Welcome to our course on Understanding and Strengthening Health Systems for Global Health. During the course we will provide you with an overview of the main elements or building blocks of a health system based on the World Health Organization’s guidance. You will have the opportunity to explore four main areas of health systems in global health with particular reference to low and middle income countries. The first area focuses on understanding health service organizations, the challenges. Our second module looks at WHO’s six major building blocks or health systems components with particular reference to primary health care and the need for community participation in planning, delivery and assessment of these systems components. in our third module we examine the specific systems component of human resource development and capacity building. The fourth area consists of health policy making and advocacy with stakeholders. This course is geared toward learners who are already involved in managing health and development programs on the ground in low and middle income countries or who are preparing for such a management role. The main lectures will span a four-week period with approximately 2-4 hours of viewing learning materials per week. We have one peer graded essay wherein you will use skills in ‘organizational’ diagnosis to better understand a challenge in an organization where you are or have worked. There are also quizzes. We hope you will engage with your fellow learners in discussion forums to learn from each other.
Preparing Health Workers
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來自 Johns Hopkins University 的課程
Understanding and Strengthening Health Systems
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從本節課中
Health Systems: Basic Functions and Building Blocks
The World Health Organization has described six major components or building blocks of a health system. In this module we will examine those components and delve more deeply into the aspects of financing, commodities and service delivery, especially through Primary health Care. We examine a ‘missing’ component, community systems.
與講師見面
William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
We've talked about the context of human resources for health.
Now we want to look at some of the activities that can prepare them for their work.
One of the first steps of course is pre-service or basic training.
Are enough of each type of health worker, each cater produced?
So, we're concerned about things like curriculum,
for our schools of nursing,
schools of health technology, medical schools,
various kinds of basic training schools.
Does this curriculum reflect national program policies and guidelines?
For example, do students in these programs learn
about the latest guidance for how to manage cases of malaria,
prevent malaria, and for that matter any other health problem?
Is the curriculum current?
Are the tutors and instructors themselves able to
deliver the information and skills related to the current policies and guidelines?
Have they themselves received in-service training to be updated?
Do the students have opportunities to practice
these current skills during their coursework?
And then when they go out to practical sites,
are the preceptors that guide them in the field in the clinics up to
date and using the current policies and
guidelines so that the students can see these in action?
And overall we're concerned that the quality of the tutors,
preceptors, and students is monitored.
I'm going to look at an example of a situation we
found in Burkina Faso in West Africa a few years ago,
when we were looking at the overall ability of
different components of the health system to provide up to date malaria services.
So, in addition to seeing how services were currently delivered,
we went to what they called the National School of Public Health,
where all of various kinds of frontline health workers from
midwives to nurses to various technicians are trained.
The school has a base in the capital,
but there are several campuses throughout the country.
And you can see in this chart
the different locations and the type of health workers that are trained in each location.
So, they are turning out quite a number of needed health workers.
So, the quantity is not so much the problem.
But in this particular case,
the staff at the school readily admitted that
the curriculum had not been updated recently concerning malaria.
What we found is that in the curriculum for nurses and midwives,
malaria was addressed only under the broad objective,
acquire competency in the case management of medical pathologies.
So, of course one assumes that malaria is
a common medical pathology that the students would eventually run into,
and this was the situation for all major diseases.
So, it was pretty much left up to the tutor's what
they wanted to cover during their coursework.
So, there was not a clear place where malaria was designated during the course work.
For the overall objective of competency in case management,
for any particular disease that they were teaching about,
they were expected to cover the definition,
the anatomy, and physiology, the pathophysiology,
looking at clinical manifestations, signs and symptoms,
methods of diagnosis, therapeutic management,
the case management, and means of prevention.
So, of course this applies to malaria,
applies to typhoid fever.
It applies to any particular illness or disease that the tutors decide to cover.
In terms of what do you do in that kind of a situation,
and the program I happened to be working on that time through Jhpiego,
which is an affiliate of our university,
that deals in maternal newborn and child reproductive health.
We were given the responsibility to provide in-service training
for new graduates from these schools of public health.
And this seemed a bit ironic because you would think that if
somebody was coming out of school as a fresh graduate,
that they would be up to date and ready to
handle the common problems they would meet in the clinics,
such as the one you see in the background of this picture.
But obviously, we had discovered that
the curriculum was not built on current malaria policies and guidelines,
and discovered that there was not much communication
between the school and the various disease control programs
within the ministry even though the headquarters of
the school was in the same premises as the malaria unit.
So, while the training went ahead,
the in-service training for these new graduates,
the work went ahead also in establishing a curriculum committee in the school.
And fortunately again since there was a unified school with several campuses,
you could have one training committee and not have to have one
for each school since there was only one main school.
So, the committee review the current status of malaria and the curriculum,
and hopefully they will think about doing it for other things such
as HIV and neglected tropical diseases.
They ensure that the curriculum as updated would align with
national guidelines and so we put them in
touch with the National Malaria Control Program,
ensure that they had the latest materials,
and then they establish plans for training the tutors and
the preceptors on these updated national guidelines and policies on malaria.
Once people have been trained and they're at work,
we need to consider the performance quality of their work.
So, issues of quality, supervision,
and monitoring should grow out of the process
of having national policies and guidelines on a particular condition.
And in this case of course malaria.
Jhpiego has a quality improvement process or performance
quality monitoring process that involves looking
at global standards which are usually developed by WTO,
but convening people in a particular country in Ministry of Health
and related partners to come together and look at those global standards,
and develop appropriate adaptations for the national level.
So, the first step in this process of monitoring the quality of health workers in
the field is ensuring that their standards develop
based on the existing national policies and guidelines.
