Health goals are not achieved without strong systems to support them. Whether a government hopes to reduce HIV incidence or increase access to modern family planning methods, it must examine these achievements through a health systems strengthening (HSS) lens. The overall health system, with its many layers and players, creates (or prevents) an enabling environment for improving coverage, quality, and scale of health interventions.

IMA programs adopt and address the World Health Organization’s recommended six building blocks of HSS: improved health service delivery, health workforce development, information systems, access to essential medicines, health system financing, and leadership and governance.

The HSS building blocks help IMA define the “ideal” capacity of a health system and to prioritize key HSS issues, ensuring that it doesn’t leave gaps in support. In addition, IMA’s health systems approach is community-driven so that services are designed to meet the needs of the community and that universal access is promoted.

In the Democratic Republic of Congo and South Sudan, IMA supports fragile health systems to address overwhelming need in an environment of constrained human and financial resources. IMA provides customized technical assistance at national and sub-national levels in each country to help the government and its partners improve in priority areas across the HSS framework that result in improved primary health care and Maternal and Child Health outcomes.

DEMOCRATIC REPUBLIC OF CONGO:
ACCESS TO PRIMARY HEALTH CARE PROJECT (ASSP)

UK aid and Swedish International Development Agency | 2012 – 2018 | $283 million

The ASSP project collaborates with the Ministry of Health (MOH) at all levels of service delivery, with focused support to health zone, health facility, and community levels. IMA and its partners ensure that more than 75% of the project resources are concentrated within the health zones for service delivery, empowerment, accountability, and capacity building of local community service organizations, partners, and MOH representatives.
ASSP supports DRC’s National Health Development Plan by working to improve access to and coverage of primary health care services for more than 8 million people living within 56 health zones in five of the country’s 26 provinces, including Kasaï, Kasaï Central, Maniema, Nord Ubangi, and Tshopo. ASSP’s priority interventions include the treatment of malaria, pneumonia and diarrhea, nutrition, obstetric and neonatal care, family planning, immunization, and water, hygiene, and sanitation interventions that are delivered through the health system. These intervention packages are aimed at improving the health of the mother, newborn and child, thus allowing the DRC to achieve significant progress towards reaching Millennium Development Goals 4, 5, and 6.

KEY 2015 ACHIEVEMENTS
  • 272,491 births attended by skilled health personnel.
  • 311,073 children immunized for measles.
  • 262,646 pregnant women received two doses of intermittent preventive treatment for malaria prevention.
  • 174,465 long-lasting insecticide-treated bed nets (LLINs) distributed to pregnant women and children under age one.
  • 40,000 LLINs  hung up in Nord Ubangi.
  • 168 facilities offered comprehensive obstetric and neonatal care.
  • 15 new health centers were inaugurated.

CHIEF LIVES TO SEE HEALTH CENTER BUILT

Chief Kibulungu and his people had no idea what was in store for them when the ASSP construction team stopped at their village, and vice versa. Kibulungu, a large village on the road between Nyanga and Tshikapa, had been selected as a site for construction of a health center. But before a health center could be built, the chief of the village needed to sign a letter ceding the land for the health center to the government.
The ASSP construction team met with Chief Kibulungu to start the discussion and process. As the team talked with Chief Kibulungu, they learned that in the 1980s he had set aside a large area of land in the middle of the village for a health center. He wrote letters to parliament asking for assistance in building it and even went to Kinshasa to deliver a letter personally. There was no response. Over the years, the chief had also asked various groups if they could help, to no avail. Now he was an old man and thought that he would die without seeing a health center built. After talking with the construction team, Chief Kibulungu immediately wrote a letter and called in his notables to sign too.

When the ASSP construction team “builds” a new health center, they don’t build the health center for the community; they build it with the community.

They usually send in only one person, a construction supervisor. The rest of the team is recruited from the village, and the supervisor takes the crew through all the steps of building. Evan Schellenberg, who leads the ASSP construction unit, says they do this intentionally because they want to develop the capacity of the local people to build for themselves. He hopes in the future other projects will be able to build schools because they will find local people who are now skilled and experienced in construction.

