Dissolve the walls of the facility

Many countries suffer from what could be called the tyranny of the health facility model.

A huge weight is placed on these facilities (particularly primary care facilities), driven by the implicit assumption that a single structure is the most effective way of meeting the multiple health needs of vast swathes of the population.

They are expected to deliver an increasingly unmanageable set of services—preventive, promotive, outpatient, and, increasingly, chronic care to address the shifting burden of disease.

The reality is far from this.

Health facility surveys regularly paint a grim picture: most do not have the staffing (either quantity or quality) or the supplies to offer quality care. One recent study of 10 African countries found an average 30% absence rate among healthcare providers, with only 42% of facilities stocked with a set of four basic medicines for common conditions.

To address persistent service delivery challenges, we need to dissolve the walls of health facilities—to move from a mental model fixated on a single point of care responsible for the full range of services to a model in which facilities are seamlessly connected both with the communities in which they are situated and with specialist providers located remotely.

Community health workers (CHWs) are central to this vision, not as isolated volunteers roaming from house-to-house but as formal, compensated parts of the system, connected with other providers through supportive supervision and mobile applications that ensure that their work is guided by national protocols and that data flow into national systems.

Technological advances allow other ways of rethinking the facility model.

Healthcare personnel no longer need to rely on the expertise of the staff physically present; instead, they can send diagnostic imaging to specialists located remotely or benefit from second opinions from providers looking at the same electronic medical records from a different city.

Meanwhile, patients increasingly have new options available to them, whether in the form of a telemedicine consultation that connects them with a nurse or doctor from the comfort of their own home or a text-based system that provides information about key topics and helps individuals understand when visiting a facility is necessary.

Dissolve the walls of the sector

Intersectoral collaboration is often discussed but rarely delivered.

Initiatives to build partnerships between health and other sectors tend to focus on the “comparative advantages” of different sectors, which often boils down to the most visible characteristics of each: the education sector offering access to school children, agriculture offering the possibility of improving nutrition, etc.

The challenge has been that these efforts regularly fall victim to competing priorities and limited incentives to work together.
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These mental models obscure a more powerful way that the sectors can connect, if they are willing to think beyond their classic roles.

The rapid fall in cost of collecting data is resulting in huge amounts of data being collected by multiple agencies, often on the same people.

Technological advances mean that it is far easier than ever before to draw connections between disparate data sources but progress has been slow in integrating more diverse data sources that capture the social and economic determinants of health that play crucial roles in health outcomes.

These new sources of data are critical because too often the health sector is stuck in the past: considerable investments have been made over the past two decades that have resulted in important improvements in routine data collection, but the types of data gathered have generally been narrow—mostly basic epidemiology and intervention coverage—and overly focused on understanding progress retrospectively, often in the context of the needs of funders.

Although everyone is aware that past performance is no guarantee of future returns, the large investments of time and money in gathering retrospective data have focused attention on these rather than on efforts to integrate an understanding of future trends into the planning of health systems.

Large parts of the world are in the middle of a massive demographic transition and an epochal shift from a burden of disease driven by communicable conditions to one where non-communicable diseases predominate.

Meanwhile, disruptive threats such as climate change, pandemics, and antimicrobial resistance, and macrotrends such as urbanization all have significant consequences for health.

These factors are widely acknowledged but it is rare that countries or donors meaningfully integrate the implications of these longer-term changes into today’s plans.

To cope with an increasingly unpredictable world, we need health systems that can look beyond the walls of the sector and the confines of the present, and be more adaptive, integrative, and predictive.