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GHF2014 – PL05 – Integrating Health, Wellbeing and Sustainability

08:45
10:15
PL05 THURSDAY, 17 APRIL 2014 ROOM: 2 ICON_QA
INTEGRATING HEALTH, WELLBEING AND SUSTAINABILITY
MODERATOR:
Dr. Carlos Dora
Department of Public Health and Environment, World Health Organization, Switzerland
PANEL:
H.E. Ambassador Michael Gerber 
Ambassador and Special Representative for Global Sustainable Development Post-2015, Swiss Agency for Development and Cooperation (SDC), Switzerland
Mrs. Pam Warhurst 
Founder and Chair, Incredible Edible Tordmorden, United Kingdom
Mrs. Meenakshi Raman
Third World Network, Malaysia
Mr. Rick Bell
Executive Director, American Institute of Architects New York Chapter, Center for Architecture, United States
AIM:
Discuss how to better integrate the three dimensions of sustainable development and embed health into the post 2015 new development agenda.
OUTLINE:
The Millennium Declaration adopted by the heads of State at the Millennium Summit in 2000 has constituted the dominant development paradigm and organizing framework of the last decade. The Millenium Development Goals have substantially contributed to focus development co-operation efforts, strengthened the accountability requirement and mobilized support. With the Millennium Development Goals scheduled to come to an end in 2015, the international community is now taking stock of the substantial advances made as well as the unevenness and gaps in achievement. As we approach the 2015 deadline, unrelenting efforts are required to accelerate progress across all the goals but debates and global consultations about what will replace the MDGs have already taken place. In June  2012, on  the  occasion of the Rio+20 Conference on  Sustainable Development, another mandate  with  similar  aspirations  was  born:  the  Sustainable  Development  Goals  (SDGs). Whilst the MDGs primarily focused on social issues such as poverty, hunger, health and education in developing countries, SDGs will seek to strike a balance between all three dimensions of sustainable development, namely the economic, environmental and the social, and will be applicable for all countries.Health as a component of social progress is a key aspect of the debates, and is being framed as a precondition for, an outcome and a possible indicator of sustainable development.The position health might take into this new framework is still subject to various narrative exercises and a lot of uncertainty still remains of what will be the next development framework by 2015.Moving away from global statements and declarations, the session will convey a diverse panel of actors involved in development, urban planning and community mobilization to discuss the enabling environment needed at a global and local level to build healthier societies and preserve our environment.Some of the questions to be discussed include:

  • What kind of systemic global reforms would be required to secure an accommodating international environment for sustainable development in both developed and developing countries?
  • How can health serve as an indicator to measure sustainable development policies progress, achievement and impact?
  • How can local communities, people’s movements and citizens contribute in shaping healthier and more inclusive societies/cities?
  • How can urban design influence behavioral changes and promote healthy living?
PROFILES:

Carlos Dora_squareDr. Carlos Dora

Carlos Dora, is a coordinator at the WHO HQ Public Health and Environment Department, leading work on health impacts of sector policies (energy, transport, housing and extractive industry), health impact assessment and co-benefits from green economy/climate change policies. He previously worked at the London School of Hygiene and Tropical Medicine (LSHTM), at the WHO Regional Office for Europe, at the World Bank, and with primary care systems in Brazil after practicing medicine. He serves in many science and policy committees, has an MSc and PhD from the LSHTM.  His publications cover health impact of sector and sustainable development policies, HIA and health risk communication.

 

Michael Gerber Jan. 2013H.E. Ambassador Michael Gerber

Perspective: Switzerland’s position on the new Sustainable Development Framework

Member of the Swiss Agency for Development and Cooperation (SDC), Mr Gerber was the Head of the SDC Analysis and Policy Section before being appointed Special Representative for Global Sustainable Development Post-2015 by the Federal Council with the rank of ambassador. In this position, he has been given the task of formulating Switzerland’s position on a Framework for Sustainable Development Post-2015 . Ambassador Gerber is also representing Switzerland in the Open Working Group on SDGs (Switzerland shares with France and Germany).

 

PL05_Pam_WarhurstMrs. Pam Warhurst

Perspective: How to empower ordinary people to take control of their communities through active civic engagement.

Pam Warhurst is a British community leader, activist and environment worker best known for co-founding the community initiative, Incredible Edible, in Todmorden, West Yorkshire.

Pam studied Economics at the University of Manchester. She has previously served as a member of the Board of Natural England, where she was the lead non-executive board member working on the Countryside & Rights of Way Bill. She is a Fellow of the Royal Society of Arts & Manufacturing, and chairs Pennine Prospects, a regeneration company for the South Pennines, and Incredible Edible Todmorden, a local food partnership. Pam has also been Deputy Chair and Acting Chair of the Countryside Agency, leader of Calderdale Council, a board member of Yorkshire Forward, and chair of the National Countryside Access Forum and Calderdale NHS Trust. Pam was awarded Commander of the Order of the British Empire award (CBE) in 2005 for services to the environment.

PL05_Meenakshi_Raman_squareMrs. Meenakshi Raman

Perspective: How to tackle the growing environment crises factoring international equity in the equation?

Mrs Raman is Legal Advisor and Senior Researcher at Third World Network (TWN) and is based in Geneva. She is also a Member of the Board of Friends of the Earth International and Honorary Secretary to Friends of the Earth Malaysia (Sahabat Alam). As Legal Advisor to the Consumers’ Association of Penang in Malaysia, she currently heads its Community Mobilization Section, which works with farmers and fisher folk. She has served as Chair of Friends of the Earth International (2004-2008), an international organization with 77 member groups. At Third World Network, Meenakshi currently coordinates the Climate Change Programme and has actively been involved in the intergovernmental climate negotiations, from Bali to Cancun. She has been monitoring and reporting on the negotiations and providing analysis and support both to developing country governments as well as to civil society participants. Upon graduation in 1982, Meenakshi and a colleague set up the first public interest law firm in Malaysia, which launched her legal practice assisting consumers. In the past 25 years, she has represented the organizations she works with at numerous conferences and presented papers on issues ranging from environmental and consumer protection, to climate change, agriculture and fisheries, and globalization and trade.

PS25_Rick Bell_squareMr. Rick Bell

I became an architect because of the inspirational oratory of professors including Vincent Scully and the physical example of buildings seen while attempting, at the age of 19, to hitchhike from Paris to Dakar. As an architect I've had three careers, first in the private sector, then at a public agency, and, most recently, in the not-for-profit domain. As a private architect, I mostly designed schools and libraries in a NYC-based firm that also did hotel projects worldwide. In the public sector, I served as chief architect and assistant commissioner of New York City’s public works department, responsible for 700 projects annually. And for the last twelve years I’ve led the New York Chapter of the American Institute of Architects and created its storefront Center for Architecture.

