ambulances (mAmbulances) for referral of obstetric emergencies to the nearest Health Facility and to compare the referral delays and costs with those of a 4WD vehicle ambulance.
Methodology Five mAmbulances were placed at 3 remote rural health centers in Manafwa (Bubutu, Bugobero and Bushika) and 2 health centers in Mbale (Busiu and Wanale) districts for transporting obstetric emergencies and other emergency cases to the health centers free of cost.
At each health center drivers were recruited and trained over 2 weeks to drive the mAmbulance, to be responsible for its maintenance , and on data recording in logbooks.
Community volunteers were identified, trained , and provided with pre-paid mobile phones to call the mAmbulance in case of an emergency for transport to suitably equipped health centers.
Data was collected over a 17 month period, from January 2011 to May 2012 using logbooks, referral forms, and maternity registers.
Specially designed referral forms were used to record data on all emergency referrals, irrespective of means of transport.
Specially designed logbooks were filled in by the drivers of the motorcycle ambulances recording data concerning all trips, including departure and arrival times for the patients referred.
The maternity registers at the health centers were used to identify all referred obstetric cases and the reason for referral.
Semi-structured interviews were conducted with health workers, ambulance drivers about transport issues, referral procedures, and referral delays
Results The mean duration of referral to reach a health facility for all emergency obstetric cases varied between 1:01-1:09 hrs.
Conclusion In resource-poor Uganda, mAmbulances are a useful means of referral for emergency obstetric care, particularly under circumstances where health centers have no access to other transport or means of communication to call for a vehicle ambulance and they are a relatively cost-effective option for the health sector. By providing on-site, designated EmOC referral transport at rural health facilities, the mAmbulances can fill a critical gap in maternal services. If implemented widely in the country, mAmbulances may also potentially help reduce cost for women and their families to access EmOC.

