Geneva Health Forum Archive

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GHF2008 – PS10 – Innovative Healthcare Financing

Session Outline

Parallel session PS10, Tuesday, May 27 2008, 11:00-12:30, Room 3
Chair(s): George Pariyo, Senior Lecturer and Head, Department of Health Policy Planning and Management, Makerere University School of Public Health, Uganda 
Fiscal Space for Health Expenditure in Mozambique: Blocking Effectiveness of International Funds through Budget Support
Gorik Ooms, Analysis and Advocacy Unit, Médecins Sans Frontières, Belgium 
Towards Successful Community Health Insurance: Lessons Learned from Five Years of Active Involvement in Sub-Saharan Africa
Maria-Pia Waelkens, Department of Public Health, Institute of Tropical Medicine, Belgium 
Exploring SWAp’s Contribution to the Efficient Allocation and Use of Resources in the Health Sector in Zambia
Birger Forsberg, Public Health Sciences and Medical Management Centre, Karolinska Institute, Sweden
Contractual Arrangements between Community Health Insurance Schemes and Health Care Providers as a Means to Improve the Quality of Care: An Overview in Sub-Saharan Africa
Pascal Ndiaye, Department of Public Health, Institute of Tropical Medicine, Belgium 

Session Documents

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Session Report

Contributors: Sue Hua (ICVolunteers)

This session on Innovative Health Care Financing reviewed three approaches being tested in a variety of countries. The first, budget support, was found to be severely hampered by the practice of saving foreign assistance instead of spending it, due to 'fiscal space' restrictions. The second, Community Health Insurance (CHI), is based on prepayment and risk sharing. The third, the Sector Wide Approach (SWAp), suffers from a lack of harmonisation in reporting systems, resulting in unnecessary additional administration in the ministries of health.

Gorik Ooms, Analysis and Advocacy Unit, Médecins Sans Frontières, explained 'fiscal space' for health expenditure as a country's capacity to finance health expenditure from domestic resources within a foreseeable future. Whenever the combination of present domestic resources and present foreign assistance exceeds fiscal space, the excess foreign assistance is saved, rather than spent.

One fiscal space tool includes a ceiling on the government wage bill, which is most often expressed in the form of a percentage of the Gross Domestic Product (GDP). Therefore, even if donors were willing to pay for more salaries for health workers or teachers, a government is not allowed to exceed the ceiling. Other fiscal space tools include: a ceiling on the domestic primary deficit, medium - term expenditure framework (MTEF) and IMF programming of the use of foreign assistance.

During 2004 - 2006, Mozambique saved the equivalent of 91% of additional foreign assistance. Are donors aware of this? A survey was conducted with the major stakeholders of Mozambique's health sector and when they were informed that Mozambique had saved 91% of all additional aid during 2004-2006, most reacted in disbelief.

Budget support might be the best funding method, to improve harmonization among donors, alignment with government priorities and for financing recurrent general health expenditure. However, as long as donors are aware of the real impact of fiscal space constraints, and therefore do not challenge them, project support is much more effective than budget support.

GHF2008 – PL05 – Sustainable Health Financing

Session Outline

Plenary session PL05, Tuesday, May 27 2008, 14:00-15:30, Room 2
Chair(s): Andrew Jack, Pharmaceuticals Correspondent, The Financial Times, UK
Health Systems: A Philanthropic Perspective 
Ariel Pablos-Mendez, Managing Director, The Rockefeller Foundation, USA 
The Case of Liberia in New Disbursement for Strengthening Health Systems
Bernice Dahn, Deputy Minister and Chief Medical Officer, Ministry of Health and Social Welfare, Liberia 
Getting the Right Resources the Right Way
David Evans, Director, Department of Health Systems Financing, WHO, Switzerland  
The Price of Health: How High Can We Go?
Allyson Pollock, Assistant Principal, International Health Policy, Professor of International Public Health Policy, Centre for International Public Health Policy, University of Edinburgh, UK  

Session Document

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Session Video

Session Report

Submitted by: Victoria Ferris (ICVolunteers); Contributors: Reem Ibrahim (ICVolunteers)
Alma Ata became known as an ideal declaration for primary healthcare. The means to developing this vision corresponds to the available funding as well as health economics in general. Critical issues include equitable allocation of health funding and developing a solid program of primary healthcare.

