Everyday health system resilience

Interest in the notion of health system resilience emerged following the Ebola outbreak in West Africa in 2014-16 and has been further stimulated by the COVID-19 pandemic.  Our work on everyday health system resilience developed in the period between these disease crises and is being sustained in considering COVID-19 experience.

Our objectives are to:

• accompany health system actors in their work of responding to a range of chronic stressors and acute shocks
• understand what collective capacities within health systems underpin these responses and explain how these capacities operate
• generate ideas about health system development by paying attention to everyday resilience

Working at district/county levels in South Africa and Kenya, we initially accompanied district level health managers in their work of everyday leadership and governance. Through cycles of action learning at district/county, sub-district/sub-county and facility levels we, first, observed and documented the range of chronic stresses a health system faces even when there is no particular acute crisis such as a disease outbreak. Second, we explored the strategies implemented to manage these stresses and the leadership practices applied – and we considered how and why such strategies came to be implemented and sustained, or withdrawn, over time; and with what consequences in terms of system functioning and established system goals.

From these initial analyses, and drawing on multi-disciplinary resilience theory, we developed the everyday health system resilience (EHSR) framework. The framework illuminates the importance of health system software in relation to resilience. This framework was then tested through application to the continuing experience of health systems in both countries. In this round of work, we paid particular attention to understanding what collective capacities within the health system underpin decision-making about how to respond to and address shocks.

We are now continuing to use the EHSR framework to document, track and examine COVID-19 responses in both countries – using a range of secondary qualitative and quantitative data, supplemented by interview data.

Initially funded through the RESYST consortium, by the UK’s Department for International Development, the current work is receiving funding from the Robert Koch Institute, Germany.

People and partners

• Lucy Gilson
• Jo Hanefeld
• Centre for Health Policy, University of the Witwatersrand, South Africa
• City of Cape Town Health Department, Western Cape, South Africa
• Health Policy and Systems Division, University of Cape Town, South Africa
• KEMRI-Wellcome Trust Research programme, Kenya
• Kilifi County Health Department, Kenya
• Nuffield Department of Medicine, University of Oxford, UK
• Sedibeng District, Gauteng provincial Department of Health, South Africa
• School of Public Health, University of the Western Cape, South Africa
• Western Cape provincial Department of Health, South Africa

Publications

• Nzinga J, Boga M, Kagwanja N, Waithaka D, Barasa E, Tsofa B, Gilson L, Molyneux S. (2021) An innovative leadership development initiative to support building everyday resilience in health systems. Health Policy Plan. May 18:czab056. doi: 10.1093/heapol/czab056. Epub ahead of print.
• Gilson, L., Ellokor, S., Lehmann, U., & Brady, L. (2020). Organizational change and everyday health system resilience: Lessons from Cape Town, South Africa. Social Science & Medicine, 266, 113407.
• Waithaka D, Kagwanja N, Nzinga J, Tsofa B, Leli H, Mataza C, Nyaguara A, Bejon P, Gilson L, Barasa E, Molyneux S. Prolonged health worker strikes in Kenya- perspectives and experiences of frontline health managers and local communities in Kilifi County. (2020) Int J Equity Health. Feb 10;19(1):23. doi: 10.1186/s12939-020-1131-y.
• Kagwanja N, Waithaka D, Nzinga J, Tsofa B, Boga M, Leli H, Mataza C, Gilson L, Molyneux S, Barasa E. (2020)  Shocks, stress and everyday health system resilience: experiences from the Kenyan coast. Health Policy Plan. Jun 1;35(5):522-535. doi: 10.1093/heapol/czaa002.
• Barasa, E., Mbau, R. and Gilson, L., (2018). What is resilience and how can it be nurtured? A systematic review of empirical literature on organizational resilience. International Journal of Health Policy and Management. 7(6), pp.491-503 DOI: 10.15171/ijhpm.2018.06
• Gilson, L., Barasa, E., Nxumalo, N., Cleary, S., Goudge, J., Molyneux, S., Tsofa, B.T. & Lehmann, U. (2017). Everyday resilience in district health systems: emerging insights from the front lines in Kenya and South Africa. BMJ Global Health, 2(2), e000224. DOI: 10.1136/bmjgh-2016-000224
• Barasa, E. W., Cloete, K., & Gilson, L. (2017). From bouncing back, to nurturing emergence: reframing the concept of resilience in health systems strengthening. Health Policy and Planning, 32(suppl_3), iii91-iii94.

Strengthening health policy analysis 

Health Policy Analysis is a critical element of the broader field of Health Policy and Systems Research. It specifically considers how policies emerge, are formed and are implemented, and pays particular attention to the forces influencing decision-making: actors, power and politics; institutions, interests and ideas.  The policy process orientation of such analysis draws from the theories and ideas of various well-established fields in higher income country settings - such as, policy studies and public administration, and political and organisational sciences. At the same time, HPA draws on ideas about the political economy of development in its applications within low and middle income countries (LMICs).

In broad terms, such analysis offers insights about how policy change unfolds – and it helps us understand the political forces that explain what has sometimes been called the ‘implementation gap’ in global health policy debates. These forces also always shape health system development, working across local, national and global levels. Yet despite its valuable insights, it remains a small area of work within health policy and systems research – and one where the scholarship is dominated by scholars based in high income countries.

Our objectives in this area of work are:

• to deepen understanding of the principles, theories and applications of health policy analysis
• to outline critical methodological steps for doing HPA and HPSR work
• to support the emergence of a body of LMIC scholars doing HPA work in LMICs

Led by the Health Policy and Systems Division at the University of Cape Town, South Africa, this work has entailed, first, the production of two open access anthologies of papers. Second, through the HPA Fellowship programme, support has been provided for 20 LMIC doctoral scholars pursuing their degrees within higher education institutions located exclusively in Africa and Asia. The programme of work has been funded by the Alliance for Health Policy and Systems Research.

