Basile Keugoung, MD, MPH, PhD; recently obtained his PhD from Université Catholique de Louvain-Belgium; Facilitator CoP Health Service Delivery (www.health4africa.net)

For more than a year already, the Ebola Viral Disease (EVD) outbreak is raging in Guinea, Liberia and Sierra Leone.  International NGOs and other stakeholders are struggling to contain the epidemic and bend the curve.  Lately we’ve been seeing encouraging progress, but the path to ‘zero Ebola cases’ is still long.  All health experts have recognized that the weakness of the health systems in the affected West-African countries was a major determinant of the spread of the disease. A lot of money has been allocated to the fight against EVD by donors through international NGOs such as MSF.  Although many of these organizations do very important work, especially in a crisis like this, we can question how this money is used and has always been used in such situations.

In most sub-Saharan African health systems, multiple vertical programs and general health services (GHS) delivering health care coexist. However, more often than not,  health systems remain weak and unable to deliver adequate care and cover the health needs of the population. This has led to continuing high morbidity and mortality rates related to preventable and/or curable conditions such as infectious diseases (like malaria, tuberculosis, HIV/AIDS, …). Ebola exposed the vulnerability of weak health systems lately. But weak health systems are also a problem for dealing with NCDs, already a huge problem in LMICs too.

As is well known, the poor performance of health systems has generated a fierce debate on the pros and cons of vertical and horizontal approaches. This debate has lasted for over 50 years, tends to be driven by ideological positions and has consumed many health resources and energy. The terminology has  changed over these years. The main debate from the early 60s to 70s was one between supporters of vertical programs and those of GHS. After the Alma Conference on primary health care, the debate then moved in the 80s to the use of selective versus comprehensive primary health care to improve the health of the population. In sub-Saharan African health systems, district-based health systems were the mantra after the Harare Conference (1987). The debate then shifted in the 90s to the integration of vertical programs at the district level (or lack of integration).

Since 2000, hundreds of Global Health Initiatives (GHI) have seen the light  – The Global Fund against HIV/AIDS, Tuberculosis and Malaria, GAVI, Roll-Back Malaria, Stop TB Partnership… are some of the most prominent ones; Foundations have also been playing an increasingly important role in the global health architecture (with the Gates Foundation as the prime example). These GHIs pool funds and expertise but they concentrate their efforts on specific diseases. They mainly focus on mitigating specific constraints that undermine the delivery of disease-specific care. Even though most of these GHIs have included health system strengthening efforts in their portfolio and are arguing for implementing relevant interventions, health systems in sub-Saharan Africa remain typically weak. Therefore, the current debate revolves around using a selective or comprehensive approach to strengthen health systems. This was the subject of my Phd thesis (http://dial.academielouvain.be/handle/boreal:152742?site_name=UCL ) which I recently defended at the Université Catholique de Louvain (UCL), Belgium.

vertic horiz3We studied the effects of programs on local health systems and found that each program can have  both positive and negative effects on general health systems. However, some effects impact the health system more than others. Therefore, the result of the interaction between a vertical program and GHS is not just the sum of positive effects counterbalancing negative ones. Potter and Brough  developed  a pyramidal conceptual framework with four levels of capacity needs of the general health system. These levels are: i) tools; ii) skills and competencies; iii) staff and facilities; and iv) the system, structures and roles. The Potter and Brough classification is similar to what Chee et al (2012) more recently  described. They clearly distinguish health system support from health system strengthening. The former includes interventions regarding tools, skills and competencies –situated at the top and the middle of Potter & Brough’s pyramid. Even though these interventions are pertinent to ensure the delivery of health care, they do not lead to processes that can bring lasting change and performance.

The latter, health system strengthening, corresponds to the basis of the pyramid. It includes system capacity, i.e organizational systems and processes, stewardship, role capacity, accountability systems, and performance management systems that enable the system to achieve its objectives. Also, structures are created and/or reinforced to maintain in the longer term the development of processes to achieve higher performance. Lastly, people play their respective role, and are accountable not only to the hierarchy but also to the lower level  of the health systems and the population.We agree that in emergency situations such as the EVD outbreak, it is difficult to think and act while keeping the longer term in mind. But when these international NGOs in fact “become” the local health systems, there is a problem. We could use the health resources more efficiently, we believe. We could learn from the mistakes of the past to build a better future.

Many opportunities are not seized at all levels – district, regional, central and international-, by health system and program managers to develop synergies between programs and GHS and to reinforce local health systems.  Our research revealed that the reasons for not seizing opportunities are due to a mix of individual, functional and structural factors. Individual factors are related to skills, competencies, attitudes and behavior of the stakeholders. Functional factors concern the implementation of health system operations such as planning, monitoring, supervision, resource allocation, monitoring and evaluation. Finally, structural factors comprise organizational structure and culture. These factors are systemic and complex and tend to act as a vicious circle that does not only lead to missed opportunities but affects the functioning of the entire health system.

