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.

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.

The event aimed to:

• Educate missions about the critical need for scaling up TB research
• Sensitise missions to the need for commitments to increase TB research funding
• Sensitise missions and key stakeholders on the importance of investing in the full spectrum of TB research, from basic science to R&D to applied health research
• Promote principles to guide research to ensure efficiency in development and equitable access
• Reach a shared vision on priority tools and applied health research needs

Introduction and Keynote Speech

Opening remarks: Mark Harrington, Executive Director, Treatment Action Group

Keynote speaker: Dr. Soumya Swaminathan, Deputy Director General for Programmes, World Health Organization

Panel 1: A Step-Change TB Research: why TB research is critical and how to respond

Opening remarks and moderator: Professor Charlotte Watts, Chief Scientific Advisor, DFID
Panel: 

• Ms. Eloisa Zepeda-Teng, TB survivor, Philippines
• Tereza Kasaeva, Director, WHO Global TB Programme
• Irene Ayakaka, Makere University and Uganda Tuberculosis Implementation Research Consortium

Respondent: Minister Counselor Philip Gough, Permanent Mission of Brazil to the United Nations

Panel 2: Devoting the Resources

Moderator: Dr. Lucica Ditiu, Executive Director of the Stop TB Partnership
Panel:

• Joanne Liu, International President, Doctors Without Borders
• Mike Frick, Senior Project Officer, Treatment Action Group
• Cheri Vincent, Chief, Infectious Diseases Division, US Agency for International Development (USAID)

Respondent: Mrs. Paulomi Tripathi, First Secretary, Permanent Mission of India to the United Nations

Panel 3: Designating Research Outcomes as Global Public Goods

Moderator: Mark Harrington, Executive Director, Treatment Action Group
Panel:

• Paula Fujiwara, Scientific Director, The Union
• Tenu Avafia, Team Leader, Human rights, law, and treatment access, UNDP HIV, Health and Development Group

Closing remarks: Rt. Hon. Nick Herbert, Member of Parliament, U.K.

Event organisation and sponsorship:

The briefing was organised by Médecins Sans Frontières, Stop TB Partnership, Treatment Action Group, and The Union.

Sponsors include Permanent Mission of Brazil to the United Nations, Permanent Mission of India to the United Nations, United Nations Development Programme and World Health Organization.

Related resources:

• Reading pack: Emerging issues in tuberculosis

This collection of videos has been produced in partnership with the K4D programme.

This presentation was delivered as part of a professional development training session for DFID health advisers in March 2018. Subject experts from the Liverpool School of Tropical Medicine (LSTM) presented the latest evidence on the communicable diseases (HIV, malaria, tuberculosis and neglected tropical diseases) that affect the poorest people in DFID partner countries.

Through the K4D programme and in partnership with HEART, a number of reading packs on the topic of communicable diseases have been produced. Related reading packs include:

• Emerging issues in HIV
• Malaria: Key challenges and potential solutions
• Emerging issues in tuberculosis
• The global challenge of NTDs  

Seminar 1: Health service costing and fiscal space analysis
Oxford, 17^th June 2016

Universal health coverage (UHC) has amassed widespread political support from global and national leaders alike, being expected to retain the momentum throughout the SDG agenda. Considerable financial resources are required to pursue UHC and several global benchmarks for government health expenditure have been proposed (e.g. 5% GDP, $86 (2012) per capita), primarily for advocacy purposes. However, for most low- and lower-middle-income countries the gap between current government health expenditure and what would be required for a package of essential interventions in line with UHC is downright prohibitive.

Fiscal space analysis is a useful tool for identifying options for closing the resource gap along four key directions (‘the fiscal space diamond’): health aid, government debt, efficiency savings and domestic spending. Simulation exercises conducted at a global level suggest that closing the resource gap is unlikely without sustained/augmented health aid, particularly in low-income countries.

This seminar brought together thinkers and country decision makers to reflect on the question “How should national policy makers approach the development and deployment of health financing strategies for UHC, with a view to sustainability, efficiency and equity?”

Its specific aims were to:

• Reflect on how the global UHC health financing discourse can be pragmatically translated in country-level health financing decisions and implementation using sector costing and fiscal space as tools
• Summarise lessons from country experiences
• Discuss technical approaches to conducting fiscal space analyses and how to complement them with other analyses.

