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.
Where Do People Go When They Are Sick and Live 10 Miles from the Nearest Clinic?
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En provenance du cours de Johns Hopkins University
Understanding and Strengthening Health Systems
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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.
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William Brieger, DrPHProfessor, Health Systems Program of the Department of International Health
Bloomberg School of Public Health
Welcome, this is Bill Brieger.
Welcome to our session on ensuring that pharmaceutical commodities go
beyond the end of the road and reach villages for primary healthcare purposes.
We had talked earlier about commodities in terms of health systems, building blocks.
And here we're concerned about
not just the commodities per say what they are but how do you move them?
How do you make sure that qualified people at the community level have
these essential medicines and can actually provide them to people when they need them?
So where do people who live 10 or more miles
or in some cases 16 or more kilometers from the nearest clinic.
What do they do when they're sick?
What do they do if they're sick in the middle of the night?
When some of the government clinics are not open.
What do they do when they're sick when there's no transportation around?
Sometimes we see that there are drug peddlers.
We have a man with who is a drug seller in the main town,
he's put a box of medicines on
his motorcycle and drives around to villages from time to time.
People, of course, can buy things,
but they may not be sick at the time he arrives,
but they may buy some supplies in advance for the common illnesses.
This is not an ideal way of ensuring commodities get to people.
And of course, there are people you can go to who sell various kinds of herbs, bark,
roots, leaves that have medicinal value
and that's clearly close to the village it's something people are used to.
And of course, research over time has found
many valuable pharmaceutical products in these various herbal concoctions,
but again they're not standardized.
But they do reach people when they need it.
So the promise of primary healthcare is that we would
like to have efficacious interventions.
We would like to have products that actually work to reach people when they need them.
So what we're aiming for is not
just the appropriate treatment but prompt and effective treatment.
As we know with a situation like malaria,
if you do not treat a child within 24 hours,
it's quite likely it will develop into severe malaria,
convulsions and potentially death.
So the appropriate drugs in a timely manner should be our goal.
We also want to make sure that commodities such as insecticide treated bed nets,
reach people where they live. How do we do that?
How do we get those commodities out there?
We also have issues of prevention.
We don't use chemo-prophylaxis.
Again, as a concept,
we're talking about intermittent preventive treatment.
This has been developed for pregnant women to prevent malaria.
Often they get it at antenatal clinic,
but often they don't get to these clinics because of distance and time.
There is intermittent preventive treatment also for malaria for children and infants.
How do we get that to them on a regular basis?
Especially during the rainy season.
So, we need to again not only have safe,
effective scientifically sound interventions and commodities,
but we need to figure a way of getting them out to people.
So access is the big problem that we're trying to face.
For the example of malaria,
most treatments do occur outside public health facilities.
Surveys and many endemic countries show this.
Even in countries that don't have laws allowing medicine shops to sell medicines.
Even countries that have few qualified pharmacists.
Even countries that have few private clinics,
people will find a way of going about getting the treatment they need.
Often this is expensive,
people buy more medicines than they need of different kinds that may or may not work.
And often these medicines are of lower quality.
Unfortunately, a large proportion of child deaths
therefore occur without any contact with the public health service.
And in many countries,
we've seen that few children are receiving
the recommended artemisinin and base combination chemotherapy to treat malaria.
And as we said before promptness or quickness in
treatment is very important because the majority of
the deaths that occur are children that die within 48 hours of onset.
So the challenge again is to achieve
universal access to prompt and effective treatment within 24 hours.
And again we're talking about some examples for malaria but the
same is true for whether it's pneumonia or diarrhea.
The lack of prompt management of these conditions is what leads to death.
And these are simple things that can be managed at the community level if there
are commodities available and people trained to deliver those.
So, we are going to be talking here about two examples of
how medicines and other essential health commodities can reach communities.
And we're looking at community delivery through community health workers,
many of whom are volunteer and also the possibility of using medicine shops,
which are ubiquitous throughout much of
rural areas in Africa and other malaria endemic areas.
But the key thing is that if we're going to be doing appropriate treatment,
the people providing the treatment using the medicines need to have some basic training.
There are a couple of different approaches for community delivery.
We are familiar with the integrated community case management,
where community health workers are trained
to look at the common illnesses that kill children;
malaria, diarrhea, pneumonia, but they can also do other things like deworming.
We're also going to look at the community directed intervention approach.
CDI is based on community involvement and decision making,
the community selects its volunteers,
the community supervises them,
the community makes decisions about how the commodities will be kept and distributed.
