Governance and management of public health programmes

Governance is central to improve health systems performance and achieve Universal Health Coverage. Good governance can enable the effective use of health finances, workforce, medicines, and information to deliver better health services and outcomes. Theories of principal-agent and network governance are introduced to better understand health governance at system level. In health governance system, the government, private sector, and civil society are the governing triangle, and form a whole-of-society governance approach for health. We introduce the governing triangle and its role in health governance, governance mechanisms and tools, and the levels of governance, respectively. The triangle plays health governance functions at four levels to collectively pursue health goals: the supranational or national or organizational or programme levels. At each level, tools of governance are central to health governance functions and enabling relationships among triangles. Tools of governance can be classified into nine governance dimensions: accountability, regulation, participation, and consensus in decision-making, formulating policy/strategic direction, organizational adequacy/system design, generating information/intelligence, partnerships for coordination and collaboration, engagement of community, communication, and transparency. Assessment frameworks are further introduced for evaluating whether health governance is effective. And several cases of health governance are introduced for better understanding.

What health systems do? Functions as a starting point to assess health systems performance

Health system assessment (HSA) tools are often built around static health system building blocks, which lead to largely descriptive narrative and lack of linkages to health system outcomes. The development of a common framework that would also focus on performance outcomes is long overdue. We analysed the key HSA frameworks and tools based on them, with the purpose of identifying a common approach that would allow to link health system components to specific outcomes. The presentation will focus on using the health system functions as the basis of conducting the performance assessment. In a second step, the presentation will elaborate on the intermediate and final health system goals as part of the HSPA framework. It will explain their links to the four functions and thus, discuss their relevance for performance assessment.

9.I. Workshop: Health systems performance – making the links between what we do and what we want to achieve

In this session, WHO together with the UHC2030 Technical Working Group on Health System Assessment and the European Observatory on Health Systems and Policies discuss the main elements of their joint approach to HSPA. The workshop intends to propose a common and practical framework that links descriptive health system analysis with evaluation, focussing on health system outcomes. The framework's approach to uncovering health system challenges and bottlenecks and the sources of variation will be discussed - showcasing how Health System Performance Assessment can be used as a means to uncover sources of health system inefficiencies and inequities. The workshop intends to identify the links between intermediate and ultimate goals and relate these to specific actions and actors within a health system, thus providing policy makers with an actionable tool to assess performance. The session is structured into two parts. In the first part the process of developing the HSPA framework and the framework itself will be introduced. The presentation will provide insights into the joint framework based on health system functions and emphasise the links to the intermediate and final goals of the HSPA framework. This will be followed by four short case studies pertaining to the four functions - governance, financing, resource generation and service delivery - and linking specific assessment areas to intermediate and final goals. The second part is an interactive discussion, to be kicked off by the input of Kanitsorn Sumriddetchkajorn and moderated by Josep Figueras, to jointly identify the strengths and weaknesses in performance of a given health system. Key messages Health Systems Performance Assessments should focus on what health systems do and how well, rather than on what they are. Health System Performance Assessment should focus on performance and use their evaluative angle to get to the root causes of not achieving final health system goals.

Transforming the Future Healthcare Workforce across Europe through Improvement Science Training: A Qualitative Approach

Healthcare improvement science (HIS) is the generation of knowledge to cultivate change towards improving health systems performance. Our purpose was to evaluate the experience of European nursing students after an intensive one-week summer program conducted in 2019 at the University of Alicante in Spain. The educational intervention combined theoretical and practical HIS contents, with students from different countries, educational programs, and health systems. The intervention was evaluated under a qualitative approach through the open discussion group technique based on the method of participatory action research (PAR), with a total of 25 students who reflected about their experiences and perceptions during the intervention. The responses were used to improve the program’s contents, its didactics, and organization. Nursing empowerment, professional recognition, and healthcare research were some of the seven main categories identified through the systematic content analysis method triangulated by three experienced researchers. According to the students’ replies, values like compassion, respect, or empathy were identified as key elements of care. Promoting international students’ networking emerged as the key to creating a positive provision for change and the generation of improvement initiatives. Building a HIS culture may potentially provide future healthcare professionals with critical thinking skills and the resources needed to improve their future work settings.

Stakeholders’ perceptions of the nutrition and dietetics needs and the requisite professional competencies in Uganda: a cross-sectional mixed methods study