Resources:

• Technical note: Financing for UHC in low- and middle-income countries
• Technical note: Costing for UHC
• Technical note: Fiscal space for health
• Fiscal space analysis for health: friend or foe? Blog article by Adrian Gheorghe, health economist, OPM.

Seminar 2: Social health protection
London, 27^th June 2017

The essential roles of public financing mechanisms in general and of prepaid contributions in particular for advancing towards universal health coverage (UHC) have been increasingly recognised by governments, donors and researchers alike. Social health insurance (SHI) and taxation are two fundamental mechanisms for raising prepaid contributions and quite a few low- and middle-income countries (LMICs) are currently at various stages of introducing some form or combination of these mechanisms.

There has been less research on the practical implementation details of social health protection (SHP) schemes compared with theoretical foundations of health financing for UHC. Collecting contributions in large pools to avoid fragmentation, focusing on equity from the outset by including the poor, and improving the efficiency of tax collection and health spending are examples of largely undisputed principles – less is known, however, of how such principles can be realistically enacted while accounting for country context. Other relevant considerations relate to ways of reaching the informal sector, the role of private sector provision, shifting from passive to strategic purchasing and ensuring technical capabilities for monitoring SHI. Deploying such complex reforms takes substantial time and resources, and there is no blueprint for preparing, designing and overseeing their implementation.

This seminar brought together leading thinkers and practitioners of SHP in LMICs to reflect on how the latest implementation evidence can systematically translate to the practice of designing and introducing SHP schemes in LMICs. Three broad questions were addressed with a view to past and ongoing country experiences:

• What does it take to prepare for the introduction of nationwide SHP schemes?
• What considerations are pertinent to the policy decision for SHP and for a given design, in combination with tax-based approaches?
• What are the SHP implementation challenges once the policy decision has been made, and what are their potential solutions?

Resources: 

• Social health insurance: the practical challenges. Reflecting on a seminar and opening the discussion, Medium story by Adrian Gheorghe, health economist, OPM.
• Video: how do we finance universal health coverage? Medium story by OPM.

Seminar 3: Technical Efficiency
London, 15^th September 2017

Improving the effectiveness of available health resources in LMICs has increasingly become important as many countries attempt to map out their paths towards achieving UHC. For many of these countries, a combination of increased health coverage targets, increased disease burden from communicable and non-communicable diseases, and sometimes reductions in global support towards the health sector has enhanced the need to improve value for money in the health sector. Indeed, the growing body of literature on measuring health system efficiency shows large variations in efficiency within and across health systems – highlighting the potential for health systems to improve efficiency. Yet, a number of challenges remain in achieving technical efficiency across and within health systems.

First, while there is a growing literature on the sources of inefficiencies in health, it is not yet clear to whom policy interventions to address these should be targeted to achieve the greatest impact. The Ministry of Health (MoH) is the custodian of the health sector but often some of the main causes of inefficiency lie outside the jurisdiction of the MoH – Human Resources for Health being one prime example – which often lies within the Ministry of Public Service (or related). The second relates to methodological challenges in quantifying efficiency in a given sector. Methods to compare health efficiency across health sectors are becoming more standardised (e.g. DEA and Stochastic Frontier Analysis), but the quantification of this remains difficult.

Participants came together to reflect on the question “How can country-specific evidence on the sources and magnitude of health system inefficiency inform policies that enable a better use of available resources?”

The seminar’s specific aims were to:

• Reflect on how the most  pressing sources of inefficiency in a particular health can system be identified
• Identify which stakeholders have decision making power over the major sources of health system inefficiency, and how can they be brought in to the discussion on health system inefficiency
• Discuss ways on how progress on efficiency initiatives can be monitored

Resources:

• Discussion paper: Social Health Protection in low- and middle-income countries: the practical challenges
• UHC Technical Efficiency in Focus, OPM
• Achieving universal health coverage: Can countries learn from each other? And why now is the best time to share knowledge
  Medium story by Alex Jones, consultant, OPM health team.

Seminar 4: Addressing hospital challenges in low- and middle-income countries
7^th November 2017

This seminar, hosted by OPM and supported by DFID, brought together a group of hospital professionals (top academics, hospital managers and international consultants) to discuss challenges in hospital governance, administration, and financial management in LMICs and to reflect on the question: “Why invest in hospital sector improvement?”

