Health Systems

Strengthening Sierra Leone Health Systems: Applying Lessons from the 2014 Ebola Outbreak to Future Emergencies

This guest post was written by Laurentiu Stan (laurentiu_stan@jsi.com), MD,MPH, MBA, Chief of Party, Advancing Partners and Communities (APC) Project, Sierra Leone, JSI Research & Training Institute, Inc. John Snow, Inc., a member of Global Health Council (GHC), and the nonprofit JSI Research & Training Institute, Inc., are public health management consulting and research organizations dedicated to improving the health of individuals and communities in the US and around the globe.

Zainab Jalloh, holding her one-year-old daughter Khadijatu, at the Gbanti Community Health Post (CHP) on April 3, 2017 in Bombali District, Sierra Leone.

I’ve lived in Sierra Leone for almost two years, working to help this country’s long-battered health system recover from the Ebola outbreak that took the lives of more than 200 health professionals. Now the country has been affected by an epic landslide. Despite these tremendous setbacks, health systems and health indicators are improving.

Even before the Ebola Virus Disease (EVD) outbreak, Sierra Leone had the world’s highest maternal mortality ratio: 1630 of 100,000 live births (UNICEF, 2010). By 2015, the ratio had dropped to 1360, but Sierra Leone still held the top spot in this dismal measurement. Ebola compounded the problem because about 1 in every 4 women stopped coming to clinics for prenatal care and delivery. In fact, although almost 4,000 Sierra Leoneans died due to the EVD outbreak (between May 2014 and January 2016), during that same period more than 4,500 women died in childbirth.

The Ministry of Health and Sanitation (MOHS) focused its post-Ebola health recovery priorities on strengthening the health system’s capacity to safely detect and prevent diseases and respond to future epidemics in cooperation with its neighbors. It also recognized the need to contribute to global health security to improve health and economic opportunities.

A health facility water pump before APC revitalization. Photo courtesy/ JSI Research & Training Institute, Inc.

Between September 2015 and August 2017, under the umbrella of the USAID-funded and JSI-managed Advancing Partners & Communities (APC) project, I have helped implement a number of programs that are contributing to MOHS recovery objectives by improving primary care service delivery in the communities hardest hit by Ebola. APC has revitalized 305 primary care facilities, ensuring access to basic health services—with a focus on improving quality of maternal health services—for almost 2 million Sierra Leoneans, including the 3,400 registered Ebola-survivors.

A health facility water pump after APC revitalization. Photo courtesy/ JSI Research & Training Institute, Inc.

APC’s community health facility upgrades dramatically improved water and sanitation standards, installed solar power systems, provided basic equipment, and trained more than 900 health professionals and 1,500 community health workers (CHWs) on reproductive, maternal, newborn, and child health and as—importantly, given how Ebola was spread—infection prevention and control practices. Today, more than 2 million Sierra Leoneans in five districts have access to revitalized primary care and community health services in these primary care units and their catchment villages.
We know that another epidemic or emergency could come at any time, and while the Sierra Leone health system is going through significant transformations as part of the five-year recovery plan, it is better equipped now to address it.

The tragic August 14 landslide was just such an emergency—and the new systems that the U.S. government has invested in are working. The emergency coordination and resource mobilization mechanisms put in place with CDC support reacted well and fast. Mental health nurses who were trained to support Ebola survivors are providing psychosocial support to the several-thousand people who lost homes and relatives: more than 1,000 people died in the landslide. The CHWs recently trained by APC have undergone a 15-day social mobilization exercise to identify and convey messages on the prevention of cholera and other waterborne diseases to at-risk populations. With USAID and DfID support, JSI is assisting the MOHS relief efforts with emergency delivery of essential pharmaceutical and medical consumables to one area hospital and six primary care units.

This most recent tragedy has demonstrated that the country’s service delivery system has improved. One year after the outbreak ended, the MOHS data showed about a 10% positive change in uptake of facility deliveries and outpatient services in the four districts where 70% of Ebola survivors live. Now that health facilities have been revitalized, and health care workers are providing higher-quality services, we are seeing more and more Sierra Leoneans returning to their local health facilities.

