A great spiritual leader once taught his disciples a very useful lesson on systems approach to management. The little agrarian community in Israel had no much difficulty understanding the analogy. In his words, “No one puts a piece of unshrunk cloth on an old garment; for the patch pulls away from the garment, and the tear is made a worse. Nor do they put new wine into old wineskins, or else the wineskins break, the wine is spilled, and the wineskins are ruined. But they put new wine into new wineskins, and both are preserved”.

This common sense systems thinking helped the peasants and farmers of pre-modern age manage their resources efficiently such that undue wastages and irreparable loss were eliminated from their managerial systems. Following the establishment of the Roll Back Malaria Partnership, the Global Fund for AIDS, Malaria and HIV/AIDS, funding for malaria programs have improved exponentially over the last couple of years. More bilateral donors like DFID have upped their malaria-specific program funding to Nigeria and other countries in Africa. In some of the donor-funded programs and projects, emphasis has been more on the prevention, control, and management of malaria. Most of the deliverables and outputs have been measured in terms of commodities like ACTS, and ITNs distributed, among others.

The monitoring and evaluation mechanisms and dashboards have only failed to capture the actual impact in and palpable and tangible deliverables that translate into improved health status of our communities. Every democratic and people-oriented government ensures that the resources of the state are deployed to improve the livelihoods of the community members for whom the systems were set-up in the first place. In essence, every vertical disease intervention program besides meeting the requirements of the monitoring dashboards and bench-marking standards, should translate to qualitative improvements in the lives and livelihoods of the populace, by enhancing their collective health and wellness potential.

An Ibo proverb says that one cannot be swimming in the river, yet ends up dying from severe thirst and dehydration! Yet we have an unacceptable paradox that we have allowed for too long. Though access to malaria control intervention rose sharply between 2004 and 2007, the global malaria burden remains high based on the statistics from The World Malaria Report 2008 recently published by WHO. Admittedly, the increased funding accelerated access to malaria interventions, including bed nets and effective medicines, but we know little of how these deliverables and consumables have helped in revamping ailing health systems. A recent research published in PLoS ONE, a peer-reviewed open access journal, shows that some 35% of antimalarial drugs sold in six major African cities located in Ghana, Kenya, Nigeria, Rwanda, Tanzania, and Uganda. The study led by Dr. Roger Bate, Resident Fellow at the American Enterprise Institute , further found that artemisinin monotherapies remain common in Africa, and an estimated 200,000 avoidable deaths occur each year from use of substandard antimalarial drugs.

Such avoidable deaths may not have occurred if health systems were functional to enforce regulations and post-market surveillance as some 78% of the artemisinin monotherapies were manufactured after WHO had proscribed their manufacture in 2006. The repeated outcry by health systems strengthening “advocates” has led donor agencies to start thinking about strengthening country-wide health systems, and subsystems in recipient countries. However, this appears to be a politically-correct trite considering that donors may not easily change their bureaucratic systems to facilitate the re-aligning of their official development assistance to be in sync with the age-old systems approach to development. Do we have to wait for another long stretch of hoping for the best before the policies and institutional frameworks of donor and recipient countries unite for the common good of delivering tangible health outcomes.

This calls for a renewed thinking that ensures that the new wine is poured into a new wine skin. The global business community seems more prepared to deal with the emerging consequences of globalization referred to by experts as ‘constructive destruction’ where what exists today is destroyed for something better to emerge. The public health community needs to start thinking out of the box to maximize the huge resources available for the delivery of the health-related MDGs. The changing health trends and constant flux throws up a lot of developmental challenges that require change management expertise. Public health experts need to know that what worked yesterday may not work today, hence not applicable tomorrow.

The public health experts in donor agencies and recipient country health systems need to understudy and utilize lessons from emerging managerial approaches that have helped business stay afloat in the turbulent economic milieu of today. The days of focusing on complex operational and administrative mechanisms for health intervention programs should be over and done with. Donors and recipients have to ensure that the concept of “performance management’ truly becomes a vital part of the health system. This policy change makes it possible for harnessed resources are used to produce the right results that impact the health system positively.

In addition, efforts should be made to strengthen feedback loops, information management systems, supply chain management, budgetary and financing mechanisms that support and enhance the overall performance of the health system. The Human Resources for Health need a lot of re-engineering to ensure that the right mix of workers are deployed to address the disease burden. This will involve the use of evidence-based HR strategies that create the right culture and organizational environment that will attract and retain the health workforce whose interests and skills-set are aligned to the systems over-arching goals of delivering quality services and health outcomes. Hence a substantial part of the budget for disease intervention programs should be devoted to building the capacities and capabilities of the health workforce in-country. Though physical and non-tangible structures make up the health system, without the human resources, no tangible and lasting outcome will be derived from the system.

Felix Abrahams Obi works with the Nigeria Office of Japan International Cooperation Agency based in Abuja, and can be reached via: halal3k@yahoo.com

Robot  Villager

# 1 A great spiritual leader once taught his disciples a very useful lesson on systems approach to management. The little agrarian community in Israel had no much difficulty understanding the analogy. ...Read the full article. Posted by Robot| 26.09.2008 19:14