Chair Andrew Jack, Pharmaceuticals Correspondent for The Financial Times, United Kingdom opened the session on health economics, introducing four well-established speakers: Mr. Ariel Pablos-Mendez, Managing Director of the Rockefeller Foundation, USA; Dr. Bernice Dahn, Deputy Minister and Chief Medical Officer of the Ministry of Health and Social Welfare, Liberia; Mr. David Evans, Director for the Department of Health Systems Financing for the World Health Organization, Switzerland; and, Ms. Allyson Pollock, Assistant Principal, International Health Policy, Professor of International Public Health Policy, Centre for International Public Health Policy, University of Edinburg, United Kingdom.

Mr. Pablos-Mendez introduced the topic of health financing by emphasizing the current dependence on overseas development agencies (ODA). In fact, 83.2 percent of private capital flows are to developing countries, yet a significant number of out-of-pocket spending is still visible. A new set of health financing issues exists with three key difficulties:

  • Availability: limited access, global human resources crisis and uneven distribution of resources;
  • Affordability: high out-of-pocket expenditures, impoverishment and undeveloped health insurance;
  • Quality: long lines of fatal mistakes, lack of quality standards and varying provider-incentive structures.

Mr. Pablos-Mendez stated that two aspects are required to contribute to good health at low cost: health equity and an economic transition of health. The Rockefeller Foundation aims to promote, maintain and restore health. The Foundation has concentrated efforts in South Asia on gathering more evidence and information since he feels more research is needed.

Mr. Pablos-Mendez also pointed out the need for improvement in the performance of health systems. Factors such as research, economic transition and Gross Domestic Production (GDP) cause variances among countries in system performances. There exists, he emphasized, a direct correlation between total health spending and GDP. The method of reining in health spending through cost control measures does not work, and he suggests accepting the paradigm, but investing the growth in equity and quality of health services, placing special emphasis on performance improvement. The Rockefeller Foundation exploratory initiatives for 2008 foster this outlook through capacity-building, technology, and policy.

Dr. Bernice Dahn addressed the question of public health services in Liberia, being only for the poorer population. She highlighted that in fact more equipment exists for public facilities than for private ones, and yet private services are used by the majority of the population. The low access to healthcare in developing countries, such as Liberia is due to many factors: brain drain, damaged or destroyed infrastructures, poor road conditions, lack of essential drugs and supplies, low salaries and incentives for staff, and health worker migration. Ongoing efforts by the government, NGOs, the public and private sector are crucial for implementing a sustainable plan.

Years of conflict disrupted health care delivery throughout Liberia. At one time, a Ministry of Health did not exist at all. But now that the hostilities have ended, several major health policies have been adopted by Liberia's innovative new government.

Addressing the duties of health financing systems, Mr. David Evans pointed out that interaction exists between revenue collection, pooling and purchasing/providing services, and this determines whether or not the financial system will be equitable and sustainable.

Several difficulties are linked to financing in general: (1) the need for fund-raising; (2) raising funds in a manner that permits global access; and (3) ensuring that the funds are used efficiently and equitably to provide services. Mr. Evans insisted that more funds must be raised. In fact, about 100 US dollars per capita is required to finance minimum access to health services; but in a total of 43 low-income countries, per capita spending is less than three dollars per year. Higher revenues can come from increased health budgets at the government level and funds can come from external sources.

Healthcare that is not dispensed at low cost to its users has a detrimental effect. A way to overcome this would be to pursue stages of coverage, from an absence of financing to intermediate stages of coverage, and, ultimately, to universal coverage. By implementing prepayment through insurance or taxes, countries can work towards universal coverage. But to do this Mr. Evans states is to instigate policies in favor of the poor.

Strategies towards better health services include:

  • A combination of external and internal funding
  • The creation of domestic financing institutions and capacities
  • To move away from out-of-pocket financing to forms of prepayment and pooling
  • to ensure inflows of external resources to strengthen the process

Ms. Allyson Pollock disagreed with David Evans, however, on the need to raise additional funds. For her, goals for health financing include:

  • Universal healthcare for all
  • Comprehensive coverage
  • Equal access
  • Free at point of delivery

She stated that to achieve these goals, mechanisms must be designed carefully to allow a fair and equitable redistribution of funding, with social solidarity as a primary function and without risk-pooling segmentation. (Risk-pool segmentation is a consumer-directed health plan (CDHP) which offers enrollees lower monthly premiums in exchange for higher cost-sharing when care is received.) Regarding the Pay for Performance Program (PPP), Ms. Pollock asked, "Where is the money really going?"