Regardless of standpoints and the diversity of expertise, participants spoke unanimously about the need to ‘rethink hospitals in contemporary health systems’. This, in a context of public- private engagement and unavoidable scarcity of resources needed to deliver high-quality services, would streamline the understanding of hospital governance, institutional arrangements, business models and models of care.

Read more about this seminar here.

Resources:

• Summary: Why invest in hospital sector improvement?

There was agreement that SHI means far more than raising contributions, as it is sometimes construed, and reaches into deep health sector reforms. These require careful staging, sustained political commitment and a focus on good governance, but also a continued engagement with core principles of universal health coverage (UHC), primarily equity. Nevertheless, some of the implementation challenges faced today are not new. Investing further in the existing health system learning mechanisms, formal and informal, will be key to avoid repeating implementation failures of the past.

This review examines the quality and range of tools used to measure literacy and foundational learning in developing countries. It covers the assessment of language and literacy skills in children from age 3 to 14 (or preschool to Grade 8). It also includes assessment tools from studies published between 1990 and 2014, rated as ‘Moderate’ or ‘High’ in methodological quality.

There are 2 main reasons to assess children’s learning and underlying skills:

• Assessment can monitor educational quality. Communicating test results about what children can do (or cannot do) can improve decision making at every level of the education system. This improves educational quality and thereby lifts children’s attainment.
• Assessment can inform teaching practice. Teachers who assess well and use test information well, teach better. Towards this aim, the synthesis collates measures that potentially could be part of a teacher’s toolkit.

The reason for assessing literacy skills is to ensure that “children can come to a point where they can read with comprehension and write and express for others to understand.”

Not all assessments are suitable for supporting the decisions that are often made on the basis of the data they produce. Therefore care should be taken to ensure that tests captures students’ level of learning and are sensitive to small differences in attainment. Tests should also be fair: “A good test is one that is considerate to the child’s learning history, child’s cultural background, child’s linguistic assets… A good test tries to not be influenced so much by contextual factors so that you get the child’s level of learning”.

Sonali’s key messages are that funders and researchers should focus on comprehension and understanding through all stages of literacy development and in all areas of test development, analysis. Protocols should be followed to ensure that assessments are appropriate to the local context. Finally she urges transparent and thorough reporting on the cycle of instrument development and the properties of the test (validity, reliability, potential sources of bias, mitigation against bias, etc.)

The main report is supported by an evidence brief and two briefing notes (on contextual issues and what to test and why).

Sonali Nag previously recorded a video for HEART Talks on Literacy, Foundation Learning and Assessment in Developing Countries, which is available to view here.

He explains that public health surveillance is a means to quantify the burden of disease in a community or country. It can be used to measure how the amount of disease is changing over time to understand what is relatively normal, and what is abnormal when something different has happened. It allows us to look at changes over time which helps in evaluating interventions and identify whether targeting is needed. It is also needed to identify unexpected public health events such as Ebola, Zika, and yellow fever to alert people and take actions early.

There are two main systems available. Firstly, health facility-based surveillance uses data already collected by health workers to monitor the normal. Taking this data out is an easy way of doing public health surveillance. Secondly, event-based surveillance which collects information on events as they happen to find the abnormal. There are some global systems for examples Global Public Health Information Network (GPHIN) and ProMED. These are computer-based systems which scan social media and online news looking for anything that might be relevant to public health.

International Health Regulations (IHRs) form the framework for disease surveillance around the world, they establish a framework for response, and put in legal requirements for the capacities that people need in their public health system. One of the challenges that came out with Ebola is that money spent on health systems strengthening hasn’t been focussed on public health systems, disease surveillance systems and human resource capacity. The 2005 IHR is a legally binding agreement for 194 member states of the World Health Organization (WHO). It builds on previous IHR’s and was updated because of changing threats. There was a move away from a focus on specific diseases to an ‘all hazards’ approach. It was agreed in coordination with travel and trade organisations. It sets out ‘core capacities’ for member states to deliver IHRs.

All member states must have a National Focal Point for IHRs. There are agreed protocols for risk assessment and reporting to the WHO. There are a number of criteria used to assess whether the WHO declare a Public Health Emergency of International Concern (PHEIC) when binding travel and trade restrictions can be made. All member states were meant to be compliant by 2012 but very few are. There have been four PHEIC since 2005: 1) pandemic flu in 2009; 2) polio became of international concern in 2009 when the decline started to reverse; 3) Ebola in 2014; and 4) Zika in 2015.  There have been in the region of 50,000 events reported to the WHO since 2005. The concern is something important maybe missed between the large number of items reported and the small number declared as PHIEC.

