Sustainability Strategies for Regional Health
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Sustainability denotes the ability of government (ministries, department, and agencies), private, and civil society sectors to perform certain activities on continuum scale, especially at the end of donor-supported regime, by keeping the project moving at a desired phase, for impact and/or outcomes (Joaquin 1998; Lyson et al. 2001). Regional health is a new healthcare concept which deals with healthcare issues at the grassroot level. It is an emerging concept which addresses health issues within a rural populace (Frank et al. 2005). Regional health system (RHS) is defined by its regional boundaries (Dash 2009), characterized by its financing, coordination, organizing, risk pooling, health services provision, and management capacity among others (Yap 2017). The fundamental goal of regional health system is to improve the health status of the target community (Frank et al. 2005).
Sustainability as a concept is vague lacking in distinct definition, characterized by complexity of how health project is sustained and used of mixed terminologies in deciding sustainability mechanism of regional health (Stirman et al. 2012). Sustainability of health project thrives on effective practices and approaches of the resources needed to sustain regional health project. Moreover, sustainable health system is the one implemented on continuous scale using available economic, social, and environmental resources that enhance quality of public health, without exhausting natural resources. Sustainable regional health system is wider in scope and orientation; it occurs in collaborations among stakeholders for sustainable healthcare. Regional health encompasses health improvement approaches like prevention and control services, corporate social accountability and responsibility, and other forms of interventions for sustainable healthcare.
Sustainable regional health system can be achieved by performing different activities such as immunization, disease prevention, control and eradication, organizing and coordination of regular and voluntary services, and implementation of transformation policies (Frank et al. 2005). Also, sustainability of regional health system requires guiding principles (Dash 2009), for the deliverance of quality, accessible, available, reachable, and sustainable healthcare. However, challenges of escalating healthcare cost and high demanding clients make meeting the objective of regional health more tasking (Dash 2009). Another area of contemplation is the method employed for regional health sustainability and lack of benchmarks on which interventions are implemented upon (Rasschaert et al. 2014).
This chapter presents some practical methods and tasks embedded in social processes that can be invoked in the pursuit of the regional health sustainability objectives (Frank et al. 2005). One of the bases for differences in regional health sustainability strategies is the topic under discussion. For instance, different strategies use different topics, approach, and activity in trying to sustain targeted regional health program.
Approach to Regional Health Sustainability
One of the approaches to regional health sustainability is adoption of sustainable health financing model. Regional health development strategies for the sustenance of population health include financing models, focusing on advancing regional health. Regional health sustainability thrives on financial strategies that determine the cost of disease prevention and health promotion (Rural Health Information 2018). In this regard, several US dollars have gone down the drain, contributing little to the objective of regional health improvement; the reasons for these include attitude, norms, culture, and mind-set of the target community.
Successful regional health system involves partnerships, collaborations, and cooperation among stakeholders. Partnership enhances collective decision-making and implementation of health project (WHO 2016). Regional health host communities provide support to the project serving them; also, the support enjoyed from the host communities for regional health helps in maintaining sustainability, distribution, and implementation of strategic activities that improve regional health. Partnership as a strategy is stipulated in goal number 17 of the 17 Sustainable Development Goals (SDGs) (SDG 2016).
It only involves smaller populations.
Is situated in towns and villages.
Does not require large technical and working capital.
Rural health services face less challenges than those found in the urban cities.
Ability to share resources between host towns.
It provides essential medical services.
Less waiting consultancy period.
Does not require complex equipment or highly qualified personnel.
At regional health level, treatment usually commences with a visit to a local clinic, where a decision of what is best for the client is taken, whether to see a visiting specialist, go to an outpatient clinic, or travel to upper regional settings or urban services for treatment. Sometimes long distances are a major setback for regional health services and, also, lack of advanced technology to conduct advance healthcare for regional health sustainability.
Sustainability Strategies of Regional Health
A number of strategies exist for sustainability of regional health programs. Evidence-based approach is an essential strategy of designing, planning, financing, resource mobilization and leadership, implementation, and assessment of regional health projects by stakeholders (Murray and Frenk 2000). Moreover, in providing regional healthcare services, health personnel make use of available health data to design qualitative health services. Quality level of the regional-based health service is on the increase in several countries across the globe, due to its adaptation of scientific-based practice as a means of achieving health-related sustainable development goals. As such, sustainability of regional health encompasses strategic coordination of functional health system that improves population health (WHO 2001).
