Reflections on COVID-19 from CHESAI members

Many of the CHESAI members are involved in various ways in trying to mitigate the effects of the COVID-19 pandemic. Here are two reflections from three of our members: the first is an article on the concept of a community-owned model of care which supports those who need to self-isolate, and the second, a reminder about how fear and stigma related to COVID-19 can potentially ignite discriminatory practices – if not addressed timely.

Sparks, flames and blazes: Epidemiological and social firefighting for Covid-19, by Eleanor Whyle, Manya van Ryneveld, Leanne Brady & Kentse Radebe

The power of people caring for those affected by Covid-19, by Leanne Brady, Axolile Notywala, Ayesha Ryklief, Nkosikhona Swartbooi, Manya van Ryneveld, Eleanor Whyle

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Reflections on COVID-19 from a health systems perspective: Digest 1 & 2 & 3

We send greetings from Cape Town, to the wider health and public health community in South Africa.

Many of you are right on the frontlines now, today, and we salute you!

We appreciate the hourly, daily, weekly efforts to protect us all, to care for us all.

And that’s what public health work is, ultimately: solidarity and action.

And we have seen both at play in these last days and weeks.

In order to support the COVID response across the country, we thought there might be some value in sharing some of the many, many, many blogs and short pieces that present COVID-related experiences that are less well publicized in the mainstream global media.

These pieces have been selected with a particular focus on health systems – looking beyond health care and beyond specific COVID-19 responses, recognising the wider influences over health, including broader political and economic factors, and recognising the need to respond to the situation and needs of particularly vulnerable population groups. We look at other countries’ experiences and think also about particular system challenges and responses.

As of 20th April 2020 there are three different digests, addressing different sets of issues.

We will continue to add to these digests over time.

COVID-19: Highlighting six themes among the current array of experiences and ideas being shared globally – Digest 1

COVID experience globally – Digest 2

Strategies to support health care workers and frontline managers during the COVID-19 pandemic – Digest 3

 

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Elevating women’s voice in the politics of newborn health

At the February 2020 CHESAI meeting, Manya van Ryneveld led the current affairs discussion on public participation. It was a simulating presentation highlighting two case studies of innovative forms of public participation, and both examples featured the powerful role of women’s participation. The discussion was a reminder of my own journey with women’s rights and women’s voice in health and politics, and most recently, efforts in bringing women’s voice into the politics of newborn health.  The aim of this blog is to share these ideas with experts in health policy and systems research and get feedback on how to strengthen public participation of women in the care of both themselves and in the care of their babies. 

Who has been participating in the politics of newborn health? Mostly health professionals and scientists. In 2016, Jeremy Shiffman published an analysis of the emergence of global attention to newborn survival of the emergence of global attention to newborn survival and found that the “newborn survival network” were primarily technically oriented actors – clinicians and academics who work for development partners, professional associations, UN, and donor agencies. He argued that the network must expand in membership and approach in order to evolve in a political direction. An analysis in The Lancet Every Newborn series (2014) found civil society to be weak to non-existent at country level for newborn health, but did acknowledge parent groups as actors helping to energize the newborn health movement.

Who needs to participate more in the politics of newborn health? Organized and outraged women, mothers, and affected parents. Women and parents have already been engaged in a multitude of ways. Parents, particularly mothers in many societies, have been and continue to be the primary caregivers for newborns but they are also the best advocates for their infant’s survival and well-being. Newborns cry and make noise, but they do not have the agency or autonomy as infants to advocate for their right to health. Stillborns have no voice. It is their parents who can shout for their rights and hold all stakeholders accountable for better care, better policies and changing of social norms around harmful practices.

Parent groups, mostly in high-income countries, have had some success (learn more here). For example, parents in the USA, the United Kingdom and Australia successfully lobbied for pain management and family-friendly hospital-wide changes, such as having the right to stay with their children. More recently, parent groups in Europe have successfully advocated to national assemblies and even to the European Union for improving the treatment and care for preterm babies leading to policy change around care for newborns, including family-centred approaches and developing new standards of care. These successful efforts were orchestrated by affected parents who collaborated with health professionals, politicians and other stakeholders to advocate for changes in policies and practice around specific health systems issues.

