A female health care practitioner hands over medication to a female patient standing nearby as another woman holding her small child looks on.
A health worker gives a woman medication at a Posyandu (Community Health Centre) in Nusa Tenggara Timur province.

Lessons learned during HSS implementation

Are there any guiding principles we can draw out of the many complexities and challenges of selecting and then implementing health systems strengthening interventions?

We can share with you our experience in implementing a health system strengthening intervention in eastern Indonesia and the lessons we learnt from this program.

The program aimed to reduce the level of maternal mortality in the eastern Indonesia province of Nusa Tenggara Timur, which was a relatively disadvantaged province with a higher level of reported maternal deaths than most other provinces in Indonesia.

We used a health systems strengthening approach to address the problem, as we knew that the high level of maternal deaths resulted from a combination of community factors (poverty, cultural preference for home births, and difficulty in accessing health services), and health system factors (lack of trained health workers and lack of supplies and equipment in community health clinics, and lack of support and capacity in district hospitals to manage childbirth complications and emergencies).

The program operated at three levels: community level; service delivery level; and health system supports.

Level Problems/issues Strategies
Community Lack awareness of risks of childbirth; preference for home delivery Mobilising communities to be aware of the risks of childbirth, to identify pregnant women, and to provide support and resources to transport them to health facilities at the time of delivery.
Health services Community clinics lack capacity to provide safe delivery; district hospitals lack capacity to manage complications Training clinic staff, upgrading facilities, provision of equipment; training district hospital doctors, provision of equipment
Health system supports Poor management and leadership; lack of accurate data; insufficient funding; lack regulatory framework Improve district level planning and budgeting, strengthen health information systems, improve health workforce management systems, provide training in management and leadership, and engage local governments to provide more funding

You can see that our program combined a number of strategies addressing the health system in a comprehensive approach.

What was our experience during implementation?

  1. Contextual changes. The provincial government introduced their own strategy to compel women to deliver in health facilities; while the national government introduced a variety of new funding mechanisms for health facilities, starting with free delivery care, and progressing to a universal health insurance program.

  2. Unexpected interaction between strategies. Following training for the clinic midwives, the trained midwives were transferred to other clinics which lacked the upgraded facilities. The introduction of 24-hour emergency surgical capacity in the district hospitals was limited by lack of laundry facilities, lack of blood banks, and insufficient support staff.

  3. Unexpected impacts from strategies on other health system elements. The provision of additional funding from national level for health services resulted in reluctance on the part of local government to allocate additional funds from their sources.

While these might be considered unexpected negative impacts, there were also unexpected positive impacts.

  1. Communities took more interest in their health clinics, and began to participate in assisting the maintenance of the clinics, and in some cases, forming advisory boards with health managers in the clinics.

  2. Local level health managers developed and implemented their own innovations, using the flexible funding available from the project. For example, SMS messaging to pregnant women to remind them to deliver in a health facility. Managers found that flexible project funding allowed them to innovate, while government funding required a long period of planning and evidence of effectiveness before they could implement.

As a result, the role of the project support gradually shifted, from providing additional resources for planned system strategies, towards supporting innovation, learning, and knowledge exchange, through conduct of small studies of innovations or specific problems, and convening cross district forums to exchange ideas and information.

Were we successful? While there was a fall in reported maternal deaths over the project period, this was mainly in the districts with better facilities. It was also difficult to determine the contribution of the project interventions, because of other national level interventions, such as the free delivery program, which occurred at the same time.


What do you think are the key lessons for HSS planning and implementation from our experience?

Please comment below.

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Health Systems Strengthening

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