Some of the issues that have been addressed have include different modes of
financing, how to improve quality of care, alternative delivery systems for
getting care to people and issues of decentralization.
So the decision making and relevant services at all levels can be achieved.
The next slide shows a small health center located about 20 miles from the district
headquarters.
The question of decentralization suddenly is of concern here and
relates to our organization diagnosis of space time coordinates.
This is the type of facility where house staff can be involved in training and
supervising village health workers.
They can be involved in ivermectin distribution, keeping the stocks
available, keeping records of coverage from each of the village.
The fact is that because of its location It's often not desired by health workers.
At present, in this particular facility, the community health officer in charge
rotates every three months, so a new person is there.
And the only stable staff are untrained, what they call ward maids,
who are supposed to simply be cleaning up, working as orderlies.
In fact, it's the ward maids who often give much of the care,
because the other staff do not live in the village,
they come maybe on Monday evening and they go back on Thursday morning.
They often don't have proper supplies of drugs.
They are not able to make choices over what to do with funds,
how to improve the health services.
They simply sit there and provide the service.
And so in order to reform that system, to make it effective,
to make it serve the people, issues of change need to come in.
And the question, in terms of contemplation of change, again,
the issue is where are problems perceived, who perceives the problems?
And because of poor communication between the villages and
the local government generally, and the health department specifically.
One particular stimulus to move from pre-contemplation to contemplation
of organizational change, that is community pressure is often missing.
These are issues that need to be explored when people visit health centers,
when they supervise, when they try to diagnose the needs for
improving or reforming a health system.
Examples of health sector reform have been the Bamako Initiative.
Bamako is the capital of Mali.
UNICEF called a big conference there in 1987, and
basically drew up the guidelines.
The participants drew up the guidelines for
setting up community-based revolving funds for essential drugs.
People would pay amounts that would be decided by the community.
The community would select and support its own village health worker who would
distribute the drugs, administer the drugs.
The community itself would have a committee for managing the funds and
ordering new drugs.
So the recognition was that people will pay for care.
They don't have to pay a lot, but they should be responsible and in charge.
So in a way, the Bamako Initiative has some of the same principles as
the Ivermectin Distribution Program.
Health insurance schemes are another example of health sector reform.
New delivery mechanisms that we talked about as
one of the examples of health sector reform are village health workers.
And another important issue in health sector reform is enhancing community
participation.
We talked about levels of community participation before with the health
facility we saw in the previous slide.
You can see that most of the participation is at the level of simply accepting.
But even that may not be possible if medication or
staff are not available at the clinic.
With community participation and input, possibly through a social action or
community action mode, communities could participate and
enhance the quality of services at a small facility like this.
There are some sections in your course notes about village health workers.
At this point it's important to comment that they themselves are an example of
second order change.
It's a new delivery mechanism.
It's not just a substitution.
It's a new way of going about it by making sure that medications, and knowledge, and
skills are in the community.
That the person who provides these services are accountable to the community.
So they are definitely a new type of provider that sets up a new
relationship between the community and the health system.
New forms of supervision and partnership are required.
It's not that the village health worker is just an extension of the health center,
and the health workers go out and give them orders and collect their returns.
But since the village health worker's chosen by, supported by the community,
they are really an extension of the community leadership.
And the health workers need to work with them as partners.
Because, again, the village health worker representing the type of
communication in the adoption model called homophiles communication,
where people of similar backgrounds communicate best.
The idea of observational learning by other people within the environment as
a way of enhancing self-efficacy for new health skills in social learning theory is
exemplified by village health workers, a number of our social network theories.
So the idea of this type of health delivery system does require
new relationship, new partnership, between the health system and the community.
Village health workers and
this type of healthcare delivery are a new form of economic support for health.
The village health workers, together with the community committees, raise their own
money, stock their own drug boxes, as can be seen in the next picture.
And this means that people in the community have a new way of
accessing care.
If they're 20 or 30 miles from the town center, from the district headquarters,
they're not going to run down at the middle of the night if their
child has fever.
They may have before tried to save some medicine from the last time the child was
sick, and it may have expired.
They may have gotten some concoctions from the local market.
They may have bought some drugs from someone peddling them
on a motorcycle going through town, but this is not acceptable.
