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International Health

Health Systems Program

Health Systems Leadership: Promoting Health Equity and Effecting Change

Dr. Krishna Rao, assistant professor in the Health Systems Program of the Department of International Health, was recently featured in the Johns Hopkins Bloomberg School of Public Health magazine in an interview with Barbara Bush, co-founder of Global Health Corps. Dr. Rao’s discussion with Barbara touched upon health equity and humility, and how to exemplify these traits in a leadership capacity. The Health Systems Program delved further into the idea of health equity as a key ingredient of effective health systems leadership by asking Dr. Rao a few questions.

1. Identifying leaders and change agents: as a teacher, how do you identify leaders and potential change agents? What are some more important qualities in a leader when it comes to promoting health equity?

In some students leadership qualities are apparent – they take charge of things naturally, don’t shy from expressing opinions and take ownership of any job given to them. There are other students who demonstrate their leadership in a quiet way – they are more watchful and reserved but are clear about what they think and how to get the job done. In both cases, I think they like taking ownership and putting in more effort than normally expected.

2. You have a lot of experience in working in human resources for health – what are some lessons you have learned about how leaders can effect change at the systems level?

Health systems are hard to change. Yet, I think, a health system is ultimately as good as the people who make it function. Particularly because all health services are ultimately delivered by people. You can take a well-designed system but incompetent people can make it ineffectual. On the other hand, there are numerous examples of individuals who have done remarkable things working in broken health systems. I have come across so many health workers – doctors, nurses, community workers, managers – who for little money and working with poor infrastructure, manage to do so much so that others can benefit from their services. So I think investing in health workers and keeping them enthusiastic about their work is as critical as the particular way a health system is organized. 

3. For researchers such as yourself, you mentioned that you can write as many papers as you want but nothing might really happen unless there are people who can see the importance of what you do – how can researchers position themselves as change agents and make sure their work is more likely to be implemented in the field?

There is an important line between being an academic and being an activist. Researchers have traditionally seen themselves as producers of knowledge, while ‘changing the world’ has been in the domain of social and political activists. More recently, you see researchers also becoming activists. In some cases it’s because the science itself is being disputed by the politically powerful like in the case of climate change. So I think there is an increasing sense that researchers should not be passive about their research and expect that it will find a voice on its own. They need to actively make it known and promote it via social media, public debates, and even demonstrations. 

For more information on Dr. Rao’s research interests and profile, read his interview with Barbara Bush, as well as his faculty feature

Launching the IDEA (Innovation+Design Enabling Access) Initiative as its founding director, Dr. Anthony So, professor of the practice, joined the Health Systems Program in the Department of International Health in September 2016. He is also thematic lead for the Transformative Technologies and Institutions arm of the recently launched Johns Hopkins Alliance for a Healthier World. Dr. So brings expertise in designing innovations that enable or improve access to novel health technologies, and leads initiatives that tackle the growing issue of antimicrobial and antibiotic resistance.

Antimicrobial resistance (AMR) is an emerging health issue across the globe, as bacterial strains are becoming resistant to the antibacterial agents meant to protect against them. In November 2015, it was discovered that a new form of resistance had developed against colistin, an antibacterial agent and the last-line of defense for warding off potentially deadly drug-resistant infections.  

If left unchecked, it is projected that 10 million people will die from drug-resistant infections in 2050, more than the number of people who die from cancer today. Growing resistance to antibiotics will put at risk adequate care for treatments such as cancer chemotherapy, organ donor transplants, and the treatment of women and babies suffering from infections during childbirth. Treating infections presumptively as bacterial can sometimes cost less than giving the diagnostic test, thereby contributing to overuse. However, underuse of antibiotics, particularly in low- and middle-income countries, can take a greater toll than overuse today.

Dr. So heads the North American and the Strategic Policy team of ReAct—Action on Antibiotic Resistance, an independent international network designed to create awareness of antibiotic resistance and advocate for global engagement in preventing this deadly phenomenon. The North American branch focuses on policy issues and supports the work of the Antibiotic Resistance Coalition (ARC), a group of civil society organizations working in human, environmental and agricultural health advocating for global action on AMR.

