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Health Systems Heroes 2016

KickerThis is a kicker.

Welcome to the Health Systems Heroes of [Future Health Systems](http://www.futurehealthsystems.org/). Health Systems Heroes are people who have made a difference. They are individuals who have led or contributed to positive change within a health system. Health Systems Heroes have been identified by Future Health Systems through our research over a number of years in Afghanistan, Bangladesh, China, India, and Uganda. All the Health Systems Heroes have played an important part in our research. The individuals operate at different levels in their health systems and bring diverse skills, characteristics and perspectives. These Health System Heroes exemplify the factors that Future Health Systems believes are crucial to the success of a health system, namely: **[Unlocking community capabilities](http://www.futurehealthsystems.org/unlocking\-community\-capabilities/)** actors who have played a critical role in identifying or harnessing community level resources in order to benefit the health system, or alternatively people who are community members who have contributed to the strengthening of health systems in a significant way. ** [Learning by doing](http://www.futurehealthsystems.org/publications/2016/5/4/fhs\-key\-message\-brief\-1\-how\-learning\-by\-doing\-can\-help\-cut\-through\-complexity\-in\-health\-service\-delivery)** individuals who have used evidence and data in their day\-to\-day work to make decisions, or strengthen implementation processes, that have in turn strengthened the health system or expanded service coverage, particularly for vulnerable populations. ** [Innovation](http://www.futurehealthsystems.org/stimulating\-innovations/) ** people who have sought to bring innovation, either technical or organisational into the health system, and spread this innovation across the system. Each Health Systems Hero has a unique and interesting story to tell. Here we share these with you, along with the stories of change that they and our research have contributed to.

**Dr Ahmed Bumba** Uganda

**Working with health workers to improve maternal health services**

**Poor quality of maternal and newborn health services in Uganda have resulted in low health service utilisation and high newborn mortality rates, both at home and at health facilities. The support Future Health Systems \(FHS\) provided to health workers to improve maternal health service delivery illustrates how a package of interventions that equips health workers with the necessary knowledge, skills and equipment, supplies and other non\-financial incentives can improve the quality of maternal and newborn health service delivery.** One contributing factor to low maternal health services utilisation, high maternal deaths and neonatal mortality in Uganda is the poor quality of maternal and newborn health \(MNH\) services. [Data from a 2013 FHS baseline survey](https://reproductive\-health\-journal.biomedcentral.com/articles/10.1186/s12978\-016\-0119\-y) showed that health workers lacked motivation, the skills required for the management of MNH conditions, and the necessary equipment for resuscitating newborns. There was also no difference between mortality rates of newborns born at home and in a health facility.

**What changes took place?**

The FHS Uganda team has supported change in the delivery of maternal and newborn services, from the district level right through to the health facility. The support was largely through training, facilitating monthly sub\-county and district review meetings, [supportive supervision](http://www.futurehealthsystems.org/publications/2016/7/11/manifest\-issue\-brief\-2\-focussed\-consistent\-supportive\-supervision\-improves\-management\-and\-performance\-at\-facility\-level), and [mentorship](http://www.futurehealthsystems.org/publications/2016/7/11/manifest\-issue\-brief\-5\-mentorship\-contributes\-to\-quality\-improvement\-in\-maternal\-and\-newborn\-care\-health\-worker\-motivation), using participatory action research. Health workers and facility and district managers have realised the importance of identifying local problems through routine health management information systems data and observations at the facility. For example, in one district a high number of stillbirths was attributed to unnecessary augmentation of labour using Pitocin. This was only discovered following the district review meetings where sustained calls were often made to the districts to use their data to identify problems and potential solutions. In one district hospital, it was noted that high neonatal deaths were partly resulting from health workers inability to resuscitate newborns. A refresher training in newborn resuscitation was provided by a District health management officer, which is reported to have subsequently improved health workers newborn resuscitation skills. Similarly, after [facility managers received training in health services management](http://www.futurehealthsystems.org/publications/2016/7/11/manifest\-issue\-brief\-3\-professionalizing\-the\-cadre\-of\-facility\-health\-managers), many were able to identify local problems and solve them. One facility manager realised that their facilitys storage and management of drugs needed to be reorganized; another recognised the need to be more punctual and arrive at work on time. Furthermore, practices such as partograph use to record the progress of labour and manual vacuum aspiration for post\-abortion care were not being done routinely. This gap was identified during supportive supervision and mentorship, conducted by both district and national level mentors supported by the study, and [support was given to health workers to improve their skills in using partographs](http://www.futurehealthsystems.org/publications/2015/8/14/manifest\-issue\-brief\-1\-embracing\-partograph\-use\-1). Previously, support supervision was conducted more like a fault\-finding exercise without the impartation of new skills. Problems that contributed to poor use of partographs, such as lack of the partographs themselves, were also identified and addressed by encouraging facilities to budget for stationery and photocopying. The district health teams are now more active in monitoring how health services are delivered. Cases of negligence or mistreatment of patients are now followed up by district health teams. In one district, a doctor who was found to have been negligent was suspended. Additionally, maternal or newborn deaths are now investigated by the management of the district. Intervention benefits were also found to extend beyond the intervention area. Some health workers were transferred from the intervention area to facilities in the control area, and activities such as support supervision were subsequently implemented in the entire district.

