Neglected Value of Small Population-based Surveys: A Comparison with Demographic and Health Survey Data

We believe that global health practice and evaluation operate with misleading assumptions about lack of reliability of small population-based health surveys (district level and below), leading managers and decision- makers to under-use this valuable information and programmatic tool and to rely on health information from large national surveys when neither timing nor available data meet their needs. This paper uses a unique opportunity for comparison between a knowledge, practice, and coverage (KPC) household survey and Rwanda Demographic and Health Survey (RDHS) carried out in overlapping timeframes to disprove these enduring suspicions. Our analysis shows that the KPC provides coverage estimates consistent with the RDHS estimates for the same geographic areas. We discuss cases of divergence between estimates. Application of the Lives Saved Tool to the KPC results also yields child mortality estimates comparable with DHSmeasured mortality. We draw three main lessons from the study and conclude with recommendations for challenging unfounded assumptions against the value of small household coverage surveys, which can be a key resource in the arsenal of local health programmers

Thinking about complexity in health: A systematic review of the key systems thinking and complexity ideas in health

Rationale, aims, and objectivesAs the Sustainable Development Goals are rolled out worldwide, development leaders will be looking to the experiences of the past to improve implementation in the future. Systems thinking and complexity science (ST/CS) propose that health and the health system are composed of dynamic actors constantly evolving in response to each other and their context. While offering practical guidance for steering the next development agenda, there is no consensus as to how these important ideas are discussed in relation to health. This systematic review sought to identify and describe some of the key terms, concepts, and methods in recent ST/CS literature.MethodUsing the search terms “systems thinkin * AND health OR complexity theor* AND health OR complex adaptive system* AND health,” we identified 516 relevant full texts out of 3982 titles across the search period (2002-2015).ResultsThe peak number of articles were published in 2014 (83) with journals specifically focused on medicine/healthcare (265) and particularly the Journal of Evaluation in Clinical Practice (37) representing the largest number by volume. Dynamic/dynamical systems (n = 332), emergence (n = 294), complex adaptive system(s) (n = 270), and interdependent/interconnected (n = 263) were the most common terms with systems dynamic modelling (58) and agent-based modelling (43) as the most common methods.ConclusionsThe review offered several important conclusions. First, while there was no core ST/CS “canon,” certain terms appeared frequently across the reviewed texts. Second, even as these ideas are gaining traction in academic and practitioner communities, most are concentrated in a few journals. Finally, articles on ST/CS remain largely theoretical illustrating the need for further study and practical application. Given the challenge posed by the next phase of development, gaining a better understanding of ST/CS ideas and their use may lead to improvements in the implementation and practice of the Sustainable Development Goals

Social Accountability and Health Systems’ Change, Beyond the Shock of Covid-19: Drawing on Histories of Technical and Activist Approaches to Rethink a Shared Code of Practice

Background: Recognition of the value of “social accountability” to improve health systems performance and to address health inequities, has increased over the last decades, with different schools of thought engaging in robust dialogue. This article explores the tensions between health policy and systems research and practice on the one hand, and health equity-focussed activism on the other, as distinct yet interacting processes that have both been impacted by the shock effects of the Covid-19 pandemic. This extended commentary brings multidisciplinary voices seeking to look back at health systems history and fundamental social-institutional systems’ behaviors in order to contextualize these current debates over how best to push social accountability efforts forward. Analysis: There is a documented history of tension between long and short processes of international health cooperation and intervention. Social accountability approaches, as a more recent strategy to improve health systems performance, intersect with this overarching history of negotiation between differently situated actors both global and local on whether to pursue sustained, slow, often community-driven change or to focus on rapid, measurable, often top-down interventions. Covid-19, as a global public health emergency, resulted in calls for urgent action which have unsurprisingly displaced some of the energy and aspiration for systemic transformation processes. A combination of accountability approaches and mechanisms have their own legitimacy in fostering health systems change, demanding collaboration between those that move both fast and slow, top-down and bottom-up. Conclusion: We argue that social accountability, much like all efforts to strengthen health systems, is “everybody’s business” and that we must understand better the historical processes that have shaped the field of practice over time to move forward. These differences of perspective, knowledge-base and positioning vis-a-vis interventions or longer-term political commitment should not drive a conflict of legitimacy but instead be named, subsequently enabling the development of a shared code of conduct that applies to the breadth of actors involved in social accountability work. If we are concerned about the state of/status of social accountability within the context of “building back better” we must approach collaboration with a willingness to create dialogue across distinct disciplinary, technical and politically-informed ways of working

Advancing the application of systems thinking in health : sustainability evaluation as learning and sense-making in a complex urban health system in Northern Bangladesh

Municipalities are legally tasked with ensuring the delivery of primary health care services to the population but had developed almost no capacity to do so. We describe how the Sustainability Framework method was implemented following the mid-term evaluation (2002), up through the final evaluation (2004), all the way to the 5-year post-project sustainability evaluation in 2009. Development aid’s efforts at scale up and acceleration of achievements are known to create stress on country systems, regardless of good intentions. This makes the question of sustainability still enormously critical to the future of global health and global development

