Welcome to our course on Understanding and Strengthening Health Systems for Global Health. During the course we will provide you with an overview of the main elements or building blocks of a health system based on the World Health Organization’s guidance. You will have the opportunity to explore four main areas of health systems in global health with particular reference to low and middle income countries. The first area focuses on understanding health service organizations, the challenges. Our second module looks at WHO’s six major building blocks or health systems components with particular reference to primary health care and the need for community participation in planning, delivery and assessment of these systems components. in our third module we examine the specific systems component of human resource development and capacity building. The fourth area consists of health policy making and advocacy with stakeholders. This course is geared toward learners who are already involved in managing health and development programs on the ground in low and middle income countries or who are preparing for such a management role. The main lectures will span a four-week period with approximately 2-4 hours of viewing learning materials per week. We have one peer graded essay wherein you will use skills in ‘organizational’ diagnosis to better understand a challenge in an organization where you are or have worked. There are also quizzes. We hope you will engage with your fellow learners in discussion forums to learn from each other.
Organizational Change (Part 1)
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Understanding and Strengthening Health Systems
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Understanding Organizations and How They Change
Health Systems are human organizations. Organizations have structure, purpose and membership. To remain “Healthy” an organization must adapt to its environment, whether that be funding and policy changes or expectations of its clients. In this module we will focus on diagnosing factors related to the health of organizations and consider strategies to help organizations adapt.
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William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
[MUSIC]
It's often said that people are resistant to change but
one needs to accept the fact that there are always changes occurring that may or
may not be under control of the local organization.
Changes in funding, changes in the broader environment,
in terms of policy, in terms of community response.
So we need to examine our assumptions about organizational change.
One that is quite obvious is the change often requires new competencies and
attitudes.
The competencies for the program included the ability for
staff to organize communities.
Not just simply hand-out drugs, but organized communities to help themselves.
And it required new attitudes that saw the communities as partners, as
capable of managing some aspects of their health care, not simply as recipients.
Change involves everyone in the organization, not just the leaders.
Again, with the Ivermectin distribution program,
the decisions may have been made in Geneva, Atlanta, national capitals.
But in fact, if front line health workers as seen in the next slide.
If front line health workers are not involved, the program will not succeed
because they are the ones that have the direct contact with the community.
Change is about fining a balance between flexibility and control.
Without flexibility the change will not be implemented.
At the same time control is necessary so that goals can be met.
Managers need to realize that they are often always not in control of situations.
As we noted in this next picture, we have a group of front line clinic staff.
There are the people that would be involved in training
village health workers for ivermectin distribution.
They would be responsible for managing a supply of ivermectin from which
surrounding hamlets could come and collect.
They would be responsible for
supervising, making occasional village visits to see how the program is going.
And they would need to compile the returns of numbers of people treated,
refuse, side effects from the different village.
Interestingly enough, we need to consider the roles of
staff in such a small clinic, as can be seen from the picture, they're seven.
One is a health inspector, there are a couple of nurse, midwives,
community health extension workers.
Or like health assistants, ward maid,
they may have a pharmacy technician but often time again the community health
extension worker is a jack of all trades at the front line.
Issues about organizing services,
coordination, bringing about change are important.
In this particular clinic, the day that we visited we found that only
three patients had been seen that whole day.
No other programme was going on in terms of coordination,
the prenatal clinic was another day, immunization clinic was a different day.
But here are seven people who are employed to look after three people.
And this was not much different than the attendance seen on other days.
Unfortunately, many of these clinics did not keep proper record books again.
But staff reported that often,
unless there's a special clinic like immunization, they don't see many people.
In this small village of about a 1,000 people,
there were two private clinics, three pharmacy shops and
even several indigenous healers had their own shops where they sold ingredients
like bark and leaves and roots to make local medications.
So in terms of assessing organizational change,
ideally in this setting, some would want to contemplate what is happening.
Why are we not seeing people?
Other health services exists, even private ones and they're making money.
We have seven people here who are only seeing three or four patients in a day.
Now the question of when contemplation starts depends on the awareness
that there is a problem.
And unfortunately in many health systems, as long as people receive their salary,
and as long as no one comes to supervise, except maybe once in two or
three months, no one may determine that there's a problem.
So again, it's important to recognize that even though
organizations may appear to be dysfunctional, or as we said unhealthy,
this may not be perceived by the people who are actually delivering the services.
Again more assumptions about organizational change
relate to our definitions of organizations.
Organizations are open systems.
And thus they are subject to change because of changes in the environment.
Either from the resource or input end, or from the output consumption end.
Organizational change results in a shift in power in most organizations.
