In Mozambique, management systems in high-volume health facilities are adapting slowly to demographic and epidemiologic changes and growth in patient demand. This often leaves management teams and clinical staff to implement ad-hoc adjustments to respond to patients’ needs. High patient volumes paired with clinical and administrative challenges and lack of clear national guidance can lead to critical consequences. For example, key primary healthcare professionals, including doctors, nurses, MCH nurses, clinical officers, and pharmacy and laboratory technicians, spend on average 34% of their time in non-clinical tasks—time that could be better spent with patients and addressing their needs.

As part of the project “A Comprehensive Approach to Improve Performance of Human Resources for Health in Mozambique,” ThinkWell’s Mozambique team collaborated with the Maputo Provincial Health Directorate to assess two health centers to understand formal and informal managerial and administrative systems currently in place and to identify quality improvement areas. We used a variety of methods, including semi-structured interviews, observation, and patient flow analysis, to assess performance areas, including human resources, pharmacy and laboratory services, data management, and service provision. Evidence from the assessments showed, among other challenges, inefficiencies in patient flow management, such as weak queue management procedures and peaks of patient arrivals early in the morning, long wait times, short consultations, overreliance on clinical staff for administrative tasks, and low utilization of strategic information for decision-making.

Following the principles of human-centered design, the team currently works with the health facility staff to identify and implement sustainable, practical interventions to improve their day-to-day operations and the patient experience. Examples of currently implemented interventions include tool design to speed-up the process of producing monthly data reports, the creation of a communication strategy between the health facility and the community of patients, and the design of a signage and wayfinding system to improve how patients navigate the health facility.

ThinkWell’s team has so far been successful in ensuring a high level of engagement, motivation and commitment from the health facilities’ leadership and staff in collecting data, critically analyzing strengths and weaknesses, prioritizing quality improvement areas, and designing interventions. The team effort of ThinkWell staff and the Provincial Health Directorate also resulted in a package of data collection tools that will ensure replicability of the study and comparability of results in other primary health centers.

Written by Federica Fabozzi, Program Analyst, and Toze Namalela, Senior Program Analyst

On March 31, 2021, staff from ThinkWell’s Strategic Purchasing for Primary Health Care (SP4PHC) project participated in HSR2020 session, “Public Financial Management challenges and innovations – Learning from COVID-19 health response.”

In 2020, coronavirus-affected countries explored and tested alternative modalities to formulate budgets and accelerate public spending to the frontlines.

During the session, “Public Financial Management challenges and innovations – Learning from COVID-19 health response,” participants presented and discussed:

• Key findings from a WHO-World Bank country review to unpack the public financial management (PFM) challenges faced by countries in the context of the COVID-19
• Some of the key innovations introduced for an effective budgetary response
• New modalities for making funding flows more accessible and responsive to facility needs
• Key learning points from the PFM approaches to make budgets more responsive to epidemic response’s needs
• How to advance lessons to provide a more supportive PFM environment for both epidemic response and universal coverage of essential health services
• Opportunities and challenges associated with Kenya’s PFM Act that was introduced to protect and accelerate the COVID-19 health response.
• Major PFM innovations introduced in the Philippines, such as the Bayanihan to Heal as One Act

Participants:

• Chair and Moderator: Srinivas Gurazada, World Bank Group
• Presenter: Hélène Barroy, World Health Organization
• Discussant: Christian Edward L. Nuevo, Technical Advisor for Health Financing, ThinkWell Philippines
• Discussant: Wangari Miukia, Economist, Expertise Kenya
• Q&A Facilitator: Nirmala Ravishankar, Program Director, ThinkWell

On March 10, 2021, staff from ThinkWell’s Strategic Purchasing for Primary Health Care (SP4PHC) project participated in HSR2020 session, “Adjusting health purchasing arrangements to support the COVID response: a global overview and country lessons.” The COVID-19 global pandemic compelled governments to rapidly examine and modify purchasing arrangements for channeling resources to health providers to increase coronavirus testing and treatment. To achieve this, many have first taken stock of available capacity in the public and private sectors. Next, they have modified existing purchasing arrangements to leverage the comparative advantage of different purchasers like ministries of health and health insurance to pay providers. Countries have expanded or clarified the benefit package and adjusted payment methods, rates, and contracting procedures. They also changed governance arrangements and information management systems.