After Ebola IHRs are being revised. What IHRs were set out to do was right, the problem was they weren’t being implemented properly in enough countries. They also weren’t being properly assessed and evaluated. This has prompted a move away from voluntary self-assessment to independent evaluation. A number of countries have challenged the idea of external assessment. Another issue is that assessment is linked to the global security agenda which is seen to be US-led. Formal agreement has yet to be reached on regular assessment on how well countries are reaching IHRs. This assessment is required for targeting countries who need support. This would be in everyone’s best interest.

Improving public health surveillance has many benefits, is an urgent priority, and should be part of health systems strengthening. It is important for the country to get this capacity right. South Korea, for example, lost 0.9% of their GDP in the six months following the outbreak of the Middle East Respiratory Virus (MERS). The health systems strengthening can also benefit, non-communicable disease burdens using the same infrastructure. And also be beneficial maternal and child health. Monitoring trends and identifying what is changing and why can help to target interventions.

Future priorities are:

• Invest in IHR core capacities
• Encourage and support independent external evaluation
• Develop the workforce and the systems
• Look at IT improvements
• Look for partners, ie in: agriculture and farming, industry/private sector, and communities.

Urbanisation
The world is urbanising. Globally, more people live in urban areas than in rural areas. By 2050, it is expected that 66% of the world’s population will be urbanites. Africa and Asia are urbanising the fastest. By 2050 56% will be urban in Africa and 64% in Asia. There are currently 28 mega-cities (i.e. with a population of 10 million or more). By 2030, the world is projected to have 41 mega-cities. However, the fastest growing urban areas are medium-sized cities and those with less than 1 million inhabitants located in Asia and Africa. UN-Habitat estimates the number of people living in slum conditions is now 863 million; growing from 760 million in 2000 and 650 million in 1990. Cities are at the forefront of ‘disease transition’ with malnutrition and obesity occurring simultaneously. Water and sanitation provision is grossly inadequate in urban slums. Tobacco consumption is a major concern among urban poor men, and increasingly women; a risk factor for both NCDs and TB. There are multi-sector influences on urban health.

Coordination
Local governments are key to coordinating inter-sectoral action. Donors are increasingly working with local government to strengthen capacity to plan, manage services, link with sector ministries, enforce public health legislation and establish local level governance structures.

There is a need to coordinate health services between local government and health ministries. The urban public health service is woefully inadequate. There has been underinvestment due to years of the perceived ‘urban advantage’. Responsibilities for staff, their training, equipment/drugs, and facilities often fall between the Ministry of Health (MOH) and the Municipality. The poor are left with little option but to use meagre resources on private facilities resulting in high levels of catastrophic health expenditure. There are poor referral mechanisms due to the plethora of NGO and private providers. There is a need for monitoring and enforcement of quality standards among providers and pharmacies. Secondary care is insufficient with maternity hospitals not open all hours and weak services. Tertiary hospitals are overloaded and not easy to access for the poor.

Public Private Partnerships (PPPs)
There are challenges with different forms of PPPs, private for-profit and not-for profit forms. For-profit PPPs have no incentive to reach out to the urban poor. They are not keen to partner for outreach care which is the key to preventative healthcare and the most crucial for urban deprived communities. Non-profit agencies tend to have few resources. Bangladesh’s Urban Primary Healthcare Programme uses partnerships with NGOs, private clinics and government health centres to expand services to slum and vulnerable communities. There are still challenges with monitoring, quality, and referrals between providers which covered in some detail by in the reading packs.

Health promotion
Helping people remain healthy and not in need of health services is a fundamental goal of any urban health strategy. There is a lack of evidence on which health promotion approaches are likely to be effective in changing ‘lifestyle behaviours’ such as tobacco use, diet, and exercise among the urban poor. Encouraging waist measurement, desired diet, physical activity and mental wellbeing at community level; peer education approaches to nutrition, physical activity, and promoting optimal behaviours in schools have shown some success. Community healthworkers (CHWs) have been effective at changing behaviours in Bangladesh, India, and Ethiopia. CHW and slum women’s groups promoting peer-to-peer health promotion shows promise. Mass media through mobile phones, print, radio and television have wide audience reach in urban centres, but it is hard to compete in the cluttered media environment. Instant messaging for skilled birth attendants is more effective in urban areas. There has been increases in zinc treatment awareness following TV, radio, and newspaper media campaign in urban areas.

