The Future Health Systems Consortium has invested in a stream of work called, “Beyond Scaling Up: Pathways to universal access.” This research has looked at some of the challenges involved in rapid scale up and what can be learnt from successes in this area. Drawing on a background paper, co-authored with Peroline Ainsworth, Gerry Bloom opened a parallel session at the Global Symposium with an overview of learning in this area.
Gerry argued that there are many challenges that might impact upon the scaling up process. Recent years have seen many political commitments to increase access and an improved financing environment for health systems strengthening underpinned by new global organisations. There is a recognition that scaling up means managing change in a dynamic and complex context (where there has been a shift from absolute scarcity to problems with safety, quality and cost with changing patterns of inequality, the introduction of new technologies and institutional arrangements, the rise of patient and citizen movements and mixed systems). Unexpected outcomes and unintended consequences caused by the scaling up process point to the need for systematic knowledge and shared understandings amongst a range of actors.
Ligia Paina and David Peters, Johns Hopkins School of Public Health, suggested that we might be using the wrong models for scaling up – that blue print, linear, one size fits all models are misaligned with the reality of health systems in practice. She explained how health systems are characterised by dynamic change which is rooted in local context. Complex adaptive systems thinking might help us to better understand a failure to scale up. It may explain why we cannot control the behaviour of communities and providers.
Emmanuel Sokpo and Jeff Mecaskey presented on the experiences of the Partnership for Reviving Routine Immunization in Northern Nigeria (PRRINN) project in northern Nigeria. Their work was rooted in an understanding of the social, political and economic history and context and included a political economy assessment. This assessment:
- Deepened understanding of the positions of major stakeholders in the state with respect to the socio-political, institutional, structural and historical context as they pertain to the health sector
- Identified issues which, in a general sense, appear to provide good opportunities for creating ‘coalitions of interest’ and for levering desired institutional changes
- Provided input into the prioritisation of key interest groups and/or organisations that can be developed as a ‘coalition of interests’ to drive change
They found that political competition was largely occurring within the elite and was structured around the power struggles of individuals, and inter-familial tensions played out within the camps of political parties. There are few alternative centres of power and little check on executive power overall, making the programme highly reliant on key individuals. State power and resource control is in the hands of the state government, while those who still retain some influence over ideology are also under the financial influence of the government. In their opinion the link between policy, strategy , planning and implementation of health interventions was broken with more focus on capital inputs than on health outcomes. Finally they discovered that a fragmented primary health care system is convenient arrangement for States and LGAs to share health resources without accountability. This knowledge was invaluable to the successful scale up of their programme.
Zhenzhong Zhang and Wang YunPing, of the China Health Development Research Centre, a government think tank, provided an assessment of the rapid scale up of health insurance in China. She concluded that the success of the schemes rested on:
- Political commitment and a change in values toward social and economic development. Health used to be a means to economic growth now it is one of the goals.
- Learning by doing. The schemes were launched incrementally in a gradual move toward reaching the whole population. Work within the Health 8 and other health sector programmes provided a solid foundation of research which helped the Chinese Government move forward. They experimented with pilots which then spread and bridged the gap between research and policy.
- The scheme was centralised and relatively decentralised. Central Government provided general principles but left space for local policy makers to think about the detail. They employed cross-ministry cooperation.
- Changing role of communities. Rural residents are no longer passive recipients. Their needs and interests are the concern of the local officers. The government promoted the schemes with positive incentives and information about how they may benefit.
Vera Schattan Coelho, Brazilian Centre for Anaysis and Planning, reflected on the success of the SUS in Brazil. She explained how it reflected the aspirations of a movement that believed in health for all and was a process where local, federal and national levels worked together for change with the Support of social movements, public health practitioners and left wing parties. Vera explained that when the SUS began the institutions that we needed were not there. At the end of the 1970s the old system really wasn’t working and so state innovations started to take place, for example, the Family Health Programme. There was a complete change in the relation between the national and the municipal level and clear contracts were established where the federal state was responsible for the policy but transferred the money to the municipalities and they were responsible for implementing. This happened by degrees not all at once so there was a gradual building of institutional capacity. The social movement, “the health movement”, was involved in policy decision making through Councils that included civil society, health providers and Government. When it was discovered that health indicators for indigenous people were much poorer than for the general population minority groups pushed for new programmes targeted at. The indigenous health system was established in 1999. You can read more about this in our briefing. The lesson from this is that within scaling up processes there is a need to balance universalism and also the need for tailored services for some.