Background Effective implementation of nutrition and dietetics interventions necessitates professionals in these fields to possess the requisite competencies for health systems performance. This study explored the stakeholders’ perceptions of the community nutrition and dietetics needs, the nature of work done by graduates of the Bachelor’s degree in Human Nutrition/Human Nutrition and Dietetics (HN/HND), and the competencies required of Nutrition and Dietetics professionals in Uganda. Methods A cross-sectional mixed methods design was used. Respondents included 132 graduates of the Bachelor’s degrees in HN/HND obtained from the Makerere and Kyambogo Universities in 2005–2016; 14 academic staff that train HN/HND in the two universities; and 11 HN/HND work/internship supervisors. Data from the graduates was collected through an email-based survey; data from other participants was through face to face interviews using researcher administered questionnaires. Results Most HN/HND respondents (84.8%) obtained their Bachelor’s degrees from Kyambogo University; 61.4% graduated in 2013–2016. Most (64.3%) academic staff respondents were females and the majority (57.1%) had doctorate training. All stakeholders viewed communities as facing a variety of nutrition and dietetics challenges cutting across different Sustainable Development Goals. The nutrition and dietetics interventions requested for, provided, and considered a priority for communities were both nutrition-specific and nutrition-sensitive. Work done by HN/HND graduates encompassed seven main competency domains; the dominant being organizational leadership and management; management of nutrition-related disease conditions; nutrition and health promotion; research; and advocacy, communication, and awareness creation. Conclusions This study shows that nutrition and dietetics challenges in Uganda are multiple and multifaceted; HN/HND graduates are employed in different sectors, provide nutrition-specific and sensitive services in a multisectoral environment, and are expected to possess a variety of knowledge and skills. However, graduates have knowledge and skills gaps in some of the areas they are expected to exhibit competency. We recommend using these findings as a basis for obtaining stakeholder consensus on the key competencies that should be exhibited by all HN/HND graduates in Uganda; developing a HN/HND competency-based education model and a national HN/HND training and practice standard; and undertaking further research to understand the quality and relevancy of HN/HND curricula to Uganda’s job market requirements.

Stakeholders’ Perceptions of the Nutrition and Dietetics Needs and the Requisite Professional Competencies in Uganda: A Cross-Sectional Mixed Methods Study

Background Effective implementation of nutrition and dietetics interventions necessitates professionals in these fields to possess the requisite competencies for health systems performance. This study explored the stakeholders’ perceptions of the community nutrition and dietetics needs, the nature of work done by graduates of the Bachelor’s degree in Human Nutrition/Human Nutrition and Dietetics (HN/HND), and the competencies required of Nutrition and Dietetics professionals in Uganda. Methods A cross-sectional mixed methods design was used. Respondents included 132 graduates of the Bachelor’s degrees in HN/HND obtained from the Makerere and Kyambogo Universities during the period 2005-2016; 14 academic staff that train HN/HND in the two universities; and 10 HN/HND work/internship supervisors. Data from the graduates was collected through an email-based survey while that from other participants was through face to face interviews using a structured key informant interview guide. Results Most HN/HND respondents (84.8%) obtained their Bachelor's degrees from Kyambogo University and 61.4% graduated in the years 2013-2016. Most (64.3%) academic staff that responded were females and the majority (57.1%) had doctorate training. All stakeholders viewed communities as facing a variety of nutrition and dietetics challenges some of which fall across different Sustainable Development Goals. The nutrition and dietetics interventions requested, provided, and considered a priority to provide to communities were both nutrition-specific and nutrition-sensitive. Work done by HN/HND graduates encompassed seven main domains; the dominant being organizational leadership and management; management of nutrition-related disease conditions; nutrition and health promotion; research and documentation; and advocacy, communication, and awareness. Conclusions This study shows that nutrition and dietetics challenges in Uganda are multifaceted. HN/HND graduates are employed in different sectors; provide nutrition-specific and sensitive interventions in a multisectoral environment; are expected to possess a variety of knowledge and skills. However, graduates have knowledge and skills gaps even in some of the key areas they are expected to exhibit competency. We recommend using these findings to develop a HN/HND competency-based education model suitable for Uganda; develop a national HN/HND training and practice standards; and undertake further research to understand the quality and relevancy of HN/HND curricula to the job market requirements.

Stakeholders’ Perceptions of the Nutrition and Dietetics Needs and the Requisite Professional Competencies in Uganda: A Cross-Sectional Mixed Methods Study

Background: Effective implementation of nutrition and dietetics interventions necessitates professionals in these fields to possess the requisite competencies for health systems performance. This study explored the stakeholders’ perceptions of the community nutrition and dietetics needs, the nature of work done by graduates of the Bachelor’s degree in Human Nutrition/Human Nutrition and Dietetics (HN/HND), and the competencies required of Nutrition and Dietetics professionals in Uganda. Methods: A cross-sectional mixed methods design was used. Respondents included 132 graduates of the Bachelor’s degrees in HN/HND obtained from the Makerere and Kyambogo Universities in 2005-2016; 14 academic staff that train HN/HND in the two universities; and 11 HN/HND work/internship supervisors. Data from the graduates was collected through an email-based survey; data from other participants was through face to face interviews using researcher administered questionnaires. Results: Most HN/HND respondents (84.8%) obtained their Bachelor's degrees from Kyambogo University; 61.4% graduated in 2013-2016. Most (64.3%) academic staff respondents were females and the majority (57.1%) had doctorate training. All stakeholders viewed communities as facing a variety of nutrition and dietetics challenges cutting across different Sustainable Development Goals. The nutrition and dietetics interventions requested for, provided, and considered a priority for communities were both nutrition-specific and nutrition-sensitive. Work done by HN/HND graduates encompassed seven main competency domains; the dominant being organizational leadership and management; management of nutrition-related disease conditions; nutrition and health promotion; research; and advocacy, communication, and awareness creation. Conclusions: This study shows that nutrition and dietetics challenges in Uganda are multifaceted. HN/HND graduates are employed in different sectors; provide nutrition-specific and sensitive services in a multisectoral environment; are expected to possess a variety of knowledge and skills. However, graduates have knowledge and skills gaps in some areas they are expected to exhibit competency. We recommend using these findings as a basis for obtaining stakeholder consensus on the key competencies that should be exhibited by all HN/HND graduates in Uganda; developing a HN/HND competency-based education model and a national HN/HND training and practice standard, and undertaking further research to understand the quality and relevancy of HN/HND curricula to Uganda’s job market requirements.

