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International Health

Future Health Systems 
Empowering Local Researchers, Innovating Health Systems

The Department’s Health Systems faculty recently won a second 6-year award to lead the Future Health Systems (FHS) consortium. During this second phase, researchers from four continents will continue investigating how to deliver effective primary health care services to the most vulnerable and disadvantaged populations around the world. Building on the Department’s long tradition of community-based healthcare, FHS is designed around the mandate of locally driven research. Not only do local experts lead research activities, local communities are also a part of the research design and implementation processes. As with the first 5 years of Future Health Systems, this innovative approach will help local communities implement sustainable programs while producing globally relevant research findings.

FHS CountriesGlobal Collaboration 
Chief Executive Officer Dr. Sara Bennett, associate professor in International Health, oversees a decentralized management team composed of representatives from across the globe. While Hopkins administers the grant, specific research activities are not predetermined by the UK Department for International Development (DFID), which funds the grant, or by Hopkins. Along with representatives from each of the partner organizations, a special advisory group will help guide research priorities based on overall program goals. Experts from various disciplines and a range of organizations comprise the advisory group. One member, Alumnus Dr. George Pariyo of Makerere University and WHO, received his doctorate from the Department of International Health. He along with the other members will help ensure that the consortium fosters south-to-south learning and overall research capacity. 

Main partner organizations are headquartered in both high- and low-income countries: Bangladesh, China, India, Uganda, the United Kingdom, and the United States. Moreover, each organization shares in the responsibility of taking the lead of important facets of the project. See the nearby table for an overview of the main partners’ roles. 

RESEARCH GOALS
FHS focuses on developing strategies for delivering effective maternal and child health services to the most disadvantaged. The consortium’s efforts are broadly organized around three overarching research goals that are not mutually exclusive:

  1. Unlocking Community Capabilities: developing systems for identifying existing resources that can be used to improve the quality and effectiveness of health services
  2. Stimulating Innovations: harnessing new technologies and organizational innovations to improve health care quality and coverage sustainably
  3. Learning by Doing: systematizing health care processes so that all stakeholders can develop and refine skills for improving services

In the previous 5 years, FHS produced a wide range of high-quality health systems research. Over the next 6, FHS will build on past experiences while expanding into new areas of sustainability and capacity. Below are three brief examples of success stories from the first round of FHS. Although the lessons learned from a project are rarely limited to one category, the following are organized by one of the three primary research goals. Plans have not been finalized for the new phase of FHS, but these projects offer promising avenues for future health systems research.

Boda boda driverUnlocking Community Capabilities
Taxi Drivers Providing Safe Delivery in Uganda

In rural Uganda, affording adequate health care is not the only challenge for expectant mothers. Finding transportation to a skilled provider is also a major obstacle. Complications during delivery, therefore, result in many unnecessary maternal and child deaths.

FHS found through many consultations with community groups and leaders that boda bodas, or motorcycle taxis, were the only available and reliable means of providing transportation to health care services for expectant mothers. After further consultation with communities, a voucher program was developed for mothers to use the taxis and to pay for antenatal, delivery, and post-natal care. At the same time, health service providers were trained to accommodate the anticipated increase in service utilization. And a media campaign was launched to spread the word about the program. 

Response to the program was overwhelmingly successful, with over 12,000 women receiving vouchers. Births with a skilled provider increased, as did antenatal and post-delivery care visits. The Ugandan research team, led by Dr. Elizabeth Ekirapa-Kiracho at Makerere University, is now developing a study to investigate how this particular program can become self-sustaining. The study should also produce generalizable information about tapping into existing local capacity to improve health delivery and services.

Village Doctor in BangladeshStimulating Innovation
Village Doctors in Bangladesh

One of FHS’s most widely recognized successes is its work with informal health markets. In Bangladesh, what are known as “village doctors” are not actually trained physicians, but rather informal providers in rural areas where formal health care services are lacking. Past research has shown that village doctors routinely prescribe medicines that are not only inappropriate but often detrimental to the patient.