People and partners

• Lucy Gilson
• Health Policy and Systems Division, University of Cape Town, South Africa
• Alliance for Health Policy and Systems Research
• HPA Fellows cohort 1 and 2

Publications

Open access Readers:

• Gilson L, Orgill MS, Shroff ZC (2018) A Health Policy Analysis Reader: The politics of policy change in low and middle income countries. Geneva: Alliance for Health Policy and Systems Research/ World Health Organization. 
• Gilson L (ed) (2012) Health Policy and Systems Research: A Methodology Reader. Geneva: Alliance for Health Policy and Systems Research/ World Health Organization.  

Special issue:

• Gilson, L., Shroff, Z. C., & Shung-King, M. (2021). Introduction to the Special Issue on “Analysing the Politics of Health Policy Change in Low-and Middle-Income Countries: The HPA Fellowship Programme 2017-2019”. International Journal of Health Policy and Management. 10.34172/ijhpm.2021.43
• Guinaran RC, Alupias EB, Gilson L. (2021) The Practice of Power by Regional Managers in the Implementation of an Indigenous Peoples Health Policy in the Philippines. International Journal of Health Policy and Management.  In Press. doi:10.34172/ IJHPM.2020.246
• Ramani S, Gilson L, Sivakami M, Gawde N. (2021) Sometimes resigned, sometimes conflicted, and mostly risk averse: primary care doctors in India as street level bureaucrats. International Journal of Health Policy and Management. In Press. doi:10.34172/IJHPM.2020.206
• Derkyi-Kwarteng, ANC, Agyepong IA, Enyimayew N, Gilson L. (2021) A Narrative Synthesis Review of Out-of-Pocket Payments for Health Services under Insurance Regimes: A Policy Implementation Gap Hindering Universal Health Coverage in Sub-Saharan Africa. In Press. doi:10.34172/IJHPM.2021.38
• Parashar R, Gawde N, Gilson L. (2021) Application of “actor interface analysis” to examine practices of power in health policy implementation: an interpretive synthesis and guiding steps. International Journal of Health Policy and Management. In Press. doi:10.34172/IJHPM.2020.191
• Okeyo I, Lehmann U, Schneider H. (2021) Policy adoption and the implementation woes of the intersectoral first 1000 days of childhood initiative, in the Western Cape province of South Africa. International Journal of Health Policy and Management. In Press. doi:10.34172/IJHPM.2020.173
• Mukuru M, Kiwanuka SN, Gilson L, Shung-King M, Ssengooba F. (2021) “The Actor Is Policy”: Application of Elite Theory to Explore Actors’ Interests and Power Underlying Maternal Health Policies in Uganda, 2000-2015. International Journal of Health Policy and Management. In Press. doi:10.34172/ijhpm.2020.230
• Whyle EB, Olivier J. (2021) Towards an Explanation of the Social Value of Health Systems: An Interpretive Synthesis. International Journal of Health Policy and Management. In Press. doi:10.34172/IJHPM.2020.159

Other papers:

• Mukuru, M., Kiwanuka, S. N., Gibson, L., & Ssengooba, F. (2021). Challenges in implementing emergency obstetric care (EmOC) policies: perspectives and behaviours of frontline health workers in Uganda. Health Policy and Planning, 36(3), 260-272.
• Parashar, R., Gawde, N., Gupt, A., & Gilson, L. (2020). Unpacking the implementation blackbox using 'actor interface analysis': how did actor relations and practices of power influence delivery of a free entitlement health policy in India?. Health Policy and Planning, 35(Supplement_2), ii74-ii83.
• Whyle, E., & Olivier, J. (2020). Social values and health systems in health policy and systems research: a mixed-method systematic review and evidence map. Health Policy and Planning, 35(6), 735-751.
• Ramani, S., Sivakami, M., & Gilson, L. (2019). How context affects implementation of the Primary Health Care approach: an analysis of what happened to primary health centres in India. BMJ Global Health, 3(Suppl 3), e001381.

Learning sites and the micro-practices of governance and leadership in health systems

Front-line health managers play a critical role in health system governance, policy implementation and accountability processes. Their decision-making practices are dynamic and complex, and it is difficult to observe and to disentangle the effects of these practices from other health system dimensions. 

Through long-term engagement in three district-level health system governance learning sites in Kenya and South Africa, we have, over time, accompanied frontline managers working at district and primary health care levels. We seek both to understand their decision-making and to consider how to support the development of frontline leadership practice. Our approach of action learning has itself been an area of inquiry in this work.

Our objectives are to:

• understand what influences frontline leadership and decision-making
• support frontline managers in strengthening their decision-making
• generate ideas about how to strengthen frontline leadership in health systems
• consider whether and how action learning processes can support frontline leadership

Working through cycles of action learning in the learning sites we have generated a range of co-produced data, including through reflective discussions and meetings with managers. Taken together the data provide wide-ranging insights into frontline leadership experiences and practices, deepening understanding about the ‘software’ of health systems. We have also developed new approaches to leadership development and implemented and assessed them in partnership with managers. Finally, we have reflected on our approach to co-production around governance as implemented in the learning sites. This body of work is also connected to the continuing research on everyday health system resilience.

In linked work outside the learning sites, we have also:

• examined how gender influences health system leadership in both Kenya and South Africa
• supported a special issue on health system leadership in Africa
• supported a special issue on the micro-practices of governance in health systems in low and middle income countries

The learning site and gender and leadership work was funded through the RESYST consortium, by the UK’s Department for International Development. The linked special issues were supported by the Collaboration for Health System Analysis and Innovation (CHESAI) with funding from the International Development and Centre, Canada.

