An excerpt from "Investing in Our Common Future", a background paper of the Innovation Working Group under the UN's Global Strategy for Women's and Children's Health:
http://www.google.ca/url?sa=t&rct=j&q=rohit%20ramchandani%20%2B%20asia&source=web&cd=8&ved=0CFIQFjAH&url=http%3A%2F%2Fwww.who.int%2Fentity%2Fpmnch%2Factivities%2Fjointactionplan%2F100922_2_investing.pdf&ei=GSQ9T4L2J6nL0QGcg8C_Bw&usg=AFQjCNG_tJul1hfvf1ZH5tWRb0958396CA&cad=rja
10. Innovation in Service Delivery, 2009
Rohit Ramchandani, MPH. Senior Health Analyst, Strategic Policy and Performance Branch, Canadian International Development Agency (CIDA) and DrPH Candidate, Johns Hopkins Bloomberg School of Public Health
At no point in history has the world been so focused on improving health and averting unnecessary loss of life. Millions of preventable deaths occur each year throughout the developing world from diseases like malaria, AIDS and tuberculosis, and because many of the world’s poor lack access to appropriate maternal and child health services. To counter this, major investments are being made to provide care and discover new treatments and technologies for the future. This new paradigm has the potential to save millions of lives, but it also draws attention to our ability (or lack thereof) to utilize new investments effectively, and to deliver health services systematically to those who need them most.
This paper aims to highlight examples of innovations in service delivery based on the experiences of the Canadian International Development Agency (CIDA). Under the Innovation Working Group’s working definition, “innovation” is:
“ ... generally understood as the successful introduction of a new thing or method ... Innovation is the embodiment, combination, or synthesis of knowledge in original, relevant, valued new products, processes, or services.”
In addition, we highlight “innovations” that, while not necessarily “new”, could have benefits through replication and/or scale-up at the global level.
Innovations
The Reach Every District (RED) approach69
Developed by WHO and UNICEF, the RED approach addresses common obstacles to increasing immunization coverage by building district capacity and focusing on planning and monitoring. The approach emerged from a search for innovative strategies to improve stagnating immunization coverage. Based on the successful approaches of the Global Polio Eradication Initiative, and taking the district as the operational level, RED includes five components:
Planning and management of resources
Supportive supervision
Re-establishing outreach services
Linking services with communities
Monitoring for action
Previously, regional and other inequalities in access to vaccines within a country were masked by the focus on national immunization coverage rates.70 However, the RED approach increases equity of access within countries by concentrating efforts, and setting targets, at the district level. Within each district, it improves the targeting of hard-to-reach populations with limited or no access to health services.
Focus on the poorest quintile and mobile services
It is of paramount importance to improve access to care, particularly for the most vulnerable and hard-to-reach populations, if we are to accelerate progress towards the health-related MDGs. Mobile services have an important role to play here.
Engaging civil society organizations (CSOs)
Essential health interventions are still not reaching the poorest fifth of the population in many areas that account for the highest number of deaths. To counter this, CIDA has a program that engages in-country CSOs to deliver life-saving health services, such as anti- malarial drugs, antibiotics to treat respiratory infections and oral rehydration therapy (ORT) to treat diarrhea-related dehydration. CSOs already deliver a large proportion of front-line health care throughout the developing world71, in countries such as Sierra Leone, Uganda, and Indonesia. Their involvement alongside government institutions is expected to have a catalytic effect on strengthening the reach of programming and research72, and is expected to increase sustainability.
Using mobile clinics
Mobile clinics are run by teams of multi-disciplinary health professionals, such as community health workers, nurses and midwives. Their use during periods of humanitarian crisis has the potential to deliver maternal, newborn and child health (MNCH) services effectively in conflict areas and fragile states. As an example, CIDA and UNICEF are collaborating to expand coverage of child survival interventions by establishing sustainable outreach services (SOS) in under-served and rural communities of Kandahar province in Afghanistan.
Linking services with communities
Monitoring for action
Previously, regional and other inequalities in access to vaccines within a country were masked by the focus on national immunization coverage rates.70 However, the RED approach increases equity of access within countries by concentrating efforts, and setting targets, at the district level. Within each district, it improves the targeting of hard-to-reach populations with limited or no access to health services.
Focus on the poorest quintile and mobile services
It is of paramount importance to improve access to care, particularly for the most vulnerable and hard-to-reach populations, if we are to accelerate progress towards the health-related MDGs. Mobile services have an important role to play here.
