Health System Strengthening Towards Universal

GHP 552. Leadership Development in Global Health: Health System Strengthening
Towards Universal Health Coverage
Spring 1 — Wednesdays from 3:30pm to 5:20pm
1.25 Credits
Room:
Class Dates: January 29, February 5, 12, 19, 26, March 5, 12
Course iSite:
Instructor:
Frank K. Nyonator, MD MPH, Acting Dean of School of Public Health at
University of Health and Allied Sciences in Ho, Former Ministerial
Advisor on Health Systems Strengthening in Ghana Ministry of Health,
Former Acting Director-General for Ghana Health Services and Ministry
of Health, Former Health Systems Advisor for the WHO Country Office
in Nigeria, Senior Leadership Fellow in the Division of Policy Translation
and Leadership Development, HSPH
Sponsor:
Wafaie Fawzi, MBBS, DrPH, Professor and Chair, Department of Global
Health and Population, HSPH
Teaching Assistant (TA):
Olivia Jung, PhD Candidate in Health Policy and
Management, GSAS/HBS
Instructor Office Hours:
By appointment (email: TBA)
TA Office Hours:
By appointment (email: ojung@hbs.edu)
COURSE DESCRIPTION:
This course outlines the challenges for Universal Health Coverage (UHC) in Africa through
the lens of Ghana. While households are often seen as the primary producers of health,
governments are making efforts to move available health services closer to households within
communities. Strengthening health systems is essential for ensuring progress toward
universal health coverage (UHC). But, what does it take to ensure equitable access and
financial protection at the same time?
Countries like Ghana recognize that moving towards UHC involves reducing the gap between
need and service use, improving quality and effectiveness, and improving financial protection
and sustainability. Health financing policies play a critical role, but progress on these UHC
objectives requires coordinated action across health system.
The Ouagadougou Declaration on Primary Health Care and Health Systems in Africa focuses
on nine major priority areas of which will be discussed in the course. Such action is required
to address the specific barriers to progress that may exist in any country. National health
plans and strategies are key elements for health system strengthening. Access to and
affordability of medicine is a major problem in many contexts. The Millennium Development
Goal 8, Target 8.E, focuses on the access to essential medicine and the WHO, with other
partners, have been tracking countries on progress against this target. Shortages and
unbalanced distribution of health workforce are obstacles to the capacity of health systems to
respond to the challenge of universal coverage. Robust health information systems are
essential for countries to correctly assess their situation regarding universal coverage follow
up and monitor the reforms. In addition, a nationally unified or inter-operable health
information system greatly facilitates progress towards universal coverage, particularly when
this is linked to provider payment systems.
Enabling
sub-system
inputs and
priorities…
Integrated service
delivery components
Health workforce
size, composition
& training
Information for
decision-making
Essential drug
supply & logistics
…generate
system
outcomes…
Extend
availability of
services and
technologies
Increase access
to care and
technologies
A Health Systems
…that alter the
climate of
demand for
services ,
Community
Ownership and
Participation;
Partnerships for
Health Development
Improve
quality of
services
Reduced
social costs
Framework
…impact on
health
behavior,
and ….
Improved
equity
Health financing &
resource allocation
Leadership &
governance
Development
Enhanced
Health
Service
Delivery
and
Utilization
Improve
survival
Improve
efficiency
In this course, students will have the opportunity to hear from and engage in discourse on the
Ghana Health Systems as it strives to attain universal health coverage within severe resources
constraints through innovations and strategic leadership from the health sector. The course
will also introduce the students to the on–going Ghana Essential Health Intervention Program
(GEHIP) in one of the Regions in Ghana.
The course will highlight the experience of Ghana in ensuring equitable access to essential
health services through community-based health planning and services (CHPS) and other
initiatives, and in providing financial protection for the poor through the National Health
Insurance Scheme. The sessions will focus on country-specific political, economic, social and
historical context, which interacted to make these policy initiatives possible. The course will
attempt to enhance the importance of securing financial sources and improving health
systems management. Finally, challenges encountered and implications for other African
countries will be shared.
