Linking public health training and health systems ... - Springer Link

Commentary

Linking public health training and health systems development in sub-Saharan Africa: Opportunities for improvement and collaboration Sharon Fonn School of Public Health, Faculty of Health Sciences, University of the Witwatersrand, Johannesburg, 7 York Road, Parktown, 2193, South Africa.

Abstract In sub-Saharan Africa previous health gains have been reversed and many countries are not on track to achieving the Millennium Development Goals. The reasons are multifaceted but relate fundamentally to poorly functioning health systems and the HIV, AIDS, and tuberculosis epidemics. Although population health can be improved through specific health interventions that target high burden diseases, these interventions must be offered within a functional health system for optimal effectiveness. Schools of Public Health in Africa should respond to the many systemic issues that confound improvements in population level health through reviewing approaches to health professional training that incorporates a public health approach, focusing on health systems research; collaboration, advocacy and networking; and strengthening health systems management. Institutional mechanisms to define joint research agendas and two-way exchanges between universities and national health systems are required. Journal of Public Health Policy (2011) 32, S44–S51. doi:10.1057/jphp.2011.37 Keywords: Schools of Public Health; universities; health systems strengthening; public health curriculum; research; Africa

Introduction In South and sub-Saharan Africa health gains, such as reductions in infant and maternal mortality and higher life expectancy, have been reversed.1 South Africa, as is the case with many other African countries, is not on track to achieve the Millennium Development Goals.2 The reasons are multifaceted but relate fundamentally to poorly functioning health systems in sub-Saharan Africa,3–5 and in southern Africa, the more recent epidemics of HIV, AIDS, and tuberculosis (TB).6,7 Many institutions have responded to the problem of resource constrained

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health systems over the years including United Nations agencies, bilateral development investments, and donor aid. This has resulted in significant investments in TB,8 maternal health,9 reproductive health,10 childhood illnesses, and HIV-related services.11 Despite these investments health gains have been below expectations, in part because agency or donor investments have taken a disease or programme-specific approach, aptly illustrated by the response to the HIV epidemic. The donor argument put forward for a vertical approach, similar to the case when child health programmes or family planning programmes were introduced in the early 1980s, was that the crisis was too big, the issue too urgent, to take time introducing HIV services into weak health systems.12 However, these programmespecific interventions have encountered similar limitations and criticisms. These include ‘a-one-size-fits-all-approach’, which may not be locally appropriate; and the creation of vertical programmes that duplicate and work around existing health systems. Vertical interventions undermine already weak health systems by drawing health workers towards the better funded health interventions rather than building the overall health system serving the multiple health needs in a particular country.13,14 Bottlenecks in the provision of antiretroviral therapy services illustrate inherent health systems’ weaknesses applicable to all healthrelated services and include: limited physical access to service sites; weak drug supply systems; inadequate infrastructure ranging from poorly maintained or too small buildings to problems with water and electricity supply; low staffing levels; and poor management of and support to staff working under difficult conditions.15 Poor stewardship of the health system has also been identified as an overarching problem that compromises the effectiveness of health systems.16,17 In the light of the urgent imperative to improve health systems performance in sub-Saharan Africa, this commentary argues that Schools of Public Health in Africa should respond to the many systemic issues that confound improvements in population level health.

Reviewing Approaches to Training Health Professionals Public health training must respond to numerous challenges. First, all health professionals need to have a public health approach and competencies so that they contribute to creating the conditions in

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which people can achieve health.18 Second, training must focus on the local disease burden so that graduates have knowledge and skills appropriate to environments in which they will work. Third, public health curricula must train graduates to be ‘change agents’ and be equipped to think critically, make decisions, work as team members, and provide leadership.19 Last, to be able to provide leadership in health and contribute to the local health system, graduates need to understand the social determinants of the disease burden to enable them to identify intersectoral partners to work with. While capacity building and continuing professional development of people working in the public health sector is offered by many institutions through a myriad of short courses, only universities or tertiary institutions can confer quality assured degrees in public health. There is limited public health training capacity in most universities in Africa. For the more than 900 million people living in Africa there are only about 500 full-time public health academics and half the countries in Africa have no post-graduate training in public health.20 This limited public training capacity is further constrained by the challenges of higher education in sub-Saharan Africa: unprecedented growth in student enrolment at universities; reduction in per capita funding; and heavy undergraduate teaching load of academics, with negative implications for staff morale and research.21 Hence, training capacity needs to increase and research and training should be linked in education institutions.20

