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Millimouno TM, Meessen B, Put WVD, Garcia M, Camara BS, Christou A, Delvaux T, Sidibé S, Beavogui AH, Delamou A. How has Guinea learnt from the response to outbreaks? A learning health system analysis. BMJ Glob Health 2023; 8:bmjgh-2022-010996. [PMID: 36854489 PMCID: PMC9980363 DOI: 10.1136/bmjgh-2022-010996] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Accepted: 01/23/2023] [Indexed: 03/02/2023] Open
Abstract
INTRODUCTION Learning is a key attribute of a resilient health system and, therefore, is central to health system strengthening. The main objective of this study was to analyse how Guinea's health system has learnt from the response to outbreaks between 2014 and 2021. METHODS We used a retrospective longitudinal single embedded case study design, applying the framework conceptualised by Sheikh and Abimbola for analysing learning health systems. Data were collected employing a mixed methods systematic review carried out in March 2022 and an online survey conducted in April 2022. RESULTS The 70 reports included in the evidence synthesis were about the 2014-2016 Ebola virus disease (EVD), Measles, Lassa Fever, COVID-19, 2021 EVD and Marburg virus disease. The main lessons were from 2014 to 2016 EVD and included: early community engagement in the response, social mobilisation, prioritising investment in health personnel, early involvement of anthropologists, developing health infrastructure and equipment and ensuring crisis communication. They were learnt through information (research and experts' opinions), action/practice and double-loop and were progressively incorporated in the response to future outbreaks through deliberation, single-loop, double-loop and triple-loop learning. However, advanced learning aspects (learning through action, double-loop and triple-loop) were limited within the health system. Nevertheless, the health system successfully controlled COVID-19, the 2021 EVD and Marburg virus disease. Survey respondents' commonly reported that enablers were the creation of the national agency for health security and support from development partners. Barriers included cultural and political issues and lack of funding. Common recommendations included establishing a knowledge management unit within the Ministry of Health with representatives at regional and district levels, investing in human capacities and improving the governance and management system. CONCLUSION Our study highlights the importance of learning. The health system performed well and achieved encouraging and better outbreak response outcomes over time with learning that occurred.
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Affiliation(s)
- Tamba Mina Millimouno
- Research Section, Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea .,Centre d'Excellence d'Afrique pour la Prévention et le Contrôle des Maladies Transmissibles (CEA-PCMT), Conakry, Guinea
| | - Bruno Meessen
- Health Systems Governance and Financing Department, World Health Organization, Geneva, Switzerland
| | - Willem Van De Put
- Public Health Department, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Marlon Garcia
- Public Health Department, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Bienvenu Salim Camara
- Research Section, Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea
| | - Aliki Christou
- Public Health Department, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Therese Delvaux
- Public Health Department, Institute of Tropical Medicine, Antwerpen, Belgium
| | - Sidikiba Sidibé
- Research Section, Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea.,Centre d'Excellence d'Afrique pour la Prévention et le Contrôle des Maladies Transmissibles (CEA-PCMT), Conakry, Guinea
| | - Abdoul Habib Beavogui
- Research Section, Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea
| | - Alexandre Delamou
- Research Section, Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea.,Centre d'Excellence d'Afrique pour la Prévention et le Contrôle des Maladies Transmissibles (CEA-PCMT), Conakry, Guinea
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Witter S, Sheikh K, Schleiff M. Learning health systems in low-income and middle-income countries: exploring evidence and expert insights. BMJ Glob Health 2022; 7:bmjgh-2021-008115. [PMID: 36130793 PMCID: PMC9490579 DOI: 10.1136/bmjgh-2021-008115] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2021] [Accepted: 02/16/2022] [Indexed: 11/29/2022] Open
Abstract
Introduction Learning health systems (LHS) is a multifaceted subject. This paper reviewed current concepts as well as real-world experiences of LHS, drawing on published and unpublished knowledge in order to identify and describe important principles and practices that characterise LHS in low/middle-income country (LMIC) settings. Methods We adopted an exploratory approach to the literature review, recognising there are limited studies that focus specifically on system-wide learning in LMICs, but a vast set of connected bodies of literature. 116 studies were included, drawn from an electronic literature search of published and grey literature. In addition, 17 interviews were conducted with health policy and research experts to gain experiential knowledge. Results The findings were structured by eight domains on learning enablers. All of these interact with one another and influence actors from community to international levels. We found that learning comes from the connection between information, deliberation, and action. Moreover, these processes occur at different levels. It is therefore important to consider experiential knowledge from multiple levels and experiences. Creating spaces and providing resources for communities, staff and managers to deliberate on their challenges and find solutions has political implications, however, and is challenging, particularly when resources are constrained, funding and accountability are fragmented and the focus is short-term and narrow. Nevertheless, we can learn from countries that have managed to develop institutional mechanisms and human capacities which help health systems respond to changing environments with ‘best fit’ solutions. Conclusion Health systems are knowledge producers, but learning is not automatic. It needs to be valued and facilitated. Everyday governance of health systems can create spaces for reflective practice and learning within routine processes at different levels. This article highlights important enablers, but there remains much work to be done on developing this field of knowledge.
