Implementing health system change: What are the lessons from the African Health Initiative?

The five African Health Initiative Population Health Implementation and Training (PHIT) Partnerships represent a rich and important set of health system strengthening initiatives. All can be called whole system strengthening initiatives in two important respects. First, from a health system perspective, as explicitly discussed, all the PHIT Partnerships are multi-dimensional, seeking to achieve performance improvements by working across the building blocks and levels of the health system. All address resource needs (human, financial, and supplies) in some way. The common focus on strengthening information use in clinical and managerial decision-making, meanwhile, tackles what some regard as the key leverage point for health system improvement [1] and quality of care is another such point [2]. Considering the role of community health workers, moreover, emphasizes that the health system stretches beyond the doors of health facilities, and that health system development requires combined community and facility-based actions. Finally, several initiatives emphasize the importance of strengthening supervision and management coaching and mentoring. Importantly, the different activities within each partnership are intended to work synergistically together. Second, although less clearly outlined in these papers, the PHIT Partnerships all reflect key features of complex social programs (Table 1) and are, in themselves, dynamic and complex adaptive systems [3]. They have all evolved over time, being developed and adapted in response to experience in implementation, for example. They have also all worked through a range of people and relationships. Indeed, as partnerships, the very essence of these projects is a relationship between actors outside the health system and those working within it: health workers, facility teams, supervisors, district management teams and so on. Finally, they have been implemented within, affecting and being affected by, dynamic, multi-layered contexts – encompassing histories and past experiences (e.g. of resource availability, management or the usual ways of working), wider sets of actors and agents (including politicians and donors), organizational and other health system reform (e.g. decentralization in Mozambique and health insurance in Ghana) and, no doubt, socio-political change (perhaps, including in patient and political expectations of the health system). There is much to learn from these experiences, and evaluation is a central element of the AHI. Against the backdrop of the increased resources for the “big diseases” achieved in the early 2000s, this evaluation seeks to show whether or not investment in health systems and at scale, rather than in particular strategies for managing responsive primary care conditions, can generate health gain [4]. The effort and time put into the evaluation itself signals the importance of learning from these experiences and will also generate methodological lessons. However, fully capturing the AHI’s lessons about implementing innovative health system development activities will also require other evaluation approaches. At present, the primary evaluation question being asked is, in essence: Can multi-dimensional health system strengthening initiatives offer health gain? This question is of particular significance in international health debates, and to funding agencies. But it does not fully address the concerns of those working within health systems and responsible for their continuous improvement. Over time, they have to manage variable investment levels and patterns, as well as changing political imperatives, demand patterns, health needs, and other system shocks. Health system managers are more likely to ask questions, such as what changes in the health system did these initiatives bring about, and how? Were there unintended consequences and, if so, how were they managed? What possibilities did the initiatives create for supporting forward momentum towards long-term health and development goals? Close examination of implementation experience is also important in addressing issues, such as Correspondence: [email protected] Health Policy and Systems Division, School of Public Health and Family Medicine, University of Cape Town, South Africa Full list of author information is available at the end of the article Gilson BMC Health Services Research 2013, 13(Suppl 2):S14 http://www.biomedcentral.com/1472-6963/13/S2/S14