**How did FHS contribute to the changes?**

Our theory of change indicated that [improving health worker motivation and skills](http://www.futurehealthsystems.org/publications/2016/7/11/manifest\-issue\-brief\-6\-health\-workers\-recognition\-as\-a\-tool\-for\-increasing\-motivation) through the provision of a package of non\-monetary incentives such as recognition, mentorship and supportive supervision would help to improve the quality of services. In addition, we believed that managerial skills, oversight and accountability are important for ensuring that good quality services are offered at facility level, and that this would influence their subsequent uptake. The FHS Uganda team used participatory research promoting collaboration and partnership with the districts to implement the intervention, which comprised of training in management of health services, refresher courses in MNH, mentorship, supportive supervision, recognition, and the provision of basic equipment required for providing MNH services. Accountability was promoted through the district and sub\-county review meetings that provided a forum for high\-level district officers to review the delivery of MNH services. Two hundred and eighty five health workers benefited from the emergency obstetric care refresher course, approximately 80\-90 health workers benefited from mentorship and support supervision, and 90 health workers, facility managers and district health team officers \(30 from each district\) benefited from the certificate course in health services management.

**What next?**

The districts have continued to provide supportive supervision and recognition of best performing health workers and facilities. Mentorship activities were undertaken in four facilities per district. The FHS Uganda team intend to continue working with the districts to extend this intervention to other facilities so that facility managers are able to mentor and provide supportive supervision to ensure continuous attention is given to quality improvement in facilities. The new Health Sector Development Plan for the country has put in place constituency assemblies, which will provide a forum for reviewing facility performance. The FHS Uganda team intends to continue working with the districts through this forum to promote accountability for health services. Dissemination activities to the Maternal and Child Health cluster at the Ministry of Health, which influences the implementation of programmes for MNH, is also underway to promote these best practices on a country\-wide level.

**Sister Edith Bogere** Uganda

**Dr Said Habib Arwal** Afghanistan

Enhancing social accountability for health care in Afghanistan

**In the United States and parts of Africa and Asia, community scorecards \(CSCs\) have improved accountability and responsiveness of services. Work supported by Future Health Systems \(FHS\) sought to evaluate CSC feasibility in a fragile context \(Afghanistan\) through joint engagement of service providers and community members in the design of patient\-centred services, to assess impact on service delivery and perceived quality of care \(QOC\).** Since 2005, the Community Based Healthcare Department \(CBHC\) at the Afghanistan Ministry of Public Health \(MOPH\) has instituted several community engagement strategies to ensure access to quality primary health services, including the deployment of over 29,000 community health workers, institution of community health councils and community health supervisors. However, while [the Afghanistan balanced scorecard \(BSC\) proved to be a successful tool for oversight of contracted services](http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.1001066), there were minimal measures for patient perspectives on QOC. The CSC \- a hybrid of a social audit and citizen report card that aims to empower communities, enhance responsiveness in the delivery of care, and strengthen progress toward national and global health goals \- has been successfully implemented in Africa and Asia. However, in 2011 the application of CSC in fragile contexts had not been documented. CSCs may work differently in fragile contexts: issues such as lack of trust between communities and the public health system, and fragmentation and conflict within communities might undermine their effectiveness. The FHS team at Johns Hopkins University therefore designed an exploratory research study to determine CSC feasibility in Afghanistan, building upon previous BSC work.

**The research**

The research had two phases. First, a multi\-stakeholder mixed methods study was conducted on community capacity investments and with MOPH and NGO interest in exploring CSC feasibility. Based on these findings, a follow\-up exploratory study was conducted in partnership with the CBHC National Coordinator at the Afghanistan Ministry of Public Health. The critical question was: how do you keep communities involved in health system governance, accountability and transparency to ensure service quality, utilization and facility performance? In 2011, an awareness workshop was conducted with the MOPH and its stakeholders, including NGOs, the World Bank, WHO, UNICEF, and CBHC technical advisory boards. CSC experience and evidence from other countries was shared, and NGOs delivering the basic package of services were solicited to join the CSC research. Initially two NGOs volunteered to launch and test CSC in two provinces. In 2013, a third NGO volunteered to test feasibility in a different province. They then engaged health facility staff and provincial directorate to gain interest. Despite intense initial scepticism among stakeholders about the ability of engaging communities in measuring facility performance and accountability, the CSC implementation research proceeded. During focus group discussions with community members and leaders on strategies and services provided by the national health service, it became clear that some community expectations were too ambitious, so the FHS team and partners developed a strategy to inform communities of their entitlements based on the BPHS standards for primary care facilities. The CSC process created community awareness and CSC metrics were determined through a collaborative process involving communities and health providers. The metrics included a health provider self\-assessment scorecard, to be conducted every three months and performance was reviewed during facilitated meetings between communities and health care providers. Communities tended to score provider performance and QOC relatively highly. Infrastructure and supplies scored the lowest, causing stakeholders to discuss how to address these issues and build community ownership. The renewed relationship seemed to have improved utilisation of the facilities. Through three rounds of CSC one every three months the community and facility staff reviewed results and developed action plans for who should take responsibility for improvements. Improvements at different facilities included assuring water supply, increasing cleanliness, creating waiting rooms for women, repair and cleanliness of toilets, increased beds for maternity units, deployment of a female nurse, and solar power installation. Participating NGOs were excited by the results, especially from some very remote areas. However, the MOPH felt that this strategy may not be as successful in remote provinces like Takhar, with ethnically diverse communities that were resistant to change and more difficult to work in. An additional CSC pilot was undertaken in Takhar, and surprisingly, even better results were observed here.

**What changes took place?**

The CSC process promoted social accountability through the participation of key stakeholders in identifying and addressing health system challenges. Overall it created an environment that enabled the sharing of opinions, perspectives and recommendations, and collective action plan development. This process appeared successful, despite the history of conflict, and potential distrust. In October 2015, due to the success of the CSC process, the Minister of Health endorsed the CSC as a national strategy for community engagement. The CSC process also had a wider impact. In 2013, three FHS Afghanistan team members travelled to Zambia to another DFID\-funded project implemented by World Vision International to exchange experiences on CSCs.

