Sustaining healthcare improvement initiatives
My visit to Malawi this week has revived familiar conversations around the challenge of transitioning from successful pilot projects to large-scale efforts that are sustainable and impactful nationally.
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The narrative is all too familiar. A non-governmental organisation carefully designs an effective intervention aimed at closing measurable gaps, scopes out a few pilot districts, aligns a high functioning motivated project team around it, and promptly gets to work. Over the course of time, the project derives compelling results. Inevitably, the end of project comes, and along with it, burning questions about sustaining these high impact interventions within the existing health system.
From my perspective, scale up always has two dimensions; content and systems. Often, ministry officials, sceptical about the success of any project may ask what one is scaling up. To answer this question, one ought to be able to adduce evidence to show that specific interventions were in fact successful in improving health outcomes – content.
Secondly, project designers ought to display rich insights into the various workings of the health system including the specific adaptations that were made at a specific level to achieve that success–systems.
All too often, however, one comes across projects that have done a great job of documenting the clinical and other interventions that drove health outcomes, but have displayed less rigour in documenting their learnings around adaptations to the workings of the health system necessary for successful scale up, including what interventions and modifications may be considered cost effective or not. It is only in presenting results from successful pilots in a bid to enlist the support of national health managers for scale up that these burning questions arise.
Unable to provide unambiguous and convincing answers, successful pilots filter away, without an opportunity to plug key lessons into the larger health system. Over time, the performance of that particular portion of the health system reverts to its original state of underperformance, while the non governmental moves on to the next pilot, in a phenomenon many have classified as a total waste of time and effort.
So, what can be done differently? A few things, actually.
Scaling up
A document published by the World Health Organisation talks about starting projects with the end in mind. To my mind, this entails project designers addressing critical questions such as whether health system owners have been identified and acknowledged and whether project conceptualisation, design, and implementation are in reality and in perception, truly adapted to the stated priorities of health system owners.
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If scaling up into existing health systems is the objective, then adaptations in project design coupled with a deliberate attempt to build system capacity through training and long-term co-implementation are critical. In other words, right from the very beginning, we have identified the key officers of the health system who will have the ultimate responsibility for overseeing ongoing priority project interventions even when the project ends, and are working with them in that capacity in a very deliberate manner.
The above point should hold true at all levels; senior management and leadership, middle management and frontline workers. All too often, projects appear very keen to dive into actual implementation with frontline workers, only to wake up to the critical role of the health system leaders when the question of sustainable scale ups emerge.
The important role of leadership and the need for a clear understanding of expectations around owning the implementation and taking responsibility for ultimately redesigning the health system to a new way of work need to be discussed and agreed upfront with health system leaders and managers at national, regional, district, facility and even community levels.
This then introduces another dilemma often seen among health system managers. Though convinced about the effectiveness of a particular intervention, some managers do not sufficiently appreciate that to have generated those impressive results, so-called pilot projects have necessarily had to, as it were, fundamentally redesign wedges of the health system, be they district hospitals or health posts.
In other words, the system in which the said pilot projects achieved compelling results tends to be fundamentally different from other systems in which scale up is planned for.
New wine in old bottles?
This is so because to have generated those results, those systems necessarily needed to be made to work in a completely different way. This is where the earlier point made about carefully documenting the adaptations made to the microsystem ought to inform redesign considerations during scale up, as a vital complement to proven interventions.
The reality tends to be different in many instances. Managers want the new proven interventions to be implemented nationwide but do not appear similarly inclined to redesign the health system to support the new way of work. In the event, new interventions are foisted onto old ways of working.
Resources continue to be poured to maintain the old way of work while managers berate the absence of fresh resources to support the new way of work rather than totally overhauling the old way of work and its supporting resources to align with newer more effective models. There is misalignment and inevitably, those former effective high-impact interventions fail to achieve impact at scale.
Basic questions such as, “is there an existing meeting that can be reoriented as opposed to creating a new structure?” Is there an ongoing outreach visit that can be enriched in terms of its content and deliverables?” “Is there a scheduled clinical training whose delivery can be altered?” etc., need to be answered.
Given the somewhat creeping fatigue in the global health community, among some funders and among ministries of health around unscalable pilots, in the light of a burning desire for improved population health, the above considerations are key in what must be a two-way dialogue between project designers and health system leaders.
Perhaps the above considerations all tie up in an exciting observation long associated with countries such as Ethiopia and Rwanda and now showing positive signs of resurgence in places such as Malawi where increasingly, ministries of health/governments are asserting themselves in coordinating the activities of multiple partners and non-governmental organisations in order to assure themselves of better alignment and use of resources and, to some extent, the technical integrity of interventions to achieve true national coverage and impact.