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Extension phase research

Deepening equity analysis within existing FHS research

During the FHS extension phase we are carrying out additional, cross-country, analyses of equity through targeted work on data that has already been collected. 

Additional analyses include:

  • Quantitative equity analyses of patient data as well as household survey data to further investigate how different sub-groups (men/women, those with different insurance status, etc.) experienced the interventions supported through FHS.
  • Extending on-going qualitative analyses of how different community members have engaged with community-level interventions in Bangladesh, India, and Uganda. 
  • Analysis in China of how payment system reform has effected equity in relation to health financing and health services utilisation for poor people. 
  • Analysis of the socio-cultural determinants of utilization of primary health care services in Ethiopia.

Extending primary research on community empowerment strategies

During the FHS extension phase we are extending work using local level data to empower communities to engage with and strengthen local service delivery. This research was inspired in part by our work in Afghanistan with community scorecards, but also reflects on–the-ground realities in Bangladesh and Uganda, where the work is being conducted.

In Uganda, FHS is seeking to contribute to efforts to address pernicious health system problems, including poor attitudes of health workers, high absenteeism, neglect of duty, and misuse of resources, by testing mechanisms to strengthen local accountability through the sharing of locally relevant health service performance data. 

In Bangladesh, the success of the current government’s community clinic strategy depends considerably on the development of strong community accountability mechanisms. FHS is supporting the development of community scorecards in community clinics in rural and urban setting, and assessing their effectiveness. 

Through this work FHS is aiming to address the following research questions:

  • Can community scorecards improve the quality, accessibility and utilization of primary health care services in Bangladesh and Uganda?
  • How do different sections of the community (e.g. men/women, rich/poor, people of different ethnicities) participate in the development and application of community scorecards, and which sections of the community benefit from (or are negatively affected by) community scorecards?
  • Which contextual factors (e.g. urban/rural, homogenous/heterogeneous communities, local political economy) and process factors (e.g. nature of facilitation support, integration into local government structures) support the effective application of community scorecards?
  • If effective, how can community scorecards best be sustained and integrated into national health systems?

Application of FHS learning to strengthen health system resilience

Much FHS work has been concerned with adaptability of health systems and their ability to respond to shocks. For example, FHS work in Afghanistan addressed the complexities of strengthening health systems in a post-conflict setting, but also one where there was continuing outbreaks of violence. In India, FHS work in the Sundarbans has focused particularly on the impact of climatic shocks, such as flooding, and how this has affected access to health services and health outcomes. 

Many of the lessons that emerged from the Ebola outbreak reinforced key findings from FHS research. For example, Ebola underscored the importance of strong community engagement in responding to the epidemic, the timely use of data to learn by doing and adapt Ebola management strategies, as well as enabling local leadership of the response. 

In the extension phase, we are seeking to apply FHS learning to national and global discussions about how to create resilient health systems, including assessing the transferability of FHS learning to other contexts (notably Ethiopia, Liberia, Sierra Leone). All of the FHS partners are engaged in this work as we investigate multiple different types of shocks, such as flooding (India and Bangladesh), drought (Ethiopia), and emerging infectious diseases (everywhere – but particularly Liberia and Sierra Leone). 

Our understanding of a health system as a complex adaptive system implies that interventions in that system will give rise to dynamic and frequently unpredictable responses. Whereas analysts use an array of systems tools from causal loop diagramming to agent-based modelling to understand such responses, decision-makers also need to monitor results and adapt strategies as they are implemented. We hope to marry the different perspectives to understand how adaptation has occurred in response to shocks, as well as to provide insights on how to better equip decision-makers in health systems to prepare and respond to shocks.

We are approaching this work through:

  • Small scale case studies that examine questions that can be used to build resilience in future health systems, such as:
    • What are the formal and informal structures through which communities, local level health care workers, local government officials, civil society and different sectors interact to support public health? 
    • How do these structures respond to health shocks, and how can they be strengthened? 
    • How do community capabilities and inequalities differ across settings, and what are the resulting implications for health systems, and how they are able to anticipate and recover from shocks?
    • How do health system managers use evidence during health system shocks, and what are the factors that support timely and informed decision-making?
  • Supporting for a for South-South exchange – FHS will support fora for exchange around specific topics or issues. For example, on the effectiveness of alternative approaches to promoting community engagement in health systems as a means to promote health systems resilience, or lessons learned from managing different types of shocks to health systems.
  • Provide thought leadership through the production of commentaries, briefs, conceptual frameworks and discussion papers that explore the relevance of FHS learning to health system resilience.