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Affiliation(s)
- Sophie Witter
- Institute for Global Health and Development & ReBUILD Consortium, Queen Margaret University Edinburgh, Edinburgh, UK
| | - Kabir Sheikh
- Alliance For Health Policy and System Research, Geneva, Switzerland
| | - Meike Schleiff
- Department of International Health, Johns Hopkins School of Public Health, Baltimore, Maryland, USA
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Trapero-Bertran M, Pokhrel S, Hanney S. Research can be integrated into public health policy-making: global lessons for and from Spanish economic evaluations. Health Res Policy Syst 2022; 20:67. [PMID: 35717247 PMCID: PMC9206096 DOI: 10.1186/s12961-022-00875-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 05/27/2022] [Indexed: 11/26/2022] Open
Abstract
WHO promotes the use of research in policy-making to drive improvements in health, including in achieving Sustainable Development Goals such as tobacco control. The European Union’s new €95 billion Horizon Europe research framework programme parallels these aims, and also includes commitments to fund economic evaluations. However, researchers often express frustration at the perceived lack of attention to scientific evidence during policy-making. For example, some researchers claim that evidence regarding the return on investment from optimal implementation of evidence-based policies is frequently overlooked. An increasingly large body of literature acknowledges inevitable barriers to research use, but also analyses facilitators encouraging such use. This opinion piece describes how some research is integrated into policy-making. It highlights two recent reviews. One examines impact assessments of 36 multi-project research programmes and identifies three characteristics of projects more likely to influence policy-making. These include a focus on healthcare system needs, engagement of stakeholders, and research conducted for organizations supported by structures to receive and use evidence. The second review suggests that such characteristics are likely to occur as part of a comprehensive national health research system strategy, especially one integrated into the healthcare system. We also describe two policy-informing economic evaluations conducted in Spain. These examined the most cost-effective package of evidence-based tobacco control interventions and the cost-effectiveness of different strategies to increase screening coverage for cervical cancer. Both projects focused on issues of healthcare concern and involved considerable stakeholder engagement. The Spanish examples reinforce some lessons from the global literature and, therefore, could help demonstrate to authorities in Spain the value of developing comprehensive health research systems, possibly following the interfaces and receptor model. The aim of this would be to integrate needs assessment and stakeholder engagement with structures spanning the research and health systems. In such structures, economic evaluation evidence could be collated, analysed by experts in relation to healthcare needs, and fed into both policy-making as appropriate, and future research calls. The increasingly large local and global evidence base on research utilization could inform detailed implementation of this approach once accepted as politically desirable. Given the COVID-19 pandemic, increasing the cost-effectiveness of healthcare systems and return on investment of public health interventions becomes even more important.
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Affiliation(s)
- Marta Trapero-Bertran
- Basic Sciences Department, Patients Institute, Universitat Internacional de Catalunya, Barcelona, Spain
| | - Subhash Pokhrel
- Health Economics Research Group, Department of Health Sciences, Brunel University London, London, UK.
| | - Stephen Hanney
- Health Economics Research Group, Department of Health Sciences, Brunel University London, London, UK
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Moussallem M, Zein-El-Din A, Hamra R, Rady A, Kosremelli Asmar M, Bou-Orm IR. Evaluating the governance and preparedness of the Lebanese health system for the COVID-19 pandemic: a qualitative study. BMJ Open 2022; 12:e058622. [PMID: 35649616 PMCID: PMC9160591 DOI: 10.1136/bmjopen-2021-058622] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVES This study aimed to assess the capacities and governance of Lebanon's health system throughout the response to the COVID-19 pandemic until August 2020. DESIGN A qualitative study based on semi-structured interviews. SETTING Lebanon, February-August 2020. PARTICIPANTS Selected participants were directly or indirectly involved in the national or organisational response to the COVID-19 pandemic in Lebanon. RESULTS A total of 41 participants were included in the study. 'Hardware' capacities of the system were found to be responsive yet deeply influenced by the challenging national context. The health workforce showed high levels of resilience, despite the shortage of medical staff and gaps in training at the early stages of the pandemic. The system infrastructure, medical supplies and testing capacities were sufficient, but the reluctance of the private sector in care provision and gaps in reimbursement of COVID-19 care by many health funding schemes were the main concerns. Moreover, the public health surveillance system was overwhelmed a few months after the start of the pandemic. As for the system 'software', there were attempts for a participatory governance mechanism, but the actual decision-making process was challenging with limited cooperation and strategic vision, resulting in decreased trust and increased confusion among communities. Moreover, the power imbalance between health actors and other stakeholders affected decision-making dynamics and the uptake of scientific evidence in policy-making. CONCLUSIONS Interventions adopting a centralised and reactive approach were prominent in Lebanon's response to the COVID-19 pandemic. Better public governance and different reforms are needed to strengthen the health system preparedness and capacities to face future health security threats.