The village health worker concept in primary healthcare means that quality,
although simple, but quality care is available.
So this is, like I said, a second order change and
brings about a whole new way of delivering healthcare to people.
Next we will look at the issue of health systems reform.
This is another word, as we said, for changes in the health system.
Four different types or situations under which reform occur have been observed.
In one setting,
the health system is a responder to changes in the broader environment.
There may be changes in the style of government,
as is happening in many countries, particularly in Africa, there's a change
from military dictatorships, or one-party rule, to multi-party democracy.
These changes require changes in the health system, as was observed in Nigeria,
in particular, where I've worked, during the military rule.
The soldiers, the officers,
were not technical experts in areas of health, agriculture etc.
And they often left the health sector and these other sectors
in ministries be run by top-level administrators.
Systems were not accountable to anyone and
were very much under internal political pressure.
In an era of democracy, all governments systems need
to be responsive to the public, people are much more outspoken.
Changes in economic patterns, growth, inflation,
recessions have implications for health sector reform.
May bring about changes in terms of financial policies, sources of funding,
access to funds, types of services that are available.
An example in your class notes comes from the Gambia.
And in this particular case, when funds were devoted to primary healthcare,
where there were adequate frontline health workers posted to
health facilities where drugs were available,
child mortality decreased during economic hard times in the past couple of years.
The quality of these services has decreased, staffing patterns,
availability of drugs, and child mortality.
[INAUDIBLE] has increased, so
the health system is responding to changes in the broader environment.
This kind of change may be fundamental, affecting all areas of government,
not just health.
Another position that the health system may find itself in
is that of resisting or adjusting.
A day by day firefighting operation to handle problems.
No perceived need, particular motive for
change, simply trying to make the best of the situation.
The goals in this particular case are specific to the health sector,
trying to ensure supplies of drugs where they've run out,
trying to reallocate staff where people have resigned.
This may be incremental change, certainly not fundamental change, in fact,
very little change may actually occur in the way things are being run.
A third type of change puts the health system in the role of reformer.
There may be an external impetus, such as the coming of democracy, or
there may be a perceived need from inside that has started
the process of contemplation and planing to reform the system.
In this particular case though,
the reforming system tries to develop specific goals for health.
Often multiple goals, in terms of child survival, maternal health,
care of the elderly, change is fundamental and sustained.
Finally, as is seen in many conditions, such as the recent floods in Mozambique,
civil wars in Angola and Democratic Republic of Congo,
health systems may have collapsed under natural or human disasters.
In the situation of post-conflict or
post-disaster, there's basic instability or insecurity.
Goals for the health system are quite specific in terms of health,
in terms of maintaining the system, the basic services and staff.
It's a question of rebuilding, rather than starting something new.
Recently the World Health Organization, in collaboration with many other
donor agencies, and international groups and
agencies, has launched the Roll Back Malaria program.
Roll Back Malaria is attempting to focus attention, political will,
and resources on existing and affordable health technologies to control malaria,
to reduce the burden of malaria disease in endemic countries.
And starting, in particular, with those in Africa.
Simple technology such as insecticide-treated bed nets,
prompt treatment of children with malaria, and
appropriate malaria prophylaxis for pregnant women.
WHO recognizes that these simple technologies cannot be implemented
unless the health system itself is healthy and functional.
Therefore plans made with regional bodies, and
particularly with national governments in Africa, to implement Roll Back Malaria,
focused on large extent on health systems reform.
Prompt treatment and appropriate treatment of childhood fevers cannot occur
unless there's a guaranteed supply of antimalarial drugs in the community.
Generally, if antimalarial drugs are not there, probably other basic drugs for
treating respiratory illnesses, supplies for managing diarrheal illness,
other childhood problems, are probably not there either.
So unless the drug supply and
management trigon protocols have been reformed, generally
in the health system it's unlikely that malaria can be addressed either.
Similarly, if the general health system does not have the capacity for
outreach, does not have staff who are trained to organize communities,
there is no way that they can promote the distribution and
use of insecticide-treated bed nets.
So clearly the Roll Back Malaria program recognizes that improvements in
services to control malaria will not be effective if the overall health system
does not reform.