Utilizing Nurses as Diabetic Educators: Sri Lankan Experience

Author(s) Manuj Weerasinghe1, Deepani Siriwardhana2.
Affiliation(s) 1Department of Community Medicine, University of Colombo, Colombo, Sri Lanka, 2Department of Disability Studies, University of Kalaniya, Colombo, Sri Lanka.
Country - ies of focus Sri Lanka
Relevant to the conference tracks Health Systems
Summary A new initiative was started in Sri Lanka to train a special category of nurses to deliver diabetic education in hospitals. Three years into the programme an evaluation was done to assess the extent of utilization of DENOs for diabetic education and the systems developed to optimize their services to the patients. A qualitative methodology was used in this study. It was found that in different hospitals were used for diabetic education in varying degrees and had different working arrangements. There were many obstacles to use DENOs in an efficient manner. However, when given the opportunity, DENOs performed in a positively as an innovative method of patient education.
Background Non Communicable Diseases (NCD) prevention and control is a new challenge for the Sri Lankan health system. The system has fewer options to offer in the present context. Although continued care and behavioual modification strategies are seen as the essence in prevention and control of NCD care, Sri Lankan healthcare delivery system is not designed to accommodate these goals. Hence, in response many initiatives were proposed and implemented by different stakeholders. The initiatives proposed ranged from a systems change to targeted interventions in human resource development. One of such initiatives is the NIROGI Lanka project established by Sri Lanka Medical Association under the Diabetes Prevention Task Force with the help of World Diabetes Foundation. The project trained selected nursing officers in hospitals as Diabetic Educator Nursing Officers (DENO) to implement educational activities in the hospital setting. In three years over three hundred DENOs were trained  from secondary and tertiary care hospitals. This training was done with the concurrence of the ministry of health and a directive was issued on how to utilize DENOs for educational activities. This is a special training programme and still not incorporated into the regular human resource development plan.
Objectives Awareness of the disease plays a major role in compliance of treatment and control of the disease. Adherence to treatment and lifestyle modification can delay the complication of diabetes. Tailor made education and regular follow up sessions can improve compliance to a greater extent. Traditionally physicians are entrusted to advise the patients. However, physicians in a busy clinic find it difficult to provide comprehensive education on diabetes to patients. Hence, there was a longstanding need to streamline the educational activities to improve treatment outcomes. DENO initiative was proposed as a supplementary activity to strengthen diabetic education in hospital settings.Being a new initiative to tackle the emerging epidemic of diabetes coordinated by a non state actor, the implementation agency, NIROGI Lanka project, does not have direct control of the DENOs working in the hospital. It relies on the Ministry of Health for this purpose. The project expects the Ministry of Health to take over the training and the implementation of this initiative after the completion of the project cycle. The health administration system in Sri Lanka is two tiered; small number of tertiary care hospitals administered by the central government and the rest by provincial health authorities. The majority of the DENOs work in secondary care hospitals in the periphery. Hence, the manner in which DENOs are utilized in hospitals after the training depends on the decisions taken by the provincial and hospital administration. DENO are a new category of health workers and the routine information system does not still report their performance in monthly or annual returns. This limits the usage of routine management information systems to assess the utilization of DENOs and their performance. In this circumstance an independent evaluation was proposed to provide inputs that would strengthen the DENO initiative. Hence, an evaluation was undertaken to assess the extent of utilization of DENOs for diabetic education in hospitals and the systems developed to optimize their services to the patients.
Methodology The evaluation was based on a conceptual framework that guided the whole research process. The conceptual framework was developed to articulate the underpinning programme theory of DENO initiative. It consisted of impact theory, service utilization plan, organizational plan and process theory. In order to understand the rationale behind the decisions undertaken to utilize DENOs for diabetic education, the actual service utilization plan and the organizational plan were tested against the articulated theory. The study employed a qualitative methodology to explore the research question. In-depth interviews and focus group discussions were the main techniques. In addition, observation of the work setting was done to verify actual practices. Interviews and discussions were held with the DENOs, clinicians involved in diabetic care, immediate supervising officers of DENO and hospital directors.DENOs of 28 hospitals from five provinces of the country participated in the study. Of those hospitals 19 were visited. Selected healthcare centers included teaching hospitals administered by central government, provincial hospitals, base hospitals and district hospitals that come under the provincial authorities. Five focus group discussions were held with the participation of 51 DENOs. In addition 25 in-depth interviews were done with DENOs. Seventeen medical administrators, 20 clinicians and 8 nursing administrators were also interviewed. Interviews with DENOs were done in local language. Most of the interviews with administrators were done in English. All the interviews were recorded and transcribed. Principal investigator conducted the interview with the help a research assistant. A flexible interview guide was used for both focus group discussions and in-depth interviews. During the field visits, working arrangements of DENOs were observed.Thematic analysis was done grounded on the data.Transcripts were coded manually. Codes were refined several times after revisiting the data. Articulated programme theory guided the analysis. Working arrangements of the DENOs were elicited and systems developed in the hospitals to utilize DENOs were constructed. Ethics approval for the study was obtained from the Faculty of Medicine, University of Colombo.
Results DENO training is a new opportunity and majority of administrators at hospitals were not aware of the nature of the training in order to guide the selection process or to use them effectively. Selecting nursing officers for training programmes is a routine and immediate procedure. Only few nursing officers volunteered to attend the training programme and the rest were forced to attend. A formal application process was present in only three teaching hospitals. There was no advance planning for utilizing DENO in most hospitals. After the trainees were sent back to their original units most administrators find it difficult to release the DENO for their expected work due to severe a nurse shortage. This shortage is approaching a critical level in many hospitals where maintaining day to day service is threatened.Even after three years the circular issued on DENO utilization has not reached most of the hospitals. Hence, different hospitals resort to varying working arrangement. In the 28 hospitals, 10 types of working arrangements were identified. In summary, only 10 out of 51 DENOs were released for full time work on diabetic education under the supervision of a medical officer. Nine others released for diabetic education had to attend to routine work in the clinic setting. This effectively reduced the time spent on education. The remainder of DENOs  were still attached to their original work stations contrary to the directive. They had limited opportunity to take part in the diabetic educating activities. Those attached to wards and theaters lost opportunities to contribute to diabetic education due to heavy work loads.Although DENOs function under many constrains, they have invented several methods to attract and educate patients. Some of their suggestions were taken by the administration while others were not. Sending birthday cards to diabetic patients along with a reminder to attend a follow up screening for complications was a successful. This provides a platform to screen patients yearly with minimum effort. They also undertook the responsibility of drawing blood for tests in medical clinic. Hence, all the patients directed for the tests have to meet the DENO for an education session before attending the clinic. Exercise sessions and promotion of traditional food among clinic attendees were other novel methods undertaken.
Conclusion All healthcare staff need to be made aware of the importance of diabetic education and the role of DENOs for effective secondary prevention. Further, it is necessary to identify possible working models to deliver diabetic education according to the current resource level with provisions to upgrade service in an incremental manner. This would help maintain the service of diabetic education in a sustainable manner.The diabetic clinics need to be reorganized to minimize waiting time. Extended waiting time for services becomes an obstacle to retain the patient's attention during education sessions. Introducing an appointment system based on time blocks can minimize waiting time and overcrowding of clinics. Few hospitals have introduced this system with success.Unrealistic expectations of some DENOs themselves have negatively contributed to the programme. Due to over enthusiasm, some DENOs expect more independence and more resources to deliver their services. Although this would be the ideal model, such expectations may not be realistic within the present healthcare system. This has led to frustration, disappointment and conflicts. Hence, DENO training should include inputs on adaption to local context, team work, diplomacy and negotiation skills.Following the training neither the NIROGI project or the ministry was able to establish a focal point for DENOs to communicate when they needed technical or administrative support. Hence, DENOs have resorted to ad-hoc measures at individual level. There is an urgent need to institute a mechanism to coordinate DENO functions within the existing system. The Ministry of Health needs to take the responsibility of maintaining and upgrading the DENO initiative if it is to sustain.