People and partners

• Lucy Gilson
• Centre for Health Policy, University of the Witwatersrand, South Africa
• City of Cape Town Health Department, Western Cape, South Africa
• Health Economics and Health Policy and Systems Divisions, University of Cape Town, South Africa
• KEMRI-Wellcome Trust Research programme, Kenya
• Kilifi County Health Department, Kenya
• Nuffield Department of Medicine, University of Oxford, UK
• Sedibeng District, Gauteng provincial Department of Health, South Africa
• School of Public Health, University of the Western Cape, South Africa
• Western Cape provincial Department of Health, South Africa

Publications

The learning site approach:

• Gilson L, Barasa E, Brady L, Kagwanja N, Nxumalo N, Nzinga J, Molyneux S, Tsofa B. (2021) Collective sensemaking for action: researchers and decision makers working collaboratively to strengthen health systems. British Medical Journal. Feb 16;372.
• The RESYST/DIAHLS learning site team. (2020) "Learning sites for health system governance in Kenya and South Africa: reflecting on our experience." Health Research Policy and Systems 18: 1-12
• Molyneux, S., Tsofa, B., Barasa, E., Nyikuri, M. M., Waweru, E. W., Goodman, C. and Gilson, L. (2016), Research Involving Health Providers and Managers: Ethical Issues Faced by Researchers Conducting Diverse Health Policy and Systems Research in Kenya. Developing World Bioethics, 16: 168–177.
• Lehmann U and Gilson L. (2015) Researching people-centred health systems: the reward and challenge of co-production for HPSR. Health Policy and Planning 30(8):957-63

Leadership and the micro-practices of governance:

• Nzinga J, Boga M, Kagwanja N, Waithaka D, Barasa E, Tsofa B, Gilson L, Molyneux S. (2021) An innovative leadership development initiative to support building everyday resilience in health systems. Health Policy Plan. 2021 May 18:czab056. doi: 10.1093/heapol/czab056. Epub ahead of print. PMID: 34002796.
• Muraya, K. W., Govender, V., Mbachu, C., Uguru, N. P., & Molyneux, S. (2019). ‘Gender is not even a side issue… it’s a non-issue’: career trajectories and experiences from the perspective of male and female healthcare managers in Kenya. Health Policy Plan, 34(4), 249-256.
• Cleary S, du Toit A, Scott  V and Gilson L (2018) Enabling relational leadership in primary healthcare settings: lessons from the DIALHS Collaboration. Health Policy and Planning 33(suppl_2), ii65-ii74.
• Nxumalo, N., Goudge, J., Gilson, L., & Eyles, J. (2018). Performance management in times of change: experiences of implementing a performance assessment system in a district in South Africa. International journal for equity in health, 17(1), 141.
• Nxumalo, N., Gilson, L., Goudge, J., Tsofa, B., Cleary, S., Barasa, E. and Molyneux, S., (2018). Accountability mechanisms and the value of relationships: experiences of front-line managers at subnational level in Kenya and South Africa. BMJ global health, 3(4), p.e000842.
• Shung-King, M., Gilson, L., Mbachu, C., Molyneux, S., Muraya, K. W., Uguru, N., & Govender, V. (2018). Leadership experiences and practices of South African health managers: what is the influence of gender? a qualitative, exploratory study. International journal for equity in health, 17(1), 148.
• Gilson L, Ellokor S, Olckers P and Lehmann U. (2014) Advancing the application of systems thinking in health: South African examples of a leadership of sensemaking for primary health care. Health Research Policy and Systems 12:30 
• Daire J and Gilson L. (2014) Does identity shape leadership and management practice? Experiences of PHC facility managers in Mitchells’ Plain, Cape Town, South Africa. Health Policy and Planning 29 (supplement 2) ii82-ii597

Linked collections:

• Health leadership in Africa. A supplement.  Health Policy and Planning 3(suppl_2), ii1-ii4.Editorial: Gilson, L and Agyepong IA. (2018) Strengthening health system leadership for better governance: what does it take?. Health Policy and Planning 3(suppl_2), ii1-ii4.
• Practicing governance towards equity in health systems: LMIC perspectives and experience. A topical collection. International Journal for Equity in Health

• Editorial: Gilson, Lucy, Uta Lehmann, and Helen Schneider. (2017) "Practicing governance towards equity in health systems: LMIC perspectives and experience." Int J Equity Health 16, 171 https://doi.org/10.1186/s12939-017-0665-0

Doing Embedded HPSR and Being Embedded

Health Policy and Systems Research (HPSR) is an applied and interdisciplinary field of research, which has emerged in parallel to the global focus on health systems and health system strengthening. HPSR combines a system lens with political and organizational analysis of health policy change to understand health system operations, and opportunities and challenges for health system development. As a field, it is primarily associated with LMICs although it is relevant in all settings.

A recent trend in HPSR has been to emphasise the importance of embedded research. As defined on the Alliance for Health Policy and Systems website, ‘Embedded research is when HPSR organizations are part of the decision-making and implementation process. This enables them to take their lead from health systems stakeholders such as policy-makers and health system staff. It ensures that research is designed to meet demand and that it addresses the most pressing challenges to health system development’.

But what does it mean to be embedded? Within the Western Cape province, South Africa, a network of academic and service managers interested in and working to support health system development has developed over time.

Our objectives are to, through collaboration:

• develop and maintain trusting relationships among people and organisations committed to health system development
• share experience and ideas about how to strengthen health systems
• develop research activities deemed important to health system development in the province
• support each other’s wider activities through advisory and educational engagements
• develop and test approaches to being and doing embedded research within this network

The network is an alliance of people drawn from different organisations, with a stable core. We have engaged together for nearly ten years in this particular formation, although building on longer-standing relationships and activities. Over time, we have purposefully reflected on our network and networking, and our engagement has also stimulated a wider range of research in the province.

This work is supported through the Collaboration for Health System Analysis and Innovation (CHESAI www.chesai/org). Although initial funding was received from the International Development and Centre, Canada, the work continues as part of our routine and everyday roles.

