Implementation objectives for this ingredient:

A strong health workforce

Reliable supply, access and availability of commodities

Effective health management information systems

Quality health services delivered at scale with resilience

Strengthening health systems is fundamental to achieving universal health coverage and developing the resilience of societies to withstand, respond and adapt effectively to health threats and shocks. Doing so requires considering all of the WHO building blocks for health systems (workforce, commodities, information systems, service delivery, financing and governance) to support delivery of the suite of interventions listed in Annexes 2 and 3 of the Global Strategy. It also requires attention to the links between these building blocks – and between health systems and other sectors. Issues relating to financing and governance are addressed in the corresponding sections of this Operational Framework. In addition, government needs to put in place appropriate policies and legal frameworks to enable access to services and steward the range of providers in public, private and civil society sectors. Considerations on the other four building blocks are outlined below.

5.1 A strong health workforce

In adapting the global strategy to their context, countries should consider the health system and workforce implications of its targets. Specifically, national commitments, plans, investment decisions and related accountability efforts that are developed should contribute to sustainable and long term strengthening of common service delivery platforms.

A strong health workforce that effectively addresses RMNCAH is one that emphasizes delivery at the primary care level, emphasizing prevention as well as treatment. The health RMNCAH workforce should include well-trained, supervised, equipped and incentivized health workers from the community to the referral level. District health managers should be equipped with or trained to develop technical, fiscal management and administrative capabilities.

Pre-service training for providers should be based on international norms, and deployment strategies should be based on identified needs to redress pre-existing inequities. Mechanisms to ensure supportive supervision of providers should also be in place.

To design and implement an enhanced workforce agenda responsive to RMNCAH needs, national institutions need to develop the capacities to collect, collate and analyse workforce data and labour economics; lead short and long term health workforce planning and development; advocate for better employment and working conditions for health workers; design, develop and deliver enhanced pre-service and in-service education and training for health workers; support health professional associations; facilitate collaboration with, and regulation of, private sector educational institutions and health providers; oversee the design of fair and effective performance management; and monitor and evaluate human resources for health interventions.

5.2 Reliable supply, access and availability of commodities

The UN Commission on Life-Saving Commodities highlighted how supply of essential commodities for health services remains a major barrier to service delivery. Countries can continue to implement the recommendations and use tools of the UN Commission (see Resources, below). Key issues for focus include, but are not limited to:

  • strengthening public sector and private supply chains (e.g. in tendering and inspection, manufacturing processes, audit standards, warehousing, personnel and transport)
  • implementing better commodity tracking systems
  • improving regulatory mechanisms (e.g. harmonization of guidelines, support for joint manufacturer inspections and prioritization and fast track registration of WHO prequalified commodities)
  • fiscal space and national supply financing assessments
  • timely release of funding to prevent procurement delays
  • enhanced quality assurance efforts to enhance post-market surveillance and pharmacovigilance
  • preparedness for surge capacity
  • establishment of clinical protocols.

The private sector and NGOs have expertise to strengthen supply chains, especially when it comes to reaching the last mile and developing effective interfaces between different segments of the supply chain.  Efforts here might include providing technical support to strengthen supply chains, developing innovative models to overcome challenges and providing training in cutting-edge forecasting and inventory practices.

5.3 Effective health management information systems (HMIS)

Health systems in all countries require valid and disaggregated data on components and performance to facilitate improved coverage. Countries can assess the quality and completeness of facility- and community-based health management information systems. They can also implement strategies to address reported shortcomings (e.g. training, revisions of forms or reporting mechanisms) and/or to take advantage of electronic reporting via SMS, tablets or the internet, depending on the country context (e.g. cell phone coverage, current HMIS platform).

One priority will be to build the capacity of district health management teams and programme staff to utilize HMIS data for timely management decisions on resource allocation and service delivery. Countries can review existing sector-specific assessment tools and management information systems to better capture information on under-represented groups, such as adolescents and minorities. They can also utilise technological platforms and innovations to improve data availability, quality and timeliness. To do so, there is a need to establish standards, common terminologies and minimum data sets, promoting the interoperability of systems. Policies can be developed on health-data sharing to ensure data protection, privacy and consent, and SMS-based technologies can be used to improve accuracy and timeliness of data and information reporting. The work of the Health Data Collaborative resulting from the 2015 Measurement 4 Health Summit will be a key resource.