GHF2014 – PS16 – Unpacking Health Systems Through System Thinking

10:45
12:15
PS16 WEDNESDAY, 16 APRIL 2014 ROOM: 3 ICON_Talk
Unpacking Health Systems Through System Thinking
MODERATOR:
Dr. Taghreed Adam, MD, Alliance for Health Policy and Systems Research (HSR), Health Systems and Innovation (HIS), World Health Organization, Switzerland
SPEAKERS:
Evaluating Systems-Thinking for District Managers : Ghana
Ms. Aku Kwamie, Researcher, Health Policy, Planning and Management, University of Ghana School of Public Health, Ghana
Understanding the Growing Complexity of Governing Immunization Services in Kerala, India
Dr. Joe Varghese, Post Doctoral Research Fellow, NCD Lifespan Training Program, Centre for Chronic Diseases Control
Dual Practice in Uganda: the Evolution and Management of a Complex Phenomenon
Dr. Ligia Paina Bergman, Department of International Health, Johns Hopkins University School of Public Health, United States
Exploring Primary Care: System Dynamics in USA and Romania
Mrs. Andrada Tomoaia-Cotisel, PhD Candidate, Health Services Research & Policy, London School of Hygiene and Tropical Medicine, United States
Learning from Evidence: Advice-Seeking Behaviour Among Primary Health Care Physicians in Pakistan
Dr. Asmat Malik, Director Research and Development, Department of Research and Development, Integrated Health Services, Pakistan
OUTLINE:
PROFILES:

PS16_Taghreed_AdamDr. Taghreed Adam

Taghreed Adam is a Pediatrician and Health Economist. Having joined WHO in 1999, she focused on methodological and analytical developments in the areas of costing and the economic evaluation of health interventions. Her main research contributions include the multi-country evaluation of IMCI and the WHO-CHOICE project on cost-effectiveness analysis.  Dr Adam joined the Alliance for Health Policy and Systems Research in February 2008. She leads various projects, notably research to advance the methods and application of “systems thinking” concepts in strengthening health systems of low-income and middle-income countries; and the Alliance’ portfolio on capacity strengthening of health policy and systems researchers. Before joining WHO, she worked with the Egyptian Ministry of Health in their Health Sector Reform Project, particularly in the development of a universal health insurance package for the Egyptian population.

AkuKwamieMs. Aku Kwamie

Aku Kwamie is a health systems researcher based at the University of Ghana School of Public Health. Her current area of research is district level governance. Ms Kwamie also has research interests in management and leadership, accountability, decentralisation, complexity science, and maternal and newborn health. She has worked internationally in community health settings in Ghana, Nigeria, Togo, Lesotho, and Canada. Ms Kwamie holds degrees from the University of Toronto and King's College London. She is currently completing her doctoral thesis.

PS16_Joe_VargheseDr. Joe Varghese

I am a NIH D43 Research Fellow associated with Centre for Chronic Disease Control, New Delhi and Rollin School of Public Health, Emory University, Atlanta. I have master and doctoral degree in public health from Achutha Menon Centre for Health Science Studies, Sree Chitra Tirunal Institute for Medical Sciences and Technology, Thiruvananthapuram and currently, undergoing MSc in Global Health Policy (Distance Learning), London School of Hygiene and Tropical Medicine, University of London. I have over 12 years of involvement in public health at the national level as a health system researcher, policy expert and program manager.  I am associated with Jan Swasthya Abhiyan, the Indian affiliate of People’s Health Movement. My research and publications are related to Panchayat Raj Institutions and health sector, sex ratio at birth of Delhi hospitals, public health ethics, analytical frameworks for public health policies & programs and immunization & health governance. My current interest and researches are in the area of policy priorities for NCD prevention and control, population level behaviour change interventions, complexity of public health governance and in the development and application of System Thinking frameworks for public health.

Ligia Paina 2014Dr. Ligia Paina Bergman

Ligia Paina is an Assistant Scientist in the International Health Department of the Johns Hopkins University Bloomberg School of Public Health (JHSPH). Her research interests include health workforce policy, complex adaptive systems, and research and organizational capacity development in low and middle income countries.

Ligia's experience in global health is focused on health systems strengthening and health systems research.  As a Research Assistant at Johns Hopkins University, she has contributed to the design, management, and analysis of qualitative, quantitative, and mixed methods research studies. Prior to joining Johns Hopkins, Ligia worked as a Health System Advisor in the Office of Health, Infectious Diseases, and Nutrition at the U. S. Agency for International Development.

Ligia holds a PhD and a MHS in International Health - Health Systems from the Johns Hopkins University Bloomberg School of Public Health.

PS16_Andrada_Tomoaia_CotiselMrs. Andrada Tomoaia-Cotisel

My long-term career goal is to improve population health via improving health systems (HS).  My PhD dissertation explores the impact of primary care structures on patients’ risk of hospitalization.  The purpose of my research is to make a robust assessment of the dynamic interactions of these health system components and resulting outcomes.  My first job in public health (PH) was studying the effect of exertional heat illness on Marine Corps recruits with Sickle Cell trait.  I saw the importance of PH in identifying and protecting vulnerable populations. As an undergraduate intern at the World Health Organization in Geneva, I observed the complex interactions between NGOs and national health ministries that characterize effective health systems. I observed the paramount role HS plays in PH. After graduation, as an unpaid, uninsured, USAID intern, I got sick.  I sought care from a local community health center. Grateful for their help, I soon found myself working at one such organization.  There, I witnessed up close how changes in the local health service delivery system, such as interdisciplinary preventive care, could result in higher quality care for patients and improve cost-effectiveness. I saw how HS improvement happens and made it my long term goal to participate, whether my career takes me in research, policy or practice – hopefully all of the above!

AsmatMalikDr. Asmat Malik

Dr. Asmat Ullah Malik, a medical doctor and health policy and systems analyst has an extensive experience of working in health system in Pakistan. He is currently heading the Research and Development Division of Integrated Health Services, Islamabad, Pakistan. His key research interests are in health policy, its translation into national health systems and programs and testing innovative strategies for strengthening health service delivery. He was awarded Rockefeller Foundation Bursary Award for his research work presented at Health Systems in Asia Conference held in Singapore in 2013. He was also awarded an Australian Development Scholarship by the Government of Australia for PhD in Health Policy and Systems (2007-2013). He was winner of ‘Emerging Voices’ essay competition organized by Institute of Tropical Medicine (ITM), Antwerp, Belgium in 2010.

 

Best Practices for Building an Integrated National Health Information System: Rwanda.