Both food production and healthcare delivery system use antimicrobials inappropriately. By volume, more antibiotics are used in raising livestock than in human medicine. ARC was, in part, created to bring civil society groups together to address AMR as an intersectoral challenge.

Through the work of ReAct and ARC, Dr. So has led policy, research and advocacy efforts to shape the priorities on tackling antimicrobial resistance and influence global conversations around AMR. With partner groups, the ReAct Strategic Policy Program has produced a monthly newsletter for ARC; co-organized an AMR briefing in lead up to the UN Political Declaration on AMR; co-authored a briefing for member States and civil society on AMR issues for the WHO Executive Board discussions; co-organized a side event on AMR at the World Health Assembly; supported policy recommendations for the Tripartite Agencies (WHO, FAO and OIE) as well as the UN’s Interagency Coordination Group (IACG) on AMR; and recently undertook a commissioned analysis for WHO to lay out policy options for global antimicrobial stewardship.

The ReAct Strategic Policy Program also co-organized a Civil Society Roundtable with the head of the WHO AMR Secretariat and the third annual, WHO-NGO Dialogue Report on AMR this past year. The program also helped to pull together a workshop on AMR for the Junior Doctor’s Network in lead up to the World Medical Association. The workshop timed with efforts within the World Medical Association to consider whether and how best to update its 2008 position on AMR in light of unfolding events.

Working with colleagues at Hopkins, the ReAct Strategic Policy Program submitted a commissioned paper for the UK Review on AMR and has begun to analyze the economics and externalities of AMR under a JHU Discovery Award.

Few programs have worked so actively to raise the issue of antimicrobial resistance on the global stage. Through the IDEA Initiative, the Program’s work on AMR has proven to be an important lens in shaping incentives, policies and intersectoral responses in a way that ensures innovation and access to life-saving antibiotics will be equitable and affordable for those in need. In speaking at the First World Conference on Access to Medical Products in Delhi in November 2017, Dr. So concluded that “The challenge posed by the faltering R&D pipeline for antibiotics is the perfect storm, but also an opportunity to chart a new course on innovation and access for these life-saving health technologies.”

Q&A with Dr. Taufique Joarder, adjunct assistant professor, Health Systems Program

Dr Taufique Joarder completed his Doctorate in Public Health (DrPH) degree from the Department of International Health at Johns Hopkins Bloomberg School of Public Health (JHSPH) in 2015. He is now an adjunct assistant professor with the Health Systems Program, based in Bangladesh, where he is also serving as an assistant professor at BRAC James P Grant School of Public Health, BRAC University. Three of the articles based on his doctoral thesis have been published recently in Health Policy and Planning, BMC Health Services Research and PLoS ONE. Dr. Joarder discusses his work and the impact of his research in rural Bangladesh below:

1. What was the specific topic of your thesis while you were a student in the Health Systems Program?

The overall goal of my thesis was to understand the elements of responsiveness of physicians in rural Bangladeshi context, to develop a reliable and valid scale to measure the responsiveness of physicians, and finally, to demonstrate the application of the scale. The title of my thesis was ‘Understanding and measuring the responsiveness of human resources for health in rural Bangladesh.’

2. What qualities define ideal responsiveness in physicians, and why is this important in the context of rural Bangladesh?

In my study context, the responsiveness of physicians is defined in terms of five domains: friendliness, respecting, informing and guiding, gaining trust and financial sensitivity. As the name of the domains suggests, an ideally responsive rural Bangladeshi physician should communicate with the patients in a friendly manner; explicitly show respect to the patients; empower them by providing information and guidance; gain the trust of the patients, or refrain from doing something that may breach trust; and understand the financial need of the patients and provide support if needed, even if it requires going beyond the consultation.

Responsiveness of physicians is important in general because it improves the trust of patients in the physicians. Lack of responsiveness may dissuade marginalized groups of patients, such as the elderly, chronic care patients, expectant and new mothers, and the LGBT community from care-seeking.

