Health system perspective

Key areas for Health Systems

Achieving VL elimination is a highly dynamic process, involving multiple stakeholders and requiring an extensive collaborative effort. A VL programme will undoubtedly need to engage with both state and local health systems to ensure all research outcomes and recommendations are translated into policy and change.

What is a Health System? (Figure 1,^[1])

The World Health Organization defines a health system as “all the activities whose primary purpose is to promote, restore or maintain health.”

Source: WHO Health Systems

It is important that a VL control programme has an integrative approach – horizontal rather than vertical, that it addresses the local context and builds on local capacity. Key areas for capacity building within health systems include:

• Training

• Financing/securing funds

• Resource allocation and streamlining of procurement

• Supervision for implementation of interventions

• Programme delivery

• Conducting surveillance

• Monitoring & evaluation

Other sources show similar priorities about key health system issues, for all other infectious diseases^[2]

• Government leadership and sustained commitment

• Active participation by civil society is essential

• Managed decentralisation

• Human resources development

• Inter-sectoral policies and programmes strengthening

• Information and surveillance systems

When control activities are ineffective, it is important to look at the support system, which (in most cases) is the existent in-country public health system. When health systems fail to respond the delivery of disease control programmes is adversely affected. Transitional populations, whether due to economic issues or conflict, will also influence the effectiveness of control programmes (see Step 4.9). Health system strengthening can significantly improve and build upon the resilience and sustainability of control efforts to achieve elimination, by optimising the coordination and delivery of services (identified in the control programme).

For a neglected disease like VL, which usually occurs in focal outbreaks, it may be important to start a VL intervention in a vertical approach in order to achieve control as soon as possible. But the end goal always must be integration into the national health system.

The strengthening of Health Systems complements the United Nations (UN) Sustainable Development Goal (SDG) of Universal Health Coverage www.uhc2030.org. Having an integrated system where, for example, specific research produces results that can have an impact on delivery of care and hence national policy^[3]. Access to diagnostics and medicines contributes to the Universal Health Coverage goal. Making it straightforward for both National Programmes to buy medicine and other tools as well as making drugs free at the point of care, for example, are factors which feed into a Health System and support universal health care.

Health Systems and organisation of control

The interactions and efforts made to improve VL treatment, control and elimination within a health system is effective when the work is done within a National Programme for VL control. Such a programme needs well-planned and clearly defined objectives, methods, schedules and budget. Working within a National Programme is advocated by WHO who provide detailed recommendations in one of their Technical Report series^[4]. The distribution of tasks at each level of the health system are clearly outlined and how each component of a VL control programme or project will interact with each other, from community centres up to Government Ministries.

A recent publication from a VL endemic country, Bangladesh, focuses on how to sustain elimination of VL. This paper^[5] emphasises the need to: (i) engage with all stakeholders in the consolidation and maintenance of elimination, (ii) the need to integrate with other infectious disease control programmes and (iii) have a clear policy to follow.

The health systems lists of roles, tasks, impacts and outputs can appear to be dauntingly long. For those working on the frontline of VL control the three essential points are clarity: (i) around your role and tasks, (ii) of the health system context in which you are working, and (iii) the key people who you need to interact with/report to/receive information from, in the parts of the health systems.

In the next step, Dr Mounir Lado talks about health systems when implementing a VL programme in rapidly-changing circumstances.