Hubris, humility and humanity: expanding evidence approaches for improving and sustaining community health programmes

Community-based approaches are a critical foundation for many health outcomes, including reproductive, maternal, newborn and child health (RMNCH). Evidence is a vital part of strengthening that foundation, but largely focuses on the technical content of what must be done, rather than on how disparate community actors continuously interpret, implement and adapt interventions in dynamic and varied community health systems. We argue that efforts to strengthen evidence for community programmes must guard against the hubris of relying on a single approach or hierarchy of evidence for the range of research questions that arise when sustaining community programmes at scale. Moving forward we need a broader evidence agenda that better addresses the implementation realities influencing the scale and sustainability of community programmes and the partnerships underpinning them if future gains in community RMNCH are to be realised. This will require humility in understanding communities as social systems, the complexity of the interventions they engage with and the heterogeneity of evidence needs that address the implementation challenges faced. It also entails building common ground across epistemological word views to strengthen the robustness of implementation research by improving the use of conceptual frameworks, addressing uncertainty and fostering collaboration. Given the complexity of scaling up and sustaining community RMNCH, ensuring that evidence translates into action will require the ongoing brokering of relationships to support the human creativity, scepticism and scaffolding that together build layers of evidence, critical thinking and collaborative learning to effect change

Reclaiming comprehensive public health

Global and national responses to the COVID-19 pandemic highlight a long-standing tension between biosecurity-focused, authoritarian and sometimes militarised approaches to public health and, in contrast, comprehensive, social determinants, participatory and rights-based approaches. Notwithstanding principles that may limit rights in the interests of public health and the role of central measures in some circumstances, effective public health in a protracted pandemic like COVID-19 requires cooperation, communication, participatory decision-making and action that safeguards the Siracusa principles, respect for people’s dignity and local-level realities and capacities. Yet there is mounting evidence of a dominant response to COVID-19 where decisions are being made and enforced in an overcentralised, non-transparent, top-down manner, often involving military coercion and abuse in communities, even while evidence shows the long-term harm to public health and human rights. In contrast, experiences of comprehensive, equity-focused, participatory public health approaches, which use diverse sources of knowledge, disciplines and capabilities, show the type of public health approach that will be more effective to meet the 21st century challenges of pandemics, climate, food and energy crises, growing social inequality, conflict and other threats to health

Unlocking Community Capabilities Across Health Systems in Low- and Middle-Income Countries: Lessons Learned from Research and Reflective Practice

The right and responsibility of communities to participate in health service delivery was enshrined in the 1978 Alma Ata declaration and continues to feature centrally in health systems debates today. Communities are a vital part of people-centred health systems and their engagement is critical to realizing the diverse health targets prioritised by the Sustainable Development Goals and the commitments made to Universal Health Coverage. Community members' intimate knowledge of local needs and adaptive capacities are essential in constructively harnessing global transformations related to epidemiological and demographic transitions, urbanization, migration, technological innovation and climate change. Effective community partnerships and governance processes that underpin community capability also strengthen local resilience, enabling communities to better manage shocks, sustain gains, and advocate for their needs through linkages to authorities and services. This is particularly important given how power relations mark broader contexts of resource scarcity and concentration, struggles related to social liberties and other types of ongoing conflicts.IS

Exploring Pathways for Building Trust in Vaccination and Strengthening Health System Resilience

Background: Trust is critical to generate and maintain demand for vaccines in low and middle income countries. However, there is little documentation on how health system insufficiencies affect trust in vaccination and the process of re-building trust once it has been compromised. We reflect on how disruptions to immunizations systems can affect trust in vaccination and can compromise vaccine utilization. We then explore key pathways for overcoming system vulnerabilities in order to restore trust, to strengthen the resilience of health systems and communities, and to promote vaccine utilization. Methods: Utilizing secondary data and a review of the literature, we developed a causal loop diagram (CLD) to map the determinants of building trust in immunizations. Using the CLD, we devised three scenarios to illustrate common vulnerabilities that compromise trust and pathways to strengthen trust and utilization of vaccines, specifically looking at weak health systems, harmful communication channels, and role of social capital. Spill-over effects, interactions and other dynamics in the CLD were then examined to assess leverage points to counter these vulnerabilities. Results: Trust in vaccination arises from the interactions among experiences with the health system, the various forms of communication and social capital – both external and internal to communities. When experiencing system-wide shocks such as the case in Ebola-affected countries, distrust is reinforced by feedback between the health and immunization systems where distrust often lingers even after systems are restored and spills over beyond vaccination in the broader health system. Vaccine myths or anti-vaccine movements reinforce distrust. Social capital – the collective value of social networks of community members – plays a central role in increasing levels of trust. Conclusions: Trust is important, yet underexplored, in the context of vaccine utilization. Using a CLD to illustrate various scenarios helped to explore how common health and vaccine vulnerabilities can reinforce and spill over distrust through vicious, reinforcing feedback. Restoring trust requires a careful balance between eliminating vulnerabilities and strengthening social capital and interactions among communication channels