Diabetes is a chronic disease, hence it is necessary to provide regular inputs to patients and opportunity for them to discuss their issues. Patients who are less compliant, ignorant and difficult to change are the very group missing from care at present. In consideration of the current workload of DENOs the follow-up system for health education need to be tailor-made according to the resource level of the institution. Although the directive on DENO duty mentions an information system, a systematic method is still not in place. An information system that can be used for planning and resource allocation needs to be established. However, even in the context of these shortcomings, when opportunity is given DENO can contribute effectively to the secondary prevention of diabetes.

Partnership with Ministries of Health for Improved Malaria Programme Management in Southwestern Nigeria

Author(s) Olusimbo Ige1, Taiwo Ladipo2, Veronica Iyamabo3
Affiliation(s) 1Program management, Malaria Action Program for States, Ibadan, Nigeria, 2Primary Health Care and Disease Control, Oyo State Ministry of Health, Ibadan, Nigeria, 3Program Management, USAID/MAPS, Abuja, Nigeria.
Country - ies of focus Nigeria
Relevant to the conference tracks Health Systems
Summary The MAPS project has been working with the Ministry of Health using a holistic capacity building approach to build capacity of health managers in malaria programme management to ensure an effective and coordinated malaria program. State officials now have a more accurate overview of performance, through proper planning and implementation assessment with skills, in order to work towards harmonisation, improved resource allocation and effectiveness. With greater attention to supply chain management, the flow of malaria commodities has improved and health managers within the States now have the technical and managerial skills to implement the state operational plan for malaria control.
What challenges does your project address and why is it of importance? Several strategic interventions for malaria control have been implemented in Nigeria since the launch of the Roll Back Malaria Initiative. However, progress towards set targets has been slow and the National Malaria Strategic Plan has recognized the need to strengthen program management at all levels to achieve the desired impact. This implies that effective implementation and enhanced efficiency can only be achieved through collective gap analysis, planning, technical and managerial coordination. The National strategy recognizes programme management capacity building as a cross-cutting issue that transcends each and every one of the National and State program outputs based on rapid appraisal of malaria control programme. Consequent to this assessment, a capacity building training package was developed with the National Malaria Control Programme to address program management using a standard set of training materials appropriate for Nigeria and consistent with national policies. This is expected to ensure that all involved in the management of malaria control at Federal, State, LGA or service delivery points understand their roles and responsibilities to improve program management and service delivery.
How have you addressed these challenges? Do you see a solution? In response to the management challenges identified in the state, the USAID funded Malaria Action Program for State (MAPS) instituted a 4 year project to support health managers at the health facility, local and state government levels in malaria programme management. The project approach was, in providing technical assistance to the State Ministry of Health(SMoH) and State Malaria Control Programme (SMCP), to facilitate the development of a State-led, costed, holistic operational plan for malaria control. The plans set out to articulate State priorities and formed the basis of a rapid scale up of interventions to achieve the ambitious targets for malaria control as articulated in the Federal Ministry of Health’s “Road Map for Malaria Control in Nigeria 2009 – 2013. This included supporting SMoH to harmonize efforts of donors and funding agencies around State plans, and providing direct support to the delivery of effective malaria prevention and treatment through the public and private sectors. In addition to operational planning support, MAPS supported the State to develop a Capacity building/Training Plan and integrated supportive supervision/On-the-Job Capacity Building implementation plans.
A significant percentage of the interventions for malaria control are driven by various partners and funding agencies who are inter-dependent. The State was supported to develop state specific plans in a participatory process involving stakeholders at all levels. While the State ensured synergy of strategies across sectors and partners to prevent duplication and ensure equitable distribution of activities across the State, partners helped build individual and team capacity through in-depth training events, coaching and mentoring. State trainers were drawn from the state officers who remained within the health system and participated in integrated supportive supervision and on the job capacity building of trainees. The efficiency and effectiveness of existing institutional structures and line systems such as procurement and supply chain management, health management information system and coordination frameworks were strengthened through process optimization and improvements in functionality and relationships. The MAPS project supported Government in its leadership role by seconding an experienced programme manager to work from the ministry of health to help strengthen management skills of the SMCP team.
