Frameworks and approaches for health systems strengthening

While there are multiple discussions regarding what HSS is, the most popular and cited definition is that of the World Health Organization (WHO). It says: “HSS is the process of identifying and implementing the changes in policy and practice in a country’s health system, so that the country can respond better to its health and health system challenges. Additionally, it is also an array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency” (WHO, 2019, p. 11). Scope of this rapid review: The aim of this rapid review is to provide a rapid synthesis of the different frameworks and approaches that have been designed and proposed for HSS. The synthesis includes frameworks conceptualised by international development and health agencies as well as those proposed by individual researchers and smaller organisations. While there are multiple frameworks, many of these frameworks build upon the WHO (2007) HSS framework and adapt this as per their needs and perspectives. Furthermore, considering the shake-up of health systems due to the COVID 19 pandemic, this review also includes frameworks which have reconceptualised HSS in response to the pandemic’s impact on health systems. Key findings: The rapid review found that a multitude of HSS frameworks exist in the public health literature. Some of these frameworks are modified from the WHO (2007) building blocks frameworks or use this framework as a basic conceptual foundation to propose new frameworks. Furthermore, there is some conflation of health systems frameworks and HSS frameworks in the literature. This review, however, has focused specifically on HSS frameworks. Evidence base: The frameworks and approaches were extracted from agency documents, journal articles and grey literature

Frameworks and Approaches for Health Systems Strengthening

While there are multiple discussions regarding what HSS is, the most popular and cited definition is that of the World Health Organization (WHO). It says: “HSS is the process of identifying and implementing the changes in policy and practice in a country’s health system, so that the country can respond better to its health and health system challenges. Additionally, it is also an array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency” (WHO, 2019, p. 11). Scope of this rapid review: The aim of this rapid review is to provide a rapid synthesis of the different frameworks and approaches that have been designed and proposed for HSS. The synthesis includes frameworks conceptualised by international development and health agencies as well as those proposed by individual researchers and smaller organisations. While there are multiple frameworks, many of these frameworks build upon the WHO (2007) HSS framework and adapt this as per their needs and perspectives. Furthermore, considering the shake-up of health systems due to the COVID 19 pandemic, this review also includes frameworks which have reconceptualised HSS in response to the pandemic’s impact on health systems. Key findings: The rapid review found that a multitude of HSS frameworks exist in the public health literature. Some of these frameworks are modified from the WHO (2007) building blocks frameworks or use this framework as a basic conceptual foundation to propose new frameworks. Furthermore, there is some conflation of health systems frameworks and HSS frameworks in the literature. This review, however, has focused specifically on HSS frameworks. Evidence base: The frameworks and approaches were extracted from agency documents, journal articles and grey literature.Foreign, Commonwealth and Development Office (FCDO

Shockproof and inclusive fiscal policies

Research supported by the Covid-19 Responses for Equity (CORE) Programme – which is supported by the International Development Research Centre (IDRC) – has revealed some emerging lessons and recommendations to address these challenges and improve the resilience of countries to future shocks. One of the first and foremost recommendations is for countries to invest strongly in social protection and health-care systems for its citizens, which would help build their resilience for future shocks. Adopting free trade policies and avoiding protectionism has also been an important lesson from the pandemic. Another key lesson is to employ a gender lens to fiscal and monetary policies as women have been disproportionately affected by the pandemic. Countries should also adopt expansionary monetary and fiscal policies as far as possible to increase the demand. Finally, countries also need to strengthen their financial institutions and mechanisms and reduce political interference, that would help maintain the asset quality of the banking secto

Shockproof and Inclusive Fiscal Policies

The Covid-19 pandemic has had a significant impact on the economies of most countries. What differed is the intensity of the impact, which ranged from mild economic contractions to devastating recessions and downturns. From a generic perspective, it is obvious to assume that high-income countries (HIC) would have faced lesser economic destruction than low- and middleincome countries (LMIC). However, a closer examination reveals that there are several factors that determined the impact of the pandemic on a country, as well as influenced its ability to respond. For instance, the existing economic structures and weaknesses strongly affected the countries’ ability to provide adequate fiscal stimulus. These weaknesses are following pro-cyclical policies and not creating fiscal buffers that would help build more resilience. An interesting finding that emerged was that the credit rating of a country was found to be the most important determinant of its Covid-19 fiscal response. This is one major area where HICs had a significant advantage compared to LMICs. Another key challenge that disproportionately affected LMICs was the lack of digitisation and access to the internet, which hampered economic growth as well as affected the countries’ ability to quickly disburse cash transfers and support. Research supported by the Covid-19 Responses for Equity (CORE) Programme – which is supported by the International Development Research Centre (IDRC) – has revealed some emerging lessons and recommendations to address these challenges and improve the resilience of countries to future shocks. One of the first and foremost recommendations is for countries to invest strongly in social protection and healthcare systems for its citizens, which would help build their resilience for future shocks. Adopting free trade policies and avoiding protectionism has also been an important lesson from the pandemic. Another key lesson is to employ a gender lens to fiscal and monetary policies as women have been disproportionately affected by the pandemic. Countries should also adopt expansionary monetary and fiscal policies as far as possible to increase the demand. Finally, countries also need to strengthen their financial institutions and mechanisms and reduce political interference, that would help maintain the asset quality of the banking sector