Furthermore, she noted that the delivery of healthcare as a service should be well-done. "Data is the primary building block and we must not lose sight of this in the needs-based planning process". The total process of delivery involves three main aspects:

  • Ensure that no groups are excluded
  • Use needs-based planning and develop better data systems
  • Adhere to public accounting and government control over resources via direct regulation

Uncoordinated diverse agendas exist and the issues regarding PPP must be brought to light. "It is time to begin a much more open and honest debate," she concluded, challenging organizations such as The Rockefeller Foundation to not think narrowly, as "free marketeers", but instead to change its direction and promote real integrated health, which requires giving up control and allowing others to become a part of the process.

GHF2008 – PS06 – Primary Healthcare Revival: Beyond Declarations

Session Outline

Parallel session PS06, Tuesday, May 27 2008, 11:00-12:30, Room 3
Chair(s): Bruno Gryseels, Director, Institute of Tropical Medicine, Belgium 
Primary Health Care: What Can We Learn from History?
Elisabeth Fee, Chief, History of Medicine Division, National Library of Medicine, National Institutes of Health, USA
Reducing Inequities in Health: PHC in the Modern Era
John Martin, Adviser, Office of the Director General, WHO, Switzerland 
Three Decades of Primary Health Care: Reviewing the Past and Defining the Future
Churnrutai Kanchanachitra, Prince Mahidol Conference, Mahidol University, Institute for Population and Social Research, Thailand 
The Community-Based Health Planning (CHPS) Initiative as PHC Strategy for Strengthening District Health Systems – Perspectives from Ghana 
Frank Nyonator, Director, Policy, Planning, Monitoring, and Evaluation Division, Ghana Health  Service, Ghana

Session Documents

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Session Report

Contributors: Ann Galea (ICVolunteers)

Photo © V. Krebs,

Although the philosophy of the Alma Ata declaration is still valid today, this session attempted to explain why its implementation has been hampered. The historical events that have occurred since the initial planning in the 1970's have tampered with the results. Insufficient health resources and poor infrastructures are stumbling blocks. The drive today should be away from more policy discussions and towards more ground action.

From a historical perspective, the Alma Ata Declaration for Primary Health Care (PHC) was the "most promising event of 1978" and a "major turning point in International Health". But according to Elisabeth Fee (History of Medicine Division, National Library of Medicine, Bethesda, United States) "it simply has not happened", because the world has changed since the planning phase in the 1970's. It was influenced by important world events such as the decolonization of African nations, the non-aligned movement, successful mass primary health care models in China and Cuba and the end of the cold war. The implementation of Primary Health Care in the 1980's was later challenged by new political and economic developments, such as the restructuring of the World Health Organization (WHO), selective Primary Health Care programs using extra-budgetary funding controlled by donors often without community participation, the dominance of International Monetary Fund economic policies linked to debt relief, as well as the concomitant increase in petrol prices and reduced commodity prices. The result of these changes in many developing countries, especially in Africa, was a complete fragmentation of the health systems. In fact, by the late 1990's, the health systems lacked infrastructure and human resources to deliver even the well funded vertical programs against malaria, diarrhea, immunization and recently the "3 by 5" ART program.

In an effort to revitalize Primary Health Care the Prince Mahidol Award Conference was organized in 2008 in Thailand.   A summary of the conference was reported by Dr. C. Kanchanachitra ( Prince Mahidol Confernce, Mahidol University, Institute for Population and Social Research, Thailand) during which the many lessons and challenges to the implementation of PHC over the past 30 years were discussed. While affirming that many changes have occurred in the global and national contexts three "unfinished agendas" related to financing, human resources and health information and disease surveillance need to be overcome. Particular reference was made to low spending on child and maternal mortality when compared to HIV/AIDS and high out of pocket payments by the poor for private health care leading to catastrophic poverty. Inappropriate skill mix and poor retention of health professionals are important human resource constraints. A clearer definition of roles, task shifting, incentive packages and enabling community health care workers are recommended actions. Although the important roles of volunteers was acknowledged it is firmly believed that  this is not the solution. The paucity of good national data  leading policy is of major concern and the potential application of new technologies such as ICT and GST and networked surveillance are possible solutions.