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Affiliation(s)
- Marianne Moussallem
- Higher Institute of Public Health, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Anna Zein-El-Din
- Higher Institute of Public Health, Saint-Joseph University of Beirut, Beirut, Lebanon
| | - Rasha Hamra
- World Health Organization Country Office for Lebanon, Beirut, Lebanon
| | - Alissar Rady
- World Health Organization Country Office for Lebanon, Beirut, Lebanon
| | | | - Ibrahim R Bou-Orm
- Higher Institute of Public Health, Saint-Joseph University of Beirut, Beirut, Lebanon
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
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Keugoung B, Bello KOA, Millimouno TM, Sidibé S, Dossou JP, Delamou A, Legrand A, Massat P, Gutierrez NO, Meessen B. Mobilizing health district management teams through digital tools: Lessons from the District.Team initiative in Benin and Guinea using an action research methodology. Learn Health Syst 2021; 5:e10244. [PMID: 34667871 PMCID: PMC8512739 DOI: 10.1002/lrh2.10244] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2020] [Revised: 06/07/2020] [Accepted: 08/04/2020] [Indexed: 01/13/2023] Open
Abstract
BACKGROUND Improving capacities of health systems to quickly respond to emerging health issues, requires a health information system (HIS) that facilitates evidence-informed decision-making at the operational level. In many sub-Saharan African countries, HIS are mostly designed to feed decision-making purposes at the central level with limited feedback and capabilities to take action from data at the operational level. This article presents the case of an eHealth innovation designed to capacitate health district management teams (HDMTs) through participatory evidence production and peer-to-peer exchange. METHODS We used an action research design to develop the eHealth initiative called "District.Team," a web-based and facilitated platform targeting HDMTs that was tested in Benin and Guinea from January 2016 to September 2017. On District.Team, rounds of knowledge sharing processes were organized into cycles of five steps. Quantitative and qualitative data were collected to assess the participation of HDMTs and identify enablers and barriers of using District.Team. RESULTS Participation of HDMTs in District.Team varied between cycles and steps. In Benin, 79% to 94% of HDMTs filled in the online questionnaire per cycle compared to 61% to 100% in Guinea per cycle. In Benin, 26% to 41% of HDMTs shared a commentary on the results published on the platform while 21% to 47% participated in the online discussion forum. In Guinea, only 3% to 8% of HDMTs shared a commentary on the results published on the platform while 8% to 74% participated in the online discussion forum. Five groups of factors affected the participation: characteristics of the digital tools, the quality of the facilitation, profile of participants, shared content and data, and finally support from health authorities. CONCLUSION District.Team has shown that knowledge management platforms and processes valuing horizontal knowledge sharing among peers at the decentralized level of health systems are feasible in limited resource settings.
