Systems thinking in practice: the current status of the six WHO building blocks for health system strengthening in three BHOMA intervention districts of Zambia: a baseline qualitative study

Mutale, Wilbroad; Bond, Virginia; Mwanamwenge, Margaret Tembo; Mlewa, Susan; Balabanova, Dina; Spicer, Neil; Ayles, Helen

doi:10.1186/1472-6963-13-291

Cited by 54 publications

(51 citation statements)

References 29 publications

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“…Although it was reported by both the service providers and the district coordinators that services are free, there are some indirect costs which service users incur to access them. These include transportation to the cervical cancer screening facilities and referral centers ( 35 ) and purchasing of health passport which is a requirement for every patient who is accessing the services. The health system in Malawi faces absolute and relative inadequacy of financing resources to adequately fund essential health package (EHP) services ( 24 ) and non-EHP services.…”

Section: Discussionmentioning

confidence: 99%

Health systems challenges in cervical cancer prevention program in Malawi

Maseko

Chirwa²,

Muula

2015

Global Health Action

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BackgroundCervical cancer remains the leading cause of cancer death among women in sub-Saharan Africa. In Malawi, very few women have undergone screening and the incidence of cervical cancer is on the increase as is the case in most developing countries. We aimed at exploring and documenting health system gaps responsible for the poor performance of the cervical cancer prevention program in Malawi.DesignThe study was carried out in 14 randomly selected districts of the 29 districts of Malawi. All cervical cancer service providers in these districts were invited to participate. Two semi-structured questionnaires were used, one for the district cervical cancer coordinators and the other for the service providers. The themes of both questionnaires were based on World Health Organization (WHO) health system frameworks. A checklist was also developed to audit medical supplies and equipment in the cervical cancer screening facilities. The two questionnaires together with the medical supplies and equipment checklist were piloted in Chikwawa district before being used as data collection tools in the study. Quantitative data were analyzed using STATA and qualitative in NVIVO.ResultsForty-one service providers from 21 health facilities and 9 district coordinators participated in the study. Our findings show numerous health system challenges mainly in areas of health workforce and essential medical products and technologies. Seven out of the 21 health facilities provided both screening and treatment. Results showed challenges in the management of the cervical cancer program at district level; inadequate service providers who are poorly supervised; lack of basic equipment and stock-outs of basic medical supplies in some health facilities; and inadequate funding of the program. In most of the health facilities, services providers were not aware of the policy which govern their work and that they did not have standards and guidelines for cervical cancer screening and treatment.ConclusionNumerous health system challenges are prevailing in the cervical cancer prevention program in Malawi. These challenges need to be addressed if the health system is to improve on the coverage of cervical cancer screening and treatment.

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Section: Discussionmentioning

confidence: 99%

Health systems challenges in cervical cancer prevention program in Malawi

Maseko

Chirwa²,

Muula

2015

Global Health Action

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“…Similarly, an Ethiopian study observed that a motivated and committed health workforce was needed to expedite healthcare reform processes [52]. The problem of staff shortages was echoed in a Zambian study where patients were being attended by non-clinicians [53]. A Georgian study observed that where there was no clear vision and plans for HRH development, employees would inevitably leave to seek better opportunities elsewhere [54].…”

Section: Health Workforcementioning

confidence: 99%

Public health system challenges in the Free State, South Africa: a situation appraisal to inform health system strengthening

Malakoane

Heunis

Chikobvu

et al. 2020

BMC Health Serv Res

126

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Background: Since the advent of democracy, the South African government has been putting charters, policies, strategies and plans in place in an effort to strengthen public health system performance and enhance service delivery. However, public health programme performance and outcomes remained poor while the burden of disease increased. This was also the case in the Free State Province, where major public health system challenges occurred around 2012. Assessment was necessary in order to inform health system strengthening. Methods: The study entailed a multi-method situation appraisal utilising information collated in 44 reports generated in 2013 through presentations by unit managers, subdistrict assessments by district clinical specialist teams, and group discussions with district managers, clinic supervisors, primary health care managers and chief executive and clinical officers of hospitals. These data were validated through community and provincial health indabas including non-governmental organisations, councils and academics, as well as unannounced facility visits involving discussions with a wide range of functionaries and patients. The reports were reviewed using the World Health Organization health system building blocks as a priori themes with subsequent identification of emerging subthemes. Data from the different methods employed were triangulated in a causal loop diagram showing the complex interactions between the components of an (in) effective health system. Results: The major subthemes or challenges that emerged under each a priori theme included: firstly, under the 'service delivery' a priori theme, 'fragmentation of health services' (42 reports); secondly, under the 'health workforce' a priori theme, 'staff shortages' (39 reports); thirdly, under the 'health financing' a priori theme, 'financial/cash-flow problems' (39 reports); fourthly, under the 'leadership and governance' a priori theme, 'risk to patient care' (38 reports); fifthly, under the 'medical products/technologies' a priori theme, 'dysfunctional communication technology' (27 reports); and, sixthly, under the 'information' a priori theme, 'poor information management' (26 reports). Conclusion: The major overall public health system challenges reported by stakeholders involved fragmentation of services, staff shortages and financial/cash-flow problems. In order to effect health systems strengthening there was particularly a need to improve integration and address human and financial deficiencies in this setting.

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“…The findings of the baseline study were used to inform the design of the BHOMA intervention. Full results of the baseline study are described elsewhere [29]. The follow-up qualitative study was conducted 12 months after the implementation of the intervention.…”

Section: The Community Strategymentioning

confidence: 99%

Application of systems thinking: 12‐month postintervention evaluation of a complex health system intervention in Zambia: the case of the BHOMA

Mutale

Ayles

Bond

et al. 2015

Evaluation Clinical Practice

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Rationale, aims and objectives: Strong health systems are said to be paramount to achieving effective and equitable health care. The World Health Organization has been advocating for using system-wide approaches such as 'systems thinking' to guide intervention design and evaluation. In this paper we report the system-wide effects of a complex health system intervention in Zambia known as Better Health Outcome through Mentorship and Assessment (BHOMA) that aimed to improve service quality. Methods: We conducted a qualitative study in three target districts. We used a systems thinking conceptual framework to guide the analysis focusing on intended and unintended consequences of the intervention. NVivo version 10 was used for data analysis. Results: The addressed community responded positively to the BHOMA intervention. The indications were that in the short term there was increased demand for services but the health worker capacity was not severely affected. This means that the prediction that service demand would increase with implementation of BHOMA was correct and the workload also increased, but the help of clinic lay supporters meant that some of the work of clinicians was transferred to these lay workers. However, from a systems perspective, unintended consequences also occurred during the implementation of the BHOMA. Conclusions:We applied an innovative approach to evaluate a complex intervention in low-income settings, exploring empirically how systems thinking can be applied in the context of health system strengthening. Although the intervention had some positive outcomes by employing system-wide approaches, we also noted unintended consequences.

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Systems thinking in practice: the current status of the six WHO building blocks for health system strengthening in three BHOMA intervention districts of Zambia: a baseline qualitative study

Cited by 54 publications

References 29 publications

Health systems challenges in cervical cancer prevention program in Malawi

Health systems challenges in cervical cancer prevention program in Malawi

Public health system challenges in the Free State, South Africa: a situation appraisal to inform health system strengthening

Application of systems thinking: 12‐month postintervention evaluation of a complex health system intervention in Zambia: the case of the BHOMA

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