Consequently, possible benefits and opportunities of utilizing local health workers in low-income countries did not only remarkably improve regional health services but also help in augmenting community participation to improve their own healthcare standard. Currently, strategies for sustainable solutions to the advancement of regional health in developing countries have led to transformed interest in the probable contribution of the stakeholders in sustaining regional health. Efforts to mitigate challenges confronting regional health may be enhanced when healthcare personnel and stakeholders share the same opinion, designated to sustain health resources at regional facilities. It is pertinent to understand specific roles and responsibilities of all stakeholders in regional health (John et al. 2004). There must be willingness to utilize available resources at regional level to sustain the healthcare of the large number of individuals. Although the objective has always been of healthcare remedy, in the presence of evolving infectious diseases. Regional healthcare system sometime operates above its target capacity, despite the fact that regional facilities may not have the required resources to handle every case presented, but ideal partnerships, good health management systems, and a responsive framework can be used to mitigate the highlighted challenges (John et al. 2004).
Sustainability framework could be drawn from several strategic factors. Framework for sustainability could both impact regional health implementation positively and negatively. Sometimes, what is not clearly understood among the sustainability elements cannot be adequately measured, to determine the influential factors in contexts, considering the dynamism of regional health sustainability. Therefore, Dynamic Sustainability Framework (DSF) (Chambers et al. 2013) should guide the intervention in focus for the attainment of regional health sustainability. DSF guides health system advocacy, implementation, and assessment of sustainability in context (Chambers et al. 2013). Also, DSF could be used in aligning cultural factors with community dialogue, referred to as “poly-logue,” with particular attention to verbal and nonverbal communication (Airhihenbuwa et al. 2009) and cultural and community understanding of sustainability (Airhihenbuwa 2007).
To sustain regional health system, there is a need to focus on three key areas: (1) public health, (2) health facility, and (3) community. The first refers to the overall capacity of the public health system to manage large health-based activities, while the other two areas focus on making resources sufficient and available for the delivery of medical care to a large number of patients. The three focus areas cover the physical space, organizational structure, and licensed and non-licensed staff, including mental health support, provision of information systems, essential drugs, and other resources needed to sustain regional health (John et al. 2004).
Partnerships: Partnerships have the potentialities of making impact on regional health sustainability, through development of collaborative synergy between organizations and stakeholders with similar goals, to enhance the visibility of the program and stress the importance of health system sustainability.
Capacity building: Training of staff to reach certain levels of expertise in a given area ensures that the skills and knowledge needed for project implementation are met, so as to improve and sustain regional health. Also, train-the-trainer models can help make certain that the needed knowledge and skills gained through the trained facilitators are fully utilized.
Funding: Programs should be supported by multiple funding sources. Source of regional health fund may include revenue, compensation, existing resources, grants, and fund raising among others. Revenue can be generated through regional health employer fees. Other sources include reimbursement from state medical aid programs and leveraged resources from governmental agencies among others.
Information: Information obtained from organizational assessments can guide decision on who does what of the health project. Information availability assists in choosing sustainability plans that scale up the operations of regional health and deciding the number of projects, participants, and services offered. Information help in distribution of responsibilities to stakeholders and identify areas in need of improvement or total changes among others.
Communication: Effective means of communication and messaging are the approaches through which health project awareness among beneficiaries is raised, discourse and discussion created, and feedback obtained from the people who have second thoughts or alternative decisions.
Other Strategies for Regional Health Sustainability
Other strategies used in strengthening regional health system include investment in the processes that improve institutional capacity of the various sectors with stake in health system (Makokha 2002), in combination with the following.
Community participation formed part of regional health strategy from both theoretical and realistic approaches to health system sustainability. Community participation in health system denotes decision-making, determined by an array of factors: endorsement by individuals (Boyce and Lamont 1998), health professionals, and decision-makers (Green and Frankish 1994); better accountability by stakeholders (Alexander et al. 1995; Morfitt 1998); function of community-level factors in ensuring a healthy community (Eastis 1998; Lomas 1998; Veenstra and Lomas 1999); and local agreement and major points of interest (Zakus and Lysack 1998).
Realistic community participation in regional health decision-making includes mobilization and utilization of local community resources and energy; availability and accessibility to variety of inputs for comprehensive solutions to regional health challenges; cost-effective interventions (Creighton 1993); and the idea that participation may lead to a more proficient delivery of services (Brownlea 1987; Farrell 2000; Frankish et al. 2002). Political motives for better community participation include loss of faith in the legitimacy and superiority of professional knowledge in healthcare decision-making (Berman 1997; Charles and DeMaio 1993). However, strong political will is a means of gaining broad-based community support, efforts from volunteers (Broadhead et al. 1989), participation in planning and deliverance of health programs, awareness creation, appropriate utilization of health services, and disease control and prevention service (Tewdwrjones and Thomas 1998).