The HSR2020 session, “Adjusting health purchasing arrangements to support the COVID-19 response: a global overview and country lessons,” explored the different ways that governments adjusted their purchasing arrangements for COVID-19 services to capture learnings that can assist countries to “build back better.” The session featured results from a multi-country survey conducted by the World Health Organization on purchasing arrangements for COVID-19 related services. It also featured a country panel with detailed country insights from the Philippines, Argentina, and the WHO European Region.

The session’s objectives were to:

• Share information about the purchasing policies and practices governments have applied to support the COVID-19 response
• Explore how countries have adjusted their purchasing arrangements to purchase health services during the pandemic and discuss implementation drivers as well as challenges
• Reflect on the medium- to long-term implications of COVID-19 on strategic purchasing reforms that middle-income countries are undertaking

Participants:

• Session chair and moderator: Nirmala Ravishankar, ThinkWell, USA
• Presenter: Inke Mathauer, WHO, Switzerland
• Country panelist: Melanie C. Santillan, PhilHealth, Philippines
• Country panelist: Martin Sabignoso, Senior Health Financing Expert, Argentina
• Country panelist: Salomão Lourenço, ThinkWell, Mozambique
• Discussant: Triin Habicht, WHO EURO

On January 13, 2021, staff from ThinkWell’s Strategic Purchasing for Primary Health Care (SP4PHC) project participated in HSR2020 session, “Strengthening Capacity for Strategic Purchasing.” The session’s purpose was to share the latest research and best practices in strategic purchasing. At its core, strategic purchasing is about improving how ministries of health and government health insurance agencies use information about population health needs and provider performance to make decisions about benefit packages, contracted providers, and payment methods.

The session featured the latest research and best practices from a range of low- and middle-income countries actively undertaking purchasing reforms. Session participants discussed specific purchasing challenges in different health systems and findings from policy and management reforms introduced to address these challenges.

The session objectives were:

• Foster conceptual clarity on strategic purchasing by ensuring participants can articulate a common definition and framework for strategic purchasing.
• Expose participants to topics in strategic purchasing where there are novel research and new information in the field, with country illustrations.
• Identify progress towards strategic purchasing and understand the drivers of progress based on a mapping of purchasing arrangements.
• Generate excitement for further research on strategic purchasing and co-develop a research agenda with participants

Participants:

• Inke Mathauer (World Health Organization)
• Cheryl Cashin (Results for Development)
• Nkechi Olarere (Strategic Purchasing Africa Resource Center/SPARC)
• Elizabeth Kiracho (School of Public Health, College of Health Sciences, Makerere University)
• Obinna Onwujekwe (Health Policy Research Group, University of Nigeria, Nsukka)
• Nirmala Ravishankar (ThinkWell)
• S Pierre Yameogo (Ministry of Health, Burkina Faso)
• Prastuti Soewondo (ThinkWell, Indonesia)
• Ellen Van de Poel (Global Financing Facility, Health Financing Lead, World Bank)

Across the world, ThinkWell staff are moving the needle on improving health and well-being around the globe. We wanted to take a moment to introduce you to some of our team in Indonesia.

Nadhila Adani, Data Management Analyst

What do you view as the greatest challenge to improving health in Indonesia?

Remote areas are hard to access. I once lived in a remote village in South-East Sulawesi, home to cocoa farms, for a community service program. The road there was just red soil that gets lumpy during rainy seasons, so we had to rent a pickup truck to get there. They had one community health clinic that was filled with sacks of cocoa beans and seemed no longer in use. The person in charge was a midwife, whose husband was a cocoa bean collector. She was seldom there but is the go-to person when anything happens to the villagers. She is the only health worker for maybe 100 households living in that village.

