Health Systems
– HEART

Translating health policies into plans for action: the role of district health managers

Thu, 19 Aug 2021 11:23:20 +0000

This piece was written by Kate Gooding, Gabrielle Appleford, Nicola Wiafe from Oxford Policy Management (OPM) and originally appeared on the OPM website.

The success of national policies and plans for universal health coverage depends on implementation. Much of this implementation takes place at the local level, where health services are managed and delivered. This means district health management teams (DHMTs) play a crucial role in promoting health service coverage, quality and public health. In many countries, decentralisation has increased the role of DHMTs, and they often have key responsibilities for designing annual plans and budgets, overseeing facilities, managing staff, monitoring and reporting.

These responsibilities need to be performed well, as effective planning and management underpin progress in other areas of the health system. Sound planning is particularly important because district health budgets are often small: district managers need to identify and prioritise activities that can make the most of limited resources and bring the greatest benefit. However, district health planning is often rushed, and sometimes based on previous activities or donor interests rather than systematic thinking about district needs.

An evidence-based approach to planning

More use of district health service data can support effective planning by helping DHMTs to identify key gaps in health service coverage and their causes – for example, whether problems relate to lack of medicines, health worker skills, or community uptake of interventions. Techniques such as the ‘5 whys’ approach or problem tree analysis can then be used to understand underlying causes, and stakeholder discussions and prioritisation criteria can help to select activities that are most likely to be feasible and effective.

UNICEF has been supporting DHMTs in East and Southern Africa to use these more evidence-based approaches, using a method called bottleneck analysis, and we are working with UNICEF to evaluate progress and identify lessons that can strengthen support for DHMT planning and management.

Our findings highlight a range of issues that can help or hinder DHMTs’ use of evidence, their approach to planning, and implementation of annual plans. Important issues include accurate health systems data that can indicate bottlenecks; planning guidelines that support DHMTs in identifying local priorities; help and collaboration from political decision makers, NGOs and other development agencies; predictable and adequate resources to implement plans; and capacity to adapt plans and budgets around unexpected shocks such as COVID-19. Several of these issues have been highlighted by others, including limited DHMT decision space due to lack of funds and associated reliance on donors, and the influence of power relations with political structures, but here are some other, perhaps more overlooked issues that we’ve found so far.

Do district managers see planning as a useful investment of their time?

One area evident in many districts was the importance of DHMT motivation and interest in detailed planning. In the past, district plans have often not been implemented – sometimes because of insufficient budgets, or because plans were not regularly reviewed and followed. Many DHMT members appreciate the use of evidence incorporated in the bottleneck analysis approach, but this approach also requires more effort. DHMT members may not immediately see value in investing time for this given their high workloads and past experience of plans not being used.

Even if we have a beautiful plan those activities will still not be implemented, because funds are never enough. … The plans are not serving any purpose. (district planning committee member, Malawi)

DHMTs’ interest in planning is also affected by budgeting systems: if the system that determines allocation of national funds to DHMTs is not linked to the annual plans, DHMTs may focus on the system that brings the resources and see less value in planning.

Planning is hard work and district managers are busy

Another important issue highlighted by several DHMT members relates to the complexity of the planning processes and time requirements: DHMT staff are busy, planning and budgeting deadlines are tight, and planning processes can be lengthy – in some cases requiring completion of numerous online forms and tables. This can mean planning is rushed, particularly at the crucial later stages of selecting priorities and budgeting. Workshops for planning can provide dedicated time for DHMTs to focus, but funding for workshops may not be sustained once donor support ends, and it can be hard to complete all stages of planning within the workshops – and to retain enough concentration for later steps.

Planning takes a very long time – there are times when we stay in the office until 22:00 hours to meet the deadlines. (district health management team member, Tanzania)

Building the value of planning

These issues are not easy to overcome: they involve stakeholders and systems at national and district level; links between ministries and departments; activities and interests among a range of development partners; engrained approaches; wider health system capacity; and tricky balances around providing support while ensuring sustainable systems. While fully embedding evidence-based planning requires action on multiple fronts, steps to ensure planning has value for DHMTs, and leads to action may help to sustain more systematic approaches. This might include, for example, encouraging DHMTs to identify activities that can be developed within existing resources so that plans are affordable, supporting regular review of plans during the year to promote attention to their implementation, and working with national and sub-national stakeholders to align budgeting and planning systems

UNICEF is continuing with DHSSi and taking steps to further enhance the value of planning for DHMTs. We are now starting round 2 of the evaluation, and will continue working with UNICEF to see how these activities progress and to identify lessons that can inform district management capacity interventions.

