Xiao, Y, Husain, L and Bloom, G (2018) Evaluation and learning in complex, rapidly changing health systems, Globalization and Health, 14:112, DOI: 10.1186/s12992-018-0429-7
Healthcare systems are increasingly recognised as complex, in which a range of non-linear and emergent behaviours occur. China’s healthcare system is no exception. The hugeness of China, and the variation in conditions in different jurisdictions present very substantial challenges to reformers, and militate against adopting one-size-fits-all policy solutions. As a consequence, approaches to change management in China have frequently emphasised the importance of sub-national experimentation, innovation, and learning. Multiple mechanisms exist within the government structure to allow and encourage flexible implementation of policies, and tailoring of reforms to context. These limit the risk of large-scale policy failures and play a role in exploring new reform directions and potentially systemically-useful practices. They have helped in managing the huge transition that China has undergone from the 1970s onwards. China has historically made use of a number of mechanisms to encourage learning from innovative and emergent policy practices. Policy evaluation is increasingly becoming a tool used to probe emergent practices and inform iterative policy making/refining. This paper examines the case of a central policy research institute whose mandate includes evaluating reforms and providing feedback to the health ministry. Evaluation approaches being used are evolving as Chinese research agencies become increasingly professionalised, and in response to the increasing complexity of reforms. The paper argues that learning from widespread innovation and experimentation is challenging, but necessary for stewardship of large, and rapidly-changing systems.
It is critical that ensuring people’s access to effective treatment for common infections is aligned with efforts to reduce the risk of emerging antimicrobial resistance. The Institute of Development Studies, a Future Health Systems partner, is influencing policy agendas to give greater focus on the need for the just and sustainable use of antimicrobials.
Waldman L, Theobald S and Morgan R (2018) Key Considerations for Accountability and Gender in Health Systems in Low- and Middle-Income Countries, IDS Bulletin, 49(2), DOI: 10.19088/1968-2018.137
This article poses questions, challenges, and dilemmas for health system researchers striving to better understand how gender shapes accountability mechanisms, by critically examining the relationship between accountability and gender in health systems. It raises three key considerations, namely that: (1) power and inequities are centre stage: power relations are critical to both gender and accountability, and accountability mechanisms can transform health systems to be more gender-equitable; (2) intersectionality analyses are necessary: gender is only one dimension of marginalisation and intersects with other social stratifiers to create different experiences of vulnerability; we need to take account of how these stratifiers collectively shape accountability; and (3) empowerment processes that address gender inequities are a prerequisite for bringing about accountability. We suggest that holistic approaches to understanding health systems inequities and accountability mechanisms are needed to transform gendered power inequities, impact on the gendered dimensions of ill health, and enhance health system functioning.
Nelson E, Bloom G and Shankland A. (2018) Introduction: Accountability for Health Equity: Galvanising a Movement for Universal Health Coverage, IDS Bulletin, 49(2), DOI: 10.19088/1968-2018.131
In July 2017, IDS hosted a workshop on ‘Unpicking Power and Politics for Transformative Change: Towards Accountability for Health Equity’, with the aim of generating dialogue and mutual learning among activists, researchers, policymakers, and funders working towards more equitable health systems and a commitment to Universal Health Coverage (UHC). This issue of the IDS Bulletin is based around three principal themes that emerged from the workshop as needing particular attention. First, the nature of accountability politics ‘in time’ and the cyclical aspects of efforts towards accountability for health equity. Second, the contested politics of ‘naming’ and measuring accountability, and the intersecting dimensions of marginalisation and exclusion that are missing from current debates. Third, the shifting nature of power in global health and new configurations of health actors, social contracts, and the role of technology.For the first time in IDS Bulletin history, themes are explored not only in text but also through a selection of online multimedia content, including a workshop video, a photo story and a documentary. This expansion into other forms of communication is explicitly aimed at galvanising larger numbers of people in a movement towards UHC and the linked agenda of accountability for health equity.The articles and multimedia in this IDS Bulletin reflect the fact that while the desired outcome might be the same – better health for all – accountability strategies are as diverse as the contexts in which they have developed.
