Hello, this is Bill Brieger in the Department of International Health at Johns Hopkins Bloomberg School of Public Health. In this lecture, we're going to be talking about health systems building blocks, the basic components of putting together a health system and we're going to be looking at some work that Jhpiego has done in trying to understand how health system strengthening can be used to improve Malaria programming. On the left side, you can see that WHO has outlined six different health system building blocks: Leadership and governance, Healthcare financing, Health workforce, Medical products and technologies, all of the consumables, Information and Research, people include monitoring and evaluation, and of course service delivery. All of these different components work together to ensure that people receive the services they need. If these building blocks are in place, if they're strengthened, hopefully people will have better access to the services and guaranteed quality of these services. Obviously, we are working toward a goal, and this goal is improved health. Also, what we're concerned about too is the responsiveness of the health system to people's needs, to their culture, to their background, because obviously, if the system is not responsive, people will not access it and their health quality will not improve. We are concerned also about protecting financial risk. People are aware that if illness can cost families, even if it is a "simple" episode of Malaria, it costs drugs, it costs transportation, it costs worktime, the family members miss to attend clinic or take children to the clinic. These are some of the concerns that we have. Obviously, there are serious diseases, like if people have stroke, and that can often bankrupt families. So, we want to make sure that the system works and is affordable to people to protect them. And then finally, along the lines of quality again, we're concerned about the outcome of improved efficiency, that we're able to serve more people with the funds we have in a way that meets their needs. So, this is the basic health systems framework of the World Health Organization and we have adapted that to looking at Malaria control programs and how they could be strengthened. So, Jhpiego is set about to understand Malaria control programs, we recognize that there were some additional elements that needed to be included. So, we do have some of the basic six. We assume that all of these nine components you see here lead toward improved service delivery. And from there to the outcomes. But, for example, community involvement and social and behavior change communication was not directly part of the WHO building blocks, whereas things like commodities and finance were monitoring evaluation or information definitely was. We've made clear the fact that quality assurance and supportive supervision is a component that needs specific attention to help strengthen the workforce. We've again talked more about the issue of leadership and governance. We're very much concerned about integration. We don't want Malaria services being delivered in a vertical approach disconnected, but we want to make sure that they are integrated into child health, family health services and general Disease Prevention and Control Services in the community. So, we've recognized in Jhpiego that Malaria control and elimination cannot be accomplished unless there is a strong health system. Again, we're not talking about parallel or vertical programs, but we're talking about activities that are part of normal health service delivery. When you go to a primary level health facility, when you go to a community health worker, when you want to access Malaria services along with services for other kinds of problems, whether it's minor injuries, whether it's diarrhea, whether it's family planning, we want to have a strong system that can deliver all the services people need in Malaria control within them. And as we said, we've just reviewed the nine major components that Jhpiego feels has been very helpful in helping us work with National Malaria Control programs to analyze their situation, identify their strengths and identify areas where capacity needs to be built. And this was based on our field experience. We've been asked to conduct assessments in several countries, to learn how they are functioning, and again in places like Malawi, Senegal, Nigeria, this framework has been used and improved upon to help the national or in Nigeria since the state of Malaria control programs, to find out where they're performing well, where their weaknesses. Just as a note, the assessment process of course starts with a look at existing health information, what services are being delivered well, where's their high coverage, where's their low coverage, and then, the systems building blocks help us to analyze why things are going well, where they are, and why there are problems where things are not achieving targets. So, again, the guide that Jhpiego has developed and it's available online, we have a reference to it earlier in the slides, can be used to guide analysis. It can be used for annual updates and evaluation, and it can be used for action planning. One of the first elements the nine building blocks is having strong policies, guidelines and strategies, that lead to action plans. And like I said in this case, Malaria. So, we want evidence based policies, evidence based guidance. And from that, guidance is developed, it can be disseminated for purposes of human resource development, can be used of course for developing strategies and annual work plans. So, this is the kind of thing that we really want to stress, is that the health system