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Health systems approaches to mental health

Thu, 06 Feb 2020 11:29:16 +0000

In this video, Jasmine Kalha, QualityRights Gujarat, discusses the benefits of a rights-based approach to mental health, the QualityRights framework in the context of health systems, the role that peer support should play in QualityRights, and her favourite Article of the Convention on the Rights of Persons with Disabilities (CRPD).

In this video, Soumitra Pathare, QualityRights Gujarat, discusses how mental health professionals need to engage with the political process of policy making, the important roles that Disabled People’s Organisations and civil society can play, and what we gain when we think about mental health as a human rights issue.

These videos were produced from a training module designed by global experts from London School of Hygiene and Tropical Medicine, CBM and the Centre for Mental Health Law and Policy, India, and delivered to DFID staff in Spring 2019, as part of the K4D Learning Journey led by the Mental Health Innovation Network on “Leave No One Behind”: Delivering on the 2030 Sustainable Development Agenda for Mental Health and Psychosocial Disabilities.

Health systems strengthening

Mon, 21 Oct 2019 13:39:31 +0000

Interview: Evidence review on health systems strengthening

Due to the lack of clear definitions and the potentially huge volume of evidence, comprehensive reviews of health systems strengthening (HSS) interventions are relatively uncommon. In this interview lead author Sophie Witter (Queen Margaret University, Edinburgh) discusses one such rapid evidence review, recently commissioned by the UK Department for International Development (DFID). The evidence review explores what works for HSS and in what contexts, providing an evidence base to support DFID’s work.

In this video Sophie Witter outlines the key findings from the review, the complexity of the health system, the value and impact of health systems research more generally, and recommendations for DFID staff and other donors.

Presentation: Health systems strengthening – what is it, how should we assess it, and does it work?

In this video, authors Sophie Witter, Dina Balabanova (LSHTM) and Sandra Mounier-Jack (LSHTM) reflect on the process of undertaking the evidence review, drawing out suggestions on definitions of HSS and approaches to assessment, as well as summarising some key conclusions from the current evidence base.

This presentation was delivered as the first activity of the DFID-K4D Health Systems Strengthening Learning Journey.

Related resources include:

This content is produced as part of a DFID-K4D Health Systems Strengthening Learning Journey.

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Why monitoring and evaluation is crucial for the success of health system reforms

Thu, 25 Jul 2019 14:09:42 +0000

Monitoring, evaluation, and learning (MEL) is used to guide the implementation of a programme, understand the performance of the programme, and assess the best approach to future developments.

To ensure the success of healthcare system reforms, and projects being implemented around them, an innovative MEL design is needed. Often, traditional models measuring the outputs of health systems are insufficient to explain the performance of systems, or how interventions affect them.

The Oxford Policy Management Health team is working to understand the software elements of the health system, looking into the attitudes and cultures within the health system that influence performance outcomes of service delivery. This involves approaching MEL in a holistic manner to generate performance evidence that can contextually inform programme design and answer whether the current approaches being used are the most appropriate.

Senior health consultant Sam Franzen discusses how this method is being used in the work we do, spotlighting the monitoring, evaluation, and learning partnership for the Bihar Technical Support Programme in India, which is focused on providing MEL services to health system strengthening reforms.

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Why global health security is gaining prominence

Thu, 18 Jul 2019 13:39:26 +0000

In recent years, the global health security agenda has gained prominence, as it pursues a multilateral and multi-sectoral approach to respond to health emergencies. It aims to strengthen capacity at a global and national level to prevent, detect, and respond to the spread of infectious diseases.

Despite great progress in improving access to healthcare for all, people around the world are still vulnerable to health emergencies. Globalisation has made disease outbreaks much more dangerous; and natural disasters, conflicts, and migrations all significantly impact the way diseases spread.

Countries need to ensure their health systems can effectively respond to emergencies, and thus reduce individual and collective vulnerabilities to risks. Rashid Zaman, senior consultant in the Oxford Policy Management health team, discusses why ensuring health security is a global priority and explores challenges to achieve it.

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Exploring challenges in health transition planning

Thu, 18 Jul 2019 13:35:14 +0000

Effective health planning is critical in ensuring affordable, accessible, and high quality health services for all. Many low- and middle-income countries rely on donor funding to establish or maintain the basic healthcare services, and often struggle to ensure sustainability of these when sources of funding in the sector change.

Multilateral organisations and government partners have in the past often focused on singular priority areas, such as eradicating specific diseases, providing vaccinations, or enabling HIV/AIDS treatments. However, as achieving universal health coverage became a global priority, ensuring all healthcare services are available and supported is crucial.

For many countries, this means focusing on ensuring the efficiency of the healthcare system is first continued, and later improved. As sources of funding shift, a managed transition is essential for keeping all services supported.