Waldman L, Ahmed T, Scott N, Akter S, Standing H and Rasheed S (2018) ‘We have the internet in our hands’: Bangladeshi college students’ use of ICTs for health information, Globalization and Health, 14:31, DOI: 10.1186/s12992-018-0349-6
Information and Communications Technologies (ICTs) which enable people to access, use and promote health information through digital technology, promise important health systems innovations which can challenge gatekeepers’ control of information, through processes of disintermediation. College students, in pursuit of sexual and reproductive health (SRH) information, are particularly affected by gatekeeping as strong social and cultural norms restrict their access to information and services. This paper examines mobile phone usage for obtaining health information in Mirzapur, Bangladesh. It contrasts college students’ usage with that of the general population, asks whether students are using digital technologies for health information in innovative ways, and examines how gender affects this.
Bloom G, Wilkinson A and Bhuiya A (2018) Health system innovations: adapting to rapid change, Globalization and Health, 14:29, DOI: 10.1186/s12992-018-0347-8
A fundamental challenge for health systems is the need to adapt to changes in the patterns of health service need, scientific and technological developments, and the economic and institutional contexts within which providers of health services are embedded. This is especially true of many low and middle-income countries, where the pace of multiple and interconnected changes is breath-taking. This paper introduces the Thematic Issue on Innovation in Health Systems in Low- and Middle-Income Countries.
Information and communication technologies (ICTs) and mHealth innovations hold great potential to improve health systems and health outcomes while at the same time enhancing citizen engagement and accountability. Yet there has been little assessment of the impact of mHealth innovations on the ground.
This paper reviews the experiences of seven mHealth initiatives funded by the Making All Voices Count programme: OurHealth, eThekwini WACs and Thuthuzela Voices (all in South Africa), Mobile Mapping for Women’s Health (Tanzania), Text2Speak (Nigeria), SMS Gateway (Indonesia) and Citizen Journalism for Quality Governance of Universal Health Insurance Scheme (also Indonesia). It discusses the accountability model adopted by each project, and the challenges they faced.
This Working Paper explores the literature on accountability in health systems and on mHealth and to build theoretical and empirical bridges between them. In so doing, the authors lay out a clearer understanding of the role that mHealth can play in accountability for public health services in LMICs, as well as its limitations. At the centre of this role is technology-facilitated information which, for instance, can help governments enforce and improve existing health policy, and which can assist citizens and civil society to communicate with each other to learn more about their rights, and to engage in data collection, monitoring and advocacy. Ultimately however, information, facilitated as it may be by mHealth, does not automatically lead to improved accountability. Different forms of health care come with different accountability challenges to which mHealth is only variably up to task. Furthermore, health systems, embedded as they are in diverse political, social and economic contexts, are extremely complex, and accountability requires far more than information. Thus, mHealth can serve as a tool for accountability, but is likely only able to make a difference in institutional systems that support accountability in other ways (both formal and informal) and in which political actors and health service providers are willing and able to change their behaviour.
Ali F, Shet A, Yan W, Al-Maniri A, Atkins and Lucas H (2017) Doctoral level research and training capacity in the social determinants of health at universities and higher education institutions in India, China, Oman and Vietnam: a survey of needs, Health Research Policy and Systems, 15:76, DOI: 10.1186/s12961-017-0225-5
Research capacity is scarce in low- and middle-income country (LMIC) settings. Social determinants of health research (SDH) is an area in which research capacity is lacking, particularly in Asian countries. SDH research can support health decision-makers, inform policy and thereby improve the overall health and wellbeing of the population. In order to continue building this capacity, we need to know to what extent training exists and how challenges could be addressed from the perspective of students and staff. This paper aims to describe the challenges involved in training scholars to undertake research on the SDH in four Asian countries – China, India, Oman and Vietnam.