There is still much to be done, of course. But Sierra Leone is on its way to a health system that meets the needs of its people—and, given the toll that Ebola took, is ready to confront the next infectious disease—be it Ebola or some other virus—with stronger, better prepared health services. And that helps us all.

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Community Health Workers: A Priority for Universal Health Coverage?

This guest post was written by Colin Gilmartin, Senior Technical Officer at Management Sciences for Health (MSH), a nonprofit global health organization and GHC member organization. Gilmartin specializes in health care financing and the planning and costing of community-based services. He can be followed on Twitter, @colingilmartin. MSH’s mission is saving lives and improving the health of the world’s poorest and most vulnerable people by closing the gap between knowledge and action in public health.

Community Health Volunteer in a remote village of Tulear, Madagascar, giving instructions to a client on the use of pregnancy tests. Image by Samy Rakotoniaina/MSH

How countries can move toward building sustainable community health programs.

Universal health coverage (UHC) is increasingly recognized as the best way to achieve the Sustainable Development Goal targets on health. But with 400 million people lacking access to essential health services and a projected shortage of 18 million health workers, it will take unprecedented effort and funding. Community health workers (CHWs) could be an important part of the solution—but without effective investments and sound planning, we will fall short of achieving UHC.

Many low- and middle-income countries rely on a robust community health workforce, but few are self-sustaining and many rely heavily on external donors. CHWs fill critical gaps while delivering quality, affordable services closer to underserved patients. Even during crises, such as West Africa’s Ebola outbreak, CHWs can ensure the continuity of services while helping to stop epidemics.

As a 2015 report shows, CHWs can also yield a sound 10-to-1 return on investment, when accounting for a healthier population’s increased productivity and formal employment and the prevention of costly health crises. Expanding access to community services could prevent up to 3 million deaths annually while substantially reducing patients’ out-of-pocket costs.

Recognizing these benefits, low- and high-income countries alike are developing and expanding CHW programs. In Ethiopia, Community Health Extension Workers (CHEWs) proved instrumental in reducing maternal and child deaths and in meeting nearly all of the country’s 2015 Millennium Development Goals on health. Countries including Ghana and Sierra Leone are training and deploying a combined 35,000 CHWs to bridge gaps. Even in American cities like Philadelphia, CHWs are delivering evidence-based health interventions to high-risk patients while reducing overall health care costs.

While CHWs are not a new concept, the recent momentum for scaling CHWs raises an important question: will they be a long-term investment or simply a palliative solution to achieve short-term results?

Amid competing funding priorities and uncertainty around foreign assistance, countries show reluctance to invest in community health systems. CHWs are often unpaid volunteers, lack a career path, and are rarely considered part of the formal health workforce. These factors, combined with growing demand for their time, contribute to high rates of attrition. Further, in the absence of proper planning, frequently there is no funding for ongoing training, program support, and supervision of CHWs. This can lead to low-quality services or, worse, a complete stoppage of services in the most challenged communities.

To achieve UHC and the health SDG targets, long-term community health planning is essential—and along with helping countries identify solutions to meet health goals, it provides an opportunity to evaluate progress and make improvements. Planning can also help countries identify the costs and resource needs to sustain CHWs, including medicines and supplies; equipment; incentives; training; as well as program management, supervision, and reporting. It also cuts down on duplicative efforts among partners.

To facilitate this process, the NGO where I work, Management Sciences for Health, partnered with UNICEF to create a Community Health Planning and Costing Tool that helps calculate the costs of delivering comprehensive community health services for up to 10 years. To-date, the tool has helped plan the long-term implementation of national community health programs in Madagascar, Malawi, and Sierra Leone.

Understanding the costs and required financing for large-scale community health programs helps governments more effectively advocate for domestic and external funding sources, including the private sector. Plus, identifying funding gaps can help countries pool different sources to ensure that health programs operate fully and consistently.

As countries move toward building and sustaining national community health programs, they should consider a few key takeaways.

First, long-term financing plans should be developed to support continuous services and funding for all elements of a community health program. While domestically-financed programs may prove unrealistic for many countries, there are opportunities to leverage existing initiatives and donor funding. For example, in Rwanda, CHWs are integrated into the country’s national performance-based financing scheme, which provides incentives to fund income-generating activities. Other countries leveraged multi-year Global Fund support to cover antimalarial medicines, rapid diagnostic tests, training, and incentives.