Author(s) Caricia Catalani1, Angela Hoth2, Dawn Seymour3, Tyler Nelson 4, Felix Kayigamba 5, Richard Gakuba6
Affiliation(s) 1Innovative Support to Emergency, Disease, & Disaster (InSTEDD) & University of California, Berkeley, School of Public Health, San Francisco, United States, 2Innovative Support to Emergency, Disease, & Disaster (InSTEDD), Berkeley, United States, 3Rwanda Health Information Exchange, Regenstrief Institute, Kigali, Rwanda, 4Maternal Health & RapidSMS, The Access Project, Kigali, Rwanda, 5The Access Project, Kigali, Rwanda, 6 Rwanda Health Information Exchange , Kigali, Rwanda
Country - ies of focus Rwanda
Relevant to the conference tracks Innovation and Technologies
Summary The Rwanda Health Information Exchange (RHIE) is among the world’s first efforts to establish an integrated national health information system in a low-resource setting. Global decision-makers and implementers can benefit from both RHIE's open source tools and knowledge of leading and managing innovation for integration. This study assesses best practices in the design, development, and deployment of RHIE from the perspective of key stakeholders. Themes from the analysis of semi-structured interviews with funders, leaders, and implementers include recommendations on governance of country-owned initiatives, technological design and development, and deployment in a low-resource setting.
Background RHIE is a cloud-based system that supports quality of care and continuity of care over time, across geographies, and across different care delivery sites. RHIE’s vision is to improve health and wellbeing by ensuring that critical information follows patients when and where they need it, despite the dozens of different information systems used nationwide. In 2010, RHIE was designed and developed under the leadership of Rwanda’s Ministry of Health by the Open Health Information Exchange (OpenHIE), a global open-source technology community including partners at PEPFAR, Canadian International Research Development Center, Rockefeller Foundation, Regenstrief Institute, InSTEDD, Jembi Health Systems, IntraHealth, and others. RHIE’s national rollout began in 2012 and entailed working across sites with minimal infrastructure and among providers with little computer experience to configure hardware, install software, build local capacity, and manage technical support . Today, and as scale-up continues, RHIE facilitates the movement of health information across Rwanda with the primary aim of improving maternal and child health and the treatment and prevention of HIV/AIDS.
Objectives The Open Health Information Exchange builds free and open-source tools to enable other national leaders, policymakers, and implementers to improve the integration of health data and systems through the establishment of health information exchanges. Today, the partnership is collaborating with national leaders from six countries, providing technical support required to spearhead this effort. However, more than just tools and technical support, decision-makers need practical insights into the process of leading and managing innovation of this kind. As such, this study aims to describe the best practices in design, development, and deployment of a health information exchange, based on the RHIE experience. Researchers conducted key stakeholder interviews among RHIE funders, leaders, and implementers with a range of expertise from computer engineering to health systems management to clinical care. From their critical reflections of the RHIE initiative, its three years of history, and its pathways forward, stakeholders provide recommendations on approaches to governance of country-owned initiatives, strategies for technological design and development, and tactics for managing deployment of technological innovation in low-resource settings.
Methodology Qualitative semi-structured interviews were conducted with RHIE key stakeholders. Stakeholders included Ministry of Health leaders & implementers, project managers & strategists, technology architecture designers & developers, and funders & other institutional partners. Semi-structured interviews guided a conversational interview, providing the interviewers with key points of discussion without requiring strict adherence to a set order of questioning or phrasing of the questions. As such, interviewees provide descriptions of their experiences, ideas, and critiques in an open and guided discussion. Interview were conducted by two trained interviewers via phone, audio-recorded, and documented through detailed notes. Interview duration ranged from 45-75 minutes. Analysis was conducted using Dedoose Mixed Methods Analysis Software, a cloud-based research and analysis application. A modified grounded theory approach was used in the analysis of qualitative data. This approach facilitated the detailed and systematic examination of data regularities in the relationships between and within codes, and for variations and contrasts within codes. Major themes emerged from the codes and a descriptive framework formed.
Results Key stakeholder interviews included 14 participants from 7 organizations and 4 countries. Several key themes emerged across the major phases, spanning partnership building, design, development, deployment, and evaluation. First, eHealth is a new field without established guidelines for management and leadership and, as such, most found it challenging to partner without clearly articulated governance rules. Terms of governance, they argued, provide guidance for decision-making, roles and responsibilities, accountability, and transparency. The RHIE experience confirmed for most that country-ownership of the initiative should be established early and embedded into the partnership’s governance structures.Second, most partners commented on the difficulty of collaboration when key contributors were spread across several countries and time-zones. They explained that in a low-resource setting, it is often necessary to look for eHealth integration expertise and capacity from people based in other countries. Cross-cultural, cross-national, and cross-disciplinary communication was immensely difficult, although building an integrated system required a well-integrated team. Stakeholders found that it was critical to have a shared commitment to regular communication and ample budget for in-person meetings.Third, experts were adamant that an eHealth integration initiative should start by looking at existing, tested, and ideally open-source tools that might serve as customizable building blocks for their own solution. While identifying these tools, most argued that the team must create a shared standard of assessment so that they can transparently evaluate tools in a world where business interests may sway these decisions. Many stakeholders shared the opinion that eHealth solutions must be simple, tested, and even boring, although “the siren song is to do something new, bold, and innovative.”Finally, most partners found that the health and human development objectives of the project were obfuscated by the technological objectives of the project. RHIE contributors spent the vast majority of their efforts on designing and developing the technology, often without a shared vision of how the system would ultimately impact health services, morbidity, and mortality. One expert argued that it should have been the opposite and that “in a sociotechnical system, the technical should be 10% and the rest of the money and time should be spent focusing on implementing.”
Conclusion The health systems integration experts involved in RHIE shared a common sense of the challenges and opportunities inherent in partnering, designing, developing, and deploying a health information exchange. Several best practices emerge from these findings: establish rules of governance to guide the partnership; plan for regular and in-person communications to facilitate collaboration among diverse contributors; build on existing, tested, and open-source technologies before considering anything new; and, create a shared strategic and practical vision for how a new eHealth tool will impact health. As the OpenHIE expands beyond Rwanda and into new country implementations, these findings can be used to guide policy-makers, implementers, and other experts. Worldwide, country leaders are struggling to take advantage of the digitization of health information while managing innovation within health centers and protecting patient privacy. In an era of big data, health information exchange is one way to integrate and manage health information across disparate systems. Health information exchange tools and best practices may improve health and wellbeing by ensuring that critical information follows patients when and where they need it, despite the dozens of different health information devices, tools, and systems emerging worldwide.

Health as an indicator of sustainable development: How health can contribute to and benefit from sustainable policies.

