Although Ebola is no longer in the news and affected countries will soon pass the one year mark with no new cases, the lasting effects of the recent outbreak in West Africa are still felt. In Guinea, the outbreak damaged an already frail health system that struggled to meet the needs of the population even before the disease arrived. This weak health system resulted in high maternal and infant mortality rates—statistics that only worsened with Ebola.
As the Ministry of Health strives to restore health services and rebuild the health system, there is an increased focus on district-level ownership of health system management. But district health managers require the capacity and authority to take on these responsibilities.
As a partner on USAID’s Health Finance and Governance (HFG) project and Maternal Child Survival Program (MCSP), Results for Development (R4D) has guided the national, regional and district level health managers through processes that involve generating evidence for decision-making, assessing priority challenges and developing locally-sourced action plans. With these supportive approaches, district-level managers are able to better use their resources to effect short- and medium-term change while long-term national shifts are set in motion.
Step one: Gather evidence
Health system strengthening must begin with a thorough understanding of how the existing system functions and is organized (both in theory and in practice). To establish this knowledge base at the national level, R4D—in collaboration with the European Union (under the HFG project)—conducted an institutional, organizational and functional audit of the Guinean Ministry of Health. The audit focused on several thematic areas: organizational structure of the ministry; health system management; resource management; health infrastructure; the pharmaceutical sector; and the economic and political landscape.
This analysis revealed misalignments between the organizational structure and the ministry’s strategic objectives across all assessment areas. For example, resources are inefficiently allocated, roles and responsibilities are fragmented and often duplicative, and overall capacity at the central and regional level is insufficient.
At the same time, we worked with the ministry as part of the MCSP program to conduct a Rapid Health System Assessment (RHSA), which focuses on the perspective of the regional and district health teams, health facility staff, community members and local government officials. The RHSA complements the national-level audit findings, and combines several qualitative approaches and analysis to assess the perceptions and realities about their health system of key health managers and worker in the four regions hit hardest by Ebola (Conakry, Kindia, Boké and N’Zérékoré).
The team mapped health system functions and processes at the regional and district level and identified key assets and weaknesses in the health system. The RHSA results showed that district health teams suffer from poor resource allocation (allocated by the national level), and often do not have the management capacity or support to use what limited local resources they do have to work with.
Step two: Translate evidence into action and engage a variety of stakeholders
Armed with the evidence generated from the national-level audit and the regional and district focused assessment (the RHSA), we worked with ministry-level officials and sub-national health system managers to begin transforming these findings into practical actions and innovative solutions.
In November 2016, we collaborated with the Ministry of Health and partners on a workshop as part of HFG to review the findings and recommendations from the audit and to develop an action plan with practical activities, timelines and measures of success. The process of talking through this action plan and identifying responsible parties will serve as an accountability mechanism for the ministry to ensure these actions are taken. Including regional and district-level stakeholders in the planning process also ensures that there is local ownership of these plans. At a high-level event, ministry officials and key stakeholders validated the audit findings and the action plan.
Simultaneously as part of MCSP, we worked with district stakeholders to assess priority problems identified in the RHSA and plan for locally sourced solutions. We also worked closely with the Ministry of Health to facilitate a process called the Comprehensive Approach to Health Systems Management that puts district health managers in the drivers seat. The ministry, with support from R4D, held a series of regional workshops to guide participants through a series of exercises to identify local priority challenges, conduct root cause analyses and make plans (based on local resouces) to improve local health system management. As a final step in the process the district teams developed corrective actions to resolve their priority problems, such as coordinating stakeholders, improving supervision (of health facilities and district health teams) and mobilizing local resources. The process was such a success in the four regions that the MoH plans to integrate the methodology into their annual planning process and scale it up nationally in the coming year.
While Ebola emergency responses may be over, health system strengthening has only just begun. The influx of funding in response to the Ebola epidemic has been catalytic, allowing for situational analyses and assessments to inform the way forward for the health system. Most importantly, the Guinean Ministry of Health and partners are committed to continuing the momentum to address priority health system challenges at the national, regional and district levels.
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