generally, but a Malaria control program, or in cases you may be working in family planning, you may be working in non-communicable diseases, whatever it is the area you're working and you want to make sure that there are clear evidence based policies, that are the foundation for any of your strategies and actions. We are fortunate that there are international guidelines that can help, for the example of Malaria. WHO has every few years puts out an updated version of case management guidelines, which also includes how you manage and prevent Malaria in pregnancy. They put out guidelines for Vector Control, what to do about mosquitoes, what to do about mosquito larvae. And so, these exist. One of the steps that is necessary then, is to work with countries to help them adapt these to their local situation, their local vector situation, their local epidemiology for Malaria, and again their local setup, in terms of how they develop guidelines, in terms of their priorities for what kind of medicines are being used. So, these international documents need to be adapted, and one of the things that we look for, when we're assessing the program, is whether updated guidelines do exist in a country for a particular program. And as I said, in this case the Malaria program. Leadership, governance and accountability is another important building block that we have been using in Jhpiego, and is also a concern for the overall WHO building blocks of a health system. What we're concerned about, is that there does need to be one focal point for leadership in Malaria. And this idea of one coordinating body, one leadership group, is common for other conditions. I think the idea first came up with HIV/AIDS. But the idea is that many donors, many agencies are involved in Malaria, just like many are involved in HIV. But there needs to be a point where, as they say, where the buck stops, where ultimately the decisions are made about Malaria. And what we're trying to ensure, is that all the partners recognize leadership by the National Malaria Control Program. In Nigeria, for example, they've changed the name to National Malaria Elimination Program. They're thinking toward the future. Whatever the name of the program, the idea is that leadership should be vested in that program, and that program brings people together, all the partners to work together on the same policy, the same guidelines, the same strategy. Therefore, in addition to having responsibility, to coordinate, we want this leadership also to be accountable. So, this idea of governance, it's a two-way street. One, we want the national program to govern, to run Malaria activities, to bring partners together, to work from the same page, at the same time they need to be held accountable for funding, for decisions, for reaching targets. In terms of governance, the information we've provided here does come from the document by Jhpiego that you can download, to help you work with National Malaria programs, or again you can adopt them to work with any kind of health or disease control programs. Here we can see that we are encouraging advocacy, to make sure that all health sector partners who are concerned about Malaria, even the private sector, even pharmaceutical companies, even the media, work together with the National Malaria Control Program, one to ensure that the program runs well, but also to ensure accountability that all the people who contribute and the community, often through the media, hold the program accountable for using the resources in the most appropriate way. Again, we want opportunities for feedback through this partnership, so that we know that when Malaria targets are set in national strategies, we ultimately hold a National Malaria Control Program accountable for implementing them. We're using the funds provided both by government, NGOs, by donor agencies, to ensure that action plans are actually carried out. We're talking about transparency mechanisms. Concern that some agencies have is whether if you give money to a program, will it be spent on what it is intended for? The Global Fund for example has an accountability or an Inspector General's Office that looks at how countries spend Global Fund money, and there have been occasions where Malaria grants have been suspended because of inability to account for money or using money in ways that were not intended. And so this is the kind of thing we want to ensure that governance does not only mean that a national program is in charge, but that the partners, the media, the public holds that program accountable for achieving targets. And again we recognize that while the National Malaria Control Program may be providing leadership, that they are not working alone. And so you can tell from what we've been talking about previously, there are partners involved whether they're donor partners, whether they're partners within other components of the health department or health ministry, whether they're NGO partners, whether they're community partners. So there are a number of partners who have roles to play in delivering Malaria services, or as I said it could be reproductive health services or whatever program that you're particularly interested in. But we want to make sure that there is a clear coordinating mechanism to bring these partners together so that you avoid duplications, so that you assess where there are gaps in terms of services and resources, so that everyone works together toward the same goals. Now, one of the things that we're talking about is integration at three different levels. We want to be sure that we deliver an integrated package of Malaria interventions that address all the concerns in the country. In