Phase 2 Research

FHS adopted an action-research model, where each of the country teams identified an intervention strategy to improve the delivery of health services in their country. In the case of India and one of the two Uganda projects, the teams identified processes (as opposed to interventions) that enabled communities and other key stakeholders to develop an intervention strategy.

In keeping with our understanding of CAS, the teams planned for the strategies to evolve over time as implementers, users, and other key stakeholders interacted in the health system, and as other events influenced how the health system operates.

The main research questions, intervention strategies, and health services outcomes are identified in the table below.



Main Research Question

Intervention Strategy

Primary Health Services Outcomes

Afghanistan: Enhancing Community Capacity for Health Service Delivery in Afghanistan

In a post-conflict society, how can trust be built in public institutions that provide health care through the use of community scorecards on health services?

Facilitation of community development, including the use of scorecards on health service delivery by local providers

Scorecard measures of quality and utilization of primary health care services (currently 25 facility-based indicators at provincial and national level)

Bangladesh: Does an integrated system of health services, linking informal and formal healthcare providers by information technology and mobile phones, strengthen health services in rural Bangladesh?

Can an innovative and locally relevant network of providers supported by technology systems be supported to improve quality, utilization, and equity of health services?

Application of mobile technology and computer-assisted guidance with network of informal and public health providers

Population and facility-based measures of utilization and quality of health care (e.g. outpatient utilization rates; percent of patients of village doctors receiving an antibiotic; percent of patients having one of 20 common conditions whose treatment follows standard guidelines)

China: Effective Drug Delivery at Rural Grass-Root Health Facilities

Can the Chinese health reforms be implemented in a way that improves the quality of and access to health services delivery at an affordable cost?

Multiple levels of intervention including mandated case-based financing reforms and the introduction of an essential drugs systems to promote rationale use of drugs, with scope for wide variation in financing, organization, and oversight at the county level

Facility-based and population based measures:

Quality of care (e.g. Proportion of prescriptions with: (i) antibiotic; (ii) intravenous injection; (iii) vitamin)

Utilization of care (Outpatient visits per capita)

Cost of care (total cost to government and out-of-pocket payments)

Patient satisfaction (index to be developed)

India Phase 1: Decoding Healthcare Access under Climate Crisis: A Case Study of Sundarbans

Can the health and livelihoods of a climatically fragile population be understood in a way to feasibly design a new model of care that takes advantage of local resources and is resilient to environmental shocks?

New model of health care to be developed from phase 1 research and interactions with DOHFW, community members, and other stakeholders

Descriptive measures on health, health services, livelihoods, risks, coping strategies, functioning of health-related markets

India Phase 2: Healthcare Access under Climate Crisis: A Case Study of Sundarbans

Can a new model of service delivery provide effective health services for children in an environmentally fragile setting?

New model of health care delivery based on phase 1 work that links formal and informal providers and holds key stakeholders accountable for effective service delivery

Increase in coverage and quality of child health care for nutrition-related and common diseases such as diarrhea and ARI in six vulnerable blocks of Sundarbans

Uganda 1: Innovations for increasing access to integrated safe delivery, PMTCT and newborn care in rural Uganda

Can an integrated system for maternal-newborn care be implemented in a way to increase utilization, quality, and impact of maternal-newborn health care?

Community mobilization through CHWs, supply and demand vouchers, integration and quality improvements of clinical services for maternal and newborn care

Population and facility-based: Rates of ANC, Institutional delivery, PNC, and Neonatal mortality (projected by LiST)

Uganda 2: Mobilizing Community Resources for Maternal Health

Can existing community resources be mobilized to support a successful voucher scheme that has increased access to institutional deliveries and post-natal care?

Community mobilization to develop financing scheme to maintain system to finance maternal and newborn care

Development of tools for community capacity and demonstration of community capacity through sustainability of voucher scheme