How do you know whether you have made a difference? The State has successfully progressed from a vertical project mode to a horizontal state malaria program mode with the commitment and buy-in of the key players supporting malaria control efforts in the State. The first Annual Operational Plan performance review revealed that overall programme performance was 59%. Achievement of planned activities for health systems strengthening was 73.7%, malaria prevention 71.4%, advocacy, communication and social mobilization 64.3% and malaria diagnosis and treatment 61.1%. Lowest performance was in monitoring and evaluation at 33.3% and procurement of prophylactic drugs for pregnant women 0%. Proxy indicators to assess state perfomance relative to national targets showed that the number of women who received two doses of malaria prophylaxis in pregnancy increased from 23.9% at baseline to 50% thorough the engagement of the private sector. Functional village development committees increased from 25% to 46.7% as a result of intense community mobilization activities. Percentage of state malaria budget released increased from 24.2% to 81.5% which is ascribed to successful budget justification and advocacy for greater funding. Timely health facilities reporting and complete data increased marginally from 50%-59.4% due to staff shortage and the need for service providers to double as data clerks. Stock out of malaria commodities reduced from 100% to 79% mostly due to better quantification and commodity supply by partners. Regular supervisory visits are conducted by the state and local government with on the job capacity building to enhance performance in service delivery and internal management and administration.
Have you or the project mobilized others and if so, who, why and how? A wide range of stakeholders and key players are involved in Nigeria’s efforts to ensure an effective malaria control program. These include public and private providers of care, the donor community, civil society organizations and the community. The state was supported to put in place systems, through which these interrelated, or interdependent components work together efficiently and effectively. Village development committees were mobilised to support primary health facilities through local resource mobilization, awareness creation and monitoring leakage of malaria commodities. Heads of primary health care departments of the local government were trained to provide supportive supervision and on the job capacity building to improve performance at service delivery points. Technical and logistic support was provided for the multisectoral malaria technical working group to address implementation challenges. Partners activities were coordinated through regular partners meetings to ensure that partners did not diverge from the state plan. The capacity of the SMCP teams was enhanced for internal coordination of activities and to provide the desired leadership for all key players to work together in a synergistic manner.
When your donor funding runs out how will your idea continue to live? MAPS’ capacity building efforts recognize sustainability planning as an integral part of its planning process. There are inbuilt mechanisms for exit that ensure that gains achieved are not only sustained but improved upon. For this reason all aspects of the program activities take into cognizance the vital role of stakeholder participation and ownership across the program outputs. As much as possible, every opportunity to provide technical assistance to the State malaria programme team was through hands-on support and on the job capacity building with activities deliberately designed to enhance stakeholder inclusion, participation, buy-in and ownership. Capacity of the SMCP has been built for resource mobilisation, advocacy, communication and social mobilization, coordination of key players in malaria control and engagement with private providers. The increasing percentage of malaria control activites are state funded. It is anticipated that the program shall continue to support the hand over process of continuous improvement for capacity building in the short run through technical assistance and hand holding as SMCP coordination and technical capacity improves. The active involvement of the personnel from SMCP in the planning and implementation of program activities, such as the program management training roll out, and other technical areas will provide the opportunity for 'learning by doing' with a resultant rise in confidence levels of key health staff and the establishment of a pool of technical resources at State and local government levels. This state technical resource pool is likely to sustain the current effort outside the geographical scope and lifetime of the program.

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.

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.

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.

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.

Making It Better: NZ GPs Improving Access to Elective Services and Bridging the Primary/Secondary Gap

Author(s): R. S. J. Gellatly*1, R. Naden1, c. Perry1, J. Palmer1
Affiliation(s): 1Elective Service team, Ministry of Health, Wellington, New Zealand
Keywords: GPs (general practitioners), primary/secondary interface, GP Liaisons, elective services

Ministry of Health committed to improving elective services waiting times from 1999.The idea of using GP Liaisons (GPs who liaise) to assist this work came from an article in the BMJ. Since the inception of the role, changes in the NZ health system such as District Health Boards being responsible for regional health needs (rather than a focus on hospital services only) and the implementation of the primary healthcare strategy require better communication across that interface.GPLs now have a broad range of activities in improving the patient journey across the primary/secondary interface.