Author(s) Natalie Mrak1, Callum Brindley2
Affiliation(s) 1Development studies, The Graduate Institute for International and Development Studies, Geneva, Switzerland, 2Development Studies , The Graduate Institute for International and Development Studies, Geneva, Switzerland.
Country - ies of focus Switzerland
Relevant to the conference tracks Environment and Sustainability
Summary This study highlights how health can be a cross-sectoral indicator for the proposed 2015 sustainable development goals. The impacts of environmental changes on human wellbeing have been clearly established but insufficient work has been done to show how sustainable policies can also benefit health. This study recommends health indicators that can be used to measure sustainable progress in the sectors of water, food, energy, housing and transportation within the urban environment. It also provides suggestions on accountability and governance mechanisms that should put be in place at local, national and global levels to ensure that everyone takes responsibility for sustainable development.
Background Growing concerns about the impact of environmental changes on health have emerged as middle-income countries have adopted the consumption and greenhouse gas emission behaviours of high-income countries. The same economic trajectory that has created a global marketplace dependent on increasing volumes of production, consumption and the long-distance transport of goods, has also led to the overexploitation of finite natural resources, energy shortages and the overburdening of the natural environment. The affects from this trajectory not only pose challenges to the sustainability of the environment but to human health as well. About 24 per cent of the global burden of disease and 23 per cent of deaths are attributable to environmental causes and around 36 per cent of the disease burden in children is caused by environmental factors. Despite this information, health has been an omitted aspect in climate policies. The collective health benefits that can be gained from a low carbon economy have been overlooked when they can actually be motivation for further cutting greenhouse emissions. Emphasizing the joint benefits could make reducing greenhouse emissions attractive since they serve as a means towards achieving both public health and climate goals.
Objectives The primary objective of this study is to demonstrate how health is a cross-sectoral theme of sustainable development that can be used to motivate behaviour change. The secondary objective is to show how human wellbeing will be impacted if sustainable approaches to development are not pursued. Since the MDGs were established in 2000, tremendous progress has been made to improve health outcomes but this progress will become compromised if measures are not taken to improve the current state of the environment. Everyone will be impacted but particularly the poorest and most vulnerable whose already scarce access to public goods could be further compromised as governments grapple with economic devastation as result of changes in the climate and environment. Urban areas will continue to grow, unable to accommodate their expanding population, which could lead to increased food insecurity as dry arable rural lands become incapable of producing crops. Prolonged drought conditions and increased occurrence of natural disasters could also lead to water insecurity. This situation, combined with poor housing conditions, unsustainable energy sources and carbon-motorized transport will negatively impact health and the environment. The tertiary objective is to show how policies across diverse sectors can improve human wellbeing and the environment. Health can be used to measure the effectiveness of policies in various sectors as well as benefit from policies that also improve the environment. In order to tackle the health risks that environmental changes pose, an integrated, cross-sectoral approach needs to be taken since human wellbeing is not only affected by such factors as health systems as but also other factors like pollutants and physical activity. The additional objective is to analyse the opportunities and challenges to promoting more sustainable behaviour. Everyone can contribute to a sustainable future from healthcare workers to businesses as well as governments and civil society. The post-2015 development agenda provides an opportunity to implement accountability mechanisms that do not currently exist. As cities become centres of human settlement, there is also a need to implement environmental-friendly policies that enhance rather than detract from economic growth.
Methodology The main question of this study is to see how health is a cross-sectoral indicator of sustainable development. The study was conducted between June and September 2013. The search strategy sourced reports and articles primarily published by the United Nations, especially the WHO, UNICEF and UNEP as well as the below leading health and development journals. We reviewed only articles published in English and concentrated on the period from 1990 to 2012. Our principal search terms were: “health” AND “sustainable development”; “environmental burden of disease”; “healthy environment”; “urban health”; “healthy cities”; “health” and “results-based management”; “health indicators.” In total, we closely reviewed over 100 reports and articles. To analyse the literature, the following questions were posed:• How can health and sustainable development be linked?
• How is health positioned in the post-2015 development agenda and the sustainable development goals debate?
• What are the strengths and limitations of indicators
• What current health indicators exist and what are their merits?
• What lessons can be drawn from the WHO’s Healthy Cities programme?
• How can inter-sectoral cooperation be promoted?The study looks at sustainable development within the context of urban areas, focusing on five key areas – food, water, energy, households and transport. Cities were selected as the geographic area of focus since their populations are expected to continue to increase over the course of this century. The five areas of focus were selected on the basis of their strong cross-sectoral communications with health and the burden of disease from their associated risk factors. The study demonstrates how the relationship between health and sustainable development can be thought of in three ways: health contributes to the achievement of sustainable goals, health can benefit from sustainable development and health is a way to measure progress across all three pillars of sustainable development policy.
Results The results of the study clearly demonstrate that health is an integral part of sustainable development whose contributions should be considered more seriously in the post-2015 development agenda discussions. First, climate change is contributing to the increased incidence of natural disasters and disease outbreaks, increasing the global burden of disease. Second, urban areas will endure great burdens as a result of climate change, which will be primarily due to the increased migration to cities. Third, there are measures that can be implemented across sectors, which can reduce greenhouse gas and pollutant emissions as well as improve human well-being. Last, this study also found that while there is an abundance of data on health as an indicator of sustainable development and the distinctiveness of each country’s context make it difficult to discern which existing indicators are most practical and useful, there are a series of assessments that can be carried out to develop a fit-for-purpose complement of indicators. The below tool outlines the method for conducting these assessments by focusing on a country’s:• Burden of disease
• Level of economic and social development, and
• Environmental condition and pressuresTables of indicators by income-level for the health-sustainable development nexus were created. It was found that each indicator has the following four strengths;

• Relates closely to both health and sustainable development
• Relies on data that is easily accessible and reliable
• Communicates clearly a development challenge
• Facilitates practical policy interventions

The primary limitation of this study was the lack of first-hand qualitative data which is due to the top-down approach of the study. A complementary bottom-up study containing ethnographic work could help confirm these findings and provide a people centered-approach to seeing how health is an integral part of sustainable development.

Conclusion Health can be a useful focal point to promote inter-sectoral cooperation at the local level but there is unfortunately no set of health indicators that are relevant to all contexts. A drawback to the work that has been done on health as an indicator of sustainable development in urban settings has been the emphasis on the quantitative aspect of indicators. This has made it difficult to single out a set of best practices and to actually see whether these interventions improve well-being. As urban populations continue to expand in the coming decades, new approaches to urban planning need to be taken which engage a variety of stakeholders and adapt to the dynamic nature of cities. Small-scale interventions in urban areas can be key to providing insights into what does and does not work. To ensure the work on health and sustainable development continues, health needs to be an integral component of the post-2015 development agenda. The sustainable development goals of the post-2015 agenda will not be achieved if a concerted effort is not made to assist low and middle-income countries in developing and implementing renewable energy techniques as their populations and economies continue to grow in the coming decades. Mechanisms should be created that not only transfer funds but knowledge and technology as well. Governance mechanisms need to be set in place, which marry policy and scientific evidence and impose accountability. Increasing public awareness of the intricate relationship between public health and the environment could help promote sustainable behaviour and raise attention to the need of holding all stakeholders accountable. Ultimately, there needs to be commitment at all levels of government and society in order for sustainable development to become a reality.

Modelling potential distribution of current and future malaria in Tanzania: An Ecological Niche framework