**How did FHS contribute to the changes?**

The leadership and buy\-in of the long\-standing CBHC National Coordinator was essential to the success of the CSC process, as people believed and trusted him. Additionally, managers of participating NGOs were enthusiastic, instrumental and committed to change. FHS provided important facilitation, and supported operations research on the CSC that was implemented in various health facilities in Afghanistan. Evidence from this research led to the adoption of CSC by the MOPH.

**What next?**

[FHS findings in Afghanistan suggest that CSC, if contextualised appropriately, can be a useful strategy](http://bmchealthservres.biomedcentral.com/articles/10.1186/s12913\-015\-0946\-5) for the integration of community perspectives in the care process to enhance local health system performance in post\-conflict settings. Other recent publications \(such as [Ho et al, 2015](https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4557760/)\) have demonstrated similar findings in other post\-conflict settings. While the MOPH has endorsed the CSC, it is important to continue to support the MOPH CBHC and advocate for support for institutionalising the CSC. This is particularly important if NGOs are to take the CSC forward without financing.

**The women of the Sundarbans** India

Through the lens: empowering women in vulnerable communities to voice their concerns

Participatory action research methodologies can empower marginalised groups to capture and articulate their experiences and concerns to decision makers. Future Health Systems has worked with women in the Sundarbans of West Bengal to use Photovoice [a participatory action research method using photographs and narrative](http://heapro.oxfordjournals.org/content/13/1/75.full.pdf) to raise awareness of the challenges the women face to access health care. The initiative has led to local policymakers and health workers being able to prioritise the issues and take steps to address them.

The Sundarbans delta in India a cluster of more than 100 islands located in the extreme south of West Bengal is a unique biosphere reserve of mangrove forests, intersected by tidal rivers and narrow tidal creeks. The area outside the reserve forest is home to about 4.5 million people who subsist primarily on agriculture, fishing and collecting forest products. The highly complex topography of the region, coupled with poor infrastructure, constrains peoples mobility, especially those in remote islands where multiple modes of transportation are required to travel between islands. Climate change has a huge impact on the people of the Sundarbans. Many islands are prone to yearly pre\-monsoon cyclones that breach the banks, flooding the localities, rendering people homeless, and making agricultural lands unusable for years. The rise in sea\-level due to global warming has led to the disappearance of a few islands within the region and threatens a large part of the Sundarbans in the next few decades. The geo\-climatic volatility of the Sundarbans makes it unique, not only with respect to the livelihood and survival of its people, but also in terms of peoples health status and the health care delivery system. [In 2010, Institute of Health Management Research \(IIHMR\), a Future Health Systems \(FHS\) partner, published a study](https://static.squarespace.com/static/5034f626e4b09af678ebcd47/52c594f5e4b01a09cde0f896/52c594f5e4b01a09cde0fb48/1308157212074/Health20care20in20the20Sundarbans20India20Challenges20and20plan20for20a20better20future1.pdf) that revealed that children in the Sundarbans are the most vulnerable to health shocks due to unacceptable levels of under\-nutrition and high prevalence of common communicable diseases. For example, the proportion of chronically malnourished children was 52% \- higher than both the state \(45%\) and the national average \(48%\). One in three children in the Sundarbans was found to have suffered at least one episode of respiratory ailments in the two weeks before the survey, compared to 13% in West Bengal. [A more recent study from FHS\-IIHMR \(2013\)](https://static.squarespace.com/static/5034f626e4b09af678ebcd47/52c594f5e4b01a09cde0f896/52c594f5e4b01a09cde0fb30/1375701176085/SHW\-forweb.pdf) revealed that over one\-third of the children are chronically malnourished. However, the prevalence is astoundingly high \- almost 60% \- for girls aged 1\-3 living in poorer households. Against this backdrop, the health service delivery system in the Sundarbans is woefully inadequate. The 2013 FHS\-IIHMR study showed that people have few desirable choices regarding health care. Publicly\-funded health care facilities are non\-existent or non\-functional in the most vulnerable areas due to staff shortages and weak infrastructure. Those facilities that are functional are generally physically inaccessible for many people due to difficult\-to\-navigate terrain. Voluntary agencies \(NGOs\) can reach only a small fraction of the population, despite their best efforts. Consequently, the gaps are filled by a huge number of Rural Medical Practitioners \(RMPs\) those who practice modern medicine without any formal training or authorisation who are often the only option. Dependence on RMPs is discernibly higher for child health care \- about three\-quarters of children with diarrhoea or Acute Respiratory Infection \(ARI\) problems are treated by RMPs, as compared to about 60% of adult patients \(IIHMR, 2010\). The fact that health care in the Sundarbans is almost exclusively provided by RMPs has potentially huge implications for childrens health, as RMP services are of varying quality and the market is virtually unregulated.

**FHS research**

As part of the research process, [FHS\-IIHMR researchers worked with women of the Sundarbans to use Photovoice](http://www.futurehealthsystems.org/publications/2016/9/12/fhs\-india\-research\-brief\-9\-voices\-from\-the\-ground\-photovoice\-research\-on\-childrens\-health\-in\-the\-indian\-sundarbans) \- a participatory action research method using photographs and narrative to empower marginalised recipients of health services in an effort to create positive change. In total, 80 women with at least one child each between 0\-6 years of age from three blocks of Indian Sundarbans led the project. The objective was to visualise: the geo\-climatic uncertainties and their manifestations in life, livelihoods, health and health systems as perceived by the communities; indigenous adaptive strategies based on traditional knowledge and ground\-level perceptions; triggers for and barriers to accessing the health system; a pathway of need\-based locally\-acceptable solutions at the local/state policy level. FHS\-IIHMR used the Photovoice method to emphasise the importance of community members having a say and taking action to inform decision\-makers about the reality of their lives. The intent of the method is to influence public policy on issues like erosion, breaching of embankments, loss of productivity due to salinity ingress, depleting natural resources and the resulting migration, accessibility, acceptability and affordability of the existing health system. The method of visually capturing the needs assessments for a community is an empowering practice which offers an alternative to traditional methods of facilitated discussion as mechanism for individuals to come together and reveal their concerns.