People and partners

• Lucy Gilson
• Health Policy and Systems Division, University of Cape Town, South Africa
• City of Cape Town Health Department, Western Cape, South Africa
• School of Public Health, University of the Western Cape, South Africa
• Western Cape provincial Department of Health, South Africa

Publications

• Engelbrecht, B., Gilson, L., Barker, P., Vallabhjee, K., Kantor, G., Budden, M. et al. Prioritizing people and rapid learning in times of crisis: A virtual learning initiative to support health workers during the COVID‐19 pandemic. 2021 The International Journal of Health Planning and Management. https://doi.org/10.1002/hpm.3149
• Mahomed H, Gilson L, Boulle A, et al. The evolution of the COVID-19 pandemic and health system responses in South Africa and the Western Cape Province – how decision-making was supported by data. Section A, Chapter 8 In Massyn N, Day C, Ndlovu N, Padayachee T (Eds) District Health Barometer 2019/20. Durban: Health Systems Trust, 2020 (p.265-282)
• Gilson L, Barasa E, Brady L, Kagwanja N, Nxumalo N, Nzinga J, Molyneux S, Tsofa B. (2021) Collective sensemaking for action: researchers and decision makers working collaboratively to strengthen health systems. British Medical Journal. Feb 16; 372.
• The Western Cape HPSR Journal Club. (2020) " Not Just a Journal Club-It's Where the Magic Happens": Knowledge Mobilization through Co-Production for Health System Development in the Western Cape Province, South Africa. International journal of health policy and management. 2020 Aug 1. doi: 10.34172/ijhpm.2020.128 Online ahead of print.
• The RESYST/DIAHLS learning site team. (2020) "Learning sites for health system governance in Kenya and South Africa: reflecting on our experience." Health Research Policy and Systems 18: 1-12
• Brady, L., De Vries, S., Gallow, R., George, A., Gilson, L., Louw, M., ... & Stuart, T. (2019). Paramedics, poetry, and film: health policy and systems research at the intersection of theory, art, and practice. Human resources for health, 17(1), 64.
• Olivier, J., Scott, V., Molosiwa, D., & Gilson, L. (2017). Embedded systems approaches to health policy and systems research. Chapter 2 in De Savigny D, Blanchet K and Adam T. Applied Systems Thinking for Health Systems Research: A Methodological Handbook, London: Open University Press, pp. 14-52.
• Gilson L, Brady L, Naldei T, Schneider H, Pienaar D, Hawkridge A and Vallabhjee K (2017). Development of the Health system in the Western Cape: experiences since 1994. Chapter 6 in Padarath A, Barron P, editors. South African Health Review 2017. Durban: Health Systems Trust; 2017. p59-69 URL:
• Lehmann U and Gilson L. (2015) Researching people-centred health systems: the reward and challenge of co-production for HPSR. Health Policy and Planning 30(8):957-63

IMPRESS: Innovative Management PRactices to Enhance hoSpital quality and Save lives in Malawi

Building on an existing platform, Newborn Essential Solutions & Technologies (NEST360), we are identifying practical ways to enhance management practices in hospitals in Malawi. IMPRESS aims to examine whether enhanced management practices can improve health outcomes and clinical quality for newborns in hospitals. A multi-disciplinary team from College of Medicine and LSHTM will address the following main objectives:

• Adapt and validate measures of hospital and district management practices
• Examine the association between management practices and quality of clinical care, and its variation by facility characteristics
• Co-design a problem-focused hospital management intervention and scalable delivery model
• Evaluate effectiveness of the intervention on neonatal mortality and secondary outcomes (including hospital-acquired infections) through a cluster randomised trial
• Assess the intervention’s acceptability, fidelity, and mechanisms through multi-methods research and estimate its cost-effectiveness

People

• Timothy Powell-Jackson
• Catherine Goodman
• Joy Lawn
• Victor Mwapasa
• Linda Nyondo-Mipando
• Queen Dube

Publications

Coming soon

Regulating e-pharmacy: challenges and opportunities for access and quality of care in LMIC health systems

Research Team

LSHTM: Catherine Goodman (PI), Benjamin Palafox

Strathmore University’s Institute of Healthcare Management, Kenya: Frank Wafula, Emmanuel Kweyu

The George Institute, India: Mohammed Abdul Salam, Devaki Nambiar

Access to essential medicines is a critical building block of the health system, but many low and middle-income countries (LMICs) continue to face substantial challenges in ensuring medicine accessibility, affordability and quality. The recent growth of medicine sales online represents a major disruption to pharmacy provision, presenting both challenges and opportunities across the globe. Whilst e-pharmacy businesses were initially the preserve of high-income countries, in the past decade they have been growing rapidly in LMICs, and have gained attention due to public health concerns, including the sale of prescription-only medicines without a prescription; the sale of substandard and falsified medicines; inadequate provision of information to patients; and erosion of the doctor-pharmacist-patient relationship. Further non-health-related risks include consumer fraud and lack of data privacy. The COVID-19 pandemic is encouraging a further surge in online sales, and an associated rise in cybercrime. However, e-pharmacy also presents opportunities for enhancing access to medicines, particularly for those with problems accessing traditional pharmacy services, or requiring regular medication. Regulatory systems are crucial in managing these risks and opportunities, but are hampered by lack of consensus on appropriate approaches, lack of skills and capacity among regulators, and difficulties in using national regulatory frameworks to control markets operating across country boundaries. However, analysis of LMIC e-pharmacy markets from a health systems perspective remains very limited.

This project will address this knowledge gap by assessing the performance of e-pharmacies in India and Kenya, and analysing the systems that regulate them. The study objectives are to:

• Characterise the markets for e-pharmacy in India and Kenya
• Assess the performance of e-pharmacies, in terms of quality, safety and affordability
• Conduct a critical appraisal of current regulatory systems for e-pharmacy and potential amendments / alternatives
• Retrospectively and prospectively study the policy processes that influence the design and implementation of e-pharmacy regulation.

Publications

• When technology precedes regulation: the challenges and opportunities of e-pharmacy in low-income and middle-income countries

Anti-Corruption Evidence (ACE)

 

Our work within the Anti-Corruption Evidence (ACE) research consortium brings together teams in Bangladesh, Nigeria, Tanzania and the United Kingdom to tackle corruption, one of the most difficult problems facing health policymakers in many countries. Our starting point is that corruption often arises in situations where health workers must make choices about how they balance the care they want to provide to their patients with the rewards that they obtain for their services. These tensions emerge where incentive structures are badly designed and where systems of governance, and particularly mechanisms for ensuring accountability and transparency, are weak. In these circumstances, traditional punitive measures do not work and can even be counter-productive. Instead, we are working with frontline health workers delivering healthcare and those to whom they are, in theory, accountable (including their informal networks) to:

• understand the dilemmas they face
• find ways to overcome dysfunctional managerial structures
• develop politically feasible and acceptable measures

The health research within ACE consortium seeks to understand the structural and socio-political causes of corruption and to use those findings to support the adoption of new, feasible, high impact anti-corruption strategies in. Bangladesh, Nigeria and Tanzania.