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Affiliation(s)
- Basile Keugoung
- Health Service Delivery Community of PracticeYaoundeCameroon
| | | | - Tamba Mina Millimouno
- Centre National de Formation et de Recherche en Santé Rurale de MaferinyahForécariahGuinea
| | - Sidikiba Sidibé
- Centre National de Formation et de Recherche en Santé Rurale de MaferinyahForécariahGuinea
| | - Jean Paul Dossou
- Centre de Recherche en Reproduction Humaine et en DémographieCotonouBenin
| | - Alexandre Delamou
- Centre National de Formation et de Recherche en Santé Rurale de MaferinyahForécariahGuinea
| | | | | | | | - Bruno Meessen
- Collective HorizonLierBelgium
- Public Health DepartmentInstitute of Tropical MedicineAntwerpBelgium
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Cappabianca P, Russo GM, Atripaldi U, Gallo L, Rocco MP, Pasceri G, Karaboue MAA, Angioi S, Cappabianca S, Reginelli A. Universal Access to Advanced Imaging and Healthcare Protection: UHC and Diagnostic Imaging. Med Sci (Basel) 2021; 9:medsci9040061. [PMID: 34698209 PMCID: PMC8544360 DOI: 10.3390/medsci9040061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 09/16/2021] [Accepted: 09/18/2021] [Indexed: 11/18/2022] Open
Abstract
Universal Health Coverage (UHC) is a set of principles adopted by the World Health Organization (WHO) aimed to guarantee access to primary care for the entire world population through a range of essential health services without neglecting the diagnostic aspect. Italy is one of the signatory states, which means that diagnostic services should be appropriated and exigible throughout the national territory equally. Our research analyzed and identified the main criticalities in terms of age, territorial distribution, and technological and health appropriateness of installed Computed Tomography (CT) needed to meet the principles of UHC. Data analyzed in our study were published by Assobiomedica at the end of 2016 and by COCIR, which included and investigated the installed fleet of diagnostic equipment in the Italian sanitary system and in various European countries. The 6th point of the Alma Ata Declaration defines the concept of “primary health care”, which includes the importance of the diagnostic phase in the Italian health care system to provide Essential Levels of Assistance (LEA). It is clear from our studies that the technology at the national level is not adequate to satisfy the UHC principles or the European criteria, with negative effects on the diagnostic standards and on advanced screenings. This study conducted on the installed CTs in Italy at the end of 2016 confirms the persistence of progressive aging that has been recorded for several years in the health facilities of the country and suggests incentive policies for the replacement of obsolete equipment, which represent a form of investment rather than a cost, due to the nature of the expenditure itself, one-off and amortizable over time.
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Affiliation(s)
- Pietro Cappabianca
- Centro Interdipartimentale di Ricerche Neurologiche, Università degli Studi della Campania "Luigi Vanvitelli", 80121 Napoli, Italy
| | - Gaetano Maria Russo
- Dipartimento di Medicina di Precisione, Università degli Studi della Campania Luigi Vanvitelli, 80121 Napoli, Italy
| | - Umberto Atripaldi
- Dipartimento di Medicina di Precisione, Università degli Studi della Campania Luigi Vanvitelli, 80121 Napoli, Italy
| | - Luigi Gallo
- Dipartimento di Medicina di Precisione, Università degli Studi della Campania Luigi Vanvitelli, 80121 Napoli, Italy
| | - Maria Paola Rocco
- Dipartimento di Medicina di Precisione, Università degli Studi della Campania Luigi Vanvitelli, 80121 Napoli, Italy
| | - Giovanni Pasceri
- Facoltà di Medicina e Chirurgia, Università Vita-Salute San Raffaele, 20132 Milano, Italy
| | - Michele A A Karaboue
- Sezione Medicina Legale, Dipartimento Medicina Sperimentale "L. Vanvitelli", Università degli Studi della Campania Luigi Vanvitelli, 80121 Napoli, Italy
| | - Silvia Angioi
- Dipartimento di Scienze Politiche "Jean Monnet", Università degli Studi della Campania Luigi Vanvitelli, 80121 Napoli, Italy
| | - Salvatore Cappabianca
- Dipartimento di Medicina di Precisione, Università degli Studi della Campania Luigi Vanvitelli, 80121 Napoli, Italy
| | - Alfonso Reginelli
- Dipartimento di Medicina di Precisione, Università degli Studi della Campania Luigi Vanvitelli, 80121 Napoli, Italy
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Sarakbi D, Mensah-Abrampah N, Kleine-Bingham M, Syed SB. Aiming for quality: a global compass for national learning systems. Health Res Policy Syst 2021; 19:102. [PMID: 34281534 PMCID: PMC8287697 DOI: 10.1186/s12961-021-00746-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2020] [Accepted: 06/23/2021] [Indexed: 12/17/2022] Open
Abstract
INTRODUCTION Transforming a health system into a learning one is increasingly recognized as necessary to support the implementation of a national strategic direction on quality with a focus on frontline experience. The approach to a learning system that bridges the gap between practice and policy requires active exploration. METHODS This scoping review adapted the methodological framework for scoping studies from Arksey and O'Malley. The central research question focused on common themes for learning to improve the quality of health services at all levels of the national health system, from government policy to point-of-care delivery. RESULTS A total of 3507 records were screened, resulting in 101 articles on strategic learning across the health system: health professional level (19%), health organizational level (15%), subnational/national level (26%), multiple levels (35%), and global level (6%). Thirty-five of these articles focused on learning systems at multiple levels of the health system. A national learning system requires attention at the organizational, subnational, and national levels guided by the needs of patients, families, and the community. The compass of the national learning system is centred on four cross-cutting themes across the health system: alignment of priorities, systemwide collaboration, transparency and accountability, and knowledge sharing of real-world evidence generated at the point of care. CONCLUSION This paper proposes an approach for building a national learning system to improve the quality of health services. Future research is needed to validate the application of these guiding principles and make improvements based on the findings.