Russo G, Bloom G and McCoy D (2017) Universal health coverage, economic slowdown and system resilience: Africa’s policy dilemma, BMJ Global Health, 2 (3), DOI: 10.1136/bmjgh-2017-00040
Achieving universal health coverage (UHC) has become a dominant policy preoccupation within the global health community. For Africa, progress towards UHC involves ambitious goals for expanding access to a range of effective health services, a substantial increase in health expenditure, and establishing a greater reliance on prepayment and pooling mechanisms to finance healthcare. According to one set of calculations, achieving UHC requires countries to spend at least $86 per capita in 2012 dollars on healthcare, and a minimum of 5% of Gross Domestic Product (GDP). Clearly, expanding the ‘fiscal space for health’ will be key to the success of UHC.
From 19-21 July 2017, the IDS programme on “Accountability for Health Equity” held a workshop bringing together over 80 activists, researchers, public health practitioners and policy makers to examine critically the forces that shape accountability in health systems, from local to global levels.
This report is a record of the presentations and discussions that occurred over the course of workshop. It is by no means exhaustive, but aims to represent accurately the debates that emerged.
Bloom G, Buckland Merrett G, Wilkinson A, Lin V and Paulin S (2017) Antimicrobial resistance and universal health coverage, BMJ Global Health, 2:e000518, doi:10.1136/bmjgh-2017-000518
The WHO launched a Global Action Plan on antimicrobial resistance (AMR) in 2015. World leaders in the G7, G20 and the UN General Assembly have declared AMR to be a global crisis. World leaders have also adopted universal health coverage (UHC) as a key target under the sustainable development goals. This paper argues that neither initiative is likely to succeed in isolation from the other and that the policy goals should be to both provide access to appropriate antimicrobial treatment and reduce the risk of the emergence and spread of resistance by taking a systems approach.
Huang F, Blaschke S and Lucas H (2017) Beyond pilotitis: taking digital health interventions to the national level in China and Uganda, Globalization and Health, 13:49, doi: 10.1186/s12992-017-0275-z
Innovation theory has focused on the adoption of new products or services by individuals and their market-driven diffusion to the population at large. However, major health sector innovations typically emerge from negotiations between diverse stakeholders who compete to impose or at least prioritise their preferred version of that innovation. Thus, while many digital health interventions have succeeded in terms of adoption by a substantial number of providers and patients, they have generally failed to gain the level of acceptance required for their integration into national health systems that would promote sustainability and population-wide application. The area of innovation considered here relates to a growing number of success stories that have created considerable enthusiasm among donors, international agencies, and governments for the potential role of ICTs in transforming weak national health information systems in middle and low income countries. This article uses a case study approach to consider the assumptions, institutional as well as technical, underlying this enthusiasm and explores possible ways in which outcomes might be improved.
Bloom G, Berdou E, Standing H, Guo Z and Labrique A (2017) ICTs and the challenge of health system transition in low and middle-income countries, Globalization and Health, 13:56, doi: 10.1186/s12992-017-0276-y
The aim of this paper is to contribute to debates about how governments and other stakeholders can influence the application of ICTs to increase access to safe, effective and affordable treatment of common illnesses, especially by the poor. First, it argues that the health sector is best conceptualized as a ‘knowledge economy’. This supports a broadened view of health service provision that includes formal and informal arrangements for the provision of medical advice and drugs. This is particularly important in countries with a pluralistic health system, with relatively underdeveloped institutional arrangements. It then argues that reframing the health sector as a knowledge economy allows us to circumvent the blind spots associated with donor-driven ICT-interventions and consider more broadly the forces that are driving e-health innovations. It draws on small case studies in Bangladesh and China to illustrate new types of organization and new kinds of relationship between organizations that are emerging. It argues that several factors have impeded the rapid diffusion of ICT innovations at scale including: the limited capacity of innovations to meet health service needs, the time it takes to build new kinds of partnership between public and private actors and participants in the health and communications sectors and the lack of a supportive regulatory environment. It emphasises the need to understand the political economy of the digital health knowledge economy and the new regulatory challenges likely to emerge. It concludes that governments will need to play a more active role to facilitate the diffusion of beneficial ICT innovations at scale and ensure that the overall pattern of health system development meets the needs of the population, including the poor.