Usually, a community delivery is based on
volunteers or very low paid community health workers.
Some countries are called community health extension workers.
The length of training for these people may vary.
It usually focuses on the most common conditions,
both treatment, case management and preventing these.
Training may be a short period of time because when you have volunteers,
they have to take off from their normal duties whether it's farming or
being tailors or shopkeepers whatever they are to attend this training.
So, you may have a few hours a day,
few days a week or maybe over the period of a month before the training is completed.
With medicine shops, again,
we find people selling medicines in all corners of rural areas.
Their existence varies a lot by national laws.
You have situation where in Ghana or Nigeria where they get licenses.
These are people usually with a high school diploma not necessarily, but most likely.
And they apply, they pay a small fee.
Sometimes they get even orientation and then they are able to sell patent medicines.
The challenge, of course,
is that in some countries they are not allowed.
You can only have a trained pharmacist selling
medicine outside of the main health facilities.
And so in this case,
what happens is that the medicine selling process is driven underground and you will find
people in markets selling all kinds of collections of expired drugs.
So it's probably more effective to
train and monitor the medicine sellers than it is to outlaw them.
Because this business doesn't disappear because
the public services are never able to completely meet the needs.
One thing we've seen is that there is a process going on in several countries,
Tanzania as an example,
where they upgrade the quality of the trained medicine sellers and we'll
talk about that as a way of having improved shops that are almost like mini-clinics.
But again, in some countries we don't have
medicine sellers per se because there isn't a good business model.
In Malawi, since independence many many years ago,
the government has always promised free healthcare and therefore
people don't expect that they should pay for
anything and medicine shops won't really make much money.
Maybe there are some private pharmacies in
the large cities where people of means can buy medicines.
But the general public doesn't expect to pay.
And so it's not a good business to go into.
And as I mentioned before it's illegal
to set up medicine shops in some countries like Rwanda.
So, the question of how these commodities reach the community needs to be addressed,
whether it's reaching the community health worker volunteer,
whether it's reaching the medicine shop.
And we've looked at this I believe in another lecture.
But it doesn't hurt to go over it again.
Let's start at the top center and we can see
that there needs to be an information management system.
Sometimes it's called a Logistics Information Management System, LMIS.
Where we know from use from
other statistics like clinics what the actual need is for ordering medicines.
And again this process needs to be done in a timely manner,
taking the information using it,
submitting requests on a monthly basis in some places it's quarterly.
But we need to use information to get the ball rolling.
This information is the foundation of what we call forecasting, what do we need?
Do we need the same amount all the time?
Do we expect the increase in certain conditions?
Do we expect seasonal variation?
Are we reaching our goals?
What if only an estimated 30 percent of children are coming to the clinic for healthcare?
If we for example,
try to deduce behavior change communication to improve clinic attendance,
we may need to forecast more medicine.
If we are the health workers in the clinic are going to be training community volunteers,
they may need more medicine forecast more medicine
to supply the volunteers in addition to what they're using.
Then we get to the procurement process.
This varies from place to place.
Sometimes individual districts or local governments have
the authority and have the funds to purchase to go to suppliers and buy.
Sometimes they go to the state or provincial medical stores to obtain their drugs,
but they basically after putting in a request,
need to get those medicines.
Once the medicines come,
they are distributed to the first level.
It may be from the provincial down to the district.
Ultimately, the district to the health facility.
So, this distribution process needs to be in place.
Where is there transportation?
One of the biggest challenges we have is that medicines may be ordered,
but there may be stock outs because there is problems with having fuel
to put in the vehicles to carry the medicines from one level to the next.
So, this is something we need to look into.
At whatever level we're talking about,
we need to ensure storage and safety.
There needs to be an appropriate room set aside
specifically to keep the pharmaceuticals and other products.
There needs to be shelves,
there needs to be organization.
We've walked into places,
small clinics in the past where everything's just piled up on the floor and boxes.
How do you know where things are?
How do you know if they're supplied?
We need safe systems of storage.
I've been to places that have
no ventilation and the external temperature can get up to something
like 104 degrees or 40 to 43 degrees outside and without any ventilation,
the place is locked up in certain days or whatever.
You have the clear problem of drugs being spoiled.
Again, distribution from one level to the next
we've talked about that from the district to the clinic,
and ultimately to the community volunteers.
At that level, we need to make sure the volunteers also keep
the drugs safe and know how to use them correctly.
Clients consume the drugs and then once that happens records are
kept and that informs our Logistics Information System.
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