Responsiveness of physicians is particularly important in the Bangladeshi context, as we have observed a massive rise of incidents of assaulting the physicians physically and vandalizing the health facilities by patients, alleging the physicians to be discourteous or unresponsive. As a response, the physicians also frequently hold strikes and refuse to provide care. These unexpected events eventually compromise the health and wellbeing of many innocent, helpless and mostly poor patients, often leading to their death.

3. What methods did you use to compare private vs. public sector responsiveness?

I used both quantitative and qualitative methods: the qualitative part included in-depth interviews with public and private sector physicians and patients; focus group discussion with male and female patients; and observation in the consultation rooms of public and private sector physicians. The qualitative part was followed by the quantitative part, which included structured observation of actual consultations in 195 public sector settings and 198 private.

4. Your study found that each sector needed improvements in order to reach optimal performance. What can each sector do better to improve their respective areas of weakness?

In the public sector, we found that physicians scored lower in friendliness, respecting, and informing and guiding domains. We also found that public sector physicians consulted a higher number of patients and spent less time per patient compared to their private sector counterparts. So, in order to improve their performance, the policy-makers may consider restricting the number of patients a physician can consult per day. There should be a minimum average consultation length made mandatory for the physicians. Engaging auxiliary service providers, such as nurses and paramedics, can also reduce the burden of the physicians and help them serve the patients with increased responsiveness.

In the private sector, we found that physicians scored lower in gaining trust and financial sensitivity domains. We believe that developing and implementing a strong regulatory mechanism is the way to go for the private sector. Secondly, at present in Bangladesh, there is no mediatory body, which may listen to the grievances of the patients and resolve their complaints. Such a body is very essential.

5. What implications does this study have for human resources for health and health service delivery in low-income settings?

This study found a deficiency of overall responsiveness of physicians; it also explored the situation of responsiveness categorized into five domains. This domain-specific understanding of responsiveness of Bangladeshi rural physicians can help the policy-makers to develop a more nuanced and targeted intervention to handle the problem. For example, in areas or sectors where friendliness, respecting, and informing and guiding domains are suffering, provision of training for the service providers (both during the medical education period and in-service), coupled with improved health systems support may be helpful. In improving the trust of the patients in the physicians, better regulatory and mediatory mechanism should be implemented.

The implications of this study are not limited to the policy-makers. Informed by the domain-specific findings of responsiveness, physicians themselves can strive for improving their own consultation practices and managers can guide their employees to improve their conduct with their clients and aim for better satisfaction. Also, the teachers of medical education institutions can derive the context-specific examples from this study and guide their students to become more responsive physicians.

Read more about Dr. Joarder and his work in his faculty profile. His research was conducted from August 2014 – January 2015. Other Program faculty involved in this research include Dr. David Peters, chair of the Department of International Health, and Dr. Krishna Rao. 

The Johns Hopkins International Injury Research Unit (JH-IIRU) in the Department of International Health, Johns Hopkins Bloomberg School of Public Health was featured in a ShareAmerica article, the USAID platform intended to disseminate American foreign policy to a global audience. ShareAmerica highlighted the Johns Hopkins-Afghanistan-Pakistan Collaborative Trauma and Injury Research Training (JHU-AfPak-ICTIRT) program, funded by Fogarty International Center, National Institutes of Health (NIH).

JH-IIRU has been in Pakistan for over a decade, dedicated to improving trauma care and emergency medical services in the area through rigorous training. Partnering with Aga Khan University (AKU), JH-IIRU worked with their Department of Emergency Medicine, established by current JH-IIRU senior technical advisor and professor of emergency medicine at Johns Hopkins School of Medicine and former collaborator Dr. Junaid Razzak. In the second round of training, JH-IIRU incorporated Khyber Medical University with the goal of promoting trauma and injury research by training a core group of faculty between the two universities.

The grant has been helpful in not only developing individuals and providing opportunities for their growth, but more importantly, it has helped institutional growth at various levels. Directly, the grant led to the development of the first academic department in the field of emergency medicine in the country. The department played the role of the World Health Organization’s Collaborating Center on Emergency Care. It also provided support to the prehospital emergency care system in the city of Karachi, which in turn impacted hundreds of thousands of patients a year. These larger system changing impacts are critical to population health,” states Dr. Razzak.