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Affiliation(s)
- Diana Sarakbi
- Health Quality Programs, Queen's University, Kingston, Canada.
- Health Quality Programs, Queen's University, Cataraqui Building, 92 Barrie Street, Kingston, ON, K7L 3N6, Canada.
| | | | | | - Shams B Syed
- Integrated Health Services, World Health Organization, Geneva, Switzerland
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Belghiti Alaoui A, De Brouwere V, Meessen B, Bigdeli M. Decision-making and health system strengthening: bringing time frames into perspective. Health Policy Plan 2021; 35:1254-1261. [PMID: 33450766 PMCID: PMC7810387 DOI: 10.1093/heapol/czaa086] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/10/2020] [Indexed: 01/20/2023] Open
Abstract
In many low-and middle-income countries, health systems decision-makers are facing a host of new challenges and competing priorities. They must not only plan and implement as they used to do but also deal with discontented citizens and health staff, be responsive and accountable. This contributes to create new political hazards susceptible to disrupt the whole execution of health plans. The starting point of this article is the observation by the first author of the limitations of the building-blocks framework to structure decision-making as for strengthening of the Moroccan health system. The management of a health system is affected by different temporalities, the recognition of which allows a more realistic analysis of the obstacles and successes of health system strengthening approaches. Inspired by practice and enriched thanks a consultation of the literature, our analytical framework revolves around five dynamics: the services dynamic, the programming dynamic, the political dynamic, the reform dynamic and the capacity-building dynamic. These five dynamics are differentiated by their temporalities, their profile, the role of their actors and the nature of their activities. The Moroccan experience suggests that it is possible to strengthen health systems by opening up the analysis of temporalities, which affects both decision-making processes and the dynamics of functioning of health systems.
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Affiliation(s)
| | | | - Bruno Meessen
- World Health Organization, Health Systems, Governance and Financing, Genève
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Akhnif EH, Hachri H, Belmadani A, Mataria A, Bigdeli M. Policy dialogue and participation: a new way of crafting a national health financing strategy in Morocco. Health Res Policy Syst 2020; 18:114. [PMID: 32993697 PMCID: PMC7523367 DOI: 10.1186/s12961-020-00629-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Accepted: 09/07/2020] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Policy dialogue for health policies has started to gain importance in recent years, especially for complex issues such as health financing. Moroccan health financing has faced several challenges during the last years. This study aims to document the Moroccan experience in developing a consolidated health financing strategy according to the policy dialogue approach. It especially considers the importance of conceptualising this process in the Moroccan context. METHOD We documented the process of developing a health financing strategy in Morocco. It concerned four steps, as follows: (1) summarising health financing evidence in preparation of the policy dialogue; (2) organising the health policy dialogue process with 250 participants (government, private sector, NGOs, civil society, parliamentarians, technical and financial partners); (3) a technical workshop to formulate the strategy actions; and (4) an ultimate workshop for validation with decision-makers. The process lasted 1 year from March 2019 to February 2020. We have reviewed all documents related to the four steps of the process through our active participation in the policy debate and the documentation of two technical workshops to produce the strategy document. RESULTS The policy dialogue approach showed its usefulness in creating convergence among all health actors to define a national shared vision on health financing in Morocco. There was a high political commitment in the process and all actors officially adopted recommendations on health financing actions. A strategy document produced within a collaborative approach was the final output. This experience also marked a shift from previous top-down approaches in designing health policies for more participation and inclusion. The evidence synthesis played a crucial role in facilitating the debate. The collaborative approach seems to work in favouring national consensus on practical health financing actions. CONCLUSION The policy dialogue process adopted for health financing in Morocco helped to create collective ownership of health financing actions. Despite the positive results in terms of national mobilisation around the health financing vision in Morocco, there is a need to institutionalise the policy dialogue with a more decentralised approach to consider subnational specificities.