Engaging civil society organizations (CSOs)
Essential health interventions are still not reaching the poorest fifth of the population in many areas that account for the highest number of deaths. To counter this, CIDA has a program that engages in-country CSOs to deliver life-saving health services, such as anti- malarial drugs, antibiotics to treat respiratory infections and oral rehydration therapy (ORT) to treat diarrhea-related dehydration. CSOs already deliver a large proportion of front-line health care throughout the developing world71, in countries such as Sierra Leone, Uganda, and Indonesia. Their involvement alongside government institutions is expected to have a catalytic effect on strengthening the reach of programming and research72, and is expected to increase sustainability.
Using mobile clinics
Mobile clinics are run by teams of multi-disciplinary health professionals, such as community health workers, nurses and midwives. Their use during periods of humanitarian crisis has the potential to deliver maternal, newborn and child health (MNCH) services effectively in conflict areas and fragile states. As an example, CIDA and UNICEF are collaborating to expand coverage of child survival interventions by establishing sustainable outreach services (SOS) in under-served and rural communities of Kandahar province in Afghanistan.
Local involvement is key to the success of SOS. Accordingly, community elders are encouraged
to participate in planning and to help identify community focal points. Mobile teams of health
workers go from village to village providing services at least four times per year. During
these visits, health workers deliver immunizations and bi-annual de-worming tablets for
children under five, and insecticide-treated bednets (ITNs) during seasons of high malaria
transmission. They also identify suitable local individuals and train them to establish bases
for the demonstration and distribution of ORT salts, micro-nutrients and zinc supplements.
These services are building on the earlier experiences of the Pulse Immunization Campaigns,
which used community structures as partners for planning and implementation.
Along with existing health facilities, SOS are ensuring access to health interventions for over 156,000 children under five, and approximately 29,000 pregnant women living in Kandahar province.73 Through these mobile services, UNICEF is now able to reach 15 of Kandahar’s 17 districts.74
Community support and strong connections to the national system are essential, especially as the security situation remains a central challenge. Moreover, discussions with community leaders have helped to improve the reach of services. Nevertheless, there are still issues to overcome, such as the difficulty of recruiting female vaccinators due to cultural barriers and insecurity. These issues need to be addressed if services are to be expanded to include more comprehensive disease prevention, health promotion, family planning and reproductive care.
Integrated community case management (iCCM)
iCCM is a cost-effective, high-impact approach that aims to prevent and treat those diseases that kill the most children, including malaria, pneumonia and diarrhea. It works by training and equipping community health workers to diagnose and treat these diseases, which together kill approximately four million children each year, and account for over 40% of deaths among the under-fives.75 Malaria and pneumonia can be fatal in children within 24 hours of symptoms developing, so treatment must be made available promptly if lives are to be saved.
iCCM is a proven strategy for reaching children at the community level and overcoming barriers to accessing care. It supports programs that achieve high equity because they reach the most vulnerable. They can also be a platform for other key interventions, such as screening for severe acute malnutrition, delivering vitamin A supplements and injectable antibiotics (for neonatal sepsis), and supporting immunization and ITN campaigns. This type of programming is also a focus of the Catalytic Initiative to Save a Million Lives, which is being implemented in countries including Rwanda, Southern Sudan, Malawi, Mali and Sierra Leone.
Along with existing health facilities, SOS are ensuring access to health interventions for over 156,000 children under five, and approximately 29,000 pregnant women living in Kandahar province.73 Through these mobile services, UNICEF is now able to reach 15 of Kandahar’s 17 districts.74
Community support and strong connections to the national system are essential, especially as the security situation remains a central challenge. Moreover, discussions with community leaders have helped to improve the reach of services. Nevertheless, there are still issues to overcome, such as the difficulty of recruiting female vaccinators due to cultural barriers and insecurity. These issues need to be addressed if services are to be expanded to include more comprehensive disease prevention, health promotion, family planning and reproductive care.
Integrated community case management (iCCM)
iCCM is a cost-effective, high-impact approach that aims to prevent and treat those diseases that kill the most children, including malaria, pneumonia and diarrhea. It works by training and equipping community health workers to diagnose and treat these diseases, which together kill approximately four million children each year, and account for over 40% of deaths among the under-fives.75 Malaria and pneumonia can be fatal in children within 24 hours of symptoms developing, so treatment must be made available promptly if lives are to be saved.
iCCM is a proven strategy for reaching children at the community level and overcoming barriers to accessing care. It supports programs that achieve high equity because they reach the most vulnerable. They can also be a platform for other key interventions, such as screening for severe acute malnutrition, delivering vitamin A supplements and injectable antibiotics (for neonatal sepsis), and supporting immunization and ITN campaigns. This type of programming is also a focus of the Catalytic Initiative to Save a Million Lives, which is being implemented in countries including Rwanda, Southern Sudan, Malawi, Mali and Sierra Leone.
