Do we have the right models for scaling up health services to achieve the Millennium Development Goals?

There is widespread agreement on the need for scaling up in the health sector to achieve the Millennium Development Goals (MDGs). But many countries are not on track to reach the MDG targets. The dominant approach used by global health initiatives promotes uniform interventions and targets, assuming that specific technical interventions tested in one country can be replicated across countries to rapidly expand coverage. Yet countries scale up health services and progress against the MDGs at very different rates. Global health initiatives need to take advantage of what has been learned about scaling up.

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Better Guidance Is Welcome, but without Blinders

The three-paper series on guidance for evidence-informed decisions about health systems, published in PLoS Medicine, and produced by members of the World Health Organization (WHO) Task Force on Developing Health Systems Guidance, offers important contributions to improving the quality of evidence-informed decision-making in health systems [1]–[3]. We recognize the importance of engendering greater structure and systematization in processes that collate and evaluate evidence, and bring it to bear on policy. However, there are significant challenges in doing this for policies related to health systems, and we caution against the adoption of rigid approaches to the development of guidance and to the application of evidence to policy.

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Targeting accuracy and impact of a community-identified waiver card scheme for primary care user fees in Afghanistan

User fees are a known common barrier to using health services, particularly among the poor. When fees are present, many facilities have waiver systems for poor patients to exempt them from paying. Targeting waivers to patients who need them most has been a challenge, especially in fragile states, where relevant data are limited and trust in institutions is low. An analysis of the asset index of beneficiaries indicated that although targeting was progressive, significant leakage and high levels of under-coverage occurred; 42% of cards were used by people in the wealthiest three quintiles, and only 19% of people in the poorest quintile received a card. Households with waiver cards reported higher rates of care-seeking for recent illnesses compared to those without cards (p = 0.02).

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Association between health workforce capacity and quality of care for children under five in Afghanistan

This presentation by Dr Anbrasi Edward at the 28th ISQua conference in Hong Kong was informed by a study to determine the association between health workforce capacity and quality of care in primary care facilities providing a basic package of health services (BPHS) in Afghanistan.

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Understanding pathways for scaling up health services through the lens of complex adaptive systems

Despite increased prominence and funding of global health initiatives, efforts to scale up health services in developing countries are falling short of the expectations of the Millennium Development Goals. Arguing that the dominant assumptions for scaling up are inadequate, we propose that interpreting change in health systems through the lens of complex adaptive systems (CAS) provides better models of pathways for scaling up.

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