**What changes took place?**

The use of Photovoice by FHS IIHMR with women in the Sundarbans has enabled community members to identify and record their community strengths and struggles; to explain their experiences through critical reflection and group dialogue; and to reach policymakers. FHS\-IIHMR facilitated the direct and indirect interactions between the island women and decision makers at the community and sub\-national levels. [The process helped create a unified community voice among the women, which helped to draw the attention of the decision makers and make them more aware of and responsive to issues faced by the communities](http://www.futurehealthsystems.org/blog/2015/10/8/towards\-change\-through\-imagery\-women\-use\-photovoice\-to\-improve\-health\-in\-the\-indian\-sundarbans), including access to health services, dilapidated public health infrastructure, and access to and quality of water and sanitation. This engagement led to various key community actors voluntarily offering to support and facilitate dissemination of the visual research evidence with the agriculture, women and child health, and water supply departments at the sub divisional and the district level. Importantly, increased awareness of the challenges the women face to access health care have meant that local policymakers and ground\-level health workers are able to prioritise the issues and the steps that need to be taken. More widely, [the media has taken up the story told by the women through Photovoice](http://www.futurehealthsystems.org/news/2015/6/18/sundarbans\-documentary\-film\-and\-photo\-voice\-make\-media\-splash) \- close to 30 media outlets disseminated the story all over the country. Additionally, other researchers have shown interest in the Photovoice process.

**How did FHS contribute to the changes?**

In advance of the research, FHS\-IIHMR provided orientation and training to the local women on the Photovoice methodology and process, including photo documentation. Participants took two rounds of photographs within 6 months, interspersed by fortnightly group meetings with FHS\-IIHMR researchers as facilitators. The women then presented the research findings to different community policy stakeholders. FHS\-IIHMR encouraged and facilitated the womens voice being heard and has provided them a platform for dissemination of their evidence.

**What next?**

There are many more stories for the women of the Sundarbans to tell through Photovoice, and they are keen for their stories to be seen and heard. FHS\-IIHMR would like to facilitate the further capture and articulation of interfaces of the experiences of the women of the Sundarbans through Photovoice, and, in particular, with civil society actors, to make the process more sustainable. There are future plans to use Photovoice as a tool to explore the challenges of climatic vulnerability and variability and its effect on health and health determinants in the Sundarbans: Photovoice through the lens of the women on a sinking island.

**Director Hou** China

Strengthening capacity to enhance delivery: implementation of payment reform in China

**In 2002, China launched a voluntary health insurance scheme to provide financial protection to people affected by disease\-related illness. Future Health Systems \(FHS\) work in Hanbin County, western China, has drawn on innovative methods from implementation and participatory research to train and support local policymakers, managers and health professionals in the evidence\-based implementation of the scheme.** China has a population of 1.35 billion, of which 642 million live in rural areas. To reduce rural peoples disease\-related burden and relieve poverty induced by disease, the Chinese Government launched the New Rural Cooperative Medical Scheme \(NRCMS\) in 2002. NRCMS has offered financial protection to rural citizens, gradually scaling\-up nation\-wide from 2003 onward. The NRCMS is a co\-payment subsidised voluntary health insurance programme for rural residents, co\-financed by individual contributions and both central and local governments. The compensation began with reimbursement for hospitalisation costs and gradually expanded to outpatient care. In 2015, the minimum fund pooled per capital will reach 380 RMB nationwide as proposed by the State Council. With a national average participation rate of over 95 percent at the end of 2014, the NRCMS plays a vital role in accommodating the health needs of the rural residents. [One pilot area in the FHS China study](http://www.futurehealthsystems.org/news/2013/5/21/fhs\-china\-launch\-research\-project\-on\-payment\-system\-reform\-a.html), Hanbin County in western China, launched the NRCMS in January 2007. In the initial phase of the implementation, the NRCMS substantially improved health care access and utilisation among participants. The volume of patients in local health institutions increased dramatically since the NRCMS made healthcare more affordable. Following further development of NRCMS, there was a risk that limited funds would not be able to match increasing demand for healthcare. Overall financing of NRCMS increased by 78 percent between 2007 and 2009, but average reimbursement rate only improved by 11 percent. The reasons for this are: Unregulated treatment by medical staff: Due to incentives to chase the mark\-up in medicine and health materials, physicians were motivated to over\-treat or inappropriately prescribe in order to make profit, resulting in waste of scarce health resources. Fee\-for\-service payment approach: With the continuing comprehensive health reforms in other domains, such as essential drug systems and hospital reforms, fee\-for\-service is not an appropriate payment approach in improving efficiency of fund utilisation. In fact, the average inpatient spending increased by 27.26 percent in 2009 in contrast to 2007. To some extent, funds did not reach the people who had the greatest need, and therefore there was no significant effect on average household out\-of\-pocket health spending. The evolving deficit brought increasing pressure to policymakers from local government, such as the Bureau of Finance, Bureau of Development and Reform, Bureau of Health and NRCMS Management Office. They were eager to explore an advanced and adaptive payment approach to improve the efficiency of NRCMS utilisation. Based on the needs and willingness of Hanbin health authorities, the FHS China team selected Hanbin as one of three pilot areas in China to strengthen capacity building of local health policymakers and assist them to explore alternative payment methods in light of the current issues.