Author(s) Benjamin Mayala1, Leonard Mboera2, Edwin Michael3
Affiliation(s) 1Disease Surveillance and GIS, National INstitute for Medical Research, Dar es Salaam , Tanzania, 2ICT, NIMR, Dar es Salaam, Tanzania, 3Department of Biological Sciences, University of Notre Dame, Notre Dame, United States.
Country - ies of focus Tanzania
Relevant to the conference tracks Innovation and Technologies
Summary Malaria is endemic in most parts of Tanzania and remains a major cause of morbidity and mortality both in rural and urban areas. Ecological niche modelling (ENM) has been considered a useful tool to assess the potential geographical distribution of various species. The application of such tool is very limited in predicting the potential distribution of diseases, especially when using occurrence (presence). In this study an ensemble model approach was employed to predict the current and future (2050) potential distribution of malaria in Tanzania. The ensemble approach demonstrated an enhanced prediction model compared to the individual model outputs.
Background Malaria is a leading cause of morbidity and mortality accounting for over 30% of the disease burden in Tanzania. Over 95% of the 37.4 million people in the country are at risk of malaria infection. Various factors account for malaria in Tanzania, which include demographic factors, socioeconomic factors, weak health systems, a limited budget, poor governance and accountability, antimalarial drug and insecticide resistance, environmental and climate change, vector migration, and land use patterns. Efforts have been employed to reduce malaria in Tanzania, which include insecticide treated mosquito nets, indoor residual spraying, improved diagnosis by microscopy and rapid diagnostic tests, effective treatment of cases, and implementation of intermittent presumptive treatment of pregnant women. In spite of the many efforts to combat malaria, the disease remains a leading public health problem in most parts of the country. Climate conditions such as precipitation, temperature, and relative humidity have a substantial impact on malaria. Despite the importance of these factors to the distribution of malaria, limited studies have been undertaken to address the association between climatic conditions and malaria epidemics.
Objectives Previous attempts to map the geographical distribution of malaria have focused on a theoretical model that is based on available long-term climate data, as well as empirical models that fit malaria data to environmental factors to predict the number of months during which transmission is possible. These studies have not demonstrated the predictive ability beyond the input data area. Ecological niche modelling (ENM) has been considered a useful tool to assess the potential geographical distribution of species. It has been applied to diseases to assess the potential distribution of vectors. Applications of ENM to study the distribution of malaria using occurrence cases are limited in Tanzania. Here, we adapt modelling techniques, to predict the current and future potential distribution of malaria. The goals of the study were to (i) identify possible distribution areas of malaria using an ensemble approach that integrate multiple individual models to generate a better and more conservative overall solution, (ii) identify the environmental and climate conditions correlated with malaria occurrences, estimate the population at risk, and (iii) determine how future climate change may affect the distribution of malaria in Tanzania.
Methodology Data: Malaria occurrence point data were obtained from the Ministry of Health and Social Welfare. These are reported cases from various health facilities in the country. The Current and future (2050) environmental data used in our study were obtained from CliMond gridded climate data, which represents an improvement on the existing global climate data available for bioclimatic modelling. Thirteen environmental variables were used from CliMond; this included eight bioclimatic variables, monthly minimum and maximum temperatures, monthly precipitation, monthly altitude and relative humidity. The 8-bioclimatic variables were mean temperature of wettest quarter, mean temperature of driest quarter, mean temperature of warmest quarter, mean temperature of coldest quarter, precipitation of wettest quarter, precipitation of driest quarter, precipitation of warmest quarter, and precipitation of coldest quarter. The study also included other variables such as human population density and normalised difference vegetation index (NDVI). To avoid fitting the model into too many environmental variables, we extracted the environmental information from each presence data and performed a Pearson correlation tests to see if any of the layers were too similar to include in a model together.
Data Processing: The environmental data used for model development were imported into ArcGIS 10.1 software in which they were re-projected to the same coordinate system, clipped to an area encompassing the administrative boundaries of Tanzania, resampled to obtain the same pixel resolution of 5km, extracted to obtain same dimensions, and converted to ASCII format.
Models development: We considered eight modeling algorithms for the ENM development, GAM, GLM, GBM, MAXENT, MARS and RF were implemented in biomod2 package in Revolution R software, SVM using dismo package and GARP using a Desktop GARP.
Ensemble Model Prediction: An ensemble approach was adapted in our study by combining the eight model output through a weighted average using two thresholds (i) the 5th percentile of the training presence (5% TP) and (ii) the least training presence (LTP).
To estimate the populations at risk of malaria, we reclassified the ensemble model outputs to binary maps (which have pixel values of 0 - no malaria and 1 - malaria present) using the two thresholds - 5% TP and LPT. ArcGIS tools were used to compute the population and districts predicted at risk to malaria
Results The overall contribution of each environmental variable to all the models ranged from 2% to 62%. Population density was the main variables influencing the potential distribution of malaria in all the models. Relative humidity contributed 10.5% to the model followed by altitude (10%) and precipitation of driest quarter (5.4%). The other variables had less influence. The prediction maps revealed that almost the whole country is endemic for malaria. However, the probability of malaria presence varies spatially. All the models depicted high probability (0.5 or greater) of occurrence of malaria in the east and south coast of Indian Ocean, north regions and along Lake Victoria. The models depicted a medium probability of malaria occurrence along the central and west regions. The ensemble model at 5% TP threshold demonstrated high occurrence of malaria in the east, coast of Indian Ocean, north regions and along Lake Victoria, a pattern from east to central, then low occurrence from central to west and also south parts of the country
The ensemble model future (2050) prediction at 5% TP threshold showed an increase/shift of malaria occurrence in the northern part and towards the central part of the country is expected. High percentage of malaria occurrence is predicted in the southern highlands and southern regions of the country. Some areas are predicted with low percentage occurrence in the central regions and areas in the west of the country. Areas in the north, around Lake Victoria and along the coast of Indian Ocean are predicted to maintain the highest percentage of malaria occurrence.
The current population at risk of malaria is estimated to be 29 and 34 million, and this could rise in the future to 81.58 and 93.7 million. About 79% of the districts are at high risk for malaria, which is predicted to increase to 84% in future
Conclusion A link between climate change and malaria has been described previously; particularly temperature and rainfall are mentioned as the major variables contributing to malaria distribution. The present study, however, shows a lesser contribution of temperature and rainfall in the development of the models, as compared to population density, which depicted the highest contribution. This suggest that (i) population density is the key variable in malaria and (ii) malaria cannot necessary be caused by climate variables, as they may exhibit a smaller role in determining the ecological niche and hence the potential distribution of malaria. However, despite the potential influence of the population variable shown in our model outputs, it is then clear that population density, environmental variables and other factors (than those we used) will need to be included in studies attempting to model malaria endemicity.
Our findings showed high percentage areas predicted by the ensemble for both current and future - 2050, whereas individual models resulted into low predicted areas. The results suggest that ensemble model predictions are more robust than the predictions from individual models.
An important implication of our model is that the predicted distribution of malaria in the various districts in Tanzania can inform the selection of locally appropriate control interventions. The malaria control program can plan better for the distribution of resources by specifically focusing on the areas predicted to be at high risk.

Lessons from the Commercial Sector: How Integration Can Transform Public Health Supply Chains