Stakeholders’ Perceptions of the Nutrition and Dietetics Needs and the Requisite Professional Competencies in Uganda: A Cross-Sectional Mixed Methods Study

Background: Effective implementation of nutrition and dietetics interventions necessitates professionals in these fields to possess the requisite competencies for health systems performance. This study explored the stakeholders’ perceptions of the community nutrition and dietetics needs, the nature of work done by graduates of the Bachelor’s degree in Human Nutrition/Human Nutrition and Dietetics (HN/HND), and the competencies required of Nutrition and Dietetics professionals in Uganda. Methods: A cross-sectional mixed methods design was used. Respondents included 132 graduates of the Bachelor’s degrees in HN/HND obtained from the Makerere and Kyambogo Universities during the period 2005-2016; 14 academic staff that train HN/HND in the two universities; and 10 HN/HND work/internship supervisors. Data from the graduates was collected through an email-based survey while that from other participants was through face to face interviews using a structured key informant interview guide. Results: Most HN/HND respondents (84.8%) obtained their Bachelor's degrees from Kyambogo University and 61.4% graduated in the years 2013-2016. Most (64.3%) academic staff that responded were females and the majority (57.1%) had doctorate training. All stakeholders viewed communities as facing a variety of nutrition and dietetics challenges some of which fall across different Sustainable Development Goals. The nutrition and dietetics interventions requested, provided, and considered a priority to provide to communities were both nutrition-specific and nutrition-sensitive. Work done by HN/HND graduates encompassed seven main domains; the dominant being organizational leadership and management; management of nutrition-related disease conditions; nutrition and health promotion; research and documentation; and advocacy, communication, and awareness. Conclusions: This study shows that nutrition and dietetics challenges in Uganda are multifaceted. HN/HND graduates are employed in different sectors; provide nutrition-specific and sensitive interventions in a multisectoral environment; are expected to possess a variety of knowledge and skills. However, graduates have knowledge and skills gaps even in some of the key areas they are expected to exhibit competency. We recommend using these findings to develop a HN/HND competency-based education model suitable for Uganda; develop a national HN/HND training and practice standards; and undertake further research to understand the quality and relevancy of HN/HND curricula to the job market requirements.

31.F. Workshop: Health system (performance) assessment: working towards a common approach

Since the publication of the World Health Report 2000, which aimed at assessing health systems performance globally, a number of health systems performance assessment (HSPA) frameworks and tools, designed for various purposes, have emerged. In 2017, the joint Universal Health Coverage 2030 Technical Working Group on Health Systems Assessment (TWG), consisting of health policy makers and global actors, such as the WHO, World Bank, USAID, Unicef, European Commission, OECD, etc., was formed with the aim to align the existing tools and develop a common approach to understanding and measuring health systems performance globally. As part of this work, the European Observatory on Health Systems and Policies (OBS) has developed a Health Systems Performance Assessment framework for Universal Health Coverage (HSPA Framework for UHC), that allows to evaluate health system performance, largely by drawing on the information available in the existing tools or through global data collection initiatives. Suggested approach is based on the detailed assessment of the four health system functions (governance, financing, resource generation and service delivery) and their sub-functions, the interaction of which jointly leads to the successes and failures in the achievement of health system goals. We propose distinct assessment areas for specific functions and sub-functions as a way to identify potential strengths and weaknesses, which can then be related to actions or responsibilities of specific actors within a health system, or linkages to other sectors. The objective of the workshop is to introduce the background, rationale, methods and process of developing of the HSPA framework for UHC; present a systematic approach to assessing various functions of health system and their interactions; relate the assessment areas of specific functions and sub-functions to the final health system goals; and, finally, to test the use of the framework in practice. The workshop is structured as follows: the workshop will start from the four 10-minute presentations (outlined below), followed by an interactive session with the audience to discuss the content of the framework and elaborate on its potential use for HSPA and applications globally. Key messages The HSPA framework for UHC is an approach that allows to bring together existing HSPA efforts and moves towards a more systematic and universally applicable health system performance assessment. The approach assesses performance through attribution of various health system outcomes to specific functions and sub-functions, allowing to identify strengths and weaknesses that affect performance.