Funded by UK Aid. Learn more about the unique ACE approach to understanding corruption, with access to resources, papers and materials on the website. Follow on twitter and Linked In for updates.

People

• Dina Balabanova
• Eleanor Hutchinson
• Martin McKee
• Obinna Onwujekwe
• Prince Agwu
• Aloysius Odii
• Syed Masud Ahmed
• Nahitun Naher
• Mir Raihanul Islam
• Peter Binyaruka
• Masuma Mamdani
• Blake Angell
• Mushtaq Khan (ACE PI)
• Pallavi Roy
• Sonia Sezille

Publications

• Abba-AjiI M, Balabanova D, Hutchinson E, McKee M. (2020) How Do Nigerian Newspapers Report Corruption in the Health System?, International Journal of Health Policy and Management

• Hutchinson E, Balabanova D, McKee M. (2018) We Need to Talk About Corruption in Health Systems. International Journal of Health Policy and Management, 8(4):191-4.

• Hutchinson E, McKee M. Balabanova D. (2019) What drives health workers to break the rules and use public resources for private gain? A review of the literature on sub-Saharan Africa, SOAS ACE Working paper 009

• Onwujekwe O, Agwu P, Orjiakor C, McKee M, Hutchinson E, Mbachu C, Odii A, Ogbozor P, Obi U, Ichoku H, Balabanova D. (2019) Corruption in Anglophone West Africa health systems: a systematic review of its different variants and the factors that sustain them. Health Policy & Planning. 1;34(7):529-543.

• Onwujekwe O, Agwu P, Orjiakor C, Mbachu C, Hutchinson E, Odii A, Obi U, Ogbozor A, Ichoku H, McKee M, Balabanova D. (2018) Corruption in the health sector in Anglophone West Africa: Common forms of corruption and mitigation strategies. SOAS-ACE Working Paper 005

• Naher N HM, Hoque R, Alamgir N, Ahmed SM. (2018) Irregularities, informal practices, and the motivation of frontline healthcare providers in Bangladesh: current scenario and future perspectives towards achieving universal health coverage by 2030. SOAS-ACE Working Paper 004

Other outputs

• Balabanova D, Hutchinson E, Mayhew S, McKee M. (2020) Health workers are vital to defeat COVID-19: but only if they are at work, Health Systems Global
• Hutchinson E, Balabanova D, McKee M. (2018) Five reasons we aren’t talking about corruption in health systems – and why we need to start, International Health Policies

Dates

Until the end of 2021

The Lives and Livelihoods of displaced healthcare workers in Uganda

This study is part of the RECAP project, a four-year project focusing on how to improve decision-making and accountability to support preparedness and response to humanitarian crises. We aim to:

• provide an in-depth case study of the political dynamics, contradictions, solutions and lived realities affecting development of human resources for health in a major contemporary refugee response
• explore avenues to better integrate South Sudanese healthcare workers in humanitarian responses for refugee populations in Uganda
• improve the lives, livelihoods and future health systems of crises-affected populations

This research is supported by the United Kingdom’s Global Challenges Research Fund and led by the London School of Hygiene and Tropical Medicine (LSHTM) in partnership with BRAC and other leading academic and NGO partners.

People

• Jennifer Palmer
• Diane Duclos
• Melissa Parker
• Harriet Ume

BRAC: Denise Ferris

Understanding and eliminating health sector corruption impeding UHC at district level in Nigeria and Malawi: institutions, individuals and incentives

The Malawian and Nigerian governments are working hard to achieve universal health coverage (UHC) but both are struggling with finding ways to put in place systems that can ensure accountability in the health systems and root out corruption. For far too long, corruption has been placed in the “too difficult” tray by health policymakers but the Sustainable Development Goals have prioritised this issue on the policy agenda. The challenge is to find measures that: 

• will have a real impact on the ground
• are feasible
• attract widespread acceptance

This can only happen if we understand why it has been so difficult to establish effective governance systems and if we can create coalitions to bring about change. In this project, we work closely with those on the frontline of the health system, listening carefully to their experiences, and working with them to develop measures that can bring about lasting change.

Read more about approaches to understanding and addressing corruption.

Dates

March 2020 – April 2023

Accelerating the development of Health Policy and Systems Research capacity in the Western Pacific Region for health system strengthening

Health systems everywhere are facing unprecedented challenges as they struggle with ageing populations, the changing burden of disease, new treatment possibilities, and innovative models of care. If they are to respond to these challenges and seize the opportunities that are arising, they must have adequate capacity for Health Policy and Systems Research (HPSR). Yet in too many countries, this is still weak.

In this NIHR-funded project, teams from the Institute for Health Systems Research and the United Nations University (Malaysia), University of the Philippines Manila and the London School of Hygiene & Tropical Medicine are working together to:

• strengthen existing capacity in Malaysia
• share lessons learned from this experience with countries in the Western Pacific region (WPR) of the WHO
• draw on the latest thinking on capacity building in this area
• contribute to the creation of an international community of practice and a body of research that is tailored to the needs of the countries in the region

The project aims to accelerate the expansion of HPSR capacity in Malaysia, and in WPR, to support health system strengthening. Working in close collaboration with national stakeholders, we are developing and piloting a training programme that can be implemented at scale. This experience will be used to inform the development of plans for HPSR capacity building in other WPR countries.

The project follows a series of steps.

1. Design and field-test an HPSR training programme in Malaysia. This will involve:

• an initial needs assessment to help tailor this to diverse audiences
• adaptation of internationally agreed HPSR competencies to the country context
• creation of a package that is supported by key actors and can be scaled up nationally
• applying an innovative theory of change to track training outcomes and processes, and to document what works, where, and when

2. Undertake HPSR capacity mapping in Malaysia and selected WPR countries (e.g. the Philippines) to identify capacity gaps, national priorities and opportunities to align HPSR training with national health policies

3. Learn from the Malaysian experience to develop locally led, country-specific plans and strategies for scaling up HPSR capacity in these WPR countries

4. Develop proposals for HPSR projects that address important health system or health service needs in Malaysia and elsewhere in WPR and seek national/regional endorsement and funding.