other words, does that package deal with vector control? Insecticide treated nets? Indoor residual spraying? Larviciding? Does it also deal with case management? How do you handle people who are sick? What kind of testing is done? What kind of medicines are used? What is done for children who are vulnerable? What is it doing for pregnant women who are vulnerable? In other words, the National Strategy addresses all of these elements of Malaria prevention and control. So that's the integrated package. The second level of integration is within the health sector. Although there is a National Malaria Control Program, the primary healthcare or clinical services also have a role in treating Malaria. The reproductive maternal neonatal and child health division or Family Health Division as it's often called, has responsibility for pregnant women, young children preventing them from getting Malaria. So there are all kinds of components within. We have, of course, our essential drugs section within the health sector. Are they ordering and providing the right type of Malaria medicine according to National Guidelines? We have our health information system. Are we collecting data on how Malaria services are being delivered? So the third level of integration is within the broader development arena. We're concerned that yes, agriculture has a role to play in Malaria. One, we may be doing types of irrigation activities that foster a mosquito breeding. On the other hand, a major reason for low productivity of agricultural workers would be Malaria. So there needs to be collaboration between agriculture and the Malaria program. Water supply programs and sanitation programs are extremely important in terms of giving people access to clean, potable, accessible water when people rely on ponds for water, they are also exposed to mosquitoes because the mosquitoes breed in those ponds. Educational ministries, educational departments are extremely important because one, we can monitor the health of children and we can provide health education in the schools about how to respond to Malaria. So, all of these again you can think about how they are integrated into Malaria work. Even in migration. What we find in some parts of southern Africa that are trying to eliminate Malaria, it's migration from neighboring countries at higher levels of Malaria that keep the disease constant in the country. And so being able to work with the immigration authorities in terms of testing people, providing clinics near the border, these are some of the ways that Malaria programs can work with other agencies. Many of you may have heard of the Millennium Development Goals which were to be achieved between the year 2000 and 2015, and they were subsequently overtaken by the Sustainable Development Goals that extend to 2030. The idea in both cases is that we are concerned about disease control but we're also concerned about it within the broader development context. And so, stressing partnerships again, the development goals look at things like education, they look at things like poverty, they do look at things like infectious diseases, including Malaria, but the important thing that these goals have is that they draw our attention to the fact that issues such as education, such as poverty, such as gender, such as environment all have bearing on the transmission and or prevention of Malaria. So this again is why we need to involve many sectors in the Malaria control effort. And again within the health sector, we talked about integration. We have primary healthcare services that provide a variety of treatment and preventive activities at the grassroots level. We have our reproductive services which are concerned about the health of pregnant women and young children. These are vulnerable groups who are very susceptible to Malaria. Within child health, we have our integrated community case management where community health workers deliver care on a variety of health conditions that face many people in the community, and Malaria being one of that. One of the things we're concerned about is at the community level a few trained village health worker, they can do tests to differentiate whether a person has fever due to Malaria, or not Malaria through these tests. Then the question arises. What are you going to do with somebody who tests negative but still has fever and other other problems? And so again that's why we want to be sure that we offer services to deal with the common illnesses at all levels. So this is why the delivery of basic primary care services needs to be integrated so that we respond to the variety of problems that people have. Again, so coordination of both service delivery and planning is very important. We've talked about the vector borne diseases. Malaria carrying mosquitoes are not the only ones. There are many mosquito interventions. Other different mosquitoes carrying yellow fever, or dengue, different mosquitoes carrying West Nile virus, and so we want to think about integrated package for Vector Control. So within the health sector, there are important ways of collaboration and coordination with the Malaria program. So again this is a basic health system principle of the idea of integration and coordination. We've mentioned some of these things in terms of the broader development sector, development processes. We've talked about agriculture, water reservoirs for hydroelectric power generation, irrigation often contribute mosquito breeding environments, so we're making some improvements on one hand, but creating another problem. As we said before, schools are an important place to do health education about prevention and prompt treatment for Malaria.