**What changes took place?**

The efficiency of fund utilisation has improved distinctly and the risk of overspending has been controlled better than expected. By 2012, the trend of overspending had been contained, with a good balance between financing income and overall expenditure. Furthermore, the rate of reimbursement to participants improved to 50.7 percent and 53.3 percent on average in 2012 and 2013 respectively. Based on the experiences and achievements during the initial implementation of the NRCMS, the scheme in Hanbin County covers 83 conditions through local hospitals. Local practitioners are now familiar with the operation of the scheme and its clinical pathways. Furthermore, the success of payment reform integration with the clinical pathways has boosted local practitioner confidence. Fee\-for\-bed and single\-case payments have replaced fee\-for\-service. Hanbin County is considered an outstanding pilot of the NRCMS payment reform, and its experience has been shared with others throughout and beyond Shaanxi province in western China. Meanwhile, health policymakers from Hanbin are encouraged by the provincial government to expand participant benefits through continuing payment reform, including trialling outpatient payment. The experience of FHS engagement in the process has increased local policymaker and stakeholder awareness and application of evidence\-based decision\-making in the implementation of the payment reform scheme.

**How did FHS contribute to the changes?**

In order to strengthen capacity building of local health policymakers and assist them to explore alternative payment methods, the FHS China team conducted two sets of activities: training and mentoring. Hanbin local policymakers and stakeholders, including health sector managers and staff, were invited to participate in training seminars and workshops delivered by domestic and international experts focusing on conceptual topics such as stimulating innovation; learning by doing, and the application of complex adaptive systems thinking. This training provided opportunities for participants to develop a deeper understanding of health systems research, and gain practical skills for designing and implementing their own payment reform strategy. Supported by the FHS China team, local health policymakers with other stakeholders then designed a plan for the adapted and contextually\-relevant implementation of payment reform. The Hanbin health authorities decided to adopt the plan and different payment approaches, such as single\-case payment and fee\-for\-bed, were introduced over time to improve the efficiency of fund utilisation for inpatient services. To ensure the success of clinical pathway and case payment implementation reform, the FHS China team provided technical assistance in close collaboration with local practitioners over a six month period. FHS researchers carried out a baseline study; screening of priority conditions; cost estimations; input to the development of clinical pathways; support to the development of necessary regulations; and construction of a monitoring and evaluation framework. Finally, based on existing treatment strategies, and with input from national clinical experts, pathways were developed and further refined by and adapted to local contexts through discussion. These pathways were used as a basis to derive appropriate case payment rates following negotiations between local payers and providers, and were incorporated into each hospitals electronic information system.

**Next steps**

Hanbin health authorities will continue to roll out and evaluate the payment reforms, and share the citys experience with others in China. The FHS China team is working on a report about the Health Payment Reform for the National Health and Family Planning Commission, and will highlight the experience of Hanbin City through this.

**Interview with Health Systems Hero, Director Hou of** Hanbin NRCMS Management Office, Hanbin Province, China

**1. How is the payment system reform established in Hanbin?**

**Director Hou:** Hanbin began to implement the New Rural Cooperative Medical System \(hereafter referred to as NRCMS\) in January 2007. As the funding criteria rise, farmers' ability to take advantage of health services has also a significant improvement, which alleviates the problem of difficulties and high expenses in seeing doctors to some extent. However, due to lack of management experience and other factors, Hanbin District still faces many difficulties and problems in its new rural cooperative medical work, and the too rapid increase in medical costs remains a very prominent problem to be solved. Hanbin began to reform and innovate the payment of NRCMS in 2010 with the support from the Health Development Project in Chinese Rural Areas Financed by the World Bank Loans and the DFID Grants.

**2. Can you introduce the payment reform in Hanbin?**

**Director Hou:** Each payment method has its own advantages and disadvantages, and we combine a variety of payment methods to give full play to their advantages and curb disadvantages. It is based on this thinking that we designed NRCMS reform program. **\(1\) Outpatient reform** In outpatient services, the first design is the whole prepaid system, which is mainly but not entirely based on the number of people. It roughly distinguishes three categories based on human factors, namely Category I, II, and III. It cuts the cost by about 2 yuan per capita in accordance with the funding criteria for outpatient service, for the funding criteria was relatively low at that time, only 33 yuan for outpatient service. We have developed a ratio to prevent excessive balances in some areas. If the ratio is exceeded, all the balance would go to the hospital, and if the ratio fails to reach the expected one, we only offer a part, and if the ratio is very low, the hospital will not get the balance. **\(2\) Inpatient reform** Mixed payment of inpatient services fall into two categories: one is for county\-level hospitals, and the other is for township\-level hospitals. There are three different payments for county\-level hospitals. The first is payment based on bed days. The treatment of patients is divided into different phases based on their conditions, and a fixed cost standard is set for each phase, and the cost is based on the actual number of days in hospital after discharge. We calculate and develop cost standards to define the costs per bed day based on past costs of medical institutions, and pay in accordance with these standards. The reimbursement ratio is fixed. For example, if the reimbursement ratio is 70%, the standard is 400 yuan per day hospital, and the patient stays in hospital for 10 days, then the reimbursement will be 2800 yuan. If the patient actually spends only 3,000 yuan in the hospital during this period, then the patient will actually receive 2,100 yuan as reimbursement, but the health insurance sector actually still pays 4,000 yuan to the hospital. In this case, the hospital will earn 700 yuan. In other words, the less the patient spends, the more the hospital will get. The second is the single disease payment. We started single disease payment in 2008, whose cost measurement is abstract. There was a unified market standard, and if such standard is adopted, the medical institution would suffer a loss, so it is rarely used at that time. The two situations where this standard is commonly used are normal and caesarean deliveries, and the state subsidizes hospitalized childbirth to reduce maternal mortality and improve the proportion of hospital delivery. As a result, the deliveries in rural areas in Shaanxi were free of charge in recent years. There was some adjustment later, which divided diseases into 90 categories, but it was not implemented. The third is payment by items. Each medical service item involved is priced, and the insured patient pays for each medical service item, and then the health insurance agency pays the insured patient or designated medical institution in accordance with stipulated ratio. Payment by item is prone to many problems. For one thing, it is difficult to accurately price the medical service in a scientific way, and for the other, it is hard to control medical costs, and there will be induced demand. Even when the unit price of medical service is determined, the health care provider can still increase the costs by increasing the amount of services. In the first year of reform, the first payment method accounted for the largest part, followed by single disease payment and payment by item, accounting for 20%, and then slowly dropping to 5%. There are two payment methods for township\-level hospitals. One is payment based on bed days, and 95% of township hospital payments adopt this method. Its greatest advantage is that it is low\-tech and can be rapidly promoted. The disadvantage is that the standard is slightly higher, and the township hospital will lose money. The second is single disease payment, which is mainly used for hospital delivery, and several other diseases.