Why do we need to elevate women’s participation in the politics of newborn health? Change has been too slow for reducing maternal and newborn survival and preventing stillbirth. Millions of women suffer from the death of their baby every year, including 2.6 million women who experience a stillbirth and another 2.5 million women who lose their baby in the first month. Then there are 30 million women each year who have newborns that require some level of inpatient care because they are small (small for gestational age or preterm) and/or sick. Far too many women still die from complications in pregnancy and childbirth, last estimate at 295,000 mostly preventable deaths. Women also face extreme challenges around their reproductive health, from lack of choice and lack of access of modern contraception to surviving severe childbirth complications, such as obstetric fistula. These women and their families often suffer for the rest of their lives in silence, as these issues, especially stillbirth, preterm and fistula, remain taboo in many societies. Empowering women, mothers and parents will influence newborn survival and long-term health and well-being and shift the issue of newborn health into a more political realm.

How do we strengthen women’s participation in the politics of newborn health? Intentional efforts are needed to bring women’s voice into all levels of the system e.g. the micro level of individual health care services, the meso level of hospital management and accountability, and the macro level of policy development and resource mobilization. For a recent report, I collaborated with a group of experts, including affected mothers, parent organizations and researchers on a chapter about a parent engagement in the care of inpatient newborn care. We developed a new framework for strengthening parent engagement (which wasn’t included in the final report). The framework seeks to strengthen engagement through strong partnerships between and among mothers, parents and health care professionals, as well as the families, communities and systems that support them. Using a social ecological model, we propose a five-level model as an organizing framework to better understand the opportunities for partnerships and strategies to strengthen these partnerships:

  • The individual infant/parent/family unit is at the centre where strategies are focused on parent and family knowledge, attitudes and skills needed to fulfil their role as primary caregiver for their sick or small newborn.
  • The interpersonal level considers care delivered by health care providers and their knowledge, attitudes and skills in people-centred care to fulfil their role as a caregiving partner.
  • The institutional level recognizes the critical role of the health facility and its personnel in creating a supportive environment for parent and family presence and family-provider partnership to occur.
  • The community level shows potential partnership opportunities for raising awareness and empowering communities to support families with small and sick newborns.
  • The social/political level includes policies, guidelines and social norms that provide an environment for partnership between parents, families and communities with institutions and health care providers, such as family leave policies or breastfeeding supportive legislation.

The different levels of the framework are interconnected, and the model illustrates the complex interplay between individual, parent, family, health care providers, health services, community, and societal and policy factors, as well as the range of factors that can enable or hinder parent and community engagement. Using this framework, we have already conducted an initial mapping of literature about parent engagement and found a wealth of knowledge, but also identified major gaps. We continue to think about it and consider how to strengthen it and advance it for future work.

Why do I care so much about women’s voice in newborn politics? My journey working on maternal and newborn health coincided with me becoming a parent. My first child was born just one year after starting with Save the Children; the second child was born three years later. Therefore, my lens on maternal and newborn health was never just from a professional standpoint; it was indeed quite personal as I physically, mentally and emotionally went through the antenatal, childbirth and postnatal periods while working on the issues. You can read more about my personal experience here.

For the past decade, I have worked for Save the Children’s Saving Newborn Lives project, which has placed me at the forefront of global policy-making and allowed me to work in other African countries at local and national levels with Ministries of Health. Time and again, I found myself sitting as a new mother, at the decision-making table for newborn health policy and programming, and thinking “where are the women who have suffered and why are they not here demanding change.” Or I would walk through a maternity ward and a mother of a stillborn was recovering in a room full of women with newborns. “Why is she not given privacy?”

With my voice as a woman in newborn politics, I have been committed to bring the voice of affected parents to the table – and thankfully have met many other women and men on the same mission. I am most humbled when meeting affected mothers or fathers of stillbirth or prematurity who have started an organization that helps other affected families or who have the courage to speak up at high-level political national or global events. Parent groups are expanding and becoming more organized and, as such, we are seeing change.  Recently, two groups representing parent interests have been officially invited into the global “newborn survival network”. We have also had success with activities, such as World Prematurity Day and promoting the Kangaroo Mother Care challenge Mother Care challenge Mother Care challenge (see picture).  Elevating women’s participation in the politics of newborn health will be at the heart of the change we wish to see for all mothers and babies to survive and thrive.