Tomas Lievens, principal consultant in the Oxford Policy Management Health team, explores the role of transition planning in managing the change in health expenditure performance, and highlights the importance of context specific diagnostics and solutions for ensuring the success of these reforms.

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Improving health system resilience in fragile and conflict-affected countries

Thu, 18 Jul 2019 13:30:20 +0000

According to the World Bank, fragility, conflict, and violence is a critical development challenge that threatens efforts to end extreme poverty, affecting both low- and middle-income countries (LMICs). Many of the world’s crises are caused by or exacerbated by fragility, from violent conflict to internal and external displacements and climate shocks.

Compared to other LMICs, fragile states have grown more slowly, with more than 80% being off track to achieve the Sustainable Development Goals. Increased global conflict and fragility means that the health of the world’s poorest and most vulnerable populations are at risk. By 2030, an estimated 80% of the world’s extreme poor will live in these places.

It is increasingly important to ensure health systems worldwide are resilient to shocks, so that health actors, institutions, and populations have capacity to:

adequately prepare for and effectively respond to crises
maintain core functions during crisis
take informed action based on lessons learned from previous crises
reorganise in the aftermath

In the following video, Oxford Policy Management health consultant Kailash Balendran explores the connections between fragile states and resilient health systems, looks at how to improve engagement in this area, and spotlights what OPM’s Health team is doing to support governments in fragile countries to improve their health systems.

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How can countries get the most out of their investments in health?

Thu, 18 Jul 2019 13:25:10 +0000

The ability of countries to provide available, affordable, and high quality healthcare services to their populations has become a global priority. However, at least half of the population around the world still don’t have access to essential healthcare, and around 100 million people are pushed into extreme poverty because they have to pay for healthcare.

Universal health coverage (UHC) enables all individuals to receive health services they require, without suffering financial hardship. While there are many ways to achieve UHC, all require sufficient funding from governments.

In the following video, senior health consultant Odd Hanssen discusses initiatives countries can implement to both mobilise more resources for health (more money for health), as well as get as much out of their spending on health (more health for the money), towards achieving universal health coverage.

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Developing local capacity to support health system reforms

Thu, 18 Jul 2019 13:18:46 +0000

Capacity building is an important element in health for successfully tackling social health inequalities by improving the capacity of health actors and institutions at national, regional, and local levels. Capacity building looks at “development of sustainable skills, organisational structures, resources, and commitment to health improvement in health and other sectors, to prolong and multiply health gains”.

Capacity building has become an integral part of health strategies worldwide, helping governments prevent, prepare for, respond to, and recover from health emergencies. There are different ways to approaching capacity building in low- and middle-income countries, however, the success of all hinges on adapting these approaches to local contexts.

The health team at Oxford Policy Management recognises the importance of doing dedicated capacity development, which brings together the needs of policymakers in low- and middle-income countries, and combines those with research and lessons learnt from countries elsewhere, to develop a careful plan of action, adapted to the local context. This approach implies that developing local capacity is as equally valued as the research outputs, and thus should be considered as carefully as research design.

To help support in-country capacity development, OPM launched a financing fellowship in Nigeria. The programme aimed to train selected fellows, 14 in the first intake, from federal and state health institutions to enable them to become results-based financing technical assistants.

In the following video, watch Alexandra Murray-Zmijewski present different types of capacity building, and highlight problems that most often constrain capacity development in low- and middle-income countries.

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Exploring the importance of effective supply chain management in health

Tue, 16 Jul 2019 15:44:19 +0000

Vimal Kumar, principal consultant in the Oxford Policy Management Health team, discusses the importance of procurement and supply chain management in supporting effective policy reforms.

Ensuring availability, affordability, and quality of commodities (for example medicines) to provide services to the patients is one of the key outcomes which procurement and supply chain management establishes.

This is especially important in low- and middle-income countries, where poor populations often experience out-of-pocket payments and financial hardship for accessing healthcare.

Improving efficiency and effectiveness of procurement and supply chain management systems can help ensure sustainable availability of quality and affordable health commodities for the vulnerable communities.

In December 2018, Vimal Kumar, an expert in health procurement and supply chain management, led a technical seminar around health supply chain management where he talked about his experience in the field.

Developing a sustainable pro-poor health commodity supply is an integral part of developing high-quality and affordable healthcare services for all, which is an important goal for the Health team at Oxford Policy Management.

Helping to strengthen the procurement and supply chain management components, the team’s work in the field included the monitoring, learning, and evaluation of the Bihar Technical Support Programme (BTSP), which focused on improving reproductive, maternal, and child health and nutrition in Bihar, India, in addition to work for HEART.

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Health Systems – HEART

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