Community health program funding should work to strengthen health systems overall. Embedded in weak health systems, CHWs programs will be ineffective and investments will fall flat. CHWs will only succeed when all building blocks are performing. For example, programs must reinforce strong supply chains, a dynamic supervisory and management workforce, and an effective flow of health information.

As frontline health workers, the CHW role should also be institutionalized in national health systems. Along with clearly defined responsibilities, they should receive ample recognition, incentives, and professional development opportunities. By doing so, countries can improve the quality of service delivery, ensure greater accountability to their communities, and increase CHW retention.

Lastly, we must continue to demonstrate the impact of CHWs and draw lessons. To strengthen the investment case for CHWs, we must go beyond demonstrating achievements of process indicators and coverage metrics and document how effectively CHWs improve patient outcomes, reduce costs to health systems and patients, and contribute to health milestones and targets. By sharing experiences and lessons-learned, other countries might avoid shortcomings and adapt program successes to address their health priorities.

This article was originally published in Global Health NOW. Join the thousands of subscribers who rely on Global Health NOW summaries and exclusive articles for the latest public health news. Sign up for the free weekday e-newsletter, and please share the link with friends and colleagues: http://www.globalhealthnow.org/subscribe.html.

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NCD Child’s Approach to Advocacy: Putting Children First

This guest post was written by, Jonathan D Klein, MD, MPH, FAAP, Executive Director, NCD Childa a global multi-stakeholder coalition championing the rights and needs of children, adolescents, and young people living with or at risk of developing non-communicable diseases (NCDs). NCD Child is a member of the Global Health Council.

NCD Child is a global multi-stakeholder coalition championing the rights and needs of children, adolescents, and young people living with or at risk of developing non-communicable diseases (NCDs).  Our message to civil society, governments, and WHO is unwavering – children are not small adults.  They require unique services, yet many national and global health policies fail to adequately account for these distinctive needs.  NCD Child actively engages and collaborates with governments, multilateral organizations (ie, WHO, UNICEF, other UN agencies), civil society, the private sector, and academic institutions to promote awareness, education, prevention, and treatment of NCDs in children, adolescents, and young people.  We support child health advocacy and policy at the global level via WHO and the UN as well as at the country-level through civil society and individual champions.  We are committed to involving youth voices across all our work, from engagement in the NCD and Sustainable Development Goal (SDG) agendas to our own governance and program activities.

Young people’s access to essential medicines and technologies for special health care needs are a particularly alarming and growing concern.  To tackle this challenge, NCD Child launched a Taskforce on Essential Medicines and Technologies during the 2017 World Health Assembly.  Whether it is insulin, an asthma inhaler, chemotherapy, heart surgery, or simple antibiotics, poor access or lack of availability to safe and appropriate medicines and technologies for children, adolescents, and young people hinders their chances of living healthy, productive and long lives.  There are several challenges to consistent, safe access to essential medicines and technologies – drug shortages, appropriate dosages for children, challenges in drug delivery, technology incompatible with systems, and products excluded from the WHO Essential Medicines for children lists.  The new taskforce, chaired by Dr. Kate Armstrong, Executive Director of CLAN (Caring & Living as Neighbors) and founding Executive Director of NCD Child, includes a diverse group of experts from government, academia, and civil society.  Kate’s vision that all children living with chronic health conditions should be afforded the same opportunities and quality of life as other children, helped NCD Child frame our mission and goals towards a rights-based approach to universal access and population health.  For the taskforce, this means addressing consistent, equitable, and affordable access to essential medicines and equipment for all children, adolescents, and young people living with NCDs – including attention to the rights and needs of all young people with special health care needs.  Its initial report, scheduled for 2018, will discuss common barriers to access and propose collaborative, practical strategies to address the gaps.

Practically, this means we want policies ensuring the health needs of young people are always included in health systems planning and accountability.  We recognize to affect policy, governments and other advocates need to fully appreciate why it is important to include children, adolescents, and young people.  How do current policies and frameworks exclude them?  What is the potential impact of not tailoring policies, health education, and health systems?  How many lives can be saved, improved, and extended if policies addressed the needs of all ages across the entire life-course?  The taskforce will serve to amplify NCD Child’s concerns by developing resources to educate governments, help guide policy development, and contribute to the WHO Essential Medicines list.

