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.
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来自 Johns Hopkins University 的课程
Understanding and Strengthening Health Systems
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从本节课中
Health Systems: Basic Functions and Building Blocks
The World Health Organization has described six major components or building blocks of a health system. In this module we will examine those components and delve more deeply into the aspects of financing, commodities and service delivery, especially through Primary health Care. We examine a ‘missing’ component, community systems.
与讲师见面
William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
The Community Health Systems Strengthening Framework
of the Global Fund has several components.
And again, we can think about these in terms of our community systems,
we can think about these in terms of the health system building blocks.
So, the enabling environment,
the advocacy is important.
We're trying to ensure that the community has a voice,
that community can speak up,
the community can get its legal rights,
the community can communicate with the leaders of the health system,
with the political leaders in their area who allocate funds for their health system.
We need to be sure that there are partnerships.
As we mentioned before that health services are not just delivered to people,
but they're delivered with communities.
That there's a partnership between the community systems,
community leaders, volunteer community health workers,
working together with the health system to ensure that
service delivery not only reflects the needs and interests of people,
but it's delivered in a way,
in a place that's convenient and accessible to people.
So, getting the community resources and the health system resources coordinated,
so you can have a collaborative working relationship
and reach as many people as possible.
Again, we looked at our community systems, the social,
geographical etc, because we want to not just identify if there are any problems,
but we want to identify resources.
What are the social resources?
What are the political leadership resources?
What are the economic resources that the community is bringing to
the table to ensure that they can access health services,
that they can participate actively in the delivery of health services?
And again, we want to make sure that the community is linked up with
an adequate resources from the health system are placed in the community,
so that when you combine the two sets of resources,
you can achieve maximum coverage and outreach of people who need the health care.
So, again as we said,
there are essential commodities that come into the community.
We want to be sure that those are managed in a way that they reach everybody,
but we also want to say, "Okay,
what resources does the community have that can help?"
For example, with people are given bed nets,
that resource comes from outside.
But to hang up the bed nets,
you need local skills like the carpenters have so you can have hooks on the ceiling,
or build frames on the bed.
So, you'll need both a combination of local resources and external resources,
your health systems resources to make sure that not only does the service get out there,
but it's actually usable in the homes of the people.
Additional elements of the Community System Strengthening Framework include,
again the direct activities by the community to participate in service delivery.
The community health worker is one good example,
and those are people who live there, so they're accessible.
Evidence exists for showing the importance
and the effectiveness of community delivery of these services.
We found that, for example,
when we did our community distribution of
intermittent preventive treatment for pregnant women to prevent malaria in Nigeria,
that those communities that have the community health workers
trained by the health workers in the clinic,
and have the supplies of the medicine needed,
they achieved greater coverage than in communities
where people could only get the services from the health center.
And we've replicated that elsewhere.
But, this has been done with
the Tropical Disease Research in WHO finding that malaria treatment provided
by community health workers is more likely to reach children
and others in need if the community can deliver those services.
So, this is an important thing,
the community directly involved in service delivery.
We want to strengthen, as we said,
the leadership and local organizations and networks.
Because again, they can play an important role in mobilizing resources,
in mobilizing community members to take advantage of services,
and also in terms of helping identify and oversee the volunteers,
community health workers who will help deliver these services.
One of the things we talked about with community health workers
is that they have in a way two bosses.
They are obviously technically
responsible to a health worker who trained them at the nearest health center,
but more importantly they are socially responsible and socially
accountable to the leadership of the community and their neighbors.
Finally, it's important to involve the community and strengthen
its ability to collect and maintain information about what is happening in the community.
Simple community registers can show when
the community health worker is delivering services.
One of the things that we are doing right now in Burkina Faso through Jhpiego,
which is an NGO affiliated with Johns Hopkins,
is expanding our community delivery
of intermittent preventive treatment for malaria and pregnancy,
and we have developed
community registers and community records to show what is happening.