Women struggle to access safe maternal care in the world’s harshest lockdown

Though India reduced its maternal mortality ratio (MMR) by 77%, from 556 per 100 000 live births in 1990 to 130 per 100,000 live births in 2016, its maternal health system remains tenuous. Many districts still do not have high-quality delivery services, referral services, or emergency obstetric care services essential for preventing maternal deaths. The COVID-19 pandemic has made this precarity worse. Here, I discuss the catastrophic impact of the COVID-19 lockdown on India’s already-stressed maternal health system. My research revealed that due to the government and health system’s sole focus on COVID 19, non-COVID 19 services were severely hampered, and women were denied access to critical maternal health services, leading to avoidable maternal and neonatal deaths

Understanding the perspectives of frontline health workers (ASHAs, Anganwadi workers & ANMs) in Bundelkhand region to improve COVID-19 containment efforts

Community health workers (CHWs) have been the backbone of the fight against the COVID-19 pandemic in India. CHWs (such as ASHA workers, Anganwadi workers, and ANMs) have played a key role in preparing the national health system for the hyperbolic rise in COVID-19 cases and containing the spread of the virus at the ground level. Owing to their embeddedness in their communities, these CHWs can offer unique insight into our community-based COVID-19 responses. Despite this, the voices of health workers have been largely ignored in policy prescriptions and initiatives. In this short-term study, SRIJAN (Self Reliant Initiatives through Joint Action) aims to address this research gap. It covers the experiences and perspectives of CHWs fighting the COVID-19 pandemic in Bundelkhand, one of the poorest regions in rural India. In capturing the ground-reality in Bundelkhand, Stutilina Pal and Devanik Saha attempt to document the lessons learnt from the past year and incorporate them into future responses to health crises

Understanding the perspectives of frontline health workers (ASHAs, Anganwadi workers & ANMs) in Bundelkhand region to improve COVID-19 containment efforts

Community health workers (CHWs) have been the backbone of the fight against the COVID-19 pandemic in India. CHWs (such as ASHA workers, Anganwadi workers, and ANMs) have played a key role in preparing the national health system for the hyperbolic rise in COVID-19 cases and containing the spread of the virus at the ground level. Owing to their embeddedness in their communities, these CHWs can offer unique insight into our community-based COVID-19 responses. Despite this, the voices of health workers have been largely ignored in policy prescriptions and initiatives. In this short-term study, SRIJAN (Self Reliant Initiatives through Joint Action) aims to address this research gap. It covers the experiences and perspectives of CHWs fighting the COVID-19 pandemic in Bundelkhand, one of the poorest regions in rural India. In capturing the ground-reality in Bundelkhand, Stutilina Pal and Devanik Saha attempt to document the lessons learnt from the past year and incorporate them into future responses to health crises

The case of MUVA assistentes: beyond income generation to a new approach for Women’s empowerment

This paper highlights the case of MUVA Assistentes, a public works programme (PWP) that provided training and mentoring to young vulnerable women (YVW) in urban Mozambique. Our paper draws out the main learnings from the MUVA Assistentes project to inform the design of other PWPs that have women’s empowerment as their major aim. We show through our analysis that it is possible for PWPs to achieve women’s empowerment, but only if they go beyond a sole focus on income provision through paid work to women. Instead, we argue that if PWPs formulate their theory of change in line with Kabeer (1999)’s notion of empowerment, with its three interrelated dimensions (resources, agency and achievements), women’s empowerment through PWPs can be both realistic and long-lasting

The Case of MUVA Assistentes: Beyond Income Generation to a New Approach for Women’s Empowerment

This paper highlights the case of MUVA Assistentes, a public works programme (PWP) that provided training and mentoring to young vulnerable women (YVW) in urban Mozambique. Our paper draws out the main learnings from the MUVA Assistentes project to inform the design of other PWPs that have women’s empowerment as their major aim. We show through our analysis that it is possible for PWPs to achieve women’s empowerment, but only if they go beyond a sole focus on income provision through paid work to women. Instead, we argue that if PWPs formulate their theory of change in line with Kabeer (1999)’s notion of empowerment, with its three interrelated dimensions (resources, agency and achievements), women’s empowerment through PWPs can be both realistic and long-lasting. PWPs have always been popular in low- and middle-income countries as tools for poverty alleviation and mitigating high unemployment rates among young people. Given the disproportionate impact of poverty on women and girls, many existing PWPs often include a ‘gender’ component in their theories of change. A common limitation of such PWPs and theories of change is their overarching focus on providing income opportunities, which they suggest leads to women’s empowerment. However, this has not been the case for most PWPs; hence, learnings from a project that has led to substantive empowerment of young women are highly valuable. The MUVA Assistentes project was a component of the broader MUVA Programme running in urban Mozambique. It provided training to YVW and gave them paid work as classroom assistants in primary schools for one academic year. The project addressed two major problems plaguing Mozambique today: (1) high unemployment among urban young people, especially women; and (2) poor educational outcomes among primary school students. Through a dedicated focus on mentoring the participants, the project supported these women to build soft assets and skills to enable them to realise their future goals and aspirations. This paper highlights that the MUVA Assistentes project led to three major outcomes: (1) building technical skills; (2) improving opportunities for women’s employability in the labour market (while improving public goods); and (3) building soft assets through training and mentoring. Through a close discussion of the experiences of four women participants, we find that the MUVA Assistentes led to an increase not only in income opportunities for YVW, but also in their sense of self‑worth and confidence to exercise their agency in achieving their goals. Further, the project also provided a critical public good by working towards improving the quality of classroom outcomes in government primary schools. We conclude that through building these skills and increasing women participants’ self-worth, PWPs can build women’s resources, agency and achievements, thereby moving closer to achieving a holistic view of empowerment, which encouragingly extends beyond the PWPs’ duration as well