Collaboration, Advocacy, and Networking The formation of the Association of Schools of Public Health in Africa (ASPHA) in November 2010 provides a strategic opportunity for Schools of Public Health to foster jointly the practice and quality of public health training in Africa. An important role is to advocate for public health policy, research, and training by engaging stakeholders. Universities and health science faculties, national science and medical councils need to understand the crucial role efficient health systems play in development and invest in their public health departments and schools. At the same time, Ministries of Education, Health, and Finance must allocate the requisite resources to public health training. The African Union has a leadership role to play by highlighting health systems development as a priority. International funding through foundations, bilateral development donors, and institutions such as the

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National Institutes of Health in the United States of America, can and have made investments in health systems research and public health capacity development. This needs to be sustained and increased.

Curriculum Changes Current public health leaders can ensure that training contributes to health systems strengthening by reviewing public health curricula. Graduates from public health programmes, both the 1–2 years Masters in Public Health (MPH) degrees (open to people with a 4-year degree in any discipline) and 4-year MMed (medical specialist training in public health open to medical doctors only) must leave with appropriate skills. These graduates should increasingly fill senior management positions in health departments. ASPHA is currently working towards standardizing the training for the MPH and defining core competencies. For example, each public health graduate should have the requisite skills to run high quality monitoring and evaluation programmes and to use the data for decision making at any level in the health service. A standardized curriculum could also serve as a bulwark against disease- or programme-specific vertical interventions favoured by donors. This could be achieved by including a curriculum that illustrates how disease-specific investments can be used to build the health system. Policy analysis and advocacy skills would enable graduates to present national priorities cogently to the donor community. Training public health graduates to understand health financing within national health accounts and sector-wide approaches would equip public health graduates to engage better in national and international debates and decision making processes on investments in health. Local, skilled public health graduates who understand their health systems and disease burden contexts would be in a better position to ensure that national governments guide and take leadership over donor investments. This will result in investments being more consistent with national priorities and, local disease burden, and supportive of building health systems.

Research Increasingly development is seen as ‘a country’s capacity to understand, interpret, select, adapt, use, transmit, diffuse, produce, and commercialize scientific knowledge in ways appropriate to its


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culture’.22 Hence, research that is conceptualized, conducted, analysed, and published by Africans is a key development strategy.23 However, development of indigenous capacity and the related health improvements require long-term sustained investment. In this regard, universities have a crucial role to play, require sustained investment, and should be placed high on national and international funding priority lists. A key strategy of Schools of Public Health should be to conduct health systems research and to train the next generation of researchers. Such research and training must be: multidisciplinary; enhance our understanding of barriers to improved population health; create an evidence base; and be able to document the impact of interventions on population health. Significant efforts in Africa to address this have been described.24 When this research is done in partnership with health services there is a greater chance that it will inform health systems planning and management. This calls for close partnerships between universities and national health systems. Creating the space for joint research projects would be an easy first step and many Schools of Public Health already do this.25 This needs to be expanded and universities must develop more active research portfolios and seek to partner with the health system. Governments would need to examine their tendency to work predominantly with international agencies and external experts and should prioritize partnerships with local university-based experts. The tendency to overvalue external, donor-driven interventions discourages local problem-solving and creates a culture of dependency.24 Funding allocated to external experts could be reallocated to experienced public health academics and health system leaders from within the region, thus ploughed back into universities rather and so build these national resources. This could form a virtuous cycle making better funded and research active university posts more attractive to African academics. Institutional mechanisms to define joint research agendas would be the first step towards achieving this.