The range of roles and activities of GPLs around the country will be described, in relation to various sized district health boards in urban and rural New Zealand. Examples of improvements in which GPLs have been involved will be detailed, such as triaging referrals, changing pathways to improve patient access, providing a primary care perspective in hospital settings. Opportunities for further collaboration and innovation will be highlighted.


Elective service access has been improved. One of the factors in this has been GP Liaisons. As hospital-based consultants and administration staff gain confidence working with GPLs, other areas for improvement are identified. These vary with the local areas needs. Primary care benefits from having a voice in the hospital and a recognised conduit for issues and ideas to be raised.

Lessons learned:

Building relationships based on improved outcomes has opened up communication across the primary/secondary interface. GPs have a combination of practical can-do attitude, experience of working in both primary and secondary care, and the ability to see the big picture in the complex system that is healthcare delivery. Supporting the GPL network is important for its success. GPLs use many tools gleaned from leaders in health. Having paid time in the day is also a success factor.

Strengthening Health Systems through Formal Links with Storekeepers, Volunteers and Community Health Committees in Urban Settings: Extending Services to Communities Project


B. M. Nhlema Simwaka*1, P. Nkhonjera1, A. Willetts2, F. M. L. Salaniponi3, R. Malmborg4, S. R. Theobald2, B. S. Squire2


1Research for Equity And Community Health Trust, Lilongwe, Malawi, 2Liverpool School of Tropical Medicine, Liverpool, United Kingdom, 3National TB Control Programme, Ministry of Health, Lilongwe, Malawi, 4Norwegian Health and Lung Patient Association, Oslo, Norway

Keywords: Health system, informal health providers, referral, tuberculosis

This abstract highlights finding of an intervention research called Extending Services to Communities. The aim of the study was to document the impact of improving the advisory, referral and health promotion skills of storekeepers, volunteers, and community health committee in improving early care seeking for tuberculosis. The intervention package included a capacity building, referral system between the community and health facilities and health promotion on tuberculosis and chronic cough.


The objectives of the study were: (1) To develop and implement the Extending Services intervention package. (2) To analyse the acceptability of the intervention by the different stakeholders involved in implementation. (3) To explore, through gender and poverty analysis, the community perspectives of the impact of the intervention. (4) To quantify the extent of the impact of the intervention on TB control indicators. (5) To make recommendations for approaches for implementing and evaluating similar community based health interventions.
The research was conducted in Malawi by Research for Equity and Community Health Trust, in three resource-poor settings of urban Lilongwe in collaboration with the National TB Control Programme, Lilongwe District Health Office and City Assembly. The first intervention area was Ngwenya and second area was Kauma. Kauma was used to test replicability of the intervention. Chinsapo was used as a control area. The multi-method approach was used to develop and implement the intervention and to evaluate its impact and acceptability from social and biomedical perspectives.


A participatory process promoted ownership of the intervention and improved the referral and health promotion skills of storekeepers, volunteers and community health committees. Health workers used the referral letters as a screening tool for tuberculosis. The major limitations were coverage of health promotion activities and the participation of men in these activities. The community members explained that the intervention had greater impact on the poor men and women than the poorest because of the nature of their livelihood activities. In the intervention areas there was a significant increase between 2003 and 2006 in the proportion of chronic coughers seeking care within two weeks of symptom onset (Kauma from 23.4% to 68.8%, [p=0.001]; Ngwenya from 9.3% to 30.8 %, [p=0.042]) compared with the control area where the change did not reach statistical significance (Chinsapo from 36.9% to 15.4%, [p=0.0142]). In addition the proportion of Lilongwe city’s total annual notifications of smear positive TB arising from the intervention areas rose significantly (Kauma from 0.2% to 1.3%, [p=0.002], Ngwenya from 1.4% to 3.2%, [p=0.004]) while the proportion reported from the control area did not rise significantly (Chinsapo from 2.7% to 3.3%[p=0.44]).

Lessons learned:

The multi-method approach helped to understand the impact of the intervention on access to services from different perspectives and in framing different research outputs for different audiences. It was also clear that integration of the informal health providers to the formal health system depended on building on their existing roles as early entry points into the health system for poor men and women and was not intended as a way of replacing the role of the health workers. The Extending Services to Communities Model is one way of strengthening the health system to increase access to elements of the Essential Health Package. Meaningful integration calls for embracing of both biomedical and social models of health.