And because of that,
we can see that when
the community health workers bring their records monthly down to the clinic,
and you combine the two,
you can see the records in the areas that were doing the intervention,
show greater coverage of this IPT than in
the control area that just has the IPT delivered through the regular clinics services.
So, it's quite additive.
Basically, if you were having 50 on
average women a month getting the third dose in the intervention area,
and that's approximately 50 in the control area,
by adding the village health workers,
and them having a strong monitoring,
evaluation and record keeping and reporting system,
you can see that yes,
they add another 50.
They're reaching women who would not have come and gotten those additional doses.
So, by having the community participate in record keeping and reporting,
you can see the impact of strengthening the community.
Here, we can see a chart that shows
the community systems compared to the system strengthening activities.
And we can see that the enabling environment strengthens the economic,
the political, the geographic system.
We can see that strengthening
organizational and leadership capacity in the community improves the social,
cultural, and political systems within the community.
I won't go through all of these because you have copies of the slide,
but you can get the idea that this framework that the Global Fund has developed
does address strengthening the basic systems within a community.
This results in an improved outcomes for health and well-being.
As we've said, more people can get services if the community plays an active role.
We ensure that the rights of people to
health care are respected by taking this community approach.
We are able to address risk, financial risk, particularly,
if we can reduce costs by bringing
health services close to people at a cost they can afford.
We are able to strengthen the community's responsiveness to interventions.
If they play an active role in the intervention,
in what the health system has to offer,
they will be more likely to take up the services,
take up the innovations that are offered,
and thus improve their health.
So, ultimately, this improves responsiveness by the community,
the effectiveness of the interventions will improve health,
will strengthen the social networks,
will improve even education and other services.
Healthier children will be able to go to school,
and people will be more able to work on their farms,
and work with agriculture extension services,
and again, economic development agencies in urban areas.
So, we do have some clear ideas that by working on these strengthening activities,
strengthening specific systems within the community leads to improved health.
There are some examples of community strengthening interventions.
And these are listed here,
there are many more, but these are some of the common ones.
Participatory rural appraisal involves people in
assessing the health and development situation within their own community.
Communities are involved in mapping,
priority setting, decision making.
Community coalitions are another approach.
This is a way of mobilizing all the different social networks and
community-based organizations to come together and share human and material resources,
and doing things that no one organization
alone could achieve to strengthen the community.
Community-directed interventions, this has grown out of the program to
control river blindness or Onchocerciasis in West Africa, or throughout Africa.
But by having the community take charge,
it's not just making sure there's a village health worker who can deliver a service,
but it deliver a commodity like malaria drugs, but what it is,
is getting the community active in deciding what to do.
So, it's not dependent on one volunteer.
It's the community with their own human resources dividing up the workload,
they may select a couple of volunteers,
but they still supervise them.
By taking charge, they have improved access to commodities,
and through this approach the partnership with the health center means that
basic medicines and supplies can be supplied to the community,
and they take charge through their community health worker,
and plan and decide how they're going to get
these services out to their own people and report back.
Care groups, is another active group that strengthens social networks.
Small groups of households are served by a volunteer.
This makes sure that there are
natural neighborhood networks to provide health information and health services,
and it also is a way of strengthening
the human resources through these community volunteers,
so that there are more people in the community who are capable of delivering health care.
The Global Fund tries to conceptualize here
how a community system strengthening creates a health impact.
And so, when you have the six activities ranging from creating
the enabling environment through
the monitoring and evaluation or health information at the community level,
you will be able to have quality services that are available,
equitable, and use by and in the community.
This will result in better coverage,
whether it's more children getting immunized,
more children getting prompt and appropriate malaria treatment,
more pregnant women getting
their intermittent preventive treatment from preventing malaria,
whether it's more people get bed nets.
And ultimately, if this coverage of these basic services and interventions increase,
then of course, that will have an impact on health.
So again, by strengthening community,
and having the community take charge of delivering basic services,
the community can play an active role in improving its own health.