Dr. Frank Nyonator (Director, Policy Planning Monitoring and Evaluation, Ghana Health Service) stressed the fact that although there is strong political commitment among African countries for Primary Health Care, the problem is "how do we get the issues down to the ground?" The Ouagadougou Declaration is yet another affirmation of the Alma Ata declaration which "expressed the need for accelerated action by African governments" to improve health. The mood today is clearly set by the "need for action", documenting best practices, innovation and sharing those ideas that work.

Dr. John Martin (Advisor, Office of the Director General, World Health Organization) had no doubt that "Primary Health Care is very much alive", citing recent examples of Brazil's family health teams, Thailand's voluntary health workers, and Jamaica's lowered costs for health care among the poor. Primary Health Care is a process that involves governments, civil societies and other partners, but it should be owned by countries and set according to their needs and demands. To affirm this the audience was specifically asked to share their views with the rest of the panel and  a number of issues where raised by participants:

  • The lack of health professionals to deliver health care even at the district level in India.
  • The dominant role of global partners which is dictating the agenda to technical bodies such as WHO and influencing the policies of many countries. Notable exceptions are Malaysia, Thailand and Sri Lanka.
  • The exact meaning of community participation, this definition may vary from one context to the other.
  • The political basis of the policy incoherence that is observed even sometimes within WHO.
  • Primary Health Care depends on both technical and political elements; however the "right to health" is often forgotten. Health policies should be aimed at poverty alleviation and no longer take the simplistic" Pro Poor" approach.
  • There is a disconnect between strengthening the health system and strengthening community health.
  • Primary Health Care must not remain an issue only for Ministries of Health but must involve also Ministries for Development..
  • There is a tendency for Primary Health Care to be interpreted as the first level source of health care delivery, but in fact it should encompass a more holistic approach towards health.
  • Primary Health Care can be a misnomer as it is sometimes regarded as a "primitive" form of health care. Perhaps it is time to re-label it as "Essential Health Care".

GHF2008 – PL01 – Tomorrow’s Health Systems: In Phase with Reality?

Session Outline

Plenary session PL01, Monday, May 26 2008, 9:00-10:30, Room 2
Chair(s): Louis Loutan, President of the Organizing Committee, Geneva Health Forum, Switzerland & Maria NeiraDirector, Public Health and Environment, WHO, Switzerland
Global Transitions: Chronic Diseases and Ageing - Challenges to Health Systems
Andy Haines, Director, London School of Hygiene and Tropical Medicine, UK  
Emerging Poles of Power and Expertise 
Richard Samans, Managing Director, World Economic Forum, Switzerland 
Health in the Digital World: Key Trends that Health Professionals Cannot Afford to Miss
Kendall Ho, Associate Dean and Director, Division of Continuing Professional Development and Knowledge Translation, Faculty of Medicine, University of British Columbia, Canada 
India at the Forefront of Health Services
Sangita Reddy, Executive Director (Operations), Apollo Hospitals Group, India 

Session Documents

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Session Videos

Session Report

Submitted by: Cathy Matovu (ICVolunteers); Contributors: Janina M. Mank (ICVolunteers)
Photo: James Gathany,

The world is moving at a faster pace than ever before. Technology is advancing considerably and people from varied backgrounds and geographic situations are now able to communicate and interact instantly. The development of health systems in the world has been particularly slow to this transition and organizations all over the world continue to strive to meet these changes by searching for ways to create better access to health care.

The world is moving at a faster pace than ever before. Technology is advancing considerably and people from varied backgrounds and geographic situations are now able to communicate and interact instantly. The development of health systems in the world has been particularly slow to this transition and organizations all over the world continue to strive to meet these changes by searching for ways to create better access to health care.