Husain L (2017) Policy experimentation and innovation as a response to complexity in China’s management of health reforms, Globalization and Health, 13:54, doi: 10.1186/s12992-017-0277-x
There are increasing criticisms of dominant models for scaling up health systems in developing countries and a recognition that approaches are needed that better take into account the complexity of health interventions. Since Reform and Opening in the late 1970s, Chinese government has managed complex, rapid and intersecting reforms across many policy areas. As with reforms in other policy areas, reform of the health system has been through a process of trial and error. There is increasing understanding of the importance of policy experimentation and innovation in many of China’s reforms; this article argues that these processes have been important in rebuilding China’s health system.
Waldman L and Amazon-Brown I (2017) New Digital Ways of Delivering Sex Education: A Practice Perspective, IDS Bulletin, Institute of Development Studies, DOI: 10.19088/1968-2017.104
This article explores new, under-researched genres of sex education for adolescents in sub-Saharan Africa resulting from access to the internet through mobile phones. It examines the history of developing online health information platforms tailored for youth through the experiences of digital developers and the reflections of users.
Bloom G, Wilkinson A and Buckland Merritt G (2017) Antimicrobial resistance and Universal Health Coverage, In Antimicrobial resistance in the Asia Pacific region: a development agenda (pp. 9-21). Manila, Philippines. World Health Organization Regional Office for the Western Pacific. Licence: CC BY-NC-SA 3.0 IGO.
Chapter two highlights priorities for an integrated approach for addressing AMR by strengthening universal health coverage (UHC). It focuses on the use of drugs in outpatient settings. The chapter gives particular consideration to low- and middle-income countries with pluralistic health systems, where government provision and health markets combine and where people seek treatment for a large proportion of common infections in weakly regulated markets.
Gupta M et al (2017) Lessons Learned From Implementing E-Learning for the Education of Health Professionals in Resource-Constrained Countries, The Electronic Journal of e-Learning, Volume 15 Issue 2 2017, (pp144-155)
The growing global demand for tertiary education has led to the increased use of e-learning approaches around the world. Demand has increased most rapidly in low and middle income countries (LMICs), which account for half of the students currently enrolled in higher educational institutions (HEIs). But the implementation of e-learning programmes in resource-constrained settings faces many obstacles. This paper explores some of the key issues involved in implementation of e-learning in HEIs involved in the education of health professionals, given the resource constraints within which many institutions have to function. We present case studies of three such LMIC institutions of varying size and primary purpose. The paper suggests use of appropriate ICT infrastructure, both in terms of hardware and software, combined with effective access and bandwidth management policies is crucial to the successful implementation of e-learning courses on health within HEIs based in LMICs.
Lucas H and Zwarenstein M (2016) A Practical Guide to Implementation Research on Health Systems, Brighton: Institute of Development Studies
This is an open access resource targeted primarily at post-graduate students intending to undertake field research on health systems interventions in resource-poor environments.
The book consists of twelve chapters addressing theory, methodology, analysis, and influencing policy. Each consists of both original text and links to relevant, open access, web-based journal and multi-media materials, including selected case studies.
Lucas H and Kinsman J (2016) Distance- and blended-learning in global health research: potentials and challenges, Global Health Action, 9:1, DOI:10.3402/gha.v9.33429
It has been argued that in every country, ‘social, educational, technological, and economic development fundamentally depends on the advancement of science through research … and [it] benefits from having a … network of actors engaged in promoting and using scientific research’. This applies in particular to life sciences research in low- and middle-income countries (LMICs), given that many such countries face the heaviest burdens of disease. However, Langer et al. lamented in 2004, that ‘In the fields of medicine and public health … papers where researchers from developing countries are the sole authors represent a very low proportion of published manuscripts’. The reasons identified for this include: poor access to scientific literature, poor participation in publication-related decision-making processes, and the bias of journals. Much has changed since then, with a dramatic growth in the number of journals addressing public health concerns, many of which are based in LMICs or which include LMIC researchers on their editorial boards. There have been substantial initiatives, most notably Hinari, to provide LMIC researchers with access to the scientific literature. However, though the number of LMIC publications has increased substantially, a recent publication found no LMIC in the top forty countries in terms of publications per capita.