So, once the standards have been developed,
the process goes to the next level where regional
and district health staff are trained on these standards,
and they can use these standards during site visits to clinics to measure progress.
They've developed what we call performance criteria for
the different elements of the standards which are
again the different elements of the policies and guidelines,
in our case malaria, and they use that as a checklist to
measure the performance of the health workers in frontline facilities.
They may do this several times,
maybe every quarter for a year,
go to the facility so that they can see progress and
improvement in performing these various standards.
And the important thing of course is recognizing
the achievement of the health facility when
they are able to at least achieve
80 percent of these performance standards or hopefully more.
This is a process that can be done by a district team visiting health facilities.
It can also be done at the facility level.
People can use these tools as self-assessment to
ensure that they themselves are keeping up
to date and maintaining high levels of performance.
This is particularly important with turnover of staff and new people coming in.
So, what we can see is in the area of maternal and neonatal health,
where malaria and pregnancy and many malaria services are delivered,
that there are several major domains,
such as care for pregnancy-related complications,
infection prevention during pregnancy, providing health education.
These are the broad domains and then each domain has a list
of actual performance standards that one can observe being carried out.
And here's a quick look at one such example.
We're talking about infection prevention in the operating room or the delivery room.
One area is ensuring that there is
appropriate cleaning equipment and that these are maintained before they are used.
So, we can see that in this particular criteria,
there are four different things one would look for in terms of decontamination washing,
rinsing and drying before the next use.
And you can mark whether it's been achieved or not, yes or no.
And then you can give that criteria a score over all.
If all are yes,
then the criteria has been achieved.
If there is at least one no, the criteria hasn't.
The comments section, then you can talk about where the gaps are.
And those gaps can then be summarized with the health staff at the end of the visit,
so that they can develop an action plan for improving.
Here's another example of just one criteria where during antenatal care,
the staff are conducting a rapid assessment of the pregnant woman.
And this is one example,
where there are again about six elements and you look to see if these are being done.
Ideally, you want to observe the health workers
providing the services and then check off,
yes or no whether they have performed these.
And as we said before,
they write comments where there are gaps,
so that these comments can be summarized at the end of the visit of
the supervisory staff to develop action plans for improvement.
So, in addition to the quality improvement, the supervision,
the monitoring of the provision of services,
we are concerned about organizing continuing education.
We talked about basic or pre-service education.
We also want to keep health workers up to date.
We want to maintain their skills.
In some countries, you have to maintain certification for
your profession and so you want to look for opportunities for training.
Sometimes at formal workshops,
sometimes you can do a distance education by reading and taking quizzes,
whatever it happens to be,
we want to organize a plan for our health workers to keep them up to date on
the technical developments and how those technical developments lead to
revise guidelines for treatment and prevention of diseases.
Again, the formal activities can be seminars and courses.
This is known as in-service training,
but there is also less formal aspects of continuing professional development,
such as mentoring during site visits where health workers and
their supervisors work side by side and discuss their professional needs,
there are readings of course,
there are exchange visits.
So, there are a variety of ways for health workers to keep on learning.
As we mentioned before,
we want to make sure that health workers are located where people need them.
But districts especially rural districts are chronically understaffed.
One of the reasons I mentioned rural is that,
health workers often prefer to live in urban settings where they have what they perceive
as better opportunities to educate their children and access to other kinds of services.
Again there may be budgetary considerations.
A district may not have the funds to hire the number of people.
We've seen disasters such as Ebola wipe out health workforce,
because of lack of infection prevention.
Health workers become infected and die.
So, the question that we want to answer is,
where can we get adequate health workers to achieve
this universal health coverage down to the district and front line level?
And this is where we come into the issue of task shifting.
And the Health Workforce Alliance initiative
in World Health Organization and allied agencies,
have looked at this and talked
about four important goals that need to be addressed simultaneously.
And again, task shifting is the idea that there are certain tasks where
highly trained health workers can pass off to more auxiliary type of health workers,
who are more likely to serve in more remote areas.
So, basically, what we're aiming to do is share and assign tasks among
health workers in the most efficient manner to
take advantage of the different competencies and mix.
So, that not every health worker has to do everything,
we want to make sure that every job gets
done but that we find the most appropriate health worker to do this.
We want to take advantage of
the most simplified health promotion and treatment protocols.
If these protocols or guidelines are developed very clearly,
it can be obvious what tests need a more qualified and
which need a less intensively trained person to carry them out.
So, we need to make sure that we build our test shifting on the protocols generally.
For example, for treating or controlling malaria.
There are certain things therefore that we can shift,
for example Health promotion treatment and
care can be shifted more toward the community level,
more front line health workers,
community health extension workers,
volunteer community health workers can do quite a number of these tests.
Again, if they are supervised by a more highly trained person
a nurse or a midwife at the health center and that link is maintained,
so that they are supervised but they can increase the outreach, increase the coverage,
in the catchment area of a health facility through this test shifting to the community.
Ultimately, this results in increased access to
health care in under served, particularly rural communities.
So, in summary, we've talked about
improving health service delivery and universal health coverage,
by having adequate numbers of high quality health staff.
We've addressed the need for planning
human resources based on understanding our program needs.
We have looked at pre-service or basic education of health workers and
the importance of basing this on national program guidelines for the particular issues,
whether it's maternity care, whether it's malaria.
We have talked about the importance of maintaining quality,
once staff start to work through various kinds of
performance quality and supervisory processes.
To keep staff up-to-date,
we've addressed continuing education opportunities
and how these could be both formal and informal.
And finally, to ensure that the services
reach the front line communities that are most in need,
we've talked about task shifting to
address these gaps and bring health care closer to the community.
In the next lectures in this module,
we'll talk a lot more on the issue of this
in-service training and other kinds of continuing education activities. Thank you.