Due to relevance and significance of community participation, the WHO renewed interest in the Alma Ata Declaration of 1978 which is an important phase in primary healthcare development (Lewin et al. 2010; Litsios 2004), for sustainable regional healthcare. However, the effort of the WHO comes at a time of inadequate health workforce, inequalities, and emerging and reemerging pattern of disease distribution, caused by consequential effects of climate change, urbanization, and globalization among contemporary issues (Anthony et al. 2009). Community participation at regional health level putatively leads to better decisions and effective and efficient health system. The reality appears to be that little empirical evidence exists as to how community participation leads to such outcomes.
However, community participation cannot suppress the organizational challenges facing regional health sustainability. To overcome the challenges, peculiar community’s social conditions of a region, suggestive of ways that promotes understanding and implementation of sustainable approaches, should be adopted (Shiell et al. 2008). The adoption will influence sustainability mechanism for effective project intervention defying complicated process. The approach enables the interactions among the components of health system implementation, using sociocultural context to influence the formation of a wider policy through which the sustainability technique is implemented. For example, in Zambia, systems thinking policy was enacted to assess the means of improving the quality of health services delivery, while, in Rwanda, sustainability of the health system was coined as a flexible question utilized to uncover not only unpopular factors but known community-based approaches (Sarriot et al. 2015).
Much remains to be done in developing models of community participation and in monitoring and evaluating its impact on the regional health system and the health of the population across diverse settings and circumstances. There is also a need to develop better methods for conducting research on community participation (Frankish et al. 2002). However, without participation by the host community, sustainability of regional health system will remain a mirage.
Different researchers have described that several groups of people mainly in rural areas adapt and develop ways of doing things that are called “traditional or indigenous” using their knowledge base in agricultural practice, food harvest and preservation, and traditional medicine among others, as means of sustaining activities (Fernandez 1994; Rengalakshmi 2006; ICIS 2002; Zane Ma Rhea 2004). These people are commonly part of the same ethnic or cultural group that form the national majority and have developed adaptations of knowledge that are considered important in protecting and preserving their environment. Rajasekaran et al. (1991) defined community knowledge as a systematic acquisition of knowledge by local people through accumulation of experiences, informal experiments, intimacy to environment and understanding of a given culture. This knowledge is known by different names such as “indigenous knowledge,” “community knowledge,” “rural peoples’ knowledge,” “traditional knowledge,” “indigenous science,” and so forth. Therefore, application of community knowledge is a means of sustaining regional health system.
Community Information Systems
Information is power; as such reliable health information is a key to achieving sustainable regional health. However, ideal health information system requires sound data processes, and processing, adequate skills staff, and evidence-based approaches (Lippeveld and Sauerborn 2000). Additionally, information flow need not to be fragmented or parallel without contradictory (Chilundo and Aanestad 2004; Damtew 2005) or improper utilization (Mengiste 2010). Community health information usually emanated from the local health facilities (Chaulagai et al. 2005; Krickeberg 2007), through which government initiates health reform policies, focusing on community-based care (Starfield et al. 2005). Ideally, community health service may provide opportunities to increase both the effectiveness of curative and preventive services; community health workers may act as a bridge between the community and the formal health services in all aspects of health development (WHO 2007).
Community-Based Health Service
The community-based health service is escalating in many developing countries as a means of achieving regional health sustainable development goals. Besides provision of primary healthcare, community health workers collect, compile, transfer, and make use of community health data. The potential benefits and opportunities drawn from the community health workers in low-income countries have brought not only remarkable improvement on access to and coverage of communities with basic health services but also help in increasing community participation for their own health activities. Recently, the search for sustainable solutions to the development problems that confront developing countries has led to renewed interest in the potential contribution of the community-based health services to sustain regional health.
Government, development partners, and civil society organizations recognized the importance of sustaining regional health, as a means of enhancing community-level public health. National governments sustain regional health through community-based primary care by strengthening in collaborations with non-state actors and other stakeholders (Rene 2003). Primary healthcare services revitalized public health through civil society engagement with community-based health institutes and world health organizations (Dickerson et al. 2012).