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***
LEARNING OBJECTIVES:
At the conclusion of this course, students will be able to:
1) Assess the challenges for Universal Health Coverage (UHC) in Africa, through the
lens of a developing country
2) Apply the knowledge on health systems building blocks to attaining universal
coverage using a global health strategy
3) Explain the process of attaining universal health coverage pertinent to leadership and
governance in the Ghanaian context
4) Examine and discuss about an ongoing health system strengthening initiative, the
Ghana Essential Health Intervention Program (GEHIP)
***
COURSE REQUIREMENTS:

Class Participation (20% of course grade): Students are expected to attend all class
sessions, come to class having completed all assigned readings, and actively participate in
class discussion. The quality and quantity of students’ in-class comments and questions
are important. Students’ final course grade allocated for class participation will be based
on their contribution to class discussion, group activities, and periodic course
feedback/evaluation surveys. Students are allowed one excused absence during the term.
Additional absences will result in a letter grade reduction.
Throughout the semester, students will work towards one deliverable, describing a
developing country that is comparable to Ghana and assessing the likelihood and feasibility
of their achieving universal health coverage. The objective of this paper is to give you the
opportunity to demonstrate your command of the course material and its application to your
selected country.

Midterm Paper (20% of course grade): The first assignment will be due at the beginning
of Session 4 and will consist of a written memo (single-spaced, Times New Roman 12pt
font on one-inch margin, no longer than four pages). This assignment will assess how
students have absorbed Sessions 1, 2, and 3.
There are two components to the midterm paper. First, describe and argue how and why
their selected country is comparable to Ghana. To support your argument, please cite
statistics pertinent to your country and put it in the context of others. Then, evaluate the
selected country’s leadership/governance, delivery system, human resources, and
financing for achieving the ultimate goal of universal health coverage.

Final Paper and Presentation (60% of course grade): The second assignment will be due
at the beginning of Session 8 and will consist of a 15-minute presentation and a written
eight-page memo (single-spaced, Times New Roman 12pt font on one-inch margin).
These two components will be weighted equally in determining your grade for this
assignment.
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Building on your midterm paper (please revise based on feedback) evaluate the additional
dimensions discussed in later sessions, such as the health information
systems/technologies and decentralization methods of your selected for achieving the
ultimate goal of universal health coverage.
***
SESSION OUTLINE:
SESSION 1
SESSION 2
SESSION 3
SESSION 4
SESSION 5
1/29
2/5
2/12
2/19
2/26
SESSION 6
SESSION 7
3/5
3/12
Leadership and Governance for Health Development in Ghana
Health Service Delivery and Human Resources for Health
Health Financing
Health Information Systems and Health Technologies
Interactive Session with Workers in the Field and Other Stakeholders
for Ghana’s Essential Health Intervention Program
Decentralization Methods
Student Presentations and General Reflection on the Course
***
SESSION DESCRIPTION:
Session 1: Leadership and Governance for Health Development in Ghana
In this session, we will discuss the goals and teaching framework of the course. Using
Ghana’s health system as an example, we will review the concept of system, structure, and
building blocks. We will analyze how developing countries strive to attain universal health
coverage given severe resources constraints through innovations and strategic leadership
from the health sector.
Required readings:
1. Rodin, Judith and David de Ferranti. (2012). “Universal health coverage: the third
global health transition?” The Lancet 380. http://www.sciencedirect.com.ezpprod1.hul.harvard.edu/science/article/pii/S0140673612613403
2. World Health Organization. (2007). “Everybody's Business: Strengthening Health
Systems to Improve Health Outcomes: WHO's Framework for Action.”
http://www.who.int/healthsystems/strategy/en/index.html
3. Barry SP, Somanje H, Kirigia JM, Nyoni J, Bessaoud K, Trapsida JM,
Ndihokubwayo JB, Soumbey-Alley EW, Nyamwaya D, Tumusiime P, Kasilo O,
Diarra-Nama AJ, Ngenda CM, and Sambo LG. (2010). “The Ouagadougou
Declaration on Primary Health Care and Health Systems in Africa: Achieving Better
Health for Africa in the New Millennium.” The African Health Monitor (12). World
Health Organization. http://ahm.afro.who.int/issue12/pdf/AHM12Pages10to21.pdf
Supplemental readings:
1. Cassels, Andrea and Janovsky, Katja. (1992). “A time of change: health policy,
planning and organization in Ghana.” Health Policy and Planning 7(2): 144-154.
