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International Health

Health Systems Program

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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: https://bmcemergmed.biomedcentral.com/articles/supplements/volume-15-supplement-2

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

Dr. Henry Perry, senior scientist in the Health Systems Program, and his colleagues recently published a major new series of articles published in the Journal of Global Health on the evidence of the effectiveness of community-based primary health care (CBPHC). The new series, published in July 2017, is a comprehensive review that describes all of the findings that assess the effectiveness of CBPHC in defined geographic populations for maternal, neonatal and child health (MNCH).

The comprehensive review is 10 years in the making and is comprised of 700 documents, going as far back as 1950. Community-based primary health care has been growing slowly in importance over the last 50 years, and while rigorous evidence of its effectiveness has increased substantially in recent years, international organizations have been slow to invest in capacity-building for successful CBPHC programs.

The series summarizes the extensive evidence that demonstrates that MNCH can be improved through community-based approaches such as use of community health workers and volunteers, and community engagement for planning, implementation and evaluation.

One of the major findings from this comprehensive review focuses on the implications for the health-related sustainable development goals (SDGs). In order to fulfill the SDGs of universal health care coverage and ending preventable maternal, neonatal and child deaths by 2030, greater investments in community-based primary health care will be required.

The majority of health care funding in low-income countries currently goes for services provided at health facilities. However, the evidence that investments in health facilities alone without investments in CBPHC will reduce mortality in geographically-defined populations is extremely limited. In resource-constrained settings, the mothers and children that do obtain care at health facilities tend to be those who are better-off and live closer to the facility. CBPHC fulfills the SDG equity indicators by expanding access to basic services in areas where facilities are often far away.

One example of a successful, national, community-based health care program is in Ethiopia, where over the past 15 years marked improvements have been achieved through the deployment of 40,000 salaried community health workers with one year of formal training (health extension workers) and three million volunteer community health workers (called the Health Development Army). Ethiopia has become a global leader in CBPHC and has recently established the International Institute for Primary Health Care in Ethiopia (IIfPHC-E), which will provide opportunities for training and research in primary health care with a focus on community-based approaches. Faculty at Johns Hopkins Bloomberg School of Public Health, including Dr. Perry, are supporting Ethiopia’s Ministry of Health in this effort so that Ministries of Health in other countries can learn how to strengthen their own primary health care system.

The journal series is publicly available online, (see Research Theme 5), and will also be published soon as a book that will be sold on Amazon. In addition to Dr. Perry, 150 other students, researchers and experts were involved in this project, including Department of International Health faculty Drs. Robert Black, Mary Carol Jennings, Meike Schleiff and Emma Sacks. Most of the students involved were from the Department of International Health.

The Health Systems Program is focused on achieving accessible, cost-effective health care and healthy outcomes across the lifespan for families, communities and nations. In the past decade, the Program has conducted projects in over 50 countries, with particular expertise in South Asia and sub-Saharan Africa, where the greatest number of people continue to struggle with deep poverty and unmet health needs.

For more information, please contact Melissa Reed, communications and program specialist, at melissar@jhu.edu

The Program welcomed over 45 students from 10 countries

The Health Systems Program of the Department of International Health recently wrapped our 2017 Health Systems Summer Institute at the Johns Hopkins Bloomberg School of Public Health, a short-term program designed for part-time students or early- to mid-career professionals who want to further their career in public health. The Institute, directed by Health Systems senior scientist, Dr. George Pariyo, is designed to provide students an entire academic term’s worth of instruction in a condensed period of time. 

During the Summer Institute, participants have the opportunity to learn a variety of health systems skills and concepts that will help them measure the burden of disease and monitor and evaluate global health programs. Courses covered areas such as primary health care, gender analysis, technology innovation for global health, hospital and trauma surveillance, and summary measures of population health.

This year, the Institute increased the number of course offerings from seven to 11 in order to accommodate for the growing number of program areas. New courses included Introduction to Gender Analysis within Health Systems Research, Monitoring and Evaluation of Health Systems Strengthening, Designing Transformative Innovation for Global Health, and Managing District Health Systems. The majority of health systems courses focus on low- and middle-income countries, but the skills are universal.

The number of international students attending the Institute increased this year: as the Program amplifies its presence around the world, we hope to build a strong base of global students who can apply the principles of health systems in their home country. One such student, Khin Pa Pa Naing from the Ministry of Health (MoH) in Laos, chose to attend the Institute so she could gain skills and knowledge from the Monitoring and Evaluation course for her daily routine working with the MoH.   

It provided very in-depth thinking about the current situation of resource limitation, availability and allocation for the public health sector and medical care in developing countries, and how we as public health professionals could improve this situation,” stated Khin Pa Pa. In addition to Ms. Naing, we welcomed students from Canada, Nigeria, South Africa, Japan, Kenya, Vietnam, Thailand and Bangladesh.  

The Institute is also working to foster the growing number of part-time MPH students coming from all regions of the country, seeking to fulfill their 20% requirement of attending on-campus courses. We provided four lunchtime networking sessions, and hope to continue to expand our social offerings next year.  

As we seek to enhance the Health Systems Summer Institute in future years to incorporate more students coming from all areas of the public health sector, we will continue to expand and diversify our course offerings. We thank all students who made the second year of our Summer Institute a great success!