This piece is part of our 2018 United Nations General Assembly series.
One year ago, after nearly a decade’s commitment to advancing the Universal Health Coverage (UHC) movement, The Rockefeller Foundation’s health team asked itself what it could do in the next 10 years to advance progress on SDG 3 and move closer to making “health for all” a reality. In pursuit of an answer, we spoke to experts around the globe, scanned recent and emerging research, workshopped hypotheses with health programs in various countries, and considered solutions proposed by innovators within and beyond the health sector.
At the start, the horizon for an entry point seemed limitless. But the underpinnings of this initial research validated our commitment to seek a different perspective – that of the people living and working in the communities we hoped to reach through our efforts.
Earlier this year, our team was invited to meet a woman named Esnat—one of Malawi’s Health Surveillance Assistants—while she spent her day working at a village health clinic about 30 km from Lilongwe. Esnat’s catchment area includes more than 700 households, and she said she sees between 10-15 patients a day at that clinic alone. You’ll see Esnat in the photo above, wearing blue, administering a rapid diagnostic test for malaria. Her supervisor, Nora, is standing just behind her.
You might also have taken note, in the photo on the right, of the large book she’s writing in—the paper-based patient register she uses to track symptoms and test results. She carries a different register to each type of clinic that she hosts during the week because in addition to this clinic for children under 5 years old, she runs separate clinics on nutrition, family planning, and immunization. She also makes home visits, by foot, for pre- and post-natal care. Those require carrying a different register.
What you won’t see in either photo is that Esnat also has more than one mobile phone. She showed us how she uses various apps on each one to manage her workflows at the clinics, request supplies, and report to the managers of the different health programs she touches—each one funded by a different donor-focused on a siloed component of maternal or child health.Without clear coordination among the donors funding these programs, none of the information that Esnat collects, on paper or by phone, flows into a single data platform that can provide a holistic view of a person’s health or a population’s health needs—let alone a dashboard that is easily accessible to the patient, the provider, the donors, or the government.
Although Malawi has made major progress on reducing the deaths of children under age 5 through clinics like Esnat’s—largely supported by funders focused on children with malaria, pneumonia, and diarrhea—Esnat showed us how her workflow is rife with redundancies and inefficiency due to this fragmentation, even when she’s doing her best work to keep mothers and children healthy.
Esnat’s data challenges might impact the quality of care she can deliver. But we saw something else that day that underscored the consequences of this fragmented health system—we saw who gets left behind.
A mother arrived at the clinic with a small, feverish boy. She handed Esnat a pale blue passbook that tracked the child’s immunizations and history of care, all fairly routine. Yet suddenly, there was an issue. The passbook was stamped with the year 2010, suggesting this child was too old to be treated at an under-5 health clinic. His mother argued, saying the passbook actually belonged to a different child, and that in her rush, she’d grabbed the wrong document.
That’s when supervisor Nora drew the little boy aside to ask him his name.
He replied “Godfrey.” Unfortunately, that name matched the one printed on the passbook—so without even a basic exam, and despite available treatment on site, Godfrey and his mother were sent off, forced to either ride out the fever or find the cash to take a bus to a district health facility quite some distance away. We wondered if we—introduced as potential donors—hadn’t been at the clinic that day, would Esnat have treated him despite his age?
A study published in Health Affairs last spring found that in 2013, development assistance for health for children under 5 was over three times more than spending in any other age group despite evidence that disease burdens have begun to shift to older populations. We are talking about much more than 7-year-olds being turned away from under-5 clinics. We are talking about a potential missed opportunity to ensure that health systems are designed to address the needs of entire communities.
Our evolving health initiative aims to take this fragmented system and optimize it through digital tools and data systems that will directly address the inefficiency of building a health system for one population at the expense of another.
Fragmentation in global health funding has slowed progress on saving lives and keeping families and communities healthy. Our team seeks to jumpstart this progress by leading partnerships that align donors and implementers around a common set of principles, practices, and reporting structures in community health—reducing redundancies and unlocking funds to broaden the scope of services families can expect to receive at the community level. We view digital tools and data systems as accelerators that will improve accountability, resource allocation, and quality of care delivered to people previously left behind.
Integrated, digitally-enabled community health systems could be a critical next step in advancing the work we’ve already begun through our advocacy for UHC and SDG 3 more broadly, and a means to truly ensure good health for all translates to all lives on the ground.
This piece was also part of a month-long focus on health in the lead up to the 2018 World Health Assembly in May 2018.