Author(s) Carmit Keddem1, Nadia Olson2, Carolyn Hart3, Joseph McCord4.
Affiliation(s) 1Center for Health Logistics, John Snow, Inc., Boston, United States, 2USAID | DELIVER PROJECT, John Snow, Inc., Washington, DC, United States, 3Center for Health Logistics, John Snow, Inc., Washington, DC, United States, 4USAID | DELIVER PROJECT, John Snow, Inc., Washington, DC,United States.
Country - ies of focus Global
Relevant to the conference tracks Health Systems
Summary Successful health programs require an uninterrupted supply of health products provided by a well-designed, well-operated and well maintained supply chain. By applying a new approach to end-to-end integration, adapted from the commercial sector, health managers can ensure that public health supply chains deliver an adequate supply of essential health commodities to the clients who need them.
What challenges does your project address and why is it of importance? Health programs can succeed only if people have access to the essential health products they need. Although many countries have strengthened their public health supply chains and, thus, improved product availability in recent years, they continuously face new challenges. Countries are under increasing pressure to deliver a rising volume of products to support expanding health programs and respond to greater demand from donors for accountability and sustainability. New technology and commercial sector approaches can help countries build dynamic supply chains that respond to these changes and yield health and development benefits.
How have you addressed these challenges? Do you see a solution? JSI has researched and applied commercial sector approaches to public health supply chains, including supply chain integration, and has seen significant results. While public health systems in resource-limited settings are very different than private companies, public health supply chain managers face many of the same challenges as commercial supply chain managers did many years ago. Over the past few decades, commercial sector supply chains of major corporations, including Apple, Proctor & Gamble, Wal-Mart, and Dell, have undergone a major transformation to become cost-effective, agile, and responsive to consumer needs. This occurred in an environment where consumers were expecting wider choice and better service from retailers, and increasing globalization encouraged companies to build international, outsourced supply chains with increased management complexity. With the right approach, integration can be as transformative for public health as it has been in the commercial sector – leading to more cost-effective and reliable supply chains that effectively deliver health products to clients and contribute to better health outcomes.When adapted for public health, supply chain integration involves linking the actors managing health products from the top to the bottom of the supply chain, or from end-to-end, into one cohesive organization, which oversees all supply chain functions, levels, and partners, ensuring an adequate supply of products to clients. Lessons from the commercial sector teach us that integration is more than merging health program supply chains - for example putting malaria and HIV and AIDS products on the same truck. JSI has worked to design and strengthen various public health supply chains according to the principles of supply chain integration by better linking people, information, and activities from where products are made to the people who need them.
How do you know whether you have made a difference? In Zimbabwe, after applying supply chain integration principles to integrate key products into a well-functioning family planning supply chain, stockout rates for nevirapine tablets decreased from 33 percent to 2 percent and supply chain costs were reduced. This, ultimately, resulted in 35 percent more mothers treated to prevent mother-to-child transmission of HIV.
Have you or the project mobilized others and if so, who, why and how? JSI, through various supply chain projects, works with government, civil society, academic and funder organizations to strengthen public health supply chains worldwide. We have incorporated supply chain integration concepts into our system strengthening approaches in various countries – from a supply chain orientation of animal health specialists in Indonesia, to pre-service training in Tanzania, to guiding the supply chain system design process for essential medicines in Nigeria.
When your donor funding runs out how will your idea continue to live? Strengthening supply chain systems requires significant investment and resources, but can reap significant long-term benefits for health programs and the broader health system. While supply chains required sustained investment, designing public health supply chains according to the principles of supply chain integration will improve their efficiency and effectiveness in the long-term, protecting the investment in commodities and the supply chain system and leading to more sustainable health solutions.

Evaluation of Accredited Social Health Activists in tribal blocks of India

Author(s) Satish Saroshe1, Suraj Sirohi2, Sunilkant Guleri3, Sanjay Dixit 4.
Affiliation(s) 1Community Medicine, M.G.M Medical College, Indore, India, 2Community Medicine, M.G.M Medical College, Indore, India, 3Community Medicine, M.G.M Medical College, Indore, India, 4Community Medicine, M.G.M Medical College, Indore, India.
Country - ies of focus India
Relevant to the conference tracks Advocacy and Communication
Summary ASHA (meaning Hope in Hindi) is a program of Accredited Social Health Activists who works at basic grass roots level in one of the world's largest healthcare programs, NRHM- National Rural Health Mission. The present study was carried out in Bagli block (primarily a tribal block) of Dewas district of Madhya Pradesh (state with highest Infant Mortality Rate= 56 in India) to evaluate ASHA based on the 8 factors critical for success of ASHA identified by Government of India.
Background ASHA is a program of grass roots workers under NRHM (National Rural Health Mission), the largest health care program of the Government of India which started in the year 2005. ASHA are female health activists in the community who creates awareness on health and its social determinants and mobilizes the community towards local health planning and increased accountability of the existing health services. The 8 factors identified by the Government of India critical for the success of ASHA are 1. Selection of ASHA by a prescribed process as per the ASHA guidelines. 2. Linkage with nearest functional health facility for referral services. 3. Identified transport for referral of cases from village to facility. 4. Priority and recognition of cases referred by ASHA to MO/ANM. 5. Successful organization of monthly Village Health Sanitation and Nutrition Committee (VHSNC) and Village Health Sanitation and Nutrition Day (VHSND) in every village with the ANM ( Auxiliary Nurse Midwife) and AWW (Angan wadi worker). Angan wadi is the basic unit of Govt. of India ICDS (Integrated Child Development Scheme) 6. Monthly meeting of ASHA at PHC. 7. Timely payment of incentives to ASHA. 8. Timely replenishment of ASHA Kit.-which contains 13 Items.
Objectives Broad Objective
To evaluate the function, knowledge & skills of Accredited Social Health Activist (ASHA) in a tribal block of a state with highest Infant Mortality Rate in India.
Specific Objectives:
To study the working of ASHA & identify the problems experienced by them within their workplace.
To assess the knowledge & skills of ASHA.
To study the training status of the ASHA.
To assess the beneficiary satisfaction of ASHA as experienced by Community .
To identify recommendations based on present study.
Methodology Type of study: Cross Sectional Descriptive.
Study Duration: June to August 2013.
Study site: 30 densely tribal villages of Bagli Tribal Block of Dewas District of Madhya Pradesh state of India.
Study Tools: 1. Pre-designed semi structured questionnaire 2. Observational check list.
Ethical Concern: Written informed consent was obtained by all the ASHAs.
Sampling Technique: Convenient sampling (Due to shortage of funds & logistic problems 50 ASHAs were selected from 30 densely tribal villages of Bagli Tribal Block of Dewas District of Madhya Pradesh State of India.
Selection Criteria:
Inclusion Criteria- 1. Those ASHAs fulfilling the selection criteria laid by NRHM guidelines identified in the selected 30 villages. 2. Those ASHAs giving written informed consent.
Exclusion Criteria:Those ASHAs not giving written informed consent.Data Analysis: Microsoft, Excel & Spread Sheet and SPSS ver. 19.
Results 100% ASHAs were the primary female residents of the village that they had been selected to serve.
84% are married, 12% are widowed and 4% of ASHAs are divorced.
4% are graduates, 14% are 10th grade pass, 82% are 8th grade pass.
26% are in age group 25-29 years, 58% are in age group 30-34 years and 16% were from 35 years to 45 years.
100% ASHA had good rapport with ANM (basic health worker posted at Sub Health Center & Primary Health Center) & AWW (Anganwadi worker – basic nutrition worker posted at Anganwadi Center which is the basic nutrition centre located in a population of 1000 in both rural & urban areas.)
100% ASHAs mobilizes the community and facilitates them in accessing health and health related services available at the village such as the Sub Health Center & Primary Health Center.
All the ASHAs (100%) coordinate with 108 Emergency Ambulance and Janani Express obstetric care Ambulance for referral of cases from villages to healthcare facility.
In 93% of the villages the Village Health Sanitation and Nutrition Committee is operational to deal with health & Nutrition issues. Sanitation is covered only in 7% villages in the present study.
Out of the 13 items to be provided in ASHA Kit, 12 were present in 95% ASHAs- DDK (Dai Delivery Kit ) which were for delivery at homes: Tab. Iron Folic Acid, Zinc based ORS Packets, Tab. Paracetamol, Tab Dicyclomine, Providine Ointment Tube, Thermometers, Cotton Absorbent Roll, Bandages (4cm x 4 meters), Tab. Chloroquine, Condoms, Oral Contraception Pills. The only item not found in the ASHA Kit during the present study was Tab. Punarvadu Mandur (ISM Preparation of Iron).
100% ASHAs complained of irregularity in the timely incentive payments of ASHAs.
100% ASHAs were trained in all the 7 mandatory modules of ASHA Training.
In 100% of the villages the beneficiaries were satisfied by the work of ASHAs in the community experience.
Conclusion In present study the ASHAs were married, widowed & divorced because according to Indian cultural norms after marriage a woman leaves her father’s house (and village) & migrates to that of her husband in accordance with the selection norms laid under NRHM. As per criteria ASHAs should be minimum 8th grade pass which was 82% in the present study. The maximum (94%) were in the 25 to 35 age bracket which is in lines with the criteria of age group 25 to 45 years according to NRHM. It is worth noted that, for selection of ASHA as per guidelines, Gram Sabha (Democratically elected local village body) or VHNSC recommends five names of suitable candidates to the Block Medical Officer (BMO). Appointment letter is issued by the BMO. Since VHNSC is not fully operational in most of the 30 villages, all the 50 ASHAs in the identified villages were selected by Gram Sabha. The 4 most common reasons for Community Mobilization for Health and Health related services by ASHA in order of frequency are as follows: immunization, antenatal care check-up, nutrition related problems and postnatal care check-up. There is no Community Mobilization by ASHA for sanitation and related services. The 108 Emergency Ambulance & Janani Express Obstetric Care Ambulance has connected almost every village to health facilities. At present in Bagli Community Health Center (CHC) there is 1 BLC (Basic Life Care) 108 and 1 Janani Express Obstetric Care Ambulance in Udai Nagar Tribal Primary Health Care Center. In Dewas District (under which Bagli is one of the Blocks) there is only 1 ALC (Advance Life Care) 108. The most common reasons for the referral of cases by ASHA to Medical Officer/ANM in order of frequency are: pregnancy and pregnancy related, GI (Gastro-Intestinal) related problems and respiratory tract infections. Recently the NGOs have trained the 7th comprehensive module to all the ASHAs of the identified villages. In all the villages the community was completely satisfied with the work of ASHA.

