The document discusses a study conducted in Ghana, Malawi, and Cameroon on strengthening health policy and systems to improve access to sexual and reproductive health services. The study found that health systems issues were the main barriers to access rather than theological issues. Systems strengthening interventions need knowledge of faith-based health systems to avoid unintended consequences. Faith-based organizations have creative strategies for universal health coverage, but they are rarely evaluated. Attention is needed on contracting, the role of Christian health associations, and demonstrating contributions to resilient national health systems.

1. Health, Policy &
Systems at UCT
Health, Policy &
Systems at UCT
Strengthening Policy and Systems for
Improved Access to SRH Services
…and UHC
Dr. Jill Olivier
University of Cape Town, Health Policy and Systems Division
International Religious Health Assets Programme
Jill.olivier@uct.ac.za

2. Health Policy &
Systems at UCT
Health Policy &
Systems at UCT
Multi‐country ethnographic case study 2013‐2014:
Ghana, Malawi, Cameroon
• Method: Documentary and policy analysis, stakeholder
analysis, individual in‐depth interviews (mainly health
workers and managers), ethnography, observation and data
analysis
• Outputs: co‐authored reports, 4 articles in press, new
research 2015
Approach and Method

3. Health Policy &
Systems at UCT
Health Policy &
Systems at UCT
CORDAID: The Catholic Organization for Relief and Development Aid
• Long‐term supporter of HSS with FB providers in Africa
• Now a mainly European funding base, so increased pressure
(around SRH in particular)
• Drew on Engender Health (2003) Informed Decision‐Making
model – attempted very loosely framed HS intervention with
Catholic partners
• Many findings on HS intervention practice and best‐practice
Reporting here briefly on some key considerations irt UHC
The Broader Study

4. Health Policy &
Systems at UCT
Health Policy &
Systems at UCT
Unsurprisingly, health systems issues are most important…
• 3 countries, very different reactions to intervention (contextual diff)
• The main barriers to SRH access are systemic not theological
• Systems strengthening could be more effective than direct SRH
program intervention (e.g. SRH policy less of an access barrier than
staffing and referral)
• HS interventions need prior knowledge of specific nature of FBH
systems … otherwise can suffer from unintended consequences
• Knowledge gaps make this difficult
The things you know about FB systems that others need to
Main findings from broader study

5. Health Policy &
Systems at UCT
Health Policy &
Systems at UCT
The challenges of working within ‘policy thickets’
National policies Multiple
funder’s
policies
systems
‘policy’
social
‘policy’
Religious
moral
theology

6. Health Policy &
Systems at UCT
Health Policy &
Systems at UCT
Complex hierarchical and decentralized governance

7. Health Policy &
Systems at UCT
Health Policy &
Systems at UCT
Complex governance, info and authority flows

8. Health Policy &
Systems at UCT
Health Policy &
Systems at UCT
Complex governance, info and authority flows
FEW
FEEDBACK LOOPS

9. Health Policy &
Systems at UCT
Health Policy &
Systems at UCT
Weak operational
information systems
e.g. No one has the power to
insist … accountability
Weak financial safety nets
e.g. Each facility sinks or
swims on own accord
Limited accounting of
contribution of FBHPs to
routine systems functioning
(e.g. immunisation)

10. Health Policy &
Systems at UCT
Health Policy &
Systems at UCT
For example
• Creative fee structures and mechanisms
• Quietly ‘gaming the system’ to get patients access
• Unique organisational culture and management strategies (e.g. to get
staff to work on time, expectation to work on weekends)
• Unique rural staff retention strategies
• Malawi: Surveillance Assistants situated in the Catholic facilities “so long
as they don’t hand them out on the premises, the Bishops don’t mind”
• Ghana: the establishment of private wards… (working sometimes)
• Cameroon: full information and (quiet) help with injectables
Towards UHC?
Creative strategies for UHC are already
being practiced… but rarely evaluated

11. Health Policy &
Systems at UCT
Health Policy &
Systems at UCT
• Being advocates irt key HS challenges you are facing
(e.g. post abortion care)
• Becoming specialists in the provision of care to the
(rural) poor (and showing this through evidence)
• Demonstrating explicit financial models for this
provision
Towards UHC…?
Key issues needing attention from CHAs

12. Health Policy &
Systems at UCT
Health Policy &
Systems at UCT
More frequent drawing of lessons from systems interventions
• e.g. secondment strategies (placement)
• e.g. poor levels and timing of cost recovery (from government)
• e.g. the current role of CHAs (e.g. CHA capacity vs National Health
Desk capacity)
Understanding unique contribution and practices of FBHPs
• E.g. unique governance and leadership capacities and
competencies required
Needing attention: Contracting
implementation and the role of CHAs

13. Health Policy &
Systems at UCT
Health Policy &
Systems at UCT
• % contribution is still very important for advocacy
• But in a new UHC‐oriented world, the underlying contribution
to UHC will become more important
• Demonstrating contribution to national health system’s
resilience and responsiveness
• Not just each facility’s resilience… but contribution to national
coverage and access in places and at times there is none
• E.g. Ghana: picking up slack during national strikes
• E.g. Cameroon: picking up slack in Northern region
• E.g. Malawi: supporting during national stockouts
Towards UHC…?
Key issues needing attention from CHAs

14. Health Policy &
Systems at UCT
Health Policy &
Systems at UCT
Thank you
Acknowledgements and Affiliations:
University of Cape Town, School of Public Health and Family Medicine,
Health Policy and Systems Division: www.publichealth.uct.ac.za
This research was funded by Cordaid: www.cordaid.org
Thanks and acknowledgement to the participants in this study
Related networks and useful websites
IRHAP: www.irhap.uct.ac.za
CHESAI: www.chesai.org
CHEPSAA: www.hpsa‐africa.org

15. NOTICE OF NEW HPSR RESEARCH…
Systems integration towards universal health coverage:
Strengthening the collaborative relationship between faith‐
based non‐profit providers and the Ghanaian state system
Research Question: In which respects has the relationship between faith‐
based non‐profit providers and the Ghanaian government been
strengthened (and in which respects undermined) through the series of
health systems interventions and mechanisms attempted over the last fifty
years? If so, how has this been achieved? Can this be said to have
strengthened the system towards UHC in Ghana?
June 2015 ‐ May2018
Supported by the World Health Organisation AHPSR
‘A historical realist case study’
Principal Investigors: Dr .Jill Olivier (UCT) & Dr. Aku Kwamie (UG)
Advisors: CHAG Director & Members, Lucy Gilson, Irene Agyepong, Gilbert Buckle
(Similar studies being conducted by colleagues in Tanzania and Uganda)

17. NOTICE OF NEW HPSR RESEARCH…
Governance, Competencies and Capacity Development for
Faith‐based Non‐profit Health Systems Strengthening
Question: What standard or unique core competencies and capacities
are required for faith‐based non‐profit systems strengthening – and how
can these be better developed?
Method: rapid internal scoping study among CHA members and
representatives
Partnering: ACHAP and UCT HPS Division ‐ IRHAP (others welcome!)
Outputs: co‐authored report and articles; implementation practice plan
and proposal
Jan 2015 – Dec 2015
Supported in‐kind by UCT‐HPSD‐IRHAP & ACHAP