Interventions and/or implementation of programs determines its sustainability (Stirman et al. 2012), by addressing the issues of what are to be sustained, how, why, and by whom and the likely time allowed for the sustainability (Chambers et al. 2013; Shediac-Rizkallah and Bone 1998). The highlighted areas of inquiries require project-driven assessment and evaluation knowledge, with which to decide the potentialities of project sustainability. Lack of evidence-based approach and practice makes several regional health programs difficult to be sustained (Stirman et al. 2012). Also, not including sustainability plan at the onset of health project inhibits its sustainability. Moreover, sustainability mechanisms sometimes occur after project implementation design, planning, and execution phase, making achieving it hard to attain.
To sustain regional health, there is a need to bring into consideration diverse contributory sustainability planning and strategies, from the institutions with stake in health system; the institutions include community-based organizations which hold the responsibility of augmenting health services provision to the community they serve and enactment of policy reforms for an improved health system project in sustained scale at the grassroots (Hayes 1981).
Knowledge sharing among diverse institutes with stake in regional health is significant to its sustainability. Knowledge is a processed data within individual minds, which once transmitted into readable text, graphics, or symbols, it becomes information (Alavi and Leidner 2001). Knowledge sharing is a difficult task to achieve due to tacit and explicit dimensions of knowledge (Polanyi 1967; Nonaka 1994; Nonaka and Takeuchi 1995). Tacit knowledge is the one gathered directly from experience and shared through discussion, story, or shared experience (Zach 1999; Kakabadse et al. 2001). Explicit knowledge is a codified knowledge disseminated verbally, in written, or electronically (Orlikowski 2002).
Conversely, learning and knowledge are considered social and cultural phenomena. Social interaction assumes a “pipeline” for knowledge sharing; the interaction enables a movement of knowledge produced in one area to another for consumption. It is a suitable condition for potential knowledge sharing (Nicolini et al. 2003). Also, knowledge takes practice view point. Knowledge is practice based as argued by Carlile (2002). According to him, “knowledge in practice” enables it accommodation across disciplines; what is practiced by a certain discipline can be adopted by another discipline. This claim suggests adoption of sustainable practice for regional health between disciplines.
Health Information Technology (IT)
Information technology (IT) is vital to regional health services; it assists in cost management and delivering of efficient and high-quality services and health information sharing through electronic channels and exchange of data for sustainable solutions (Yasnoff et al. 2004). Regional health information exchange makes use of IT facilities to link occurrences at local level to national level timely and clinical data sharing for strategic action that could enhance sustainable practice (Adler-Milstein et al. 2007).
Utilization of IT in regional health allows specific handling of health data for optimal care deliverance. It was evident that information is stored and exchanged electronically between organizations, bringing stakeholders together for a common sustainability goal (Bates et al. 2003). It seems to possess great high benefits; it makes implementation of sustainable solutions possible through contemporary electronic information exchange and storage medium. If regional health is to succeed, it should be built around sustainable models, which require practicality of approaches that ensure resilience. Therefore, IT-based approach should be used to determine how much electronic-based facilities are needed to facilitate clinical and preventive data gathering and sharing and what types of data sources and sharing are required, among others. This piece presents the relevance of IT potentiality in the success efforts for the sustainability of regional health (Adler-Milstein et al. 2007).
Involving community and stakeholders in planning and decisions
Establishing appropriate target and indicators for evaluation
Proper documentation of project data and progress
Sharing of project success and challenges
Prioritizing and recognition of ideal sustainability strategies
Identification of the needed human, financial, in-kind, and capital resources
Personnel empowerment through capacity building on sustainability strategies
Creating means of challenges identification and solutions (Rural Health Information 2018)
Sustainability of the regional health system has evolved and conceptualized around diverse approaches and strategies, attributes, methods, resources and systems, thus governance, organization, coordination, financing, service provision, and management among others. Additionally, sustainability of the health system entails the use of result-based financing models, standard guidelines, information technology, capacity building, and partnerships. In this regard, non-state actors in partnership with state actors should engage meaningfully, to slowly achieve long-term regional health project sustainability. Also, it is significant to be dynamic in initiative and strategic thinking focusing on approaches that enhance regional health project resilience.
Generally, the governance sector should put to practice a sustainable health service model post-donor era. A sustainable model needs to focus on creating enabling environment, management capacity, resource availability, effective service delivery, and improved structures and coordination that could enhance regional health sustainability. Succinctly, sustaining regional health project is a vital public health gain, attained through community ownership which is imbedded in local culture, norms, and tradition and utilization of locally available resources such as local health workers.
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