To address these inadequacies, FHS, led by ICDDR,B, developed a branding system called ShasthyaSena, or Health Soldiers. Village doctors were invited to participate in a certification program that included training to treat the most common illnesses such as pneumonia, diarrhea and malaria. They were given a free reference guide, and were able to market themselves as part of the ShasthyaSena Network. Media campaigns helped spread the word about the quality of the network to give members a competitive advantage in the marketplace. Initial findings show an increase in appropriate prescriptions by trained providers compared to those with no training. 

JHSPH Faculty and Staff
Future Health Systems

Sara Bennett, Associate Professor, International Health, Chief Executive Officer

David Peters, Associate Professor, IH, Research Director

David M. Bishai, Professor Population, Family and Reproductive Health

Anbrasi M. Edward, Assistant Scientist, IH

Robert Franks, IH, Budget Manager

Asha George, Assistant Professor, IH

Adnan Hyder, IH, Associate Professor, IH

Daniela Lewy, Research Associate, IH, Research Manager

Sachiko Ozawa, Assistant Scientist, IH

Prasanthi Puvanachandra, Assistant Scientist, IH

MD. Hafizur Rahman, Assistant Scientist, IH

New research is being planned to link this network of providers with physicians through mobile phones and the internet. Systems for providing financial incentives for referring patients to the formal sector are also being discussed. This linking of the informal sector is part of the FHS goal of both unlocking capacity and stimulating innovation.

Learning by Doing
The Balanced Scorecard in Afghanistan

The development and successful implementation of the Balanced Scorecards in Afghanistan has led to a remarkable improvement in health services in a war-torn country. Since 2004, Health Systems faculty and the Indian Institute of Health Management Research (IIHMR) have worked with the Ministry of Health to develop a set of tools that has become the cornerstone of the government’s monitoring and evaluation system of its primary health care sector. Through consultations with stakeholders, baseline levels of services were set and indicators developed. Regular data collection has helped managers and service providers alike track and improve their own performance. 

In addition to learning by doing, findings from Afghanistan will help inform another priority topic for FHS: health care in post-conflict states. FHS will explore expanding the use of the scorecard into other problem areas affecting fragile states, such as social capital and capacity. Researchers will also investigate how improvements in health care can lead to improvements in other sectors of society and to a greater trust in public institutions. 

Building Capacity
The African Hub

Health Systems faculty are very excited that FHS includes a mechanism for collaborating with seven African schools of public health. These schools are part of the Higher Education Alliance for Leadership through Health (the HEALTH Alliance) and are referred to as the African Hub. The schools are located in the Democratic Republic of Congo, Ethiopia, Kenya, Rwanda, Tanzania, and Uganda.

Makerere University in Uganda is the lead partner of this initiative, which is designed to improve health systems research and instructional capacity in sub-Saharan Africa. A long-time collaborator with the Bloomberg School, Makerere University recently partnered with Johns Hopkins Schools of Medicine, Nursing, and Public Health to conduct institutional capacity-building activities. The program was funded by the Bill & Melinda Gates Foundation and findings were published this year in a special issue of BMC International Health and Human Rights, entitled, “An innovative approach to building capacity at an African university to improve health outcomes.” These findings will inform many of the capacity-building activities planned under FHS. 

FHS Partner Organizations

China National Health Development Research Center, China

International Centre for Diarrheal Disease Research, Bangladesh (ICDDR,B)

Indian Institute of Health Management Research (IIHMR), Jaipur, India

Institute for Development Studies, Sussex, UK

JHSPH, International Health, Health Systems

Makerere School of Public Health, Uganda

The connections built between faculty and staff at these institutions and other FHS partners will serve the dual purpose of building local capacity while also engaging local researchers in the development and conduct of studies. Plans are already underway to mentor faculty on grant writing and course development. An evaluation tool to assess current health research capacity has also been developed by Associate Professor Sara Bennett and faculty in the African Hub.

The Next 6 Years
Future Health Systems continues the Department’s commitment to partner with local organizations to better serve disadvantaged and marginalized populations. The next 6 years of FHS will build on its previous success by reaching out to African schools of public health and empowering local researchers to take the lead on many research priority areas. While the mission of FHS is to improve health care delivery through quality systems research, it is also a successful model of a truly global research collaboration.FHS Research goals

--Brandon Howard, May 2011
(Jeff Knezovich at IDS and Daniela Lewy at Hopkins contributed to this article)