Director of the London School of Hygiene & Tropical Medicine (LSHTM), Professor Andrew Haines discussed the issues concerning chronic diseases, aging populations in the world and the challenges these pose towards health systems. Over the years, we have witnessed a considerable increase of older persons in the world, Haines explained. Statistics predict that by 2050 almost 25% of the world's population will be over 65. Public expenditure has increased due to these ageing populations and, in addition, people are becoming more and more dependent and reliant on health care. Lung cancer and diabetes are the leading diseases affecting populations today. Haines argueed that this largely affects the cost of health systems. He maintained that in order to reduce these problems, governments must promote the decrease in salt-intake and the regulation of tobacco use which could potentially prevent up to 15 million deaths a year. Moreover, low- and middle-income countries are beginning to experience these types of health problems. Some preventive strategies for low- and middle-income countries, Haines added, include more public and tax funding and task shifting which essentially means delegating certain responsibilities to less skilled health workers.

IT (Information Technology) usage has become increasingly widespread in almost all sectors of the economy, but the health sector seems to stagger. Professor Kendall Ho from the University of British Columbia, Vancouver, Canada, questioned how we can use the digital world to bring excellence to health. We must shift from the traditional setting to a cyber world, where patients are able to virtually collaborate with their health care facilities through, for example, the creation of common documents, a private health record that is patient-centered or common information systems available on the Web, Ho argued. In order to do so, we have to incorporate the interconnected trends already present, e.g social networking, self-organizing communities, the democratization of information-sharing, the co-creation of knowledge and the individualization of knowledge management.

Richard Samans, Managing Director of the World Economic Forum, added that IT has empowered market actors to handle risk a lot better, which has also enabled people to be more comfortable with investing. The role of IT plays an important part in the development of health systems and is actually, according to Sammans, one of the elements needed to stimulate the global economy. He further argued that the problems that we experience in the health sector are largely linked to the economic problems in the world today. He pointed out that multilateral institutions are struggling to contend with the relatively recent fundamental shifts in power and expertise in the world.

In relation to this last point, Sangita Reddy from Apollo Hospitals Group stated that important organizations such as Doctors without Borders, continue to experience these barriers and still encounter "borders" as far as health issues are concerned. She presented the case study of her native India, where the health system can be described as "islands of excellence in an ocean of inadequacy", having recognized the trends of change in speed, momentum and direction of public health, customer awareness in a fast and connected digital world, technology and eHealth, increasing healthcare expenditure, an increase in lifestyle diseases, and lastly, the shortage in global manpower in the health sector. Reddy claimed that her nation-state India is a "healthcare destination", where its vision for healthcare excels and is not only relevant for the population of India, but for people all over the world. With a large main-d'oeuvre, India has an abundance of qualified doctors and nurses and is the world's leader of medical research and technology. She further claimed that health care today is disparate and disconnected. We must unite and work in parallel in order for changes to be made. "I believe that health care will no longer be shaped by [the] differences of our past but the commonalities of our future," she concluded.

There is potential for effective interventions not only in order to reduce costs substantially, but also to create a health system that is in phase with reality. Mr. Samans' recommendation is to engage business in public health, in order to be able to reach the majority of the world's population at decreased cost. Professor Haines suggested that since a rapidly aging population inflicts major social change especially in low-income countries, it is our duty to improve the system in a timely fashion, for example, by creating a clinical information system to track progress and enhance support for patients, as well as by scaling up the amount of health workers available. Ms. Reddy was quick to point out the tremendous importance of standardizing and validating health knowledge, terminology, legislation and training, creating applications that are in touch with the market, as well as keeping the costs down to facilitate an easy flow of information. Thus, her vision is to provide accessible healthcare for people everywhere, which is achievable if management of access, technology, infrastructure and human resources can be improved. Professor Ho's complimentary idea is to captivate the digital technology trends and find out how they can help us improve the system of global and public health.

Websites mentioned and recommended:

GHF2010 – PS25 – Rebuilding Post-Conflict Health Systems: Challenges and Opportunities

Session Outline

Parallel session PS25, Tuesday, April 20 2010, 16:00-17:30, Room 2
Chair(s): Yves Etienne, Head, Assistance Divisions, International Committee of the Red Cross, Switzerland, Davide Mosca, Director, Migration Health Department, International Organization for Migration, Switzerland
Ethics in the Delivery of Humanitarian Health Assistance: Learning from the Narratives of Health Workers
Lisa Schwartz, Clinical Epidemiology and Biostatistics, McMaster University, Canada
Managing a Health Crisis with Limited Health Systems Capabilities
Lenias Hwenda, Executive Education, IHEID, Switzerland
Health Sector Support: A Bridge to Peace in the Northern Caucasus
Khassan Dzgoev, Lecturer, Department of Surgery, State Medical Academy, Vladikavkaz, Russian Federation
Ensuring Provision of Appropriate Physical Rehabilitation Services: From Emergency to Long-Term
Claude Tardif, Head of Physical Rehabilitation Programmes, Health Unit, Assistance Division, International Committee of the Red Cross, Switzerland

Session Documents

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Session Video

This session is available to watch using Dudal. To watch it you will need to have Java installed on your computer.

