In search of health system strengthening algorithms

In the Daily Maverick of 16 October 2018, Mark Heywood wrote: “The greatest tragedy, though, is that when it comes to the cause of the (South African) health system’s sickness we have the diagnosis, we have the knowledge, we even have the resources. We also have a mountain of barely considered expert reports suggesting solutions. But we don`t have an algorithm between the problem and the solution”. This, our pursuit of the “HOW”, the algorithms between the problems and the solutions, was a shared quest with those at the 5th Global Symposium on Health Systems Research, held in Liverpool, UK in October this year.

As three senior policy makers from the Western Cape Province in South Africa, we were amongst hundreds of researchers, and rubbed shoulders with colleagues from the World Health Organisation (WHO), Rockefeller Foundation, the Bill and Melinda Gates Foundation, and the Alliance for Health Policy and Systems Research, to name a few.

But even more significant was meeting and spending time with other policy makers and researchers from low- and middle-income countries. We shared experiences and learnings from trials and efforts to improve health. The themes covered were “multisectoral action”, “engaging the private sector”, “leaving no one behind” and “community health systems”.

It was clear that countries have different “algorithms” and approaches to give effect to three global policies on the health system strengthening agenda: the journey towards Universal Health Coverage (UHC), forming part of the Sustainable Development Goals (SDGs), and strengthening Primary Health Care (PHC) as embedded in the Alma Ata vision 40 years ago.

I have a particular interest in leadership and governance as these capabilities are central to health system strengthening. I was therefore thrilled to connect with WHO experts as part of the Health Systems Governance Collaborative, which is deliberating on policy guidance for multi-level governance. It was evident that relationships, distributive leadership, values, and power distributions are foundational for good governance.

The interest in the Western Cape Whole of Society Approach (WoSA) initiative was also gratifying. WoSA is our home-grown collaborative governance case study, implemented in a few municipalities as we strive towards the SDGs through multi-sectoral partnerships and action for health system strengthening and resilience. From the questions about WoSA it was clear that something we have taken for granted as an organic development is not so natural elsewhere. Our approach of collaboration and learning is clearly standing us in good stead.

Interfacing with communities is a particular challenge in the Western Cape. My learning from the plenary session is that the principles of collaborative governance, as developed by Emmerson and colleagues in 2012, also apply to a community health system.

Looking ahead, the Western Cape has to position itself for the major health reform envisaged in the National Health Insurance Bill. I was particularly interested in the insights on incentive systems in the private sector (the excellent plenary discussion is available here) and the fact that there are “Fifty Shades of Financing”, allowing countries to develop the most appropriate for their context. With so many experts around, Lucy Gilson helped us to connect with experts in WHO and countries similar to South Africa to discuss health financing and strategic purchasing. These learnings are powerful in our journey towards UHC.

The launch of two strategic publications - the Lancet Report on Quality and the Health Policy Analysis Reader (soon to be available on the web) – was particularly relevant to us. The Reader is a valuable learning resource not only for researchers, but also for policy makers eager to influence policy change.

Finally, from a more strategic perspective, my learnings on finding an algorithm between the problem and the solution are:

About learning

• Learnings at sub-national level have global relevance.

• One often takes achievements for granted. Given the complex adaptive nature of health systems and our volatile, uncertain, complex and ambiguous environment, achievements in the policy areas of SDGs, UHC and PHC should be shared more. We will have to invest in documenting our provincial learnings. It was clear that we have a story to tell.

• Embedded research is a strategic lever for health system strengthening.

About governance

• Innovation in health systems flourish when there is good governance, dispersed leadership, a culture of learning and growth, of decentralization, and a mindset of building relationships and partnerships.

About being a “policy maker”

• Policy makers have the responsibility to provide leadership and governance and direct resources and strategy towards meeting needs, especially of the vulnerable. These experiences and insights provide opportunity for collaborative research and learning.

About collaboration

• Networking with people sharing the same passion and vision is easy. There is immense goodwill and willingness to support those policy makers and systems that demonstrate new ways of doing.

• It is encouraging to realize that the Western Cape Department of Health’s Transformation Strategy essentially captures the elements of the "HOW", the algorithm. The Transformation Strategy was an organic development in a governance space of openness and respect. Continued collaboration with researchers, especially from an embedded research perspective, is critical to continue to improve health.

Full article on the HSG website