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Affiliation(s)
- El Houcine Akhnif
- World Health Organization Country Office of Morocco, 3 Avenue S.A.R. Sidi Mohamed, Rabat, Morocco
| | - Hafid Hachri
- World Health Organization Country Office of Morocco, 3 Avenue S.A.R. Sidi Mohamed, Rabat, Morocco
| | - Abdelouahab Belmadani
- Ministry of Health, Directorate of Planning of Financial Resources, 335, Avenue Mohamed V, Rabat, Morocco
| | - Awad Mataria
- World Health Organization Regional Office for the Eastern Mediterranean, PO Box 7608, Nasr City, Cairo 11371 Egypt
| | - Maryam Bigdeli
- World Health Organization Country Office of Morocco, 3 Avenue S.A.R. Sidi Mohamed, Rabat, Morocco
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Kiendrébéogo JA, De Allegri M, Meessen B. Policy learning and Universal Health Coverage in low- and middle-income countries. Health Res Policy Syst 2020; 18:85. [PMID: 32693808 PMCID: PMC7374847 DOI: 10.1186/s12961-020-00591-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Accepted: 06/18/2020] [Indexed: 01/18/2023] Open
Abstract
Learning is increasingly seen as an essential component to spur progress towards universal health coverage (UHC) in low- and middle-income countries (LMICs). However, learning remains an elusive concept, with different understandings and uses that vary from one person or organisation to another. Specifically, it appears that 'learning for UHC' is dominated by the teacher mode - notably scientists and experts as 'teachers' conveying to local decision/policy-makers as 'learners' what to do. This article shows that, to meet countries' needs, it is important to acknowledge that UHC learning situations are not restricted to the most visible epistemic learning approach practiced today. This article draws on an analytical framework proposed by Dunlop and Radaelli, whereby they identified four learning modes that can emerge according to the specific characteristics of the policy process: epistemic learning, learning in the shadow of hierarchy, learning through bargaining and reflexive learning. These learning modes look relevant to help widen the learning prospects that LMICs need to advance their UHC agenda. Actually, they open up new perspectives in a research field that, until now, has appeared scattered and relatively blurry.
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Affiliation(s)
- Joël Arthur Kiendrébéogo
- Department of Public Health, Health Sciences Training and Research Unit, University Joseph Ki-Zerbo, Ouagadougou, Burkina Faso.
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium.
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany.
| | - Manuela De Allegri
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Bruno Meessen
- Health Systems Governance and Financing, WHO, Geneva, Switzerland
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Sheikh K, Agyepong I, Jhalani M, Ammar W, Hafeez A, Pyakuryal S, Abimbola S, Ghaffar A, Swaminathan S. Learning health systems: an empowering agenda for low-income and middle-income countries. Lancet 2020; 395:476-477. [PMID: 32061280 DOI: 10.1016/s0140-6736(19)33134-4] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2019] [Accepted: 12/12/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Kabir Sheikh
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva 1211, Switzerland.
| | | | - Manoj Jhalani
- Ministry of Health and Family Welfare, Government of India, New Delhi, India
| | - Walid Ammar
- Ministry of Public Health, Government of Lebanon, Beirut, Lebanon
| | - Assad Hafeez
- Ministry of Health, Government of Pakistan, Islamabad, Pakistan
| | - Sushil Pyakuryal
- Ministry of Health and Population, Government of Nepal, Kathmandu, Nepal
| | - Seye Abimbola
- School of Public Health, University of Sydney, Sydney, NSW, Australia
| | - Abdul Ghaffar
- Alliance for Health Policy and Systems Research, World Health Organization, Geneva 1211, Switzerland
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Meessen B, Akhnif ELH, Kiendrébéogo JA, Belghiti Alaoui A, Bello K, Bhattacharyya S, Faich Dini HS, Dkhimi F, Dossou JP, Gamble Kelley A, Keugoung B, Millimouno TM, Pfaffmann Zambruni J, Rouve M, Sieleunou I, van Heteren G. Learning for Universal Health Coverage. BMJ Glob Health 2019; 4:e002059. [PMID: 31908875 PMCID: PMC6936401 DOI: 10.1136/bmjgh-2019-002059] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 11/15/2019] [Accepted: 11/17/2019] [Indexed: 12/04/2022] Open
Abstract
The journey to universal health coverage (UHC) is full of challenges, which to a great extent are specific to each country. 'Learning for UHC' is a central component of countries' health system strengthening agendas. Our group has been engaged for a decade in facilitating collective learning for UHC through a range of modalities at global, regional and national levels. We present some of our experience and draw lessons for countries and international actors interested in strengthening national systemic learning capacities for UHC. The main lesson is that with appropriate collective intelligence processes, digital tools and facilitation capacities, countries and international agencies can mobilise the many actors with knowledge relevant to the design, implementation and evaluation of UHC policies. However, really building learning health systems will take more time and commitment. Each country will have to invest substantively in developing its specific learning systemic capacities, with an active programme of work addressing supportive leadership, organisational culture and knowledge management processes.