Prevention and treatment of NCDs helps children, adolescents, and young people live life to their fullest potential. These investments are also critical to successfully addressing preventable maternal and child deaths, and to effective, sustainable development.  At the July High Level Political Forum on SDGs, Dr Nata Menabde, Executive Director of WHO at the United Nations, closed the review of the health goal by noting that “every minister should be a health minister.”  When it comes to health in all policies, “put children first” is essential to all plans, whether for health systems, NCDs, or other global goals.

For more information and to sign up for the NCD Child listserv, visit www.ncdchild.org.

 

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Defeating malaria through pharmaceutical systems strengthening

This guest post has been provided by GHC-member Management Sciences for Health (MSH). MSH works with health leaders throughout the world on global health’s biggest challenges, with a focus on HIV & AIDS, TB, malaria, chronic diseases, family planning,  and maternal and child health.

A technician tests a child for malaria at a health center in Kinshasa, DRC. Photo credit: Aubrey Clark

Between 2000 and 2015, great strides have been made in fighting malaria. Globally, malaria case incidences declined by 41% and mortality rates by 62%. However, approximately 212 million people were infected and 429,000 people died in 2015, with the majority being children under the age of 5 in sub-Saharan Africa. Malaria also places a great financial burden on individuals and health systems. In sub-Saharan Africa alone, the annual cost of case management related to malaria is estimated at USD 300 million.

Much has been done since 2000 to eliminate this disease, and ensuring improved access to and appropriate use of quality-assured malaria medicines is necessary to sustain these gains.

The USAID-funded Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program recently published the results of its activities in eight countries (Angola, Burundi, the Democratic Republic of the Congo, Ethiopia, Kenya, Guinea, Mali, and South Sudan) to control malaria.

This report summarizes systems strengthening interventions that support the prevention and treatment of malaria. With funding from the US President’s Malaria Initiative (PMI) and based on PMI’s priorities, SIAPS provided assistance to build capacity to manage malaria products and to strengthen financing strategies and mechanisms that would improve access to malaria medicines and the quality of pharmaceutical services for malaria patients. SIAPS also collaborated with national malaria control programs and central medical stores to develop and implement activities aimed at strengthening the pharmaceutical management of antimalarial products.

A significant challenge for countries is the lack of accurate and timely information that would enable a steady supply of medicines and accurate quantification and procurement for medicines and other health supplies. To facilitate the use of logistics data, the development of electronic early warning systems must be encouraged.

SIAPS launched the End Use Verification (EUV) tool to help assess malaria commodity stock status and malaria case management practices. Data collected using this tool have helped to monitor and avoid stock-outs and disseminate relevant information that directly supports the availability of commodities at the right place and time. In Ethiopia, as a result of findings from EUV surveys, a manual to guide redistribution of antimalarial medicines among public health facilities was developed to help facilities maintain acceptable stock levels and reduce expiries. In Burundi, the introduction of the EUV tool decreased the time needed for the medicine requisition process from two weeks to two days.

Another issue highlighted in this review is constraints caused by weak human resource capacity, poorly defined supply chain operating procedures, inadequate infrastructure, and poor medicine storage conditions and practices. To reduce malaria mortality, antimalarial medicines must also be provided through systems and services that ensure that the medicines themselves are safe and of good quality. For this reason, medicines need to be properly stored to maintain their quality.

In Angola, SIAPS provided support to reorganize the national central medical store to align with key warehouse functions. SIAPS also conducted trainings on good warehousing practices to support staff capacity and performance. These trainings and the reorganization of the medical store, which integrated and improved supply systems for essential commodities, made the entire warehousing processes more effective and efficient.

Strengthening health systems takes time, but controlling and eliminating malaria is possible. Strong partnerships among stakeholders, web-based tools, and ensuring sustained achievements for a strong and reliable supply chain of medicine help make it possible to increase and maintain effective interventions to support the prevention and treatment of malaria.

Read SIAPS’ full report here.