Session Report

Submitted by: James Reynolds-Brown (ICVolunteers); Contributors: Josefine Ridderstrale (ICVolunteers)

Theo Verhoeff of ICRC. Photo by V. Krebs,

A series of short presentations covering the increasingly complex work of following immediate crisis response with effective capacity building systems. Case studies from the North Caucasus, Afghanistan and from the recent experience of the ICRC highlight the issues involved and various attempts to address them.

Yves Etienne and Davide Mosca chaired this series of presentations looking at the longer term implications for health systems in the short and long post-conflict terms. Mr Etienne, setting the tone for the rest of the presentations, reminded the audience of the difficulties in making the link between an emergency situation and reconstruction phases. A new paradigm of chronic-crisis situations, where the ICRC and similar agencies found it difficult to tell whether a conflict situation had ceased or simply paused, was emerging.

Lisa Schwartz of McMaster University gave a presentation on dealing with ethical and moral distress in returning health workers. Her team’s study of several health workers had uncovered ethical challenges where no response to a situation would be without a moral dilemma. Covering her slides in detail, Dr Schwartz noted four main themes from her research as the cause of moral and ethical distress: resource scarcity, social inequities, the policies and agendas of aid agencies, and the roles and interactions with western norms. Her recommendation for the future was to find a new approach to pre-deployment training and providing support for moral distress and the ability to talk about it.

A comment from the audience pointed out that it took courage to dig into these ethical issues, and suggested that the role of impartiality should also be built into any new approach for pre-deployment training. The audience member also agreed with the notion that the creation of ‘space’ for health professionals was key.

Khassan Dzgoev gave a view on health sector support as a means to achieving and embedding peace in the North Caucasus, a region of recent armed conflict. Each of the three republics, North Ossetia, Chechnya and Ingushetia, had suffered serious problems with their health systems, consisting of underfunding, destruction of services, poor laboratory quality, lack of professional training, and problems diagnosing TB/HIV. The Swiss Agency for Development and Cooperation (SDC) had focussed on these areas and produced several steps for improvement. Laboratory services had been strengthened or re-established, a DOTS strategy had been implemented, training had been provided, and prevention/prophylactic services had been enhanced. A key element of the work had been cooperation between the three republics, especially in the fields of training, ministerial effort and medical collaboration. The work of a trusted third party, competent professionals, and a clear focus on health concerns had been some of the most important success factors.

Yves Etienne agreed with the principle of Dr Dzgoev’s talk in stating “health should be stronger than politics”.

The work of the International Committee of the Red Cross (ICRC) in long-term physical rehabilitation projects was covered by Theo Verhoeff. The ICRC, in recognising that those with physical disabilities arising from conflict situations needed assistance in social integration and medical support beyond the conflict phase, sought to address their long term needs through access to rehabilitation services; the ‘physical rehabilitation continuum’. The ICRC had established the Special Fund for the Disabled (SFD), to complement the work of its Physical Rehabilitation Programme (PRP). Although the main objectives of the PRP and SFD are the same, their respective responsibilities are different. The PRP substitutes itself for the national authority, while the role of the SFD is just to support the re- or newly-established national authority. Giving some statistics, Mr Verhoeff noted that the PRP had 90 projects in 25 countries, and the SFD had 64 projects worldwide. He summed up by noting that the SFD can help embed physical rehabilitation programmes, the help is appreciated by all parties including donors, that sustaining services is a challenge, and that success depends on the commitment of nations, organisations and donors.

Yves Etienne noted that once a programme, such as the provision of prosthetics to children, had started, many organisations found it difficult to end that programme and had not considered the need for near permanent involvement in the programme; the work of the SFD was key to sustainability.