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Affiliation(s)
| | | | - Joël Arthur Kiendrébéogo
- Department of Public Health, University Joseph Ki-Zerbo,Health Sciences Training and Research Unit, Ouagadougou, Burkina Faso
- Heidelberg Institute of Global Health, Medical Faculty and University Hospital, Heidelberg University, Heidelberg, Germany
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | | | - Kefilath Bello
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Public Health, Centre de recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| | - Sanghita Bhattacharyya
- Collective Horizon, New Delhi, India
- Community Health Community of Practice, New Delhi, India
| | | | | | - Jean-Paul Dossou
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
- Public Health, Centre de recherche en Reproduction Humaine et en Démographie, Cotonou, Benin
| | | | | | - Tamba Mina Millimouno
- Centre National de Formation et de Recherche en Santé Rurale de Maferinyah, Forécariah, Guinea
| | | | - Maxime Rouve
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Isidore Sieleunou
- Médecine Sociale et Préventive, Université de Montréal, Ecole de Sante Publique, Montreal, Quebec, Canada
- Collective Horizon, Montreal, Québec, Canada
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D’Ambruoso L, van der Merwe M, Wariri O, Byass P, Goosen G, Kahn K, Masinga S, Mokoena V, Spies B, Tollman S, Witter S, Twine R. Rethinking collaboration: developing a learning platform to address under-five mortality in Mpumalanga province, South Africa. Health Policy Plan 2019; 34:418-429. [PMID: 31243457 PMCID: PMC6736195 DOI: 10.1093/heapol/czz047] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/11/2019] [Indexed: 01/08/2023] Open
Abstract
Following 50 years of apartheid, South Africa introduced visionary health policy committing to the right to health as part of a primary health care (PHC) approach. Implementation is seriously challenged, however, in an often-dysfunctional health system with scarce resources and a complex burden of avoidable mortality persists. Our aim was to develop a process generating evidence of practical relevance on implementation processes among people excluded from access to health systems. Informed by health policy and systems research, we developed a collaborative learning platform in which we worked as co-researchers with health authorities in a rural province. This article reports on the process and insights brought by health systems stakeholders. Evidence gaps on under-five mortality were identified with a provincial Directorate after which we collected quantitative and qualitative data. We applied verbal autopsy to quantify levels, causes and circumstances of deaths and participatory action research to gain community perspectives on the problem and priorities for action. We then re-convened health systems stakeholders to analyse and interpret these data through which several systems issues were identified as contributory to under-five deaths: staff availability and performance; service organization and infrastructure; multiple parallel initiatives; and capacity to address social determinants. Recommendations were developed ranging from immediate low- and no-cost re-organization of services to those where responses from higher levels of the system or outside were required. The process was viewed as acceptable and relevant for an overburdened system operating 'in the dark' in the absence of local data. Institutional infrastructure for evidence-based decision-making does not exist in many health systems. We developed a process connecting research evidence on rural health priorities with the means for action and enabled new partnerships between communities, authorities and researchers. Further development is planned to understand potential in deliberative processes for rural PHC.