People with new skills are valued over people who do not know how to perform
certain new procedures.
Another assumption is that change is a good thing ultimately.
Because if change occurs and the organization adapts to its environment.
The organization as a whole will survive and the individual members who are staffed
at that organization will also survive in the sense they will maintain their jobs.
They will also maintain their satisfaction with their work.
An important thing to recognize also,
is that the goal of change is not survival of the organization for its own sake but
the survival of the organisation to meet a need in the environment.
Class notes give more details about the issues of change in the organization and
change in the individuals who are working for or serving the organization.
It's important to look through these materials and
to think about the fact that again.
What are the factors that motivate individuals who work in an organization?
What are the factors that discourage them?
We can use our preset framework to understand health worker behavior.
And again as we said, one of our basic
assumptions about organizational change is that everyone is involved.
And therefore if we want to learn who will be in favor of change,
who will be resisting change, we need to understand the role and
behavior of individual members of the organizations.
We also want to look briefly in this chapter about
the issue of health sector reform.
This is another name for organizational change.
The World Health Organization is devoting much attention to this issue.
How sector reform is defined as a sustained process
of fundamental change in policy and institutional arrangements
to improve the functioning of the health system and thereby people's heath.
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.
Finally, it's important to look at the role of nongovernmental organizations
in health and development.
In recent years there has been
much emphasis on looking at the nongovernmental sector.
As we mentioned with the program in Lagos,
it was organized by the BASICS project of USAID.
It was incumbent upon the organization to look directly to the private sector and
leave the government behind.
Because of the government being put on the blacklist by
USAID by the State Department for political suppression and drug trade.
And therefore the organization had to consider local community-based
organizations and NGOs.
We also gave examples of how USAID is involving NGOs
such as World Vision, Africare, in child survival programs.
One of the reasons NGOs are receiving much attention
is that they are able to innovate.
They are often relatively smaller, they lack disabling bureaucracies,
and they're able to try new ideas, work in new settings.
Also NGOs represent civil society, and
they're in a much better position to look into the needs of minority groups.
NGOs in countries often reflect community needs and interests, and
are able to do so and lobby much more than along state government bureaucracy.
This does not mean that NGOs are perfect.
When effort was being made to establish the West African Youth Initiative,
an idea of providing reproductive health education through peer education in
Nigeria and Ghana.
Staff from an NGO in Washington went to Nigeria and
worked with a nationwide NGO there to try to identify community-based youth
serving organizations who could take up the role of community education for youth.
They found more than 400 groups that called themselves NGOs, and
the joke was that even a bicycle repairman and his wife call themselves an NGO.
And NGOs have been springing up in Nigeria, and other developing countries,
because it's recognized that many funders want to work with the private sector.
And one has to be careful to distinguish those NGOs that
have created themselves simply to be a money-making venture and
those that are responding to a real community need.
Again, as we said, organizations,
in the very beginning, are created in response to their environment, and
one of these responses could be that donor money is available for the NGOs.
Another response could be, as you'll see in the case study at the end of this
chapter, an organization that responded to the reproductive
health needs of women and youth in Nigerian communities.
Just like large health systems,
NGOs themselves may reform the process of innovation.
Also means that they change from time to time, adding new programs,
increasing staff, responding to different community needs.
The final two slides show us that NGOs, particularly based in the US and Europe,
do receive a lot of scrutiny, much more than the bicycle repairman and his wife.
Before people donate money, they want to know what it's going for.
And these two slides show fliers that are send out by two NGOs to
show how they use their money to convince individual contributors
that their involvement would be beneficial, effective, efficient.
As we said, NGOs represent civil society and
in that sense can bring in quite a lot of resources and
not be dependent on one source and influenced by that particular source.
So in summary we have different kinds of organizations involved in health,
the local clinic and its staff, being part of a larger district health department.
We have large health systems or ministries of health.
We have international agencies such as the African Program For
Onchocerciasis, which involves UNDP, World Bank, UNICEF, WHO, various contributors.
We have nongovernmental organizations involved in health,
the Carter Center, Doctors Without Borders, and
these systems are composed of individual people who have their own goals and needs.
Organizations like these were created in response to a need in the environment, but
they also change because the environment changes.
Either their supply of resources that they need to run the organization changes or
the response of the people who consume the services and products changes.
Therefore, it's not adequate for us in public health simply to be concerned
about changes in behavior of individuals and families in the community.
But we also need to understand what influences change in the organizations
where we work.
And how we can bring about positive change
through a proper organizational diagnosis
to make our own organizations more effective and
responsive to the needs of the community.
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