For the final session, Pierre Gauthier preceded a short film, ‘A new life for Mohsin’ with some pithy words. Echoing the other presenters, he noted that providing patient services is not enough, you have to consider the social integration of a patient. The ICRC had sought to institutionalise this in various projects, including this particular one in Kabul. The film, about social integration in Afghanistan, covered the work of an ICRC unit in Kabul in rehabilitating patients and providing for their re-integration into their family and the wider society. They were able to provide micro-credit, home based support services and had established a local workshop for the production of mobility aids.

GHF2010 – PS12 – Participatory Tools Influencing Health Systems

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Session Outline

Parallel session PS12, Tuesday, April 20 2010, 11:00-12:30, Room 13
Workshop Chair(s): David Musendo, Capacity Development team, Healthlink Worldwide, United Kingdom
Summary: Community participation has become a key component of both primary healthcare programmes and development programmes seeking to empower communities. Despite widespread use of the term in health policy documents and publications, genuine understanding of what the term actually encompasses is often lacking. 'Community participation' is often used in cases where community members are merely invited to participate in programmes introduced by outsiders, with no account taken of the complexity of the community's culture, power dynamics, and expectations. This workshop explores participatory approaches, by offering hands on activities such as drawing images that illustrate the value of participatory approaches, classification of different types of decision making, and determining the levels of power according to a participatory ladder. This session is linked to another parallel session entitled, 'Participatory Approaches to Health: Cases Studies from around the World'.

Session Document

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Strengthening Health Systems for Improved Access to Health Services for Pregnant Women in Rural Areas: Nigeria