Institutional Arrangements The role of Schools of Public Health as training and research institutions in developing ‘institutional arrangements that enable systematic analysis and learning’26 to develop health systems has been

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neglected. We must also pay attention to training professionals to manage and lead health systems. The complexity of health service management should not be underestimated and there are a range of possible and equally legitimate ways to prioritize the way health services are delivered and what services are provided. Yet in South Africa, and in many other African countries, as human resources are limited, young and less experienced staff are promoted rapidly and may be appointed without adequate training to work as managers and policymakers in health services. These work environments are complex and are characterized by urgent, competing demands. Possible institutional arrangements to support improved management include a mechanism for individuals to move between academia, non-governmental organizations, and government health services, as is the case for Oxford University’s St Anthony’s College Senior Associate Members Programme in the United Kingdom and for The Woodrow Wilson International Center for Scholars in the USA. Similar arrangements can provide an opportunity for health service or systems managers and policy-makers to step out of their roles in service delivery to explore options for new practice by spending time in a School of Public Health. Academics could move, for a time, into service delivery roles. This could also ensure that the academic enterprise is grounded in the realities of health system functioning and service delivery. Such circular migration is not common in sub-Saharan Africa. There are a number of reasons for this. Universities appoint and remunerate staff based on formal degrees and publication output, and staff of ministries of health may not have such outputs. Salary scales in academia do not compete with those that ministries of health offer. However, these barriers are not insurmountable and secondment in both directions may offer a mechanism for achieving this circular migration. Joint provincial/university posts held by public health (and other) medical specialists and public health medicine registrars (training posts) offer a good mechanism to link academia with service. These joint appointments occur commonly and are found, for example, in South Africa and Nigeria. In South Africa, methods for how institutions of higher learning can work in strategic ways with provincial health departments are still poorly developed. Currently health service managers working in complex and under-functioning health systems operate in a ‘fire fighting’


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rather than strategic mode and political considerations sometimes trump evidence-based rational decision making.27 Such realities can make the relationship between universities and health systems difficult to negotiate. Buy-in, mutual respect, and trust between schools of public health and national health systems is a prerequisite to achieve joint research endeavours and greater interchange of staff between these institutions. Part of the answer to improving health systems lies in skillfully negotiating partnerships between academia and health systems that are mutually respectful and beneficial. Although there are limited human resources in Africa, there are many outstanding people in the public sector and internationally recognized public health academics across the continent. It is time to find new ways of working together to improve health systems so as to contribute to population health.

About the Author Sharon Fonn, MBBCh, PhD, is Professor and Head of the School of Public Health, University of the Witwatersrand, Johannesburg. She is the deputy chair of the Association of Schools of Public Health in Africa.

References 1. World Health Organization. (2006) The African Regional Health Report: The Health of the People. Geneva: WHO. 2. Chopra, M. et al (2009) Achieving the health Millennium Development Goals for South Africa: Challenges and priorities. Lancet 374(9694): 1023–1031. 3. World Health Organization. (2003) The World Health Report 2003 – Shaping the Future. Geneva: WHO. 4. World Health Organization. (2004) The World Health Report 2004 – Changing History. Geneva: WHO. 5. World Health Organization. (2005) The World Health Report 2005 – Make Every Mother and Child Count. Geneva: WHO. 6. Blaauw, D. and Penn-Kekana, L. (2010) Maternal health. In: S. Fonn and A. Padarath (eds.) South African Health Review 2010. Durban, South Africa: Health Systems Trust. 7. McKerrow, N. and Mulaudzi, M. (2010) Child mortality in South Africa, using existing data. In: S. Fonn and A. Padarath (eds.) South African Health Review 2010. Durban, South Africa: Health Systems Trust. 8. Nunn, P., Harries, A., Godfrey-Fausset, P., Gupta, R., Maher, D. and Raviglione, M. (2002) The research agenda for improving health policy, systems performance and service delivery for tuberculosis control: A WHO perspective. Bulletin of the World Health Organization 80: 471–476. 9. Maine, D. and Rosenfield, A. (1999) The safe motherhood initiative: Why has it stalled? American Journal of Public Health 89(4): 480–482.