Child Health Days and Weeks (CHDW) as a service delivery platform
CHDW programs provide the main mechanism for distributing vitamin A supplements. They involve events organized to deliver an integrated, community-based package of low-cost, high-impact health and nutrition interventions for children aged from six months to five years. Other services, such as malaria prevention and immunization, are also provided and have helped to reduce inequities in service coverage by increasing the access of communities in poor and low-performing districts. In fact, the average coverage achieved by CHDW programs has been over 80%.76 Canada was one of the first countries to fund CHDW and provide it with the impetus to reach countries such as Ethiopia, Madagascar, Mali, Mozambique, Tanzania, Zambia, Nigeria and Niger.
Studies should be undertaken into costing, cost-effectiveness and impact to consider CHDW as a platform for other health and nutrition interventions for MNCH. These might include: distribution of ORT salts to combat diarrheal diseases; promotion of iodized salt consumption; screening for and treatment of severe acute malnutrition; promotion of hand washing with soap; antibiotics to fight pneumonia; family planning; promotion of exclusive breastfeeding; complementary feeding; and/or provision of antenatal care.77
Global Polio Eradication Initiative (GPEI) – an established program leads to innovation in service integration and health systems strengthening
GPEI is the largest single public health project the world has ever known. Coordinated internationally, it is spearheaded by national governments, WHO, Rotary International, the Centers for Disease Control and Prevention (CDC) and UNICEF. Its work to strengthen immunization services can accelerate progress towards the Millennium Development Goals (MDGs) by:
Increasing coverage with the full range of Expanded Program on Immunization (EPI)
childhood vaccines (especially for measles)
Facilitating the timely introduction of new vaccines against pneumococcal and rotavirus infections
Assisting with the delivery of other important child survival interventions such as vitamin A, zinc supplementation, and distribution of ITNs
The infrastructure that has been established by the GPEI for the purposes of polio eradication encompasses both physical assets (including skilled human resources) and a combination of institutional arrangements and operating procedures that can be leveraged in new ways.
African Health Systems Initiative – Research (AHSI-Res) partnerships
AHSI supports African-led efforts to strengthen health systems by emphasizing the scale-up of human resources for health. It also promotes synergies between multilateral, bilateral and research mechanisms (Canada's contribution under the Catalytic Initiative supports the AHSI).
Another component of the AHSI is support to African research partnerships (AHSI-Res). This is funded through the Global Health Research Initiative (GHRI), which is a unique research funding partnership of five agencies and departments of the Government of Canada. These include CIDA, the Canadian Institutes of Health Research (CIHR), Health Canada (HC), the International Development Research Centre (IDRC) and the Public Health Agency of Canada (PHAC). GHRI funds research on global health and strengthens the capacity to conduct global health research and apply findings to address real-world problems.
AHSI-Res brings together both decision-makers and researchers to look for innovative ways to strengthen health systems. Each team is co-led by a researcher and a decision-maker and works to connect research, policy and action to improve knowledge translation, health decision-making and programming across the sub-Saharan region. All solutions are aligned with government priorities.
In Malawi, for example, Dignitas International and the REACH (Research for Equity and Community Health) Trust have partnered with key stakeholders to test a novel intervention for the training of primary health care workers (HCWs). Called PALM-PLUS (Practical Approach to Lung Health and HIV/AIDS in Malawi), it is designed to simplify existing national guidelines for the management of HIV/AIDS, tuberculosis and primary care conditions, and integrate them into a single, simple and user-friendly guideline. This approach has the potential to be scalable within the country and beyond. Given that the ultimate purpose of the research is to inform policy-level decisions around the training of HCWs and the integration of HIV/AIDS care into primary health, it has been beneficial to have a team comprised of both policy makers (decision makers) and researchers.78
Facilitating the timely introduction of new vaccines against pneumococcal and rotavirus infections
Assisting with the delivery of other important child survival interventions such as vitamin A, zinc supplementation, and distribution of ITNs
The infrastructure that has been established by the GPEI for the purposes of polio eradication encompasses both physical assets (including skilled human resources) and a combination of institutional arrangements and operating procedures that can be leveraged in new ways.
African Health Systems Initiative – Research (AHSI-Res) partnerships
AHSI supports African-led efforts to strengthen health systems by emphasizing the scale-up of human resources for health. It also promotes synergies between multilateral, bilateral and research mechanisms (Canada's contribution under the Catalytic Initiative supports the AHSI).