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Author(s): Chioma Nwuba1, Umoh Mary1, Lawal Salimat2, 3Livinus Ibiang
Affiliation(s): 1Management Sciences for Health, Kwara, Nigeria, 2Kwara State Ministry of Health, Nigeria, 3Management Sciences for Health, Abuja, Nigeria
1st country of focus: Nigeria
Relevant to the conference theme: Redesigning health services
Summary: In Nigeria, the uptake of Prevention of Mother to Child Transmission (PMTCT) services for HIV positive women remains notably low despite significant advances in HIV/AIDS care and treatment. The burden of traveling long distances from their villages and waiting for long hours in order to access treatment has resulted in a most pregnant women opting out and this poses a barrier to the effective implementation of PMTCT programs. Thus, strengthening of health systems is vital in addressing these challenges of limited health service that prevent large numbers of HIV positive pregnant women in rural communities from accessing care and treatment services.
What challenges does your project address and why is it of importance?: Eligibility for antiretroviral therapy (ART) for the over 360,000 children and 1.6 million women living with HIV in rural areas in Nigeria is based on absolute CD4 count. This laboratory investigation is only available once a week on clinic days making it difficult for the vast majority of children and pregnant women who test positive on non clinic days to have access to baseline CD4 estimation. In addition, the burden of travelling long distances to and from clinics for initial blood draw and receipt of test results has led to attrition in the number of pregnant women who test positive to HIV versus the number who eventually commence antiretroviral therapy.. Furthermore, shortage of human resources for health also made it difficult to have enough workers attend to patients promptly. Patients have to wait for the few available doctors who are already overburdened by huge workloads to fill laboratory and pharmacy request forms before accessing laboratory investigations or collecting their antiretroviral drugs.
How have you addressed these challenges? Do you see a solution?: In order to increase uptake of CD4 monitoring for pregnant women attending HIV care and treatment clinics in North Central, Nigeria, the USAID funded PrO ACT project of Management Sciences for Health, strengthened existing systems using the following data driven interventions: 1. Provided hands-on facility based capacity building on HIV rapid testing for antenatal and maternity clinic staff. 2. Established point of service HIV testing in the antenatal clinics (ANC) and maternity units. 3. Introduced point of care CD4 sample collection for clinics where the laboratory is far from the ANC/maternity unit. 4. Task shifting to data clerks to fill laboratory request forms for CD4 investigations instead of the few available doctors. 5. Bridged the gap in human resources for health by task shifting to laboratory technicians on the use of automated CD4 equipments after consistent onsite training and supervision. 6. Adopted a flexible duty roster which ensures that a staff is always available every working day to attend to clients. 7. Task shifting to pharmacy technicians and assistants to assist in dispensing drugs daily. 8. Initiated daily (Monday – Friday) access to CD4 investigations for all pregnant mothers in order to capture women who test positive to HIV on non clinic days and ensure that they have access to baseline investigations on the same day.  9. Establishing daily investigations to provide an opportunity for pregnant women attending clinics from long distances and difficult terrains to have access to laboratory and pharmaceutical services on any day of the week. 10. Instituted 24 hours turnaround time for receipt of CD4 test results for all pregnant women to ensure rapid initiation of eligible clients on ART. 11. Harmonized patient appointments for antiretroviral drug pick up and laboratory monitoring on the same day in order to improve adherence to clinic appointments.  12. Integrated ART laboratory into existing general laboratory ensuring that the same phlebotomy point is used for all clients irrespective of their HIV status.
How do you know whether you have made a difference?: At the end of 12 months, the number of HIV positive pregnant women who accessed baseline laboratory CD4 investigations at our comprehensive care and treatment clinics increased from 53.8% to 90%. In addition, the number of pregnant women placed on antiretroviral therapy increased from 50% before the initiation of our interventions to 83% after the interventions. Laboratory turnaround time for CD4 result, which used to be 7 days, has reduced to 24 hours resulting in rapid initiation of eligible patients on antiretroviral therapy. Average client waiting time on clinic days reduced from 4 hours to 1 hour 30minutes resulting in more pregnant mothers being willing to access care and treatment services at our clinics. Furthermore, the number of patients lost to follow up reduced from 58.7% to 10.7% at the end of twelve months. More importantly, after the intervention, the number of exposed infants who tested negative to HIV increased from 85% to 100%.
Have you or the project mobilized others and if so, who, why and how?: The successes recorded after strengthening health systems for effective delivery of HIV care and treatment services at our pilot treatment center (Specialist Hospital Offa) prompted us to implement these strategies at two other treatment centers in Kwara state (General Hospital, Omuaran and Children Specialist Hospital, Ilorin).  At each clinic, we held a sensitization meeting with the hospital management committee, community leaders, health workers, community women groups and other relevant stakeholders. At these meetings, we presented data on the prevalence of HIV in each community as well as the number of women who tested positive to HIV since the inception of the program. We went further to highlight the number of HIV positive pregnant women who did not commence ART or were lost to follow up . Data concerning the high rate of under five mortality in these communities were also discussed.  Thereafter, working as a team, participants at the meetings made suggestions as to why most women who are diagnosed with HIV do not access treatment or are lost to follow up. Some of the suggestions made include ignorance about mother to child transmission of HIV, distance and difficult terrains of some communities, long waiting time encountered by most patients at the clinics, stigmatization by health workers, long turnaround time for laboratory results, different appointment days for laboratory investigations and drug pick up etc.  Possible solutions were then proffered by each group present. The women’s group agreed to have community health talks regarding HIV transmission given at their meetings. The hospital management committee introduced the idea of having more than one clinic day in a week. Working in collaboration with the Kwara state Ministry of Health we assisted in building the capacity of available health workers and adopted task shifting approaches to address the shortage of health workers. The capacity of data clerks and nurses were built up to enable them to fill laboratory and pharmacy request forms thereby reducing client waiting time and alleviating the workload on the few available doctors.  The laboratory unit instituted “same day CD4 system” ensuring that CD4 investigations are done five working days of the week for all patients who test positive to HIV. Test results are also released on the same day to ensure rapid initiation of eligible patients on antiretroviral therapy. Appointment days for laboratory investigations and drug pick up were harmonized to improve adherence to clinic appointments.
When your donor funding runs out how will your idea continue to live?: At the inception of this program, we strengthened the capacity of health sector institutions, systems and personnel to plan and manage the delivery of sustainable comprehensive and quality prevention, care and treatment support services. To also ensure that the program continues to survive and succeed even after our donor funding runs out, we instituted the following measures• Each hospital management committee drives the program and makes independent decisions necessary for the delivery of quality services. • On the job trainings facilitated by each unit head is held for incoming new staff on HIV rapid testing, filling of laboratory and drug request forms, use of automated equipments for laboratory investigations, ARV drug dispensing, adherence etc. This will ensure that more trained health workers are available to attend to patients.• At the laboratory unit of each clinic, quality assurance meetings led by the heads of each unit are held to address issues relating to improvement in the quality of services provided.• The idea has a 100% buy in from the state government as we neither employ nor pay the salaries of health workers working in the hospitals. The state government does so.