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10. Lush, L., Cleland, J., Walt, G. and Mayhew, S. (1999) Integrating reproductive health: Myth and ideology. Bulletin of the World Health Organization 77: 771–777. 11. Bryce, L. et al (2003) Reducing child mortality: Can public health deliver? Lancet 362: 159–164. 12. Walsh, J.A. and Warren, K.S. (1979) Selective primary health care: An interim strategy for disease control in developing countries. New England Journal of Medicine 301: 967–974. 13. Bill and Melinda Gates Foundation and McKinsey & Company. (2005) Global Health Partnerships: Assessing Country Consequences. McKinsey & Company. 14. World Health Organization Maximising Positive Synergies Collaborative Group. (2009) An assessment of interactions between global health initiatives and country health systems. Lancet 373(9681): 2137–2169. 15. Schneider, H., Blaauw, D., Gilson, L., Chabikuli, N. and Goudge, J. (2006) Health systems and access to antiretroviral drugs for HIV in Southern Africa: Service delivery and human resources challenges. Reproductive Health Matters 14(27): 12–23. 16. Schneider, H., Barron, P. and Fonn, S. (2007) The promise and the practice of transformation in South Africa’s health system. In: S. Buhlungu, J. Daniel, R. Southall and J. Lutchman (eds.) State of the Nation South Africa 2007. Cape Town, South Africa: Human Sciences Research Council Press, pp. 289–311. 17. Rispel, L.C. and Moorman, J. (2010) Analysing health legislation and policy in South Africa: Context, process and progress. In: S. Fonn and A. Padarath (eds.) South African Health Review 2010. Durban, South Africa: Health Systems Trust. 18. El Ansari, W., Russell, J., Ryder, E. and Chambers, C. (2003) New skills for a new age: Leading the introduction of public health concepts in healthcare curricula. Public Health 117: 77–87. 19. Frenk, J. et al (2010) Health professionals for a new century: Transforming education to strengthen health systems in an interdependent world. Lancet 376(9756): 1923–1958. 20. IJsselmuiden, C.B., Nchinda, T.C., Duale, S., Tumwesigye, N.M. and Serwadda, D. (2007) Mapping Africa’s advanced public health education capacity: The AfriHealth project. Bulletin of the World Health Organization 85(12): 914–922. 21. World Bank. (1995) Retaining teaching capacity in Africa Universities: Problems and Prospects. Findings; Africa Region No 39. IBRD, Washington, DC. 22. Crawford, M., Watson, R. and Farley, S. (2003) Strategic approaches to science and technology in development. The World Bank Policy Research Working Paper Series 3026. 23. Fonn, S. (2005) African PhD research capacity in public health raison d’eˆtre and how to build it. In: S. Matlin (ed.) Global Forum Update on Research for Health. London: Pro-Brook Publishers, pp. 80–83. 24. Ezeh, A.C. et al (2010) Building capacity for public and population health research in Africa: The consortium for advanced research training in Africa (CARTA) model. Global Health Action 3(5693), doi:10.3402/gha.v3i0.5693. 25. Fonn, S. and Tint, K.S. (2002) Transforming reproductive health services in South Africa: Women’s health advocates and government in partnership. In: N. Haberland and D. Measham (eds.) Responding to Cairo: Case Studies of Changing Practice in Reproductive Health and Family Planning. New York: Population Council, pp. 74–96. 26. Evans, T., Nishtar, S., Atun, R. and Etienne, C. (2008) Scaling up research and learning for health systems: Time to act. Lancet 372(9649): 1529–1531. 27. Butler, A. (2007) The state of the African National Congress. In: S. Buhlungu, J. Daniel, R. Southall and J. Lutchman (eds.) State of the Nation South Africa 2007. Cape Town, South Africa: HSRC Press, pp. 35–52.


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