Water, sanitation and hygiene (WASH)
WASH needs to be promoted in households and schools to improve, health, nutrition and education. The three interventions of the WASH sector (hand-washing, food storage, garbage disposal) – depend on one another for full realisation of their benefits. For example most sanitation systems cannot function without water. School WASH impacts education outcomes, especially for girls. Menstrual hygiene and girl friendly toilets in schools affect school attendance of girls and reproductive tract infections. Hand-washing with soap and water and other personal hygiene practices have the potential to substantially reduce within household transmission of diarrhoea and improve nutrition. Promoting practices such as hand-washing with soap and water, and safe disposal of child faeces benefit health and nutrition and can be incorporated in a wide range of public health strategies at low cost.

Participatory neighbourhood mapping
Participatory mapping has been used in India to expand the reach of urban services. Slum women’s groups use hand drawn maps to ensure that no family is left out from municipal/NGO lists used for housing, sewage systems, toilets, and entitlements. They are also used to track access to health services eg. immunisation, antenatal care,  and delivery. The maps help identify recent migrants for linkage to services and entitlements. Gentle negotiation is occurring through collective petitions. Inclusive urbanisation requires disadvantaged communities to actively participate in governance.

Healthy places
Pressure from real estate developers, poor governance and corruption undermines local government’s role in controlling urban development to keep healthy places within the city. Access to green spaces reduces mental illness and has been shown to reduce inequities in cardio vascular disease and all-cause mortality in high income countries. Green spaces are rarely considered in controlled and uncontrolled expansion of urban areas. Urban agriculture can make an important contribution to household food security, especially in times of food crisis or food shortages. This needs support and regulation so food is grown in healthy environments.

Health and safe places for children
Urban poor women are more likely to work outside the home than other women in urban or rural settings. Working outside the home provides opportunities to improve income and increase self-esteem and gender equity. However, there is a lack of childcare and supervision for children. This could be solved with early childhood development opportunities. An NGO mobile crèche run day care centres in partnership with government’s National Creche scheme and with support funding agencies in India. Day care centres operate in coordination with builders and contractors near construction sites.

Transport and communications
10 billion trips are made every day in urban centres around the world. An increasing proportion of urban trips are using high carbon and energy-intensive private motorised vehicles. The urban poorest are disproportionately affected by key negative externalities generated by transport, including road accidents, air pollution and displacement when transport developments are occuring. Regulation to improve road safety can make a substantial difference to accidents. For example regulation of ‘matatus’ (mini-buses) in Kenya was introduced where drivers had to increase their driving and safety skills. This legislation resulted in a 73% reduction in accidents. Keeping cities compact, with opportunities for walking, cycling and public transport reduces emissions and support public health.

All of these issues and more are covered in the reading packs which point out key resources.

Humanitarian crises are important as they contribute to 60% of all preventable maternal deaths. They also contribute to 53% of under 5 deaths, as well as 45% of neonatal deaths. The most common causes of mortality in emergencies are pneumonia, diarrhoea and malaria. As well as the initial response  to a crisis, it is important to consider the long-term impacts. Water borne diseases tend to emerge a week or two after a crisis. Vector borne diseases emerge after one or two months. In the video, Chris summarises the impact of crises on health systems.

Different types of monitoring are required for different post-crisis periods. Chris outlines how the initial assessment should be carried out in the first 72 hours. In weeks one to two field assessments shout be carried, and from week three onwards more health specific assessments should be conducted. Details of health assessment methods for each health topic are available in the reading pack. Key response activities for different diseases and health areas are presented.

Chris states that it is important to be aware of the opportunities for health system reform. The end of a crisis may be an opportunity to implement effective reform. Chris outlines the principles and conventions that exist within humanitarian response, which one of the reading packs is about. There are 11 clusters in the humanitarian system to be aware of. They have different roles and responsibilities that are outlined in the pack.

WHO global health cluster update

A recent WHO global health cluster update describes areas of crisis response planning that still require attention. More thought must be given to coordination efforts across the different support mechanisms. Chris describes humanitarian response as a continuum from humanitarian relief to sustainable development. Humanitarian advisers must consider the opportunities to strengthen health systems after a crisis.