Other priorities include developing and using geographic information systems to map health system resources (including health workers), community needs and priority areas (not just limited to health sector considerations e.g. prioritizing areas with severe malnutrition or poor development indices); and optimization of HMIS data collection and use for quality improvement, performance measurement, and reporting/accountability.

5.4 Quality health services delivered at scale with resilience

Of the many innovations and advancements in RMNCAH, only a sub-set have been implemented “at scale” to reach large percentages of target populations and/or geographic areas within countries. In spite of this, it is increasingly recognized that scaling up quality services is fundamental for reducing discrimination and inequities; meeting the health needs of the most vulnerable, marginalized and excluded; and achieving overarching targets.

Country governments and their partners can support scale up of quality services with attention to both a transparent, inclusive, systematic, evidence-based decision-making process and a participatory, rights-based policy process. Specific issues for particular attention include:

  • establishing evidence of effectiveness and efficiency of the intervention(s)
  • building capacity of sub-national government and partners to implement the intervention(s)
  • identifying existing bottlenecks and barriers to effective implementation (considering enabling environment, supply, demand and quality of care determinants of coverage)
  • monitoring and reporting on progress and impact as the intervention(s) are replicated and expanded
  • adapting global service delivery standards and protocols to country conditions
  • developing policies, strategies and systems for quality improvement and sustainability at national and subnational levels
  • measurement of health service outcomes and quality and client satisfaction
  • developing and supporting use of tools and quality assurance methods e.g. perinatal or near-miss audits and tools for monitoring quality of care
  • implementing guidelines, training and monitoring mechanisms for the provision of respectful and compassionate care, in particular for stigmatized and marginalized groups
  • providing essential services to health facilities, including clean water, sanitation and energy.

Despite increasing attention to the need to make health systems more resilient, the exact measures required to do so, particularly in weak health systems, need further consideration. One priority is to strengthen the resilience of community health systems – where most people receive health services. Particular attention should be paid to strengthening supply chains, empowering and protecting health workers who deliver services in the community and ensuring they are recognized and institutionalized into national health systems. Key influencers in communities should be identified and trained in advance for roles in disease outbreaks.


Bottleneck analysis to support district health systems strengthening in Uganda

In 2011, the Ugandan Ministry of Health (MOH) initiated district health systems strengthening activities in several districts. Along with their in-country partners, the MOH brought together District Health Management Teams (DHMTs) to assess local data, identify supply-side bottlenecks and their causes and develop solutions appropriate to decision and fiscal space limits. Community interviews explored perceptions on financial and social barriers to accessing health services to better understand the causes of demand-side bottlenecks.

Using the information gathered, participating DHMTs identified key barriers to health, nutrition and water and sanitation interventions at the facility, outreach and community levels of service delivery, as well as their underlying causes. These included illegal fees and bribes demanded of mothers for services that are supposed to be free; persistent stock-outs of antimalarials and zinc; lack of community awareness of hand-washing and sanitation practices; lack of familiarity with pneumonia, malaria and diarrhoea danger signs among both mothers of children under five and community health workers; and insufficient outreach sessions. Using data from a Lot Quality Assurance Sampling (LQAS) household survey, inter-district differences in immunization were identified. These data indicated that several rural districts faced chronic staff shortages due to low staff retention, while more urban districts had better staffing. In part, this resulted from inequitable investments, with some districts receiving more financing for human resources. Another factor was illegal user fees, which community members in all five districts identified as one of the greatest barriers to use of services, particularly in the case of poorer households.

Based on these and other findings from the bottleneck analysis exercises, the DHMTs developed locally tailored interventions they identified as feasible, such as improving initial utilization and effective coverage through radio spots, village health team quarterly meetings chaired by local political and community leaders, increased messaging via churches/mosques, implementation of the SMS-based and community-empowering “uReport” monitoring system, expanded use of an SMS-based ‘mTrac’ system to report human resources and stock shortfalls and complete birth registration for children under five. In addition, DHMTs developed a plan for each facility to be assessed regularly by managers and community members (via SMS-based community oversight) to ensure the fee schedule was visible and complete and that staff members wore name badges to improve accountability for the care they provide.

Source: O'Connell T, Sharkey A. Reaching Universal Health Coverage through District Health System Strengthening: Using a modified Tanahashi model sub-nationally to attain equitable and effective coverage. New York, 2013.