5. Document and disseminate Malaysian and WPR country experiences through Health Systems Global (HSG), providing a roadmap to accelerate the expansion of HPSR capacity in other low and middle-income countries.

Dates

March 2020 – June 2021

Migration, gender and health system response in South Africa: A focus on the movement of healthcare users and workers

This project investigates the intersection of migration, population mobility, and gender with health systems by applying a set of innovative qualitative and quantitative research methods and the lens of intersectionality. We conduct the research in South Africa, a country that has faced high levels of internal migration and population mobility - historical and contemporary; inward and outward.

In our mixed-methods research, we:

• focus on the mobility of both healthcare users and healthcare workers within, into and out of South Africa
• study the interactions of healthcare users and workers with the public health system
• pilot and evaluate an innovative method of tracking healthcare user and worker movement over time using social media (WhatsApp) to generate new data on mobility and interaction with the health system
• make a new quantitative analysis of existing data sets (for instance from the Tourism South Africa Border Survey)
• analyse, for the first time ever, National Department of Health data regarding patients travelling into South Africa under regulated bilateral agreements between the governments of South Africa and 11 neighbouring countries

We ask key research questions:

• How do migration and population mobility affect the South African health system?
• How does the health system respond and adapt as a result of migration and population mobility?
• How do these processes intersect with gender?

Our objectives are to:

• assess levels of migration by patients and health workers within, into and out of South Africa
• examine the health care experiences of both migrant and non-migrant patients and health workers.
• analyse how the South African health system adapts and responds in light of the population movements identified in Objective 1.
• examine how the experiences and responses garnered during objectives 1-3 are shaped by gender

People

• Johanna Hanefeld (PI; LSHTM)
• Helen Walls (LSHTM)
• Jo Vearey (University of the Witwatersrand)
• Moeketsi Modisenyane (South Africa Department of Health)
• Sassy Molyneux (Oxford University and KEMRI Wellcome)
• Lucy Gilson (LSHTM, University of Cape Town)
• Jill Oliver (University of Cape Town)
• Richard Smith (University of Exeter)

Dates

Ongoing

Do Agricultural Input Subsidies on Staples Reduce Dietary Diversity?

The Political Economy of Health and Health Policy (PEHHP) Group seeks to understand the structure and function of political and economic institutions and their impact on population health and the health policy process, including the implications of economic production and trade for health.  Researchers within the group bring to their work diverse disciplinary backgrounds and perspectives, including from economics, political science, sociology, anthropology, public health and development studies.

Population health is influenced (and increasingly so, with globalisation) by factors outside of national borders and beyond the health sector. These factors are often described as the structural determinants of health, and are made up of important economic and political factors.

Economic production and trade policy have enormous influence on the health and well-being of populations globally, through shaping the distribution of power, money and resources within and between countries. Political factors – the norms, policies and practices that arise from political interaction (at different levels, including globally and nationally) across all sectors – also greatly influence population health.

Important issues and questions can be studied by taking a political-economy approach to research. These include seeking to understand the population-health impact of organisational policies, seeking to understand why policies and programmes apparently socially and economically desirable are often so difficult to implement, and seeking to find policy or programme solutions that are feasible in a local political and institutional context even if technically second-best.

To help understand these political-economy issues better, take the population-health influence of economic activity as an example:

• On the one hand, businesses play an important role in supporting population health through, for instance, the production of pharmaceuticals and other medical devices and technologies. Economic wealth is a key structural determinant of health and industry plays a key role in wealth creation and the generation of tax revenue, which can be spent on health services and public health programmes.
• On the other hand, corporations in health-harming industries (tobacco, alcohol, processed food and sugary beverages) are key structural drivers of morbidity and mortality, particularly non-communicable diseases. As well as the health impact of their products, such corporations pursue highly nuanced political strategies, including through international trade regimes, that seek to shape the regulatory context – often, in ways that conflict with public health and undermine evidence-based health policies. 

Such corporate influence on population health is an issue relevant to countries globally, but particularly now to low- and middle-income settings as they experience epidemiological transitions and bear the dual burden of communicable and non-communicable diseases – and as they are increasingly targeted by corporations due to weaker regulatory regimes. Of relevance here is the impact of attempts by health-harming industries to oppose policies that jeopardise their profits, including through legal challenges under international trade and EU single market law.

Approach

Mixed methods

Publications

• Matita M, Johnston D, Walls H. Understanding the drivers of food choice to improve population nutrition: An application of economics to public health. In press, Malawi Journal of Economics. 2021.
• Matita M, Chirwa EW, Johnston D, Mazalale J, Smith R, Walls H. Does household participation in food markets increase dietary diversity? Evidence from rural Malawi. Global Food Security. 2021;28:100486.
• Walls H, Baker P, Chirwa E, Hawkins B. Food security, food safety and healthy nutrition: Are they compatible? Global Food Security. 2019;21:69-71.
• Walls H, Johnston D, Mazalale J, Chirwa E. Why we are still failing to measure the nutrition transition. BMJ Global Health. 2018;3:e000657.
• Others in progress and under review.