About SIAPS | The Systems for Improved Access to Pharmaceuticals and Services (SIAPS) program works to ensure access to quality pharmaceutical products and effective pharmaceutical services through systems-strengthening approaches to achieve positive and lasting health outcomes. SIAPS is funded by the US Agency for International Development (USAID) and implemented by Management Sciences for Health. For more information, visit www.SIAPSprogram.org.

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GLOBAL HEALTH SECURITY: INVESTING GLOBALLY MATTERS LOCALLY

This post was written by Anupama Varma, Communications Associate at Global Health Council.

The panel of speakers at the event.

A disease outbreak anywhere is a risk everywhere.” – Dr. Tom Frieden, former Director of the Centers for Disease Control and Prevention (CDC).

In today’s world, when diseases can reach American borders in less than twelve hours, it is more imperative than ever that the global health community open space for dialogue on global health security. The World Bank estimates that the United States could have a loss of $80 billion dollars each year due to a global health security risk. Hence, the country must be prepared. The latest initiative, the Global Health Security Agenda (GHSA), aims to improve transparency through Joint External Evaluations (JEE) and develop lasting multilateral relationships among WHO member nations in order to ensure a world safe and secure from infectious disease threats.

Global health security starts at home – making sure the United States has the tools to prevent, detect, and respond to health threats. It is also critical that efforts address building systems and capacity in low- and middle-income countries with weak health infrastructures that prevent them from adequately responding to disease outbreaks. As Amie Batson, Chief Strategy Officer and Vice President of Strategy and Learning at PATH, reminds us, “We are only as strong as the weakest country in the system.”

Dr. David Smith, Acting Assistant Secretary of Defense for Health Affairs, delivers keynote speech.

In July, Global Health Council (GHC) partnered with one of its organizational members, Friends of the Global Fight Against AIDS, Tuberculosis and Malaria, to host “Global Health Security: Investing Globally Matters Locally,” on Capitol Hill focused on current and future global health security efforts. Friends of the Global Fight also released a new brief highlighting how U.S. investments in bilateral health programs fighting HIV/AIDS, tuberculosis and malaria, in coordination with strategic investments in The Global Fund to Fight AIDS, Tuberculosis and Malaria (The Global Fund), save millions of lives and protect the U.S. from future disease threats. Dr. David Smith, Acting Assistant Secretary of Defense for Health Affairs, delivered the keynote speech, and a panel of speakers from PATH, the U.S. Department of Health and Human Services (HHS), Center for Strategic and International Studies (CSIS), and CDC discussed how investments in global health prevent epidemics at their sources and reduce the likelihood that infectious diseases will undermine public health in the United States.

The key takeaways from the panel discussion include:

1.) Technical expertise for global health security exists, but designated leadership is required.

2.) Epidemic preparedness is critical in order to ensure economic, social, and political security, as well as the stability of all nations, including the U.S.  As Garrett Grigsby, Director of the Office of Global Affairs at HHS, reiterated, “We can pay now, or we can pay a lot more later.”

3.) According to Dr. Nancy Knight, Director of the Division of Global Health Protection at CDC, “The key to successful global health security efforts lies in community-based response.”

4.) The focus of global health security is on four core areas: improving surveillance systems, strengthening laboratory capacity and capability, developing a robust global health workforce, and building a strong emergency operations and response system.

5.) The GHSA has become a model for governments to emphasize ownership of their borders.

6.) It is critical to work not only with governments and international organizations, but also with the private sector to increase the impact of global health security efforts.

7.) According to Dr. Audrey Jackson, Senior Fellow at CSIS’s Global Health Policy Center, tuberculosis (TB) remains a primary health threat to the U.S., and multilateral relationships such as The Global Fund are critical to fight TB.

Ultimately, U.S. leadership is key to the global health security vision and mission, and could help save millions of American lives both here and abroad.

Download the Friends of the Global Fight brief.
View Dr. David Smith’s keynote speech.
Advocate for global health security using facts and figures and success stories from GHC’s Global Health Briefing Book.
Join GHC’s Global Health Security Roundtable. The purpose of the Roundtable is to provide a space for NGOs, private sector organizations, and academia to work together to advance sound policy and advocate for robust investment in global health security. Learn more.

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