Another component of the AHSI is support to African research partnerships (AHSI-Res). This is funded through the Global Health Research Initiative (GHRI), which is a unique research funding partnership of five agencies and departments of the Government of Canada. These include CIDA, the Canadian Institutes of Health Research (CIHR), Health Canada (HC), the International Development Research Centre (IDRC) and the Public Health Agency of Canada (PHAC). GHRI funds research on global health and strengthens the capacity to conduct global health research and apply findings to address real-world problems.
AHSI-Res brings together both decision-makers and researchers to look for innovative ways to strengthen health systems. Each team is co-led by a researcher and a decision-maker and works to connect research, policy and action to improve knowledge translation, health decision-making and programming across the sub-Saharan region. All solutions are aligned with government priorities.
In Malawi, for example, Dignitas International and the REACH (Research for Equity and Community Health) Trust have partnered with key stakeholders to test a novel intervention for the training of primary health care workers (HCWs). Called PALM-PLUS (Practical Approach to Lung Health and HIV/AIDS in Malawi), it is designed to simplify existing national guidelines for the management of HIV/AIDS, tuberculosis and primary care conditions, and integrate them into a single, simple and user-friendly guideline. This approach has the potential to be scalable within the country and beyond. Given that the ultimate purpose of the research is to inform policy-level decisions around the training of HCWs and the integration of HIV/AIDS care into primary health, it has been beneficial to have a team comprised of both policy makers (decision makers) and researchers.78
Leveraging Web 2.0 technologies
Knowledge translation has continually been cited as a challenge in global public health. Information abounds but access is often limited, and only now are barriers being removed that in the past have contributed to the inaccessibility of information. In large part this is due to information and communication technology (ICT)79 and in particular to Web 2.0. The latter is a form of ICT that facilitates interactive information sharing, interoperability and collaboration on the World Wide Web.80 Web 2.0 holds great potential for enabling health information (once restricted to individual organizations and people) to flow rapidly to all parts of the world – from the halls of CIDA to rural communities in sub-Saharan Africa and back again.
Forward-looking organizations can use Web 2.0 to harness their collective capability and knowledge to spur innovation, collaboration and problem-solving in order to address global health challenges in creative new ways. Policy and programming are often set by experts and vested interests, and this can lead to excessive partisanship, gridlock and stagnation of policy and programming.81 Experts and individuals outside of the traditional global health systems should be engaged in the process of finding new solutions. This does need to constitute a risk if efforts are made to support the appropriate checks and balances.
One example of how Web 2.0 technology is being leveraged to improve global health is the website DevelopmentWell.com, which will showcase development solutions via online profiles. It will include resources such as videos, images, links to evidence, results/impact information, cost-effectiveness data and related contact information. The website is expected to launch in 2011 and will allow users from around the world to create profiles of solutions (e.g. technologies, service delivery models, innovative financing methods, interventions) that can be ranked and sorted by various categories (e.g. country, disease, affiliated organization).82 Another site to keep our eyes on is the Centre for Health Market Innovations (CHMI).
Knowledge translation has continually been cited as a challenge in global public health. Information abounds but access is often limited, and only now are barriers being removed that in the past have contributed to the inaccessibility of information. In large part this is due to information and communication technology (ICT)79 and in particular to Web 2.0. The latter is a form of ICT that facilitates interactive information sharing, interoperability and collaboration on the World Wide Web.80 Web 2.0 holds great potential for enabling health information (once restricted to individual organizations and people) to flow rapidly to all parts of the world – from the halls of CIDA to rural communities in sub-Saharan Africa and back again.
Forward-looking organizations can use Web 2.0 to harness their collective capability and knowledge to spur innovation, collaboration and problem-solving in order to address global health challenges in creative new ways. Policy and programming are often set by experts and vested interests, and this can lead to excessive partisanship, gridlock and stagnation of policy and programming.81 Experts and individuals outside of the traditional global health systems should be engaged in the process of finding new solutions. This does need to constitute a risk if efforts are made to support the appropriate checks and balances.
One example of how Web 2.0 technology is being leveraged to improve global health is the website DevelopmentWell.com, which will showcase development solutions via online profiles. It will include resources such as videos, images, links to evidence, results/impact information, cost-effectiveness data and related contact information. The website is expected to launch in 2011 and will allow users from around the world to create profiles of solutions (e.g. technologies, service delivery models, innovative financing methods, interventions) that can be ranked and sorted by various categories (e.g. country, disease, affiliated organization).82 Another site to keep our eyes on is the Centre for Health Market Innovations (CHMI).
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