Other outputs

• Matita M, Walls H (co-presenters). Household participation in food markets and dietary diversity: Evidence from rural Malawi. DFC program / IMMANA webinar series, Webinar #1 of Drivers of food choice in low- and middle-income countries: a synthesis of evidence. 2021. https://www.youtube.com/watch?v=MGwKHHm3yRI&feature=youtu.be
• Walls H (presenter), Johnston D, Matita M, Kamwanja T, Smith R, Nanama S. Agricultural input subsidy programmes and dietary diversity: a qualitative assessment in Malawi with implications for policy implementation theory. 5th Agriculture, Nutrition & Health (ANH) Academy Week, June 30 – July 2, 2020. https:// www.youtube.com/watch?v=5phAsNHzUjs&feature=youtu.be
• Matita M. Has the provision of legume seed subsidies affected dietary diversity? Household survey evidence from Malawi Farm Input Subsidy Program (FISP). 4th Agriculture, Nutrition & Health (ANH) Academy Week, June 24 – June 28, 2019. https://www.youtube.com/watch? v=yIHjua-VkYg
• Walls H (presenter), Johnston D, Chirwa E, Matita M, Mazalale J, Quaife M, Kamwanja T, Smith R. Does Malawi’s Farm Input Subsidy Programme (FISP) improve dietary diversity? 4th Agriculture, Nutrition & Health (ANH) Academy Week, June 24 – June 28, 2019. https://www.youtube.com/watch?v=_4gMncBhqMA
• Mazalale J (presenter), Johnston D, Matita M, Chirwa E, Quaife M, Smith R, Walls H. Designing a Discrete Choice Experiment to Understand Food Choice Based on Maize Price Variations in Rural Malawi. 3rd Agriculture, Nutrition & Health (ANH) Academy Week, June 25 – June 29, 2018. https://www.youtube.com/watch?v=jGUAU6rK-dM
• Chawantha S. ‘I haven’t eaten in three days’: Understanding personal experience of food insecurity in rural Malawi. Drivers of Food Choice. 2018. https://driversoffoodchoice.org/2018/05/14/i-haven-t-eaten-in-three-day…
• Masala G, Masanche B, Mazalale M. Collecting data on agricultural policy, food choice and dietary diversity in rural Malawi. Drivers of Food Choice. 2018. https://driversoffoodchoice.org/2018/03/01/collecting-data-on-agricultu… H. Observations from the field: Agri-nutrition research in Malawi. Drivers of Food Choice. 2017. https://driversoffoodchoice.org/2017/11/03/agri-nutrition-research-in-m…

People involved (staff as well as students)

• Helen Walls (PI; LSHTM),
• Deborah Johnston (SOAS University of London),
• Ephraim Chirwa (University of Malawi),
• Mirriam Matita (University of Malawi),
• Jacob Mazalale (University of Malawi),
• Tayamika Kamwanja (University of Malawi),
• Richard Smith (University of Exeter)

Other outputs

• Agricultural Input Subsidies project website  Observations from the field: Agri-nutrition research in Malawi (Helen Walls)
• Collecting data on agricultural policy, food choice and dietary diversity in rural Malawi (Gift Masala, Bridget Masanche, Masiye Mazalale)
• ‘I haven’t eaten in three days’: Understanding personal experience of food insecurity in rural Malawi

Project status

Ongoing

Migration, gender and health system response in South Africa: A focus on the movement of healthcare users and workers

This project investigates the intersection of migration, population mobility, and gender with health systems through the application of a set of innovative qualitative and quantitative research methods, applying an intersectionality lens. The research is undertaken in South Africa, a country that has faced high levels of both historical and contemporary inward, outward, and internal migration and population mobility. The research focuses on the mobility of both healthcare users and healthcare workers within, into, and out of South Africa and their interactions with the public health system.  It will include piloting and evaluating an innovative method of tracking healthcare user and worker movement over time using social media (WhatsApp), which will generate new data on how movement by both healthcare users and healthcare workers within, into, and out of South Africa interacts with their experiences of the health system. This is paired with new quantitative analysis of existing data sets on the movements of both healthcare users and healthcare workers within, into and out of South Africa. Specifically, this quantitative analysis includes the Tourism South Africa Border Survey, and the first ever analysis of data from the National Department of Health regarding patients travelling into South Africa under regulated bilateral agreements between the government of RSA and 11 neighbouring countries, and others.

Key research questions 

• How do migration and population mobility affect the South African health system?
• How does the health system respond and adapt as a result of migration and population mobility?
• How do these processes intersect with gender?

Objectives

• To assess levels of migration by patients and health workers within, into and out of South Africa.
• To examine the health care experiences of both migrant and non-migrant patients and health workers.
• To analyse how the South African health system adapts and responds in light of the population movements identified in Objective 1.
• To examine how the experiences and responses garnered during objectives 1-3 are shaped by gender.

Approach

• Mixed methods

Publications

• In progress

People involved (staff as well as students)

• Johanna Hanefeld (PI; LSHTM), Helen Walls (LSHTM),
• Jo Vearey (University of the Witwatersrand),
• Moeketsi Modisenyane (South Africa Department of Health), Sassy Molyneux (Oxford University and KEMRI Wellcome),
• Lucy Gilson (LSHTM, University of Cape Town),
• Jill Oliver (University of Cape Town),
• Richard Smith (University of Exeter)

Other outputs

• Migration, gender and health systems response project website

Project status

• Ongoing

Completed Projects

KePSIE-Qual – Understanding the impact of innovations in the regulation of Kenya’s health facilities

There has been little evaluation of strategies to strengthen regulation in low and middle-income countries (LMIC), a notable exception being the Kenya Patient Safety Impact Evaluation (KePSIE), a collaboration between the Kenyan Ministry of Health and the World Bank. This randomised controlled trial assessed the impact of a set of innovative regulatory interventions in public and private facilities:

• a Joint Health Inspection Checklist
• increased inspection frequency
• risk-based timing of inspections
• display of regulatory results outside facilities

To understand the effectiveness of the intervention and why aspects did (or did not) work, we conducted a companion study of the perceptions and experience of all stakeholders involved, though a mix of document review and in-depth interviews. We also assessed the incremental costs of the JHIC interventions compared to those of the current regulatory system.

The study demonstrated that objectivity and transparency are central for regulatory legitimacy, and an inspection culture supportive to facility staff is important. The system must be designed to avoid both opportunities for corruption and logistical challenges. The display of scorecards had little impact on patients but did raise reputational concerns for staff. A reformed inspection system can support compliance with licensing, but requires licensing procedures that are themselves efficient.

Finally, inspection is necessary but not sufficient to improve patient safety – this also requires financial and technical support for some facilities, strong focus on continuous process improvement and an emphasis on behaviour change.

Funded by Health Systems Research Initiative (MRC, ESRC, Wellcome Trust, DFID).