**3. How do you develop the clinical text for clinical pathway in single disease payment \(10+X\), and can you introduce the payment standard and compensation scheme?**

**Director Hou:** 10+X refers to disease entities. 10 refers to the 10 diseases in all pilot counties, and X is the disease specific to each area. A disease is selected via treatment optimization, and in clinical optimization, it is first for clinical text. For the first 12 pilot disease clinical pathways, the text is discussed and developed by professional experts and health care staffs from relevant departments of pilot hospitals, with the participation of hospital administrators and health care management personnel. Text development follows the evidence\-based and cost\-effective principle. The pilot clinical pathway text of the project is refined based on the clinical pathway text issued by Department of Medical Administration of the Ministry of Health, and developed based on the procedure from admission to discharge. The guiding framework of the Ministry of Health is converted into specific operational prescription items, and all prescription items fall into mandatory and optional ones. Mandatory items must be provided for patients, while optional ones are based on the specific conditions of patients. With regard to compensation scheme, clinical pathway patients only pay self\-borne costs at discharge, and the remaining costs are paid by medical insurance departments after audit. The balance will go to the hospital, and the overrun compensation will also be borne by the hospital itself, hence fully mobilizing its enthusiasm. The compensation scheme is discussed and jointly formulated by the hospital, health bureau, social security, and NRCMS departments. The fixed payments standards for pilot clinical pathway diseases mainly take into account the following three aspects: \(1\) to calculate the average growth rate for each disease according to the inpatient costs over past 3 years before the pilot, which shall not generate higher costs than previous years, to control the increase in total costs at a reasonable level; to refer to the standard covering 80% of patients in previous years, to ensure that the majority of diseases can be covered; to refer to the accumulated value of medical advice items in clinical pathway texts, and determine the cost interval with mandatory item costs as the minimum, and total of mandatory and optional item costs as the maximum.

**4. I heard that there were branch pathways for clinical pathway single disease payment later. Can you tell us about it?**

**Director Hou:** hypertension and diabetes these two diseases are combined. We have developed 18 texts. It is the same as before in district hospitals. For complex diseases, for example, severe diabetes and hypertension now can choose this pathway or its pathway branch. If the patient has hypertension, he can follow the pathway of hypertension, and if there is also diabetes, then he can follow the pathway of diabetes. The only difference lies in different branches. The so\-called integration falls into two types: one is the integration of prevention, treatment and rehabilitation, and the other is the integration of district, township and village\-level management. Prevention is the starting point, and the general public is divided into three groups. One is the patient at moderately high risk of stroke and their families; the second is the high\-risk patient; the third is the general population. There will be community publicity to remind the public to prevent and avoid these risk factors as much as possible. Lifestyle intervention is also quite important. We need to guide these people to smoke less and drink less, which is a difficult and needs long\-term efforts. Besides, and we need to pay attention to the medication for high\-risk groups to control hypertension and diabetes. In addition, we have identified the symptoms that can be diagnosed as stroke, and developed procedures for transfer treatment for grassroots. In addition to the branch pathway, we also have rehabilitation pathway during inpatient period. In prevention treatment and rehabilitation, the district hospital will transfer the patient suffering stroke to community hospital after discharge, and it will also transfer all the basic information, especially the personalized treatment and rehabilitation program, to township hospitals and community service centers, and the township hospital then includes the patient into chronic disease management. Some still need continued inpatient treatment, and in this case the personalized treatment and rehabilitation program of the district hospital can be used as reference. The patient that needs further inpatient treatment will be hospitalized, and the one needing home treatment will be included in chronic disease management. Home treatment is to include the patients costs into the category of chronic diseases, and about one thousand yuan can be reimbursed per year. The community needs to grasp the information of patients, and the community doctor needs to make regular follow\-up, and offer regular rehabilitation guidance. In this case, these two diseases are included in the management of basic public health service program, and they consume public health services. Therefore, this is implemented in combination with chronic disease management in basic public health services.

**5. Do you think medical healthcare insurance fund will be arranged on the municipal level?**

**Director Hou:** This seems to be a trend. It has both advantages and disadvantages. The advantage is that the higher the level the stronger the ability to resist risks. Some counties have only a pollution of tens of thousands, and our district has a pollution of hundreds of thousands, much better. Put together, there are too many hospitals to be monitored. Will the monitoring be left to the market or grassroots authorities? If it is left to the district, there may be a bias in favor of the district itself, which certainly involves many institutional restraints. As I see it, some areas have already begun this work when information technology has developed to a certain extent.

**6. Have you ever met any problems in the course of reform?**

**Director Hou:** We have encountered two problems. The first is the cost overrun of cooperative medical fund in these two years. 40% of patients and 60% of the funds flow to the cities. The average cost of inpatient was over 4,000 in the first year, but now it is 10,000 yuan. The other problem is serious brain drain. More than 100 doctors have gone to the city from districts in recent years, for there are better technologies and better benefits. If I were a doctor, I would also go to some large hospitals to improve my skills.