http://heapol.oxfordjournals.org.ezp-prod1.hul.harvard.edu/content/7/2/144
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2. Ministry of Health, Ghana. August (1998). Medium Term Health Strategic Plan 19972001. (available on course iSite)
Session 2: Health Service Delivery and Human Resources for Health
Good service delivery is a vital element of any health system. This session will cover the
physical availability of services and delivery of prevention and intervention services to the
population as well as the challenges that developing countries face in training and retaining
the health workforce. These will be in line with the principles of Ghana’s District Health
Systems and the framework for implementing the Ouagadougou. We will assess and critically
analyze the gaps and make inputs in improving the system.
Required readings:
1. World Health Organization. (2010). “Monitoring the building blocks of health
systems: a handbook of indicators and their measurement strategies.” Chapter 1.
Health Service Delivery.
http://www.who.int/healthinfo/systems/WHO_MBHSS_2010_section1_web.pdf
2. Campbell J, Buchan J, Cometo G, David B, Dussault G, Fogstad H, Fronteira I,
Lozano R, Nyonator F, Pablos-Mendez A, Quain EE, Starrs A and
Tangcharoensathien V. (2013). “Human resources for health and universal health
coverage: fostering equity and effective coverage.” Bulletinof the World Health
Organization 91:853-863. http://www.who.int/bulletin/volumes/91/11/13-118729.pdf
3. Gupta N, Maliqi B, Franca A, Nyonator F, Pate MA, Sanders D, Belhadj H, Daelmans
B. (2011). “Human resources for maternal, newborn, and child health: from
measurement and planning to performance for improved health outcomes.” Human
Resource For Health 9(16). http://www.human-resourceshealth.com/content/pdf/1478-4491-9-16.pdf
Supplemental readings:
1. Peters DH, Garg A, Bloom G, Walker DG, Brieger, WR, and Rahman MH. (2008).
“Poverty and Access to Health Care in Developing Countries.” Annals of the New
York Academy of Sciences 1136(1): 161-171. http://onlinelibrary.wiley.com.ezpprod1.hul.harvard.edu/doi/10.1196/annals.1425.011/pdf
Session 3: Health Financing
Health financing refers to the collection of funds from various sources (e.g. government,
households, businesses and donors) pooled to pay for services from public and private health
care providers, thus sharing financial risks across larger population groups. Ghana has
embarked on innovative ways of financing its health delivery organizations. This has drawn
local and international attention, wondering whether this is a hazardous experiment or a way
forward for African Countries. This session explores Ghana’s National Health Insurance
Scheme and draws lessons for other African countries.
Required readings:
1. Schieber G, Cashin C, Saleh K, and Lavado R. (2012). “Health financing in Ghana.”
The World Bank. http://wwwwds.worldbank.org/external/default/WDSContentServer/IW3P/IB/2012/08/20/000333
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037_20120820001118/Rendered/PDF/718940PUB0PUBL067869B09780821395660.
pdf
2. Witter, S. and B. Garshong. (2009). “Something Old or Something New? Social
Health Insurance in Ghana.” BMC International Health and Human Rights 9(20).
http://www.biomedcentral.com.ezp-prod1.hul.harvard.edu/content/pdf/1472-698X-920.pdf
3. Agyepong, I.A. and S. Adjei. 2008. “Public Social Policy Development and
Implementation: A Case Study of the Ghana National Health Insurance Scheme.”
Health Policy and Planning 23(2):150-160. http://heapol.oxfordjournals.org.ezpprod1.hul.harvard.edu/content/23/2/150.full.pdf
Supplemental readings:
1. Browse: http://www.nhis.gov.gh
2. Siadat, B. 2013. The Impact of Ghana’s National Health Insurance Scheme on Patient
and Provider Behavior. Dissertation, Harvard School of Public Health. Unpublished.