For example, when the Kibulungu construction started, one young man was hired as a mason’s assistant without any previous training, but by the end of the project he was an excellent mason. One day as he was working on the health center, he said to a construction team member, “My wife is pregnant. I never dreamed that I would ever be building the health center in which my child will be born.”

A couple of months into construction, the community got wind that Larry Sthreshley, who directs the ASSP project, and representatives from UK aid, which funds the ASSP project, were coming to the area. They stepped up work on the health center and finished it in time for their visit. They put together an inauguration ceremony using their own means. Half an hour before the inauguration ceremony a woman was brought to the health center with obstructed labor. The case was too complicated for the local health center nurse, but the health zone doctor who had come for the ceremony was able to save the mother and baby—and the baby was named Larry.

At the ceremony Chief Kibulungu said: “Now I can die happy. My people have a health center.”

Kibulungu health center is just one of 200 new health centers being built and 250 health centers being renovated through the ASSP project. Currently many of the health facilities are just stick-and-mud brick construction, with thatched roofs and dirt floors. Through ASSP, nearly 4.5 million people will have a new or a renovated health center in their community made of compressed brick, with cement floors and tin roofs, furnished with beds and medical equipment.

SOUTH SUDAN:
RAPID RESULTS HEALTH PROJECT

Ministry of Health – Republic of South Sudan/World Bank | 2012 – 2016 | $53 million

Community mobilizers support a mother with obstructed labor to a location where transport is available for those referred to Pochalla PHCC.

Emerging from nearly three decades of conflict to achieve independence, South Sudan set forth its vision of justice, liberty, and prosperity. One important component of this vision is the health of its people.

IMA is a key partner in the government’s health strategy through its implementation of the Rapid Results Health Project (RRHP).
The goal of RRHP, which builds on IMA’s work in South Sudan since 2008, is to strengthen the capacity of local County Health Departments to provide basic health services in Jonglei and Upper Nile states and, as of 2015, the newly created Greater Pibor Area Association.

Through RRHP, IMA works in partnership with the national Ministry of Health and 12 international and local partners to meet the health care needs of 3.3 million people, representing over 25% of South Sudan’s population.

KEEPING PACE IN A CHANGING ENVIRONMENT

Jacob Nuer sits at his desk in IMA’s office in Bor. Holes in the walls of his office, in his door, and on the side of his filing cabinet, are a reminder of the day the office was looted in December 2013.

South Sudan has experienced ongoing conflict and change since gaining independence in 2011. One such change was the establishment in May 2015 of the Greater Pibor Administrative Area (GPAA), the functional equivalent of a new state. Created from the former Pibor and Pochalla counties of Jonglei State, where IMA works to improve health care, the new GPAA was a significant peace dividend between warring factions in Pibor County. For IMA, this meant taking swift action to get a health care system up and running to ensure health care needs could be met.

With World Bank support, IMA participated in extensive planning with the Ministry of Health and GPAA Chief Administrator to create a comprehensive implementation strategy for delivering primary health care services. Then IMA staff mobilized to implement it, establishing County Health Departments for the new counties, training the new leadership and staff; overseeing service delivery; providing technical support; creating infrastructure for permanent health facilities; and taking services to remote communities.

With no time to lose before seasonal rains set in, making access extremely difficult for months to come, IMA secured six pre-fab units and transported them to key areas where health facilities had been destroyed or did not exist. In collaboration with UNICEF and WHO, IMA supported the local health authorities to install solar fridges for vaccines and trained staff on vaccine administration. Reaching out in these communities where health services are now much more accessible, IMA is helping to establish a network of village health committees to manage the health facilities and spread the word about the services that are available and the difference they can make in people’s lives, women and children in particular.

As work continues into 2016, IMA is encouraged by the zeal, courage, and resilience of the local leadership and health workers, who have acted quickly and worked together under very challenging conditions to save lives of the vulnerable. To date, tens of thousands of patients have already been seen under the new system.