**Nakawala Anita** Uganda

Saving money; saving lives: community saving groups lead to improvements in maternal and newborn health care in Uganda

**Future Health Systems work on maternal and newborn health in the poorest districts of eastern Uganda has contributed to a story of community empowerment where people have learnt to prioritise, prepare and save money for childbirth. This increases the likelihood of delivery in a health facility, and therefore the chances of a healthy pregnancy and safe childbirth under skilled care.** Six thousand Ugandan women die every year from preventable pregnancy and child birth related complications. Yet, if women delivered under skilled care, about 80 percent of these deaths could be prevented. Many women do not deliver in a health facility as they are unable to afford the financial costs associated with seeking health care during pregnancy and labour. Phase One of the FHS Uganda 'Safe Deliveries Project' implemented a project with demand\-side \(vouchers for transport and maternal services\) and supply\-side initiatives \(training health workers and provision of essential equipment, drugs and supplies\), resulting in a significant increase in facility delivery. However, sustainability of these initiatives was a challenge. The second phase built on this work, and had three components: increasing birth preparedness; facility staff supervision, mentorship and training; and [a focus on exploring different methods of mobilising resources](http://www.futurehealthsystems.org/publications/2015/8/14/manifest\-progress\-brief\-2\-working\-with\-communities\-to\-save\-money\-for\-meeting\-maternal\-and\-newborn\-needs) \- community financial, social and human \- for maternal and newborn health. To support this work, in 2013 a baseline study was undertaken by FHS Uganda researchers in the districts of Kamuli, Kibuku and Pallisa \- situated in rural Uganda. It found that 27 percent of women did not deliver in a facility because the facility was too far, there was no transport, or the cost of seeking care was too high. Across Uganda, many households save money to help each other during funerals, buy meat during festive days, and contribute to wedding preparations, among many other things. However, the survey revealed that households rarely saved for pregnancy and birth, and women were often not delivering in a facility or with skilled care, contributing to the high rate of preventable pregnancy and childbirth\-related complications.

**What changes took place?**

The FHS Uganda team based at Makerere University witnessed and documented an increase in saving for maternal and newborn health services across all three districts, achieved through womens saving groups and individual household level saving. Comparing the baseline and endline data, women saving for maternal and newborn services in the intervention area increased from 10 percent to 69 percent. Women in the intervention area were more likely to access money for meeting their maternal and newborn health needs \(10 percent\) from savings groups than those in the control \(4 percent\). The endline survey for the study revealed that saving for maternal and newborn health had a direct effect on health facility delivery: women who saved for maternal and newborn health in the intervention area were more likely to deliver from the health facility. At household level, there is better birth preparedness than before the intervention. Increasingly, women can easily arrange for transport to and from hospital without worrying about waiting. Many men are equally relieved that even when they are not at home their spouses can secure transport to health facilities. Using savings, women can now buy baby clothing and supplies to facilitate a safe birth. The involvement of Community Development Officers \(CDOs\) has also assisted development efforts in the districts by bringing together the health and community departments. For the Local Government Authorities, evidence of improved maternal and newborn health outcomes was key to their engagement, with more women delivering in health facilities proving most significant. Improvements have even extended beyond the intervention areas. For example, in the control area, the percentage of women saving for maternal and newborn health services rose from 7 percent to 64 percent. This could be attributed to the radio spot messages and talk shows that promoted saving for maternal and newborn health services, which were also listened to in the control areas, as well as the district health teams and CDOs promoting lessons learned from intervention sites to control areas. Additionally, other groups of people \- for example, coffee farmers, transporters and community health workers \- are now also saving due to the general trend in saving.

**How did FHS contribute to the changes?**

FHS Uganda worked in partnership with district health teams in Kamuli, Kibuku and Pallisa using existing structures such as the Village Health Teams \(VHTs\) and the CDOs. [The VHTs were instrumental in knowledge sharing through home visits and community dialogues](http://www.futurehealthsystems.org/publications/2015/8/14/manifest\-progress\-brief\-1\-village\-health\-teams\-vhts\-are\-an\-important\-resource\-for\-community\-mobilization\-and\-health\-information), while the CDOs were key in nurturing the saving groups. Both encouraged participation in existing financial social networks where households can save money, such as womens saving groups, burial groups and financial circles, in addition to other saving methods. This activity was featured on radio and in community dialogues to enhance financial knowledge. FHS Uganda also promoted methods that would help avail money when needed for health care for example the early purchase and sale of easily convertible assets such as livestock, depositing money with transporters and buying required items ahead of birth for a safe delivery. The sub\-counties and the FHS Uganda team also mobilised local transporters to form partnerships with saving groups to provide transport services for mothers who were part of the saving groups. However, mothers could also use their savings to contract riders who were not part of this partnership. In addition, the team mobilised resources to purchase tricycle motorbike ambulances. These initiatives enabled local boda\-boda taxi drivers, who were not previously interested or involved, to help with referral transport from lower level health facilities to health centres and district hospitals.

**What next?**

Saving groups have the potential to extend beyond maternal and newborn health into other welfare issues. These groups could also be used as a stepping stone into community health insurance, since money saved can be used to pay for insurance premium. Nurturing these groups is therefore critical given that Uganda is preparing to implement a national health insurance scheme.

**Dr Abdus Salam** Bangladesh

In from the cold: shifting the discourse on informal providers in Bangladesh and India

**In Bangladesh and India, village doctors \(VDs\), also known as rural medical practitioners \(RMPs\), have long been part of the countries health systems. However, formal recognition of their existence is a sensitive issue, partly due to resistance and concern from professional health bodies. Research by Future Health Systems \(FHS\) partners, icddr,b and IIHMR has been instrumental in bringing the issues to discussion tables. Consequently, stakeholders have begun to recognize and work with VDs something previously unheard of.** In remote areas of India and Bangladesh, VDs \- those who practice modern medicine without any formal training or authorisation provide the majority of health services. This is often to fill the gap where publicly funded health care facilities are either non\-existent or non\-functional, or because VDs offer 24 hour services and more flexible payment methods. In Bangladesh, 96 percent of health care providers are informal medical practitioners, and in the Sundarbans in West Bengal, India, about 75 percent of children and 60 percent of adults are treated by RMPs.