Publications

• Tama, E., Khayoni, I., Goodman, C., Ogira, D., Chege, T., Gitau, N., Wafula, F. (2021). What Lies Behind Successful Regulation? A Qualitative Evaluation of Pilot Implementation of Kenya’s Health Facility Inspection Reforms, International Journal of Health Policy and Management

Other outputs

• Policy brief
• KePSIE scorecard 

People

• Catherine Goodman (co-PI)

Strathmore University: Francis Wafula (co-PI), Gilbert Kokwaro, Eric Tama, Irene Khayoni, Timothy Chege, Dosila Ogira

World Bank Group: Njeri Mwaura

Dates

Completed February 2020

Health system governance and adaptation in conflict: a case study of Syria

This research project examines health system governance initiatives and adaptation in the three main military-controlled areas of Syria, to inform current and future health system governance strengthening. Findings will be relevant to local health authorities, non-governmental healthcare providers, and international partners with an interest in health services provision in these areas and Syria’s future health system.

A novel feature of our approach is the emphasis on testing and refining remote participatory methods. For example, we have conducted 72 key informant interviews with public and private healthcare providers and service-users in Syria using internet call applications. We are thus well positioned to examine governance of COVID-19 health system responses in Syria and to track how the health system will adapt to such shocks.

The aim of the study is to examine health system governance and adaptation during the ongoing Syrian conflict and propose strengthening measures in this and similar settings.

Publications

• Douedari Y, Howard N. (2019). Perspectives on Rebuilding Health System Governance in Opposition-Controlled Syria: A Qualitative Study. International Journal of Health Policy & Management, 8(4), 233-244. 
• Fardousi N, Douedari Y, Howard N. (2019) Healthcare under siege: a qualitative study of health-worker responses to targeting and besiegement in Syria. BMJ open, 9 (9). e029651-. ISSN 2044-6055

People

LSHTM: Natasha Howard (PI), Yazan Douedari, Mervat Alhaffar, Eiman Hussain, Syreen Hassan, Nasser Fardousi

Aula Abarra (Imperial), Samer Jabbour (AUB), Mohamed Altwaish (Relief Experts Association), Diana Rayes (UC Berkeley)

PANDEM: Pandemic Risk and Emergency Management

A European Union-funded Horizon 2020 project, this consortium of seven institutions across Europe aimed “to identify innovative concepts to strengthen capacity-building for pandemic risk and emergency management in the EU”.

LSHTM was responsible for Work Package 4: Governance and Legal Frameworks. We produced three reports which were presented to the EU in March 2017 and accepted without amendment:

• Review of policy and legal frameworks including EU and US case studies
• Review and analysis of ethical and human rights issues
• Identification of knowledge, capability/capacity gaps, priorities and candidate solutions

Publications

• Speakman EM, McKee M, Coker R. (2017) If not now, when? Time for the European Union to define a global health strategy,The Lancet Global Health. 2017 Apr 1;5(4): e392 3. 

• Speakman EM, Burris S, Coker R. (2017) Pandemic legislation in the European Union: Fit for purpose? The need for a systematic comparison of national laws. Health Policy. Oct 1;121(10):1021-4.

People

• Professor Richard Coker: Co-Investigator
• Elizabeth Speakman: Research Fellow

Dates

2015–17

Measuring management practices in India's district public health bureaucracy

Weak management is widely recognised as a key impediment to scaling-up coverage of health interventions and ensuring health systems are responsive to population needs. Yet there is scant evidence linking management practices in public administration to effective health service delivery.

We sought to develop a tool to measure management practices in India's district health bureaucracy. Across 16 management practices, we drafted and piloted questions to be used with a scoring grid to evaluate process-orientated management practices. The tool was implemented in 34 districts of Maharashtra between April and July 2016.

Using rigorous psychometric methods, we assessed the acceptability, reliability and validity of the tool. We found that

• the tool was feasible to implement (with few missing data and high response rates)
• the psychometric performance of the tool was reasonably strong
• reliability and validity were commensurate with other management tools.

These findings provide novel evidence on the psychometric properties of a tool designed to measure management practices in the public administration of a developing country.

People

• Timothy Powell-Jackson
• Kara Hanson
• Camilla Fabbri

Publications

• Timothy Powell-Jackson, Bhaskar Purohit, Deepak Saxena, Mahaveer Golechha, Camilla Fabbri, Partha Sarthi Ganguly, Kara Hanson (2019). Measuring management practices in India's district public health bureaucracy. Social Science and Medicine

Designing fit-for-purpose regulation for evolving health systems

Regulation in low- and middle-income countries (LMICs) can seem frozen in time, rarely incorporating modern perspectives, and ill-suited to manage the needs of evolving health systems. This project sought to analyse recent developments in LMIC healthcare markets by:

• identifying the challenges and opportunities these pose for designing fit-for-purpose regulation
• reviewing trends in private sector development and regulation in Nigeria, India, and Kenya, three countries with rapidly changing healthcare markets

We identified the consolidation of health services, mHealth, and e-pharmacy as ‘hot topics’ warranting further study though document review and key informant interviews. For example, for e-pharmacy we found that regulation had not kept pace with this innovation and e-pharmacy markets have evolved in a regulatory vacuum. Informant fears included the danger of online medicine sales in the absence of regulation; the lack of regulatory capacity; and of both under- and over-regulation. Conversely, informants posited that consolidation through e-platforms may bring regulatory opportunities and online records of medicine sales may offer the prospect of traceability and transparency. Follow-on work included developing a broader programme of work around fit-for-purpose regulation of e-pharmacy in LMICs.

Funded by the Wellcome Trust.

Publications / Reports

• The challenges and opportunities of e-pharmacy in LMICs – Presentation
• Country Report – India
• Country Report – Kenya
• Miller R, Wafula F, Onoka CA, et al. When technology precedes regulation: the challenges and opportunities of e-pharmacy in low-income and middle-income countries. BMJ Global Health 2021;6:e005405

People

LSHTM: Kara Hanson (PI), Catherine Goodman, Pauline Allen, Stefanie Ettelt, Marie Sanderson, Rosalind Miller

Strathmore University: Francis Wafula

University of Nigeria: Chima Onoka

The George Institute for Global Health, India: Prasanna Saligram

International Health Policy Programme, Thailand: Viroj Tangcharoensathien

Dates

Completed in April 2018