The program represents the first doctoral training program on injury research at AKU; by helping AKU to take this next step from masters to doctoral training, JH-IIRU is helping to build capacity in a region with a high burden of death and disability from injuries.

The JHU-AfPak-ICTIRT program aims to do the same in Afghanistan, a country where many live in conflict-affected areas and injury rates are high. The training program provides an alternative to having to fly all the way to high-income countries such as the United States for education, an expensive and often inaccessible trip for many, and also combats the brain drain in the area.

JH-IIRU hopes that research from Pakistan will influence the neighboring region in Afghanistan, and also address the issue of intentional and unintentional violence in the area. The research is driven by individual trainees, who are examining issues such as domestic violence, child injuries and road traffic injuries. One particular mega project currently being conducted is studying the burden of acute injuries and emergency medical care by examining emergency rooms and collecting data from over 3,000 people.

The burden of injury and trauma in both Pakistan and Afghanistan is considerable and keeps on growing. There is a dire need to have both masters and doctoral training with concentrations in injury and trauma. The program we are offering through the Afghanistan-Pakistan International Collaborative trauma and injury research training will help elaborate further the need and sources of data on injuries in developing countries,” states Dr. Nadeem Ullah Khan, JH-IIRU collaborator and associate professor and consultant of emergency medicine at AKU, on the importance of the JHU-AfPak-ICTIRT program.

The programs in Pakistan and Afghanistan reflect a need for prioritizing injuries as a public health burden worldwide, an issue that has been neglected far too often on the global agenda. JH-IIRU’s work culminates in a desire to ensure that injury and trauma are recognized as a health policy issue in Afghanistan and Pakistan, as well as globally.

For research papers from the grant see:

Dr. Krishna D. Rao, assistant professor, joined the Health Systems Program in 2014, bringing expertise in health systems and health economics. He received his master’s degree at Cornell University in agriculture and resource economics and his PhD in health systems from the Program.

Prior to joining the Health Systems Program, Dr. Rao worked with the Public Health Foundation of India (PHFI), where he conducted research on health systems and taught health economics. Before coming to PHFI, Dr. Rao worked in Afghanistan as part of the Johns Hopkins team supporting their Ministry of Public Health (MoH) to evaluate models of community financing of health services. Dr. Rao started his career in public health at the World Bank, working on the delivery of child nutrition and health services in India. In 2016, Dr. Rao was selected as a practitioner resident fellow to the Rockefeller Foundation Bellagio Center Residency Program.

Dr. Rao’s research focuses on three major areas – human resources for health, health financing and evaluation. He is particularly concerned with issues around strengthening primary care and nutrition services, measuring quality of care, and reducing financial hardship faced by households due to health care payments. He teaches courses in health financing in low- and middle-income countries, and the role of health in economic development. Dr. Rao also co-leads the Program’s health systems seminars.

Dr. Rao is involved with a variety of research projects. One of Dr. Rao’s key projects includes evaluation of a large-scale mentoring program for nurses at primary health centers in the state of Bihar, India. The mentoring program is funded by the Gates Foundation and provides nurses with the knowledge and skills to improve their obstetric skills. This evaluation is being conducted in partnership with the Johns Hopkins School of Nursing.

Dr. Rao is also currently working on designing a conditional cash-transfer program for improving nutrition in young children in India. The study uses a discrete choice experiment to understand the preferences of mothers for program conditionalities and cash transfer amounts. Other key projects include mentoring researchers from eight different countries to help them improve their research skills, conducting a cost-effectiveness analysis of a nutrition program in Malawi, and a previous health financing project in Kyrgyzstan that examined how health financing issues affect delivery of services.

Going forward, Dr. Rao is interested in studying conditional and unconditional cash transfer programs, aging and what implications that has for health systems and the financing of health care, and how the management and institutional structures of health services affect health worker performance and quality of care. Read more about Dr. Rao’s work in his faculty profile