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National, subnational and community components of the health system

How do the three levels of the health system (the national, the subnational or “district”, and the community) interact? Watch this video to find out.
KRISHNA HORT: In this session, we are going to explore the interaction between the three levels of the health system. The national, the district, and the community. And to do that I’ve invited my colleagues Peter and Alison to talk with me about how the levels of the health system interact in delivering the functions of the health system and achieving the health system objectives. So, Alison, I might ask you to begin.
ALISON MORGAN: Well, I think we should start by considering a story. We’ve got a mother bringing a sick child to the local health clinic. She’s accompanied by the community health worker and… who’s encouraged her to seek care at this rural clinic. After a long wait, she gets to see the doctor who diagnoses the child has a chest infection and prescribes antibiotics. Problem is the clinic has run out of antibiotics. The doctor’s blaming the local district health office for not sending the supplies. He notices the child is missing an immunisation, the schedule is behind, and takes the opportunity to give a catch-up vaccine that he’s been provided from the national suppliers.
He then recommends that they go to the district health– district hospital to get the treatment. Trouble is the ambulance that would normally take them has run out of petrol. The health clinic has no funds to pay for petrol, so the mother is told to make her own way there. She can’t do this and make this decision on her own and she ends up returning home with the health worker and the sick child to discuss further options with her family.
KRISHNA HORT: Well, thanks Alison. This is a sort of circumstance that we do often hear about and it provides a good opportunity to look at the way in which the national, district, and community levels interact. So I might ask Peter to provide a comment from the perspective of the national level.
PETER ANNEAR: Well, I think it’s clear at the national level that the priority has been set in the national plans to provide care for mothers and children, so that’s established to begin with. Secondly, at the national level, funding has been set aside to provide vaccines and medicines to keep up the supply of pharmaceuticals for this area. So as far as national responsibility is concerned, that seems to have been catered for. Appears to me we might look more carefully at the district level. And at district level there’s clearly responsibility for service delivery– that’s where the responsibility lies. And there’s some breakdown in service delivery here.
District level also responsible, it seems, for providing the funding for transport for referral to a higher level of service. So it’s something to look at there.
KRISHNA HORT: Thanks, Peter. Well, why don’t we also have a look at this from the community perspective. Alison, what’s your view?
ALISON MORGAN: I think this is a beautiful illustration of the importance of the community health worker. This community health worker has recognised that the child is unwell, has then persuaded the mother and the family to seek care at the health clinic, and has taken the trouble to accompany the mother. When they arrive, they’re left waiting for a long time, there’s no acknowledgment of her role, and then, lo and behold, there’s no medicines and no referral system in place. So from the community health worker’s perspective, her credibility is really threatened. Because next time another family is sick, will they trust her to go to seek care?
KRISHNA HORT: Yes, that’s an important point. It seems that the district health service is being blamed from both the national and the community levels. So let us seek the opinion of the district health manager. I managed to speak to the district health manager and he explained that they have already distributed the medicines that they received from the national office to the health centres, so they should have the medicines. They requested more, but have yet to receive more from the national level. They’ve also received the funds for the purchase of medicines at a local level, but that procurement is stalled waiting for the local mayor’s signature.
In terms of funds for petrol that has been distributed to the health centre, but the health centre has used up those funds on transporting their own staff before the end of the month. So what does that tell us about the roles of the different levels of the health service? Again, Peter, from the national level?
PETER ANNEAR: Well, first of all, I think it tells us that there has to be good coordination and cooperation between the three levels of the service. And something here is breaking down, so that needs to be looked at. National level again– look, first point is national level sets the direction, sets the policy, sets the priorities, makes the plan. So step one, get those things straight. National level, two. Secondly, responsible for coordination between government departments and other ministries, in particular, Ministry of Finance, which provides and distributes the funding normally.
Another aspect for national level is to take care of the major health system functions– of course, part of the planning process and strategy– including health care financing functions, providing the money that’s needed, distribution, training, preparation of the health workforce, procurement of pharmaceuticals, supplies, drugs. So national level responsibilities have to be taken care of there. And the last one, probably, that’s important is in the delivery of tertiary care services and normally national ministries– national departments will be responsible for national referral hospitals.
KRISHNA HORT: All right. Thanks, Peter. Now, that’s a pretty good summary of the national level. If we think now about the district level– what is their role– well, clearly, it’s more on the implementation of these national level policies, and directives, as well as the management of resources for that implementation at a national level. Implementation is usually through a network of facilities, including the hospital and the primary health care service. The district level is– has the advantage of being in a better position to understand the local community needs, and to respond to them, and to align and adapt resources to those needs.
It’s also the level at which we can establish accountability mechanisms, such as local community health boards, which can improve their communication and the engagement of the community in health services, which leads us to the role of the community. Alison, would you like to give us some thoughts on that?
ALISON MORGAN: Well, it seems like the community health system’s come in last again. But I think it is true that the community health system is less well-defined than the national and the district level. Often the visible presence of the community health system is embodied in the community health worker. But I think it’s really important to recognise that community systems go well beyond the community health worker. And, indeed, there are many settings that don’t have community health workers at all. When I think about community health systems, I think about the community first and foremost and most central to all of the health planning.
But it also includes other institutions at the community level, civil service organisations, other informal providers, and together this loose collaborative has a range of responsibilities. First, they know exactly what the community wants and needs and can voice that and express it. And I think they have a big role in both holding the national health planners to account for the policies being enacted and, at the district level, for those services to be provided with the scope of services and the quality of services that are mandated by the government.
KRISHNA HORT: So thank you Alison and Peter. I think that’s provided a good outline of the roles at national, district, and community level. We will now explore in more depth some of the functions of the different levels of the health system and how they interact to deliver health services.

The different roles and functions of each level of the health system require expertise when intervening at that level. The presenters in this discussion imply that successful health systems strengthening may require an understanding across levels of the health system, and interventions that address different levels.

Reflect on what the main barriers to intervention across levels might be in your own setting.

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