Merlin believes it is important to adopt a long-term vision for health systems in fragile states from the earliest opportunity. Fiona Campbell, Head of Policy, shares Merlin’s experiences of working in different contexts to try to do this. She argues that NGO responses should aim to realise this vision and that funders should be more adaptable to support long-term capacity strengthening.
Merlin works predominately in ‘fragile states’ 1. These are some of the poorest and most disaster-affected countries and have a disproportionately high level of maternal and child mortality and morbidity. They lag furthest behind in meeting the Millennium Development Goal targets (DFID, 2010) 2. A functioning health system in these contexts is vital. It is also critical in reducing the risk from future disasters. Often this is challenging. In many places, the health system is unable to provide even the most basic package of health care for the population.
What is a ‘health system’?
Health systems can be understood in many ways. Merlin uses the World Health Organization’s definition; ‘all the organisations, institutions, and resources that are devoted to producing health actions’ (WHO, 2000) 3. This includes all actors involved in providing and funding health services in the public or private sectors. It encompasses all levels from the household, community, district, regional and central levels.
The health system is made of a number of building blocks and functions, which together ensure that the system is able to respond to the health needs of the population. They include: how services are managed to ensure access, quality and safety of health care (service delivery); how the health system is staffed (health workforce); how information and evidence is generated and used to make decisions on health care provision and performance (health information); how access to essential drugs and technology is provided (medical products); how the funds are raised and allocated to ensure equitable access to health (health financing); and how the system is governed and managed (leadership and governance) (WHO, 2007) 4.
A volunteer nurse reads a thermometer at the People's United Community Clinic,
Monrovia, Liberia.
Photo: Tugela Ridley/Merlin
How does Merlin work to strengthen health systems?
For Merlin, a health system strengthening approach means working within the existing health system to build capacity at all levels, from the earliest opportunity. A key component of the approach, where and when appropriate, is working in partnership with the Ministry of Health (Merlin, 2008) 5.
Merlin’s experience of working in Liberia for over 15 years shows the need to adapt to changing contexts over time, and in particular the changing role of the Ministry of Health. Merlin’s initial response was to meet the health needs of a population in the midst of a violent conflict which left nearly one million people displaced. The health system was disrupted through loss of health staff and the destruction and looting of clinics and hospitals. Merlin responded by supporting health services in two counties through clinics and hospitals owned by the Ministry of Health. Merlin’s programmes provided support to the health facilities and staff including drugs and equipment, supervision and mentoring as well as incentive payments to staff to top up their very poor salaries.
Over the years Merlin expanded its programme to cover six (out of 15) counties in Liberia and continued to strengthen existing health facilities and the delivery of health care. However, with increased Ministry of Health engagement, the focus has shifted from Merlin as implementer to Merlin implementing with the MoH, supporting the capacity of the Ministry of Health and Social Welfare to manage the services in the longer term. Merlin is currently doing this through a ‘counterpart approach’ that supports the Ministry in its decentralisation process. The programme is working to enhance the capacity of county health teams to effectively handle health service delivery at the county level. This shift has taken time to make and the experience has illustrated that it is important to monitor the context and available capacity constantly, to make best use of the windows of opportunity that exist as soon as the context allows.
This experience, similar to others in fragile states, shows the importance of recognising that although the health system is weak, some aspects of the system exist at some level. For example, these might be policies and protocols (although they may be outdated); infrastructure such as health facilities and equipment (although it may be in need of refurbishment or repair); health staff (although they may be under-supported, both financially and in terms of professional support). Ensuring that interventions are provided within the current system, however weak, is vital to the long-term strengthening of the system.
Interventions could include: using available protocols and policies; mapping existing infrastructure and health staff and working with them, such as through training and supervision/mentoring support; using Ministry of Health budgeting and planning cycles when developing programmes and sharing budgets and plans with Ministry of Health personnel; piloting innovative or other new approaches to the provision of quality care; and using the lessons learnt to influence changes within the system.
In some cases it may be possible to strengthen the overall building blocks themselves, such as the health workforce system or the health financing system. Actions that can help support this include helping to develop national health human resource plans and supporting more equitable national health financing policies.
Challenges
Strengthening the health system in fragile states is not without difficulties. Support is required over multiple areas and levels and many years. The dominance of humanitarian funding, with its short timeframes (three to nine months is common) often limits opportunities for agencies to ensure a capacity strengthening focus to their approach. Guidelines often restrict the nature of the activities that can be supported, prioritising service delivery over capacity strengthening. For example, Merlin has operated in Eastern Democratic Republic of Congo since the mid 1990s, working closely with the Ministry of Health to support health facilities, including at hospital level. In 2002 Merlin approached a donor to support access to referral services in selected health zones in Maniema province. It was agreed that over a three-year period Merlin would rehabilitate and equip the hospital, improve access to referral services and set up effective management systems within the hospital. The project was implemented in three phases (each with its own proposal and exit strategy) and the final 12 month phase was extended for a further 34 months on a series of cost and no cost and risk extensions, with no individual period greater than seven months. A fourth phase (2008-2011), supporting the systematic handover of responsibility for the management of the hospital to the hospital management team is currently running.
In total Merlin has been supporting the hospital and surrounding health facilities for nearly 10 years, but the proposals and the funding have not been developed with this longer term engagement in mind. The question for Merlin and donors is what more could have been done if we had planned for this period of engagement at the beginning and had set expectations and timeframes (with the necessary funding) accordingly?
In summary, it is vital that NGOs and other actors are able to provide support for both the immediate and long-term health needs of people in fragile states. This means working in partnership with the Ministry of Health, where appropriate, strengthening existing structures and systems, and crucially, having the right support and understanding from donors to be able to take a long-term perspective.
Fiona Campbell
References
1 DFID defines fragile states as those countries where the government is either unable or unwilling to delivery core functions to the majority of its people including the poor (DFID, 2005)
2 DFID Agenda 2010. Background paper on conflict affected and fragile countries (2010)
3 World Health Organisation The world health report 2000 – Health systems: improving performance (WO: Geneva) http://www.who.int/whr/2000/en/
4 WHO Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action (WHO: Geneva) (2007) http://www.who.int/healthsystems/strategy/everybodys_business.pdf
5 Merlin Health and Policy Department. Review of Merlin’s partnership with Ministries of Health. (Internal document) (April 2008)
Filed under: Emergencies Tagged: | capacity strengthening, emergencies, fragile states, health systems