And until then, as a woman, I remain enraged that other women are suffering. As a parent, I am heartbroken that other parents suffer the preventable death or disability of their child. As a health policy and systems researcher, I am determined to bring new ideas to the table and shift the tradition of burden specific advocacy into something bigger and more useful to health policy makers and health managers. As an advocate, I am committed to strengthening public participation of women in newborn politics.

MaryBlog

Women and men practicing the Kangaroo Mother Care challenge in order to be a voice for affected women at Women Deliver in 2017 (photos taken with permission).

Maryblog2

My son Reuben at 2 days.

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The dissemination and diffusion of innovations: what helps managers to lead change in the district health system?

A key challenge of top-down policy formulation is that those on the ground - in health districts, health facilities and communities - are typically excluded from the process. They often do not have full information on the policy’s rationale and/or full details on how to implement it. This can result in the policy implementation or know-do gap.

It is therefore important for policy formulators to effectively disseminate information on the rationale, content and system requirements of new policy to frontline implementers, especially those who must lead and manage the change. Managers on the ground must be able to make sense of the change for themselves and translate new policies for their staff, although some information will also spread through natural diffusion.

Fortunately, there are lenses to help us think about the dissemination and diffusion of new policies and programmes. Diffusion and dissemination exist on a continuum: dissemination strategies are formal, planned efforts to persuade target groups to adopt an innovation (often centralised and occurring through vertical hierarchies) whereas in pure diffusion, the spread of innovations is unplanned, informal, decentralised, and largely mediated by peers (Greenhalgh et al. 2003).

In this blog I summarise findings from a paper in which I sought to garner key lessons about what dissemination strategies (or lack thereof) make life easier or more difficult for senior managers in health districts to adopt reforms. I looked at the period 2012 – early 2014 when the national government introduced new innovations into the National Health Insurance pilot districts in South Africa. I interviewed 37 senior managers in three health districts and found:

  • Reform champions can play a role in disseminating information. A roadshow by the Minister of Health helped managers to make sense of the rationale for reforms, including the need for change and an integrated PHC platform. Face-to-face time with the Minister also made managers feel valued.
  • When ideas underpinning new reforms aligned well with existing ideas and programmes in the district, it was easier to diffuse reforms into the district.
  • When articulating the innovations to stakeholders, it helped to show how they linked to existing policies in the health system; demonstrating continuity between practices.
  • Managers need early information about which new actors (donors, NGO partners etc.) will be arriving in their districts to support change. They also valued pre-scheduled visits from national government to align with the routine district activities already planned.
  • To lead change, managers need full information on the how, why and what to do of individual innovations, as well as lessons on how it had worked in other contexts. This helps them to understand the innovations and disseminate information to their staff.
  • Dissemination and diffusion is not a once-off activity. Managers successfully employed some of the new reforms to support the implementation of other reforms later introduced in the same district. For example, a new team of district clinical specialists helped to develop an induction programme for a group of private general practitioners contracting into the public sector.
  • NHI coordinators, who served as project managers, helped to anchor the reforms in the district, as they explicitly liaised up, down and across the health system. The NHI coordinators valued being accepted as part of the district management team.
  • It is helpful if some members of the innovation team have a history in the district, supporting them to capitalize on existing networks, which enables further dissemination.
  • It is helpful to link new members of the management team with others who have institutional memory to help them navigate the system. For example a new NHI coordinator attended meetings with someone who had long been in charge of PHC in the district to help with his confidence.
  • When support teams from national government assist in managing change, it helps if they are open minded to the local context shaping the reform to support local needs, can make decisions quickly and are responsive to requests for information.
  • Managers know what the basic needs in their districts are, so provide them with some space to also fix existing local problems through harnessing these new resources.
  • Chronic systemic challenges make it hard to implement change, especially in contexts with vacancies and a history of poor performance, but new innovations like NHI piloting also bring funding and renewed interest which can improve life in the district.

Senior managers in the district health system are critical boundary spanners between top-down reforms and local implementation. Those who work at the top must think strategically about how to be most helpful when disseminating information about reforms and think through mechanisms that enable managers to influence their staff to adopt reforms. Senior managers hold a critical space between national policies and lower levels of government.

 

Marsha Orgill, Division of Health Policy and Systems, School of Public Health and Family Medicine, University of Cape Town

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