Engaging national governments for scale-up

[Mali Kambandu]

The BLN recently had an informative webinar on how to scale up health programmes from pilots. The presentations were informative, but there probably wasn't sufficient time to exhaust the discussions. One area of interest that was touched on briefly was how to engage national governments for successful scale-up of the health programme. To enable people to continue the discussion or share experiences and expertise, I wonder:

What experiences do countries have with engaging national governments when implementing or proposing new interventions in the health system? What approaches have been effective? Is there a marked difference between implementing digital systems and more traditional systems? What does it take to institutionalise a health innovation?

[chris_...@jsi.com]

Hi Mali.

When it comes to digital solutions, there have been many pilots that never went to scale. Either they were too program/silo focused and therefore only addressed a small problem without regard to broader health system needs, and/or they were implemented by partners without prior engagement or support of the government. For example, we've all seen headlines trumpeting this or that mHealth solution that will change the world, only to see it fade away because it was driven by a development partner or a corporate social responsibility program and never really had traction within the government. All too often, ministries of health acquiesce to these solutions because they lack the governance framework and technical capacity to really take control of the agenda. But absence of "no" does not mean "yes". 

In terms of immunization, far better to engage not the EPI program alone, but the higher MOH levels, and to look broadly at systemic needs, not just the immunization silo, not just the vaccine supply, but at the continuity of care and broader health commodity requirements. Integrated health services is the goal, but we cannot get there without enterprise architecture for interoperable information systems that supports integrated health delivery.

It's okay to start small and pilot, but there needs to be a longer-term vision towards going to scale, integration, interoperability, and (at the point of care) better continuity of care. And that vision must be aligned and embraced by the MOH and the health sector at large.

[Darcy, Niamh]

From my experience, the only way to bring a project to scale is to have worked earlier on with the MOH and other MOH related agencies, with their own integrated plans either in eHealth or M&E (which is often a driver of some of the eHealth solutions) and their 5 year health sector strategies, which may identify a need for a specific solution.  They have already identified country priorities, and what their targets are, particularly now with the Sustainable Development Goals.  Working with the MOH and their agencies, seeing where eHealth either from an enterprise level (depending on their level of adoption of Enterprise Architecture) or from a more solutions focused level can actually assist with achieving the health sector goal, then there is an opportunity to determine how this will improve existing ‘health’ processes, and then work within the country eHealth strategy/frameworks with a local IT or software partner to either use existing open source solutions that can be customized or with local vendors who have a lot of experience, building in the scaling plans into the overall project plan from the ground up.

 

For example, most countries are now moving to use short codes for any mHealth solution, and may already have adopted an mHealth platform for SMS based or USSD or smartphone based applications, and engaged in MoU with telcos to provide reduced or zero-rated services.  Building on top of these existing platforms that the MOH and their agencies support, with evaluation built in to the ‘solution’ for this area will allow ongoing M&E to see if this is really delivering on the benefits that have been proposed.   So, if a telco only operates in one area of a country and you have a pilot planned with that telco then this will have real problems scaling nationally.  It takes years to get MoUs in place with telcos that allow for lower rated or zero rated costs.   

 

Most countries do not want to see more eHealth or mHealth pilots – what they are interested in is where eHealth can help them achieve their health sector goals.  There is limited evidence out there that shows that eHealth actually delivers on its promise, usually because the more important pieces of how ehealth supports and delivers on the health sector strategy, business process re-engineering, change management, people and organizational change management, political support either champions or detractors are not given enough attention and too much attention is focused on the technology.

From 30 years of work in information systems, the technology is usually the easy part.  It is the enabling environment focused on people and process that is really where the rubber meets the road.

 

So, in a nutshell, working with the MOH and other agencies on what their plans are is key here, and using what they have already built and decided as their eHealth platforms and architecture is really the only way to do any implementation that has a chance of scaling.

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[Vincent Seaman]

Bravo!  This is a very good distillation of the problem, and points us towards the solution.  However, even if one embraces these ideas, enabling change through MOHs and other high-level government agencies is not easy and in many cases not possible – at least on the timelines that we work with.  This should probably be assessed at the beginning of every project instead of in mid-stream or at the end, when we begin to realize there is no one eagerly waiting to realize all the wonderful benefits of our efforts.

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