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Affiliation(s)
- Lucia D’Ambruoso
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Department of Public Health and Clinical Medicine, Umeå Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
| | - Maria van der Merwe
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Oghenebrume Wariri
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Medical Research Council (MRC) Unit, The Gambia at London School of Hygiene and Tropical Medicine (LSHTM), London, UK
| | - Peter Byass
- Centre for Global Development and Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
- Department of Public Health and Clinical Medicine, Umeå Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
| | - Gerhard Goosen
- Mpumalanga Department of Health, Nelspruit, South Africa
| | - Kathleen Kahn
- Department of Public Health and Clinical Medicine, Umeå Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | | | | | - Barry Spies
- Mpumalanga Department of Health, Nelspruit, South Africa
| | - Stephen Tollman
- Department of Public Health and Clinical Medicine, Umeå Centre for Global Health Research, Epidemiology and Global Health, Umeå University, Umeå, Sweden
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
- INDEPTH Network, Accra, Ghana
| | - Sophie Witter
- Institute for Global Health and Development, Queen Margaret University, Edinburgh, UK
| | - Rhian Twine
- MRC/Wits Rural Public Health and Health Transitions Research Unit (Agincourt), School of Public Health, University of the Witwatersrand, Johannesburg, Johannesburg, South Africa
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Akhnif E, Macq J, Meessen B. The place of learning in a universal health coverage health policy process: the case of the RAMED policy in Morocco. Health Res Policy Syst 2019; 17:21. [PMID: 30791925 PMCID: PMC6383252 DOI: 10.1186/s12961-019-0421-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2018] [Accepted: 02/05/2019] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND To progress towards universal health coverage (UHC), each country will have to develop its systemic learning capacity. This study aims at documenting how, across time, learning can feed into a UHC policy process, and how the latter can itself strengthen (or not) the learning capacity of the health system. It specifically focuses on the development of a major health financing policy aligned with the UHC goal in Morocco, the RAMED, a health financing scheme covering hospital costs for the poorest segment of the population. METHODS We conducted a retrospective analysis of the RAMED policy for the period between 1997 and 2018, along with a case study design. For the data collection and analysis, we developed a framework combining Garvin's learning organisation framework and the heuristic health policy analysis framework. We gathered data from key informants and document reviews. RESULTS The study confirmed the importance of learning during the different stages of the RAMED policy process. There is evidence of a leadership encouraging learning, the introduction and adoption of knowledge management processes, and the start of a transformation of the administrative culture. Yet, our study also showed some major shortcomings, especially the lack of structure of the learning, and insufficient effort to systemise and sustain a transformation of practices within the health administration. Our study also confirms that the learning changes in nature across the different stages of the policy process. CONCLUSION The policy decisions and the implementation strategy create a learning dynamic, though not structured in all cases. Despite the positive interaction between learning and the RAMED policy, the opportunity to push forward a more structural transformation towards a learning system has not been fully seized. Hierarchical logics still largely prevail in the Moroccan health administration. The impact of future health policies for both the target beneficiaries and the health system will be bigger if their design integrates purposeful and structured actions in favour of organisational learning. This recommendation probably applies beyond Morocco.
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Affiliation(s)
- E. Akhnif
- School of Public Health, Rue Lamfadel Cherkaoui, Madinat Al Irfane, BP-6329 Rabat, Morocco
- IRSS - Clos Chapelle-aux-champs 30 bte B1.30.13 à 1200 Woluwe-Saint-Lambert, Université Catholique de Louvain (UCL) Ottignies-Louvain-la-Neuve, Brussels, Belgium
- Institute of Tropical Medicine, Antwerp, Belgium
| | - J. Macq
- IRSS - Clos Chapelle-aux-champs 30 bte B1.30.13 à 1200 Woluwe-Saint-Lambert, Université Catholique de Louvain (UCL) Ottignies-Louvain-la-Neuve, Brussels, Belgium
| | - Bruno Meessen
- Institute of Tropical Medicine, Antwerp, Belgium
- Community of Practice ‘Performance-Based Financing’, Antwerp, Belgium
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Naimoli JF, Saxena S. Realizing their potential to become learning organizations to foster health system resilience: opportunities and challenges for health ministries in low- and middle-income countries. Health Policy Plan 2018; 33:1083-1095. [DOI: 10.1093/heapol/czy100] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/12/2018] [Indexed: 11/14/2022] Open
Affiliation(s)
| | - Sweta Saxena
- Bureau for Asia/Technical Services, US Agency for International Development, 1300 Pennsylvania Avenue, Washington, DC, USA
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Meessen B. The Role of Digital Strategies in Financing Health Care for Universal Health Coverage in Low- and Middle-Income Countries. GLOBAL HEALTH, SCIENCE AND PRACTICE 2018; 6:S29-S40. [PMID: 30305337 PMCID: PMC6203415 DOI: 10.9745/ghsp-d-18-00271] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 09/12/2018] [Indexed: 11/15/2022]
Abstract
Countries finance health care using a combination of 3 main functions: raising resources for health, pooling resources, and purchasing health services. In this paper, we examine how digital health technologies can be used to enhance these health financing functions in low- and middle-income countries and can thus contribute to progress toward universal health coverage. We illustrate our points by presenting some recent innovations in digital technologies for financing health care, identifying their contributions and their limits. Some examples include a mobile-health wallet application used in Kenya that encourages households to put money aside for future health expenses; an online software platform developed by a startup in Tanzania in partnership with a private insurance provider to give individuals and families the opportunity to choose among different health coverage options; and digital maps by a number of startups that bring together data on health facility locations and capacity, including equipment, staff, and types of services offered. We also sketch an agenda for future research and action for digital strategies for health financing. The development and adoption of effective solutions that align well with the universal health coverage agenda will require strong partnerships between stakeholders and enough proactive stewardship by authorities.
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