Improving governance and local level planning through community mobilisation: lessons learnt from Bangladesh

Author(s) Rumana Huque1
Affiliation(s) 1Department of Economics, University of Dhaka, Dhaka, Bangladesh.
Country - ies of focus Bangladesh
Relevant to the conference tracks Advocacy and Communication
Summary Poor governance in the health sector is negatively influencing service delivery mechanisms in Bangladesh, which in turn results in low utilization of public facilities. Although the principle of strengthening effectiveness and accountability of service provision through ‘participation’ has been introduced in the recently created Community Clinics and the associated Community Groups (CG) in rural Bangladesh, reviews to date have shown very slow progress in this area. The current project strengthened capacity of CGs through providing skilled based training. This enhanced the voice of citizens which inturn improved governance at CCs.
What challenges does your project address and why is it of importance? Poor governance in the health sector is negatively influencing service delivery mechanism in Bangladesh, which in turn results in low utilization of public facilities. Non-availability of drugs and commodities, imposition of unofficial fees, lack of trained providers and weak referral, feedback and monitoring systems contribute to low use of public facilities in Bangladesh. A number of other factors also adversely influence the service delivery mechanism. One such challenge is the inadequate participation of civil society in decision making processes. Evidence suggests that closed decision making processes in unequal societies can result in priorities that are biased towards elite interests and not adapted to the needs and priorities of the poor, which may have a negative impact on equity and social justice. Although the principle of strengthening effectiveness and the accountability of service provision through ‘participation’ has been introduced in the recently created Community Clinics and the associated Community Groups in rural Bangladesh, reviews to date have shown very slow progress in this area. Out of 13000 Community Groups very few are functional, leading to inadequate participation of the poor in local level planning or initiating accountability.
How have you addressed these challenges? Do you see a solution? The project has strengthened the Community Groups through providing skilled based training to its members in four upazilas in two districts. It provided relevant information and data including potential sources of funding and information on changes in rules and regulations to CG members. The process contributed to developing self confidence among people in discussing and analysing issues, identifying a problem, visualizing disparities, understanding their entitlements, identifying their duty bearers, articulating issues, developing plans as a team to address their problems, and communicating this properly to the appropriate forum/platform. The project has created a better referral linkage of Community Clinics with Upazila Health Complex (UHC). The patients they refer get special attention and preference at UHC. Due to the monitoring of CG, CC remains open from 9 am to 3 pm six days a week. The greatest success the development of coordination between health care providers and clients, people now conceive as public health care facilities as being their property, the reputation of the CG members in the community has gone up and the utilisation of services and respect for providers at CC has also increased.
How do you know whether you have made a difference? Clearly this project created opportunities for capacity strengthening of the local political leaders as well as community representatives so that they become better informed on health issues. It contributed to facilitating the relationships of citizens with health providers and governments. This in turn has given a platform to improve the quality of information available to citizens and to raise their voices. The project has created a sense of ownership among the citizens in functioning CG's. Interaction between service providers and patients became informal which increased access to services. It reduced the ‘illegal’ operations such as absenteeism and misuse of drugs.
Have you or the project mobilized others and if so, who, why and how? The project has created a link between Community Clinics, which is under Ministry of Health and Union Council members, who are under Local government. Union Council Members now attends the monthly meetings of the CG and monitor their functioning.
When your donor funding runs out how will your idea continue to live? The project will be sustainability even if donor funding is withdrawn, as the community group members are adequately trained and have been empowered to conduct the activities without third party facilitation. A mechanism to generate fund through community mobilisation to meet some expenses as also been created.

Health governance in Ethiopia: Does systems theory strengthen district health planning and procedural fairness?

