Health sector fragmentation: three examples from Sierra Leone

Barr, Arwen; Garrett, Lauryn; Marten, Robert; Kadandale, Sowmya

doi:10.1186/s12992-018-0447-5

Cited by 37 publications

(55 citation statements)

References 22 publications

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“…This also included non-program commodities to reduce duplication and stockout and thus to strengthen efficiency of overall health systems. These findings are in line with the recommendations on systems strengthening in Sierra Leone [ 9 ].…”

Section: Discussionsupporting

confidence: 90%

“…Previous studies in low- and middle-income countries documented that weak leadership and health system have led donors to establish their own planning, implementation, monitoring, accounting, and reporting mechanisms [ 6 – 8 ]. This has resulted in fragmentation of service delivery and availability of medical supplies for non-commodity programs which, in turn, led the community to high out-of-pocket (OOP) spending [ 8 , 9 , 41 ]. The consequence of financial fragmentation was that the allocated budget was not used for the priority agendas, leading to duplications and gaps.…”

Section: Discussionmentioning

confidence: 99%

“…This fragmentation has resulted in suboptimal care, higher cost due to duplication of efforts and resources, reduced efficiency, and poor quality of care, and it has negatively affected efforts to strengthen health systems. Multiple reasons were provided for this fragmentation, including a tendency among global actors towards vertical programs [ 6 , 9 , 10 ]. Such fragmentation is particularly common in low- and middle-income countries, and Ethiopia is no exception.…”

Section: Introductionmentioning

confidence: 99%

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Analyzing efforts to synergize the global health agenda of universal health coverage, health security and health promotion: a case-study from Ethiopia

et al. 2021

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Background Evidence exists about synergies among universal health coverage, health security and health promotion. Uniting these three global agendas has brought success to the country’s health sector. This study aimed to document the efforts Ethiopia has made to apply nationally synergistic approaches uniting these three global health agendas. Our study is part of the Lancet Commission on synergies between these global agendas. Methods We employed a case study design to describe the synergistic process in the Ethiopian health system based on a review of national strategies and policy documents, and key informant interviews with current and former policymakers, and academics. We analyzed the “hardware” (using the World Health Organization’s building blocks) and the “software” (ideas, interests, and power relations) of the Ethiopian health system according to the aforementioned three global agendas. Results Fragmentation of health system primarily manifested as inequities in access to health services, low health workforce and limited capacity to implementation guidelines. Donor driven vertical programs, multiple modalities of health financing, and inadequate multisectoral collaborations were also found to be key features of fragmentation. Several approaches were found to be instrumental in fostering synergies within the global health agenda. These included strong political and technical leadership within the government, transparent coordination, and engagement of stakeholders in the process of priority setting and annual resource mapping. Furthermore, harmonization and alignment of the national strategic plan with international commitments, joint financial arrangements with stakeholders and standing partnership platforms facilitated efforts for synergy. Conclusions Ethiopia has implemented multiple approaches to overcome fragmentation. Such synergistic efforts of the primary global health agendas have made significant contributions to the improvement of the country’s health indicators and may promote sustained functionality of the health system.

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Section: Discussionsupporting

confidence: 90%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

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Analyzing efforts to synergize the global health agenda of universal health coverage, health security and health promotion: a case-study from Ethiopia

et al. 2021

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“…The efficiency of these interventions, targeting specific diseases like hypertension, without considering structural constraints related to health systems has been debated (McCoy et al, 2005; Mills, 1983; Mounier-Jack et al, 2017; Schneider et al, 2006). Taking HIV/AIDS policies as an example, it has been shown that bypassing health systems by creating vertical structures that drain resources from a ‘crumbling core’ may address short-term needs (Schneider et al, 2006), but also contribute to health systems’ fragmentation, the duplication of services because of decontextualized donors’ priorities, the dilution and distortion of limited human and financial resources, and weak coordination between levels of care (Barr et al, 2019). The ‘health systems strengthening’ approach has been perceived as one way to improve health outcomes and the efficiency of these programs.…”

Section: Checking Persistencymentioning

confidence: 99%

Medical disposals and problem solving: About high blood pressure in Morocco

Tantchou

2020

Soc Stud Sci

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In this article, I analyze how in basic health-care facilities in Morocco, general practitioners transform patients’ problems into solvable problems, taking into account constraints related to medical standards, financial issues, the organization of the health system, and care. My focus is on hypertension, or high blood pressure. I argue that standards allow the solving of patients’ problems through the production of an entity called high blood pressure. However, the ‘high blood pressure’ enacted is different from the entity defined by standards. Fragments of the latter, borrowed from other contexts, are put to work in Morocco, while the material arrangements needed to enforce and have them work without discontinuities do not exist. This contributes to the production of an entity configured at a moment in time between standards and patients’ lives.

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“…However, these innovations are embedded in wider health system contexts that are often characterised by organisational fragmentation and siloed functioning 2–4. The ‘disarticulated state’5 is the end result of a variety of forces impacting health systems in both the global north and south: proliferation of donor aid and vertical health programmes in the Millennium Development Goal era,6 New Public Management reforms and the splitting of purchaser and provider functions,7 8 various forms of decentralisation and the growth of private (for profit and non-governmental) health sectors 4 8.…”

Section: Introductionmentioning

confidence: 99%

The governance of local health systems in the era of Sustainable Development Goals: reflections on collaborative action to address complex health needs in four country contexts

et al. 2019

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This analysis reflects on experiences and lessons from four country settings—Zambia, India, Sweden and South Africa—on building collaborations in local health systems in order to respond to complex health needs. These collaborations ranged in scope and formality, from coordinating action in the community health system (Zambia), to a partnership between governmental, non-governmental and academic actors (India), to joint planning and delivery across political and sectoral boundaries (Sweden and South Africa). The four cases are presented and analysed using a common framework of collaborative governance, focusing on the dynamics of the collaboration itself, with respect to principled engagement, shared motivation and joint capacity. The four cases, despite their differences, illustrate the considerable challenges and the specific dynamics involved in developing collaborative action in local health systems. These include the coconstruction of solutions (and in some instances the problem itself) through engagement, the importance of trust, both interpersonal and institutional, as a condition for collaborative arrangements, and the role of openly accessible information in building shared understanding. Ultimately, collaborative action takes time and difficulty needs to be anticipated. If discovery, joint learning and developing shared perspectives are presented as goals in themselves, this may offset internal and external expectations that collaborations deliver results in the short term.

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Health sector fragmentation: three examples from Sierra Leone

Cited by 37 publications

References 22 publications

Analyzing efforts to synergize the global health agenda of universal health coverage, health security and health promotion: a case-study from Ethiopia

Analyzing efforts to synergize the global health agenda of universal health coverage, health security and health promotion: a case-study from Ethiopia

Medical disposals and problem solving: About high blood pressure in Morocco

The governance of local health systems in the era of Sustainable Development Goals: reflections on collaborative action to address complex health needs in four country contexts

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