The safety of care offered by VDs is often questionable, due to varying quality and lack of regulation. A review of 89 cases in Bangladesh revealed that only 18.4 percent of the drugs used for treating diarrhoea, pneumonia and fever and cold were appropriate according to relevant treatment guidelines, 7.1 percent were harmful, and 74.5 percent were unnecessary. This widespread existence of VDs and their significance as an integral contributor of healthcare within rural communities in Bangladesh and India means that it is important to improve the access, quality and safety of their services. Indeed, in FHS phase one studies in Bangladesh and India highlighted the importance of working with informal providers. In 2006, FHS teams in Bangladesh and India started working with VDs, in Chakaria and West Bengal respectively, with the aim of improving skills, increasing accountability and ensuring adherence to established standards for treatment and drug prescription. To address inappropriate prescribing behaviour among VDs the FHS team at the International Centre for Diarrhoeal Disease Research, Bangladesh \(ICDDR,B\) began by offering VDs in Chakaria harm\-reduction training focusing on the Dos and Donts of antibiotics and steroids. VDs who completed this training were then able to join the Shastya Sena franchise which ICDDR,B began in 2009 to encourage good practice. In 2011, FHS partnered with the Telemedicine Reference Centre Ltd to establish eClinic24 \- Bangladeshs first 24\-hour telephone\-based helpline designed for informal providers. Although VDs could see the benefits of this service, technical problems meant there was low uptake of the service. In West Bengal, the FHS team at the Indian Institute of Health Management Research \(IIHMR\) started by collecting data in three districts \(Malda, Bankura and North 24 Porgonas\) through a household survey, interviews with patients in selected government felicities and in\-depth interviews with 71 RMPs.

**What changes took place?**

In Chakaria, the training has led to a reduction in the rate of inappropriate medicine prescription by VDs. When the Bangladesh team compared the levels of three categories of prescribing \(appropriate; inappropriate, harmful; and inappropriate, non\-harmful\) between baseline and end line in intervention and control areas, there was a statistically significant decline in the prescription of inappropriate and harmful drugs in the intervention area. In 2014, the Technical Training Unit of icddr,b and pharmaceutical company Advanced Chemical Industries Limited \(ACI\) jointly undertook a training programme to improve the quality of RMP services offered in Bangladesh, with the goal of training 1,800 RMPs by the end of 2016. As of March 2016, 1,340 RMPs from all 64 districts of Bangladesh attended the training. mPower Social Enterprises Limited is also collaborating with the FHS Bangladesh team to train 30 VDs to provide affordable, convenient, and quality healthcare to under\-served populations, using telemedicine and remote doctors. icddr,b will be evaluating this intervention. In West Bengal, FHS research started generating evidence in 2007\-08 on the spread and practice of informal providers. This evidence was used by the government and a few non\-government agencies such as the Liver Foundation of West Bengal to build a favourable environment for dialogue among key stakeholders. In November 2015, despite concerns from the Indian Medical Association, the government took a landmark decision to train RMPs through the state Nursing Training schools and integrate them into the formal health system as Village Health Workers \(VHWs\). The government is preparing a standard operating procedure for VHWs in consultation with clinical pharmacologists, physicians, surgeons and administrators. There will be clear delineation of the care that VHWs can provide, and they will not be allowed to use the doctor prefix. Training of trainers and State and District Monitoring cells would also be set up.

**How did FHS contribute to the changes?**

FHS Bangladeshs engagement and training with VDs created awareness as to the number of VDs in the healthcare system, and their potential for harmful and inappropriate practice. This has led to initiatives to address this issue. Although not yet formally recognised by the Government of Bangladesh, the initiative undertaken by icddr,b and ACI, which has been influenced by FHS long engagement with the VDs in Chakaria, has contributed to the growing recognition of VDs as being part of the Bangladesh healthcare system. In India, FHS helped build a favourable environment to initiate a dialogue on informal providers and break the policy silence on this particular issue. Before FHS research, there was little scientific evidence on the nature and gravity of the informal health market in West Bengal. The evidence produced and communicated by the FHS research team provided important input to build policy momentum to take positive action on informal providers. In both countries, FHS research has highlighted that VDs cannot be eliminated from the system and must instead be trained to improve their quality of care.

**What next?**

The progress made in West Bengal is just the beginning. FHS India would like to continue to collaborate and communicate with organisations and forums working on RMPs to monitor and add value to the scale\-up process. FHS has been asked by the Chief Secretary to undertake research on the pilot to allow government to fine\-tune the intervention. Despite progress on training VDs in Bangladesh, the challenge of establishing an appropriate and effective regulatory framework to monitor and control what drugs VDs prescribe remains. Government should construct a regulatory framework with incentives and penalties for VDs for adhering to or disregarding the framework.

The Future Health Systems \(FHS\) consortium is a DFID funded global programme which aims to generate knowledge that shapes health systems to benefit the world's poor. FHS addresses fundamental questions about the design of health systems and works closely with people who are leading the transformation of health systems in their own countries. The programme is coming to the end of its second phase of activities \(running from 2010\- 2016\). The aims of the programme during this period has been to provide high quality knowledge about how health systems can improve quality of and access to basic health services for the poor. This has focused on how to improve services that benefit the poor and socially marginalized groups, and how to strengthen service delivery in complex contexts where there is conflict, unstable social and environmental conditions, and/or gender discrimination. Find out more \- [futurehealthsystems.org](http://www.futurehealthsystems.org)