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Governance. Credit: Richard Coker

Governance

Improving governance in the real world to strengthen health systems

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About

Our research seeks to understand the multifaceted nature of governance at local, district and national level; pinpoint ways in which governance policies and interventions can improve health systems performance; and support decision makers to implement feasible solutions.

About
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Effective governance leads to better health outcomes and access to essential and good quality services. For this reason, studies of governance underpin all health systems research in the Department of Global Health and Development. Effective governance determines:

  • health systems resilience
  • ability to respond to crises such as the Ebola epidemic in West Africa
  • the processes through which policy decision are made
  • the regulations and practices through which providers are licensed and unlicensed
  • the ways in which healthcare providers, managers and service users interact with each other – formally and informally – with these exchanges determining how services are provided and to whom

We conceptualize and examine governance at different levels:

  • macro-level governance (e.g. enacting national and international laws, regulations and management practices)
  • district governance (e.g. implementation shaped by local resources and interests)
  • local governance (e.g. frontline practices that invoke formal and informal socio-political relationships)
  • intersectoral governance, linking health and climate and agriculture governance
  • governance of human resources (‘health system software’) through strengthening management and leadership, and working with traditional practitioners and community volunteers
  • incentives, values and behaviours underpinning in governance at the level of system, institution and individual

All these different levels are interconnected and interdependent, but studying linkages helps to explain why often well-intentioned policies fail to achieve their intended consequences. They help us to elicit why some actors are able and willing to follow the rules while others engage in harmful practices such as rent seeking (using public resources for private gain) and inappropriate prescribing (leading, for example, to antimicrobial resistance).

Understanding governance and its relation to power helps us to engage and to answer policy-relevant questions and promote change in health systems. An important aspect of research is on the governance of teaching and learning health policy and systems research (HPSR). We explore how to accelerate creating capacity and link training to research and priority setting while considering the political environment.

Team
Team Block

Dina
Balabanova

Associate Professor

Johanna
Hanefeld

Associate Professor

Kara
Hanson

Professor

Martin
McKee

Professor

Rosalind
Miller

Assistant Professor

Sandra
Mounier-Jack

Associate Professor

Timothy
Powell-Jackson

Associate Professor

Elizabeth
Speakman

Distance Learning Tutor

Helen
Walls

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

Research Team:

LSHTM: Catherine Goodman (PI), Rosalind Miller
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.
 
 
Anti-Corruption Evidence (ACE)

 

ACE logo

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

Other outputs

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

Do Agricultural Input Subsidies on Staples Reduce Dietary Diversity?

There has been a resurgence of interest in agricultural input subsidy (AIS) programmes to boost agricultural productivity and food security. However, considerable debate continues regarding the effectiveness and efficiency of AIS investments, including their impact on nutrition. AIS are almost always applied to production of staple crops and aim to increase their productivity and smallholder incomes, usually with nutrition objectives. However, the overall impact on nutrition is unclear, not least because staples tend to be calorie-dense but low in other nutrients. AIS targeting maize, for example, may lead to increased concentration of production and consumption of maize and could reduce the intake of nutrient-rich foods. Alternatively, if the maize prices fall in real terms, this may enable consumers to purchase other goods including other food items. There is little evidence to determine the direction of impact.

The aim of this mixed methods research is to examine the impact of Malawi’s AIS programme (which primarily targets maize) on overall food choices, by examining not just price and consumption of maize but crucially the effects of the AIS programme on consumption of other foods. It also explores the wider context of food preferences and trade-offs, including by gender and socio-economic status. 

People

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

Publications

Other outputs

Dates

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 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?

There has been a resurgence of interest in agricultural input subsidy (AIS) programmes to boost agricultural productivity and food security. However there is considerable debate regarding the effectiveness and efficiency of AIS investments, including their impact on nutrition. AIS are almost always applied to production of staple crops and aim to increase their productivity and smallholder incomes, usually also with nutrition objectives. However, the overall impact on nutrition is unclear, not least because staples tend to be calorie-dense but low in other nutrients. AIS targeting maize, for example, may lead to increased concentration of production and consumption of maize and could reduce the intake of nutrient-rich foods. Alternatively, if the maize prices fall in real terms, this may enable consumers to purchase other goods including other food items. There is little evidence to determine the direction of impact.

The aim of this research is to examine the impact of Malawi’s AIS programme targeting mostly maize on overall food choices, by examining not just price and consumption of maize but crucially the effects of the AIS programme on consumption of other foods. It will also explore the wider context of food preferences and trade-offs, including by gender and socio-economic status. 

Approach

  • Mixed methods

Publications

  • Walls HL, 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.

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

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

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).

Other outputs

People

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

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

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

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

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