(available on course iSite)
Session 4: Health Information Systems and Health Technologies
Monitoring and evaluating the progress towards UHC has been a priority for the health
sector. A well-functioning health information system ensures the production, analysis,
dissemination and use of reliable and timely information on health determinants, health
system performance, and health status. The adoption of e-health solutions and mobile
technology presents new opportunities for making progress in the sector performance.
Required readings:
1. World Health Organization. (2008). “Framework and standards for country health
information systems.”
http://whqlibdoc.who.int/publications/2008/9789241595940_eng.pdf
2. Gladwin J, Dixon RA, and Wilson TD. (2003). “Implementing a new health
management information system in Uganda.” Health Policy and Planning 18(2):214224. http://heapol.oxfordjournals.org.ezpprod1.hul.harvard.edu/content/18/2/214.short
3. Browse: http://www.mailman.columbia.edu/academic-departments/populationfamily-health/research-service/mobile-technology-community-health
Supplemental readings:
1. Braa J, Monteiro E, and Sahay S. (2004). “Networks of Action: Sustainable Health
Information Systems across Developing Countries.” MIS Quarterly 28(3):337-362.
http://www.jstor.org.ezp-prod1.hul.harvard.edu/stable/25148643
2. Skim: http://www.isfteh.org/files/media/ghana_national_ehealth_strategy.pdf
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Session 5: Interactive Session with Workers in the Field and Other Stakeholders for
Ghana’s Essential Health Intervention Program
In recent years, Ghana has been at the forefront of health systems development in Africa.
Following the Navrongo Experiment in 1998, which reduced childhood mortality by
mobilizing rural villages to develop systems for primary care, the Ghana Health Service
(GHS) launched the Community-based Health Planning and Services (CHPS) Initiative to
scale up the same approach. This session will connect students with three personalities
(GHS, academia and collaborating institution) who have been working with and within the
GHS on the Ghana Essential Health Intervention Programme. Dr. Koku Awoonor-Williams,
Upper East Regional Director of Health Services in the Ghana Health Service, Professors
James Phillips of the Mailman School of Public Health at Columbia University, and Prof
Fred Binka, Dean of the School of Public Health and Professor of Epidemiology at
University of Ghana will be joining us via Skype.
Required readings:
1. Awoonor-Williams JK, Bawah AA, Nyonator FK, Asuru R, Oduro A, Ofosu, A, and
Phillips JF. (2013). “The Ghana Essential Health Interventions Program: A
plausibility trial of the impact of health systems strengthening on maternal and child
survival.” BioMed Central Health Services Research 13(Supplement 2):S3.
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3668206/pdf/1472-6963-13-S2-S3.pdf
2. Awoonor-Williams JK, Sory EK, Nyonator FK, Phillips JF, Wang C, and Schmitt
ML. (2013). “Lessons learned from the scale-up of a community-based health
program in the Upper East Region of northern Ghana” Global Health: Science and
Practice 1(1):1-17. http://www.ghspjournal.org/content/1/1/117.full.pdf
3. Browse: www.ghs-gehip.org
Session 6: Decentralization Methods
In an effort to encourage community ownership and participation, many developing countries
have pursued decentralization strategy, totally devolving local governance to district
assemblies (example: CHPS in Ghana). In this session, we will discuss different methods of
decentralization, such as community ownership, participation, and partnership for health
system development.
Required readings:
1. Nyonator FK, Awoonor-Williams JK, Phillips JF, Jones TC, and Miller RA. (2005).
“The Ghana Community-based Health Planning and Services Initiative for scaling up
service delivery innovation.” Health Policy and Planning 20(1):25-34.
http://heapol.oxfordjournals.org.ezp-prod1.hul.harvard.edu/content/20/1/25.full.pdf
2. Bossert TJ and Beauvais JC. (2002). “Decentralization of health systems in Ghana,
Zambia, Uganda and the Philippines: a comparative analysis of decision space.”
Health Policy and Planning 17(1):14-31.
http://heapol.oxfordjournals.org/content/17/1/14.long
Session 8: Student Presentations and General Reflection on the Course
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