Author(s) Kadia Petricca1, Dereje Mamo2, Whitney Berta 3, Clare Pain 4, Jennifer Gibson 5
Affiliation(s) 1Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada, 2Policy and Planning Directorate, Ministry of Health, Addis Ababa, Ethiopia, 3Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, Canada, 4Psychiatry , University of Toronto, Toronto, Canada, 5Joint Centre for Bioethics, University of Toronto, Toronto, Canada.
Country - ies of focus Ethiopia
Relevant to the conference tracks Governance and Policies
Summary Building strong health systems in resource-poor settings involves strengthening good governance. This study explores the ability of a new district-health planning strategy in Ethiopia to strengthen procedural fairness and district-level capacity, while further reflecting on the systemic features that act as barriers and facilitators in this process. Results explore various dimensions of the district-health planning process and in strengthening procedural fairness at all levels. Strengthening mechanisms for building good governance can enhance the  transparency and accountability of health systems.
Background Health planning and priority setting is a complex undertaking in all health systems. Therefore, building strong health systems in resource-poor settings involves strengthening good governance for health planners to assert their local needs, and build capacity for multistakeholder engagement, and transparent and accountable decision-making. In 2008, the Ethiopian government implemented district-based health sector planning; a national strategy to streamline evidence-based planning, harmonize stakeholder agendas and promote democratic decision-making. While evaluations revealed some improvements in these areas, they also revealed a variety of system-level constraints influencing the adoption of such processes. However, conceptual guidance in the use of systems theory and in its ability to guide our understanding of health governance and procedural fairness remains in its infancy. Using a systems analysis and a framework for procedural fairness, this study analyzes challenges and strengths emergent from implementation.
Objectives The overall objectives of this presentation will be to (i) reflect on the experiences of implementing district-based health sector planning in Ethiopia through the views of health planners and non-government partners; (ii) assess its implications on strengthening fair and legitimate decision-making; and (iii) to further reflect on the application of a systems analysis to gain a deeper understanding of important systemic factors influencing health planning and procedural fairness.
Methodology Multiple case studies were conducted in three districts (in three separate regions) of Ethiopia. Methods included: (i) Fifty-eight in-depth interviews with national, regional, and district health planners and non-government partners, (ii) participant observation in health planning meetings; and (iii) policy analysis. Analysis was guided by the Transformative Systems Change Framework (TSCF) and Accountability for reasonableness (A4R).
Results Overall, district-based health sector planning had a strong impact on strengthening both evidence-based planning and democratic decision-making. A new evidence-based planning and budgeting (EBPB) tool guided district health planners to set priorities through generating priority targets. A4R revealed the process upheld principles of fairness based on the inclusion of multistakeholder engagement, disclosure of planning outcomes, evidenced-based planning and an appeals mechanism. Leadership capacity at the district level was still considered weak and varied across districts. To guide our understanding of the system, the TSCF dissects the system structure into four components that may act as barriers or facilitators in district health planning. It identified: (I) System Norms, where strong cultural values were present for strengthening evidence-based practice and promoting participatory dialogue; (II) System Regulations, where policies and national strategies promoted and valued evidence-based planning and stakeholder inclusivity, yet did not highlight explicit mechanisms for promoting transparency; (III) System Resources, where limited technical and environmental capacity hindered the management of the excel-based planning and budgeting tool and the ability to conduct on-going training; and (IV) System operations, where on-going communication delays between district health offices and NGOs and overlapping stakeholder roles impacted the clarity and efficiency of planning. There is clear interconnectedness between each of these system elements that will be further reflected upon, for changes in one domain will yield consequences in another.
Conclusion Strengthening the capacity of district health planners to set health priorities can enhance the transparency and accountability of health systems in low-income settings. District-based health sector planning appears to be a valuable mechanism in strengthening the evidence-based planning and procedural fairness as it guides evidence-based planning through the EBPB tool and promotes democratic decision-making through multistakeholder engagement. A systems lens can reveal unique insights as to the interconnected parts of a system and how they impact the ability of district health planners to set health plans and priorities fairly, legitimately and in accordance with national policies and local health needs.

Maternal Health Workforce Management in Vietnamese Health Communes

Author(s) Thi Hoai Thu Nguyen1, Andrew Wilson2, Fiona McDonald3
Affiliation(s) 1Faculty of Health, The Queensland University of Technology, Hanoi, Vietnam, 2Menzies Centre for Health Policy, The University of Sydney, Brisbane, Australia, 3Faculty of Law, The Queensland University of Technology, Brisbane, Australia.
Country - ies of focus Vietnam
Relevant to the conference tracks Health Workforce
Summary As part of a study into the governance of health workforce in Vietnam, this study examined the impact of staff qualifications, training opportunities and other factors on reported ability to perform Essential Obstetric Care services (EOCs) in two provinces. While qualifications and training were the most important factors, national and district policies, such as which health professionals can prescribe essential medications, were also important factors in limiting provision of EOCs.
Background Vietnam’s national policies recognise the importance for an effective health system to ensure sufficient human resources (Politburo Resolution No. 46/NQ-TW dated 23 February). However, current analysis indicates a number of issues, including an imbalance and maldistribution of the essential health workforce, shortages of appropriately skilled health workers and constraints in management and utilization of health workers. Parallel studies on the impact of health policies on the health workforce, the implementation of health policies and provision of health care services in Vietnam have identified a number of governance-related issues, including a lack of staff accountability, quality control measures in relation to workforce training and skills maintenance, inadequate participation of community and civil society organizations, and an unreliable health information system. Underdevelopment of governance mechanisms may be a significant barrier to the effective implementation of policies. However, so far there has been no systematic analysis to identify the points of weakness and gaps in the governance and internal management of human resources in the health care system at the provincial and district levels in Vietnam.
Objectives Ensuring access to good maternal health services is critical for Vietnam to achieve the relevant Millennium Development Goals and this requires a well-qualified maternal health workforce able to provide the EOCs. This study aims to examine the impact of national and district policies relevant to human resource management and organisational factors on the maternal health services. Specific objectives were:a) To identify the availability and qualifications of maternal healthcare providers at commune level in two provinces.
b) To identify the ability of maternal healthcare providers to provide the EOCs and the barriers to providing these services.
c) To understand how the existing organizational and policy factors influence maternal healthcare provider’s ability to provide EOCs.
Methodology The research has been conducted in five districts in two provinces in the Northern mountainous area of Vietnam. A mixed methods approach was used consisting of a self-administered questionnaire given to commune level staff and in-depth interviews with commune maternal healthcare providers and managers engaged in maternal health at district and provincial levels. The questionnaire consisted of four sections namely: demographic information relevant to maternal healthcare providers, the training opportunities they attended, self-rated ability to perform EOCs and a scale to measure elements of work motivation.The sample for the quantitative survey is 192 maternal healthcare staff who volunteered to complete the questionnaire. In-depth interviews were conducted with 60 participants of whom 18 chosen to represent the different workforce groupings and have been fully analysed.Initial analysis to explore the differences in maternal health workforce between the two provinces consisted of two way tabulations with statistical significance testing using the Chi-square test. All variables found to be significant in this analysis and the potentially confounding variables were incorporated into multivariate regression analysis to identify the independent associations with the ability to perform EOCs.

For the qualitative analysis the subset of 18 interviews was transcribed. Inductive analysis was used to identify, code and organize themes arising from the raw data, with quotations servings as units of analysis. Data was analysed for consistently occurring themes or categories using a qualitative research package, N-Vivo software.

Results Analysis of the survey indicates there are distinct differences between the provinces as to the mix of maternal health professionals, their qualifications, their access to further training, and their self-reported ability to perform EOCs at the commune levels.The multiple logistic regression analysis showed that staff were more likely to report having training on all EOCs if they worked at district level, had higher qualifications (university and equivalent or higher) and obstetric expertise.In both provinces, only 21.6% of staff reported being able to perform all EOCs. The most common reasons reported by staff for not being able to perform EOC services is “Because I am not allowed to do this”, followed by “Lack of training” and “Lack of drugs and equipment”.

The most important determinants of ability to perform the EOCs were qualification and training. Although having attended training course in the last 12 months was not significantly associated with ability to perform EOCs in univariate analysis, in the multivariate analysis it was significant.

Data from the in-depth interviews confirms a common theme that respondents felt constrained in their potential roles by policies. It is also identified other organizational, policy and resource constraints faced by staff and managers at the commune and district levels.

Conclusion 1. The study provides a better understanding of the factors influencing the health workforce’s capacity and capability in the maternal health context in Vietnam.
2. The restrictions on who can perform EOCs should be reviewed to improve access to full EOCs.
3. To use health workforce most efficiently and effectively, all appropriately trained staff need to be given the authority to carry out all EOCs including prescription of essential medicine regardless of qualifications.Given that access to maternal health services provided by appropriately trained health care workers has been shown to be important to better maternal and child health, this reform would assist Vietnam to achieve the MDGs.