Seizing opportunities thus requires the transformation of the vicious circle into a virtuous one. This is not an easy task. A first recommended strategy is to strengthen the stewardship function at all levels of the health system. A second one is to monitor the interface between GHI and NGOs and health systems in order to prevent negative effects and reinforce positive ones. A third strategy is to move from health system support to health system strengthening. This requires moving from short term deliverables to long term planning and vision. Improving systemic and structural capacity is more complex and needs more time than providing tools or reinforcing skills.

Fighting against diseases – as has been the case for many decades – might be more sensational and facilitate fundraising for GHI or international NGOs.  The new ‘Global health security’ agenda will probably not change that. But by implementing the three strategies listed above, the relationship between GHIs, vertical programs and GHS could be optimized (or at least improved substantially). If not, populations and especially the poor will continue to pay a heavy price for sub-optimal interfaces between GHIs, vertical programs and GHS. Conversely, these strategies, if done well, will empower local health systems to deliver adequate care and cover the health needs of the population.

2 Responses to Fighting against diseases or strengthening health systems to deliver adequate care: what is the better choice?

  1. Dr TAPTUE FOTSO Jean Claude says:

    Great Basile. very interessting subject.
    Can someone ask these questions concerning health systems in Africa?
    What can we say to a lady who went to the hospital with her mother suffering from diabetes and his 6 years old son suffering from pneumonia and found that there were neither adequate staff nor necessary medicines to treat them, and one day later people knock at her door and tell her that they work for the Ministry of Health and they come to vaccinate her 3 years old daughter who has followed her vaccination calendar very well against polio and who has no problem, while her son and mother are suffering in the room?

    Can you imagine a mother who has to walk five kilometers to go to a health center to have vitamin A for her child and being told that Vitamin A is out of stock for six months and a week later, people knock at her door and say we are here to give vitamin A to your child; the nurse will explain that the government has organized the campaign because it realizes that many mothers do not bring children to health center where vitamin A should be given to children every 6 months. Can her understand our health system?
    How can we explain the lack of vitamin A in the health center for routine activities and overstocking during the mass campaign?
    It seems like vertical programs to fight against deseases do not only weaken health system in Africa. They are even poorly organized and undermine their own results. We shouls build health systems capable to respond to the health problems of population.

  2. Filippo Curtale says:

    I read with great interest your post and agree with your analysis on the negative consequences vertical programs may have on the district health system, rather than strengthening it. I have been a strong supporter of selective PHC since it was first proposed by Walsh & Warren (Selective primary health care: an interim strategy for diseases control in developing countries. New England Journal of Medicine 1979; 301-18: 967-74). However, in my support to a selective approach, I always considered it an interim strategy, as it was originally conceived, to achieve short term results and quick gains for specific high mortality diseases. It is for me natural and logic to shift toward a comprehensive approach after infant and child mortality have been brought to less alarming levels.
    I would never have expected that, after 35 years, we were still debating the role of vertical programs and cost of a comprehensive approach. In these years the world around us drastically changed and the insistence in financing and promoting vertical programs is less and less justified. Still in the international community not many realize that a stronger health system able to deliver all range of services needed by the population, interacting with other sectors, and promoting changes in the surrounding environment and life style of the people, represent not only the best strategy to bring a permanent improvement in the health of the people but also the best way to prevent and contain emergencies such as the recent Ebola outbreak.
    I also support your recommended strategies. In moving from short term deliverables to long term planning and vision, we need a complete reorientation of the functions and responsibilities at all levels of the public health sector. The role of the DHO and the DHT will be crucial, since comprehensive PHC will never be achieved with a directive by the center.
    When we talk about the need to strengthen the stewardship function of the DHO this should mean upgrading his role from a simple representative of MoH at district level to the focal person responsible for leading and coordinating health activities and using resources in the district with a system-wide perspective. This will require changes in the organizational and functional structure but also a revision of the DHOs terms of reference. Beside the need for to fully understand the importance of a sectorial approach, where all resources are used to bring changes in the overall living condition of the people, there should be the promotion of new skills to empower them with the capacity to effectively deal with vertical programs, other sectors, private operators and all other stakeholders present in the district. Finally, to make this strategy effective, the necessary regulatory changes should be adopted, decentralizing authority and responsibility of central institutions, and recognizing to the DHO a leading role in advising, mobilizing and coordinating on health matters other government sectors, vertical programs and the other actors present in his district.

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