What’s been the most meaningful lesson that you’ve learned during your health career?

It’s expensive to be sick, especially when you’re a poor person who lives in rural areas. Despite government subsidies, access to good quality facilities and physicians are often the barrier to receiving proper care. Villagers rely on each other when a person gets sick, and social capital becomes important. Preventive and promotive measures [in rural areas] should not be neglected when designing a health system.

What’s a health statistic or fact that you can’t get out of your head? Why should everyone know it?

Indonesia has a high maternal mortality ratio (117 maternal deaths out of 100,000 live births in 2017), one of the highest in Southeast Asia. This stuck with me when I delivered my first child last August. Even though I knew most deaths happen because of high-risk pregnancies, or because they are attended by only one skilled person or sometimes nobody, or that deliveries happen in unsafe environments, the statistic made me chant endless prayers in my head as I went into labor.

Ryan Nugraha, Program Analyst

What was your life like before ThinkWell and why did you decide to join ThinkWell?

Before joining ThinkWell, I was a researcher with the Center for Health Economics and Policy Studies, University of Indonesia, as well as a practicing physician within the same university’s hospital. My life was spent juggling clinical, health economics, and health policy work (I know, a lot to juggle with!) until I decided to get my master’s degree at Johns Hopkins Bloomberg School of Public Health. There, I decided to leave clinical work and pursue public health fully. Before working for University of Indonesia, I pursued an MD at the University of Padjadjaran and worked as a research intern in the same university for a year. I also worked as a medical officer in Bandung before coming to Jakarta (University of Indonesia).

What makes you hopeful about health progress in Indonesia?

We are approaching health in a collaborative manner. When breaking down important health issues, stakeholders jump in together and discuss it in a constructive manner. That makes me hopeful about the future of health and health systems in Indonesia. Things such as vested interest might reverse the progress. In health and development, it is important to come with clear conscience.

What’s been the most meaningful lesson that you’ve learned during your health career?

Listening is more powerful than counting. When we are looking at issues from the policy perspective, many things we decide come from numbers, correlation, etc. However, up to now, I still think that listening, especially listening to the voices of those who are not normally heard, yields the biggest impact.

Sushanty, Country Manager

What was your life like before ThinkWell and why did you decide to join ThinkWell?

I have 24 years of experience in development prior to joining to ThinkWell, providing technical and project management support to public health, education, gender, and humanitarian response programs. I do really enjoy my work because it impacts people to have a better life. I decided to join ThinkWell with eagerness to learn health financing! I agree with ThinkWell that a well-functioning health financing system facilitates the efficient delivery of affordable and high-quality health services. And I can see that is the area in Indonesia that needs to be strengthened.

What do you view as the greatest challenge to improving health and wellbeing in Indonesia?

Indonesia faces the challenge of increasing access to health services for marginalized people. Despite steady progress in improving the health and life expectancy of its citizens, Indonesia straggles in reducing maternal mortality and neonatal mortality, TB, HIV, and non-communicable diseases.

What makes you hopeful about health progress in your country?

Indonesia’s Universal Health Coverage system, which grew rapidly and covers 203 million people as the largest single-payer scheme in the world. It is showing that it is improving health equity and service access.

Nirwan Maulana, Senior Analyst

What was your life like before ThinkWell and why did you decide to join ThinkWell?

Before ThinkWell, I hadn’t yet worked directly in the health sector. The Covid pandemic showed me that the health sector in Indonesia still has many problems and vulnerabilities. I wanted to contribute to improving the health sector by joining ThinkWell.

What do you view as the greatest challenge to improving health in Indonesia?

I think the main challenge is political will from government leaders. This can be translated to many things, such as finding the most capable people to manage the health sector, as well as deciding fiscal spending for the health sector, which should be larger than other non-productive spending (e.g., non-human capital investment), especially during the pandemic.

What’s a health statistic or fact that you can’t get out of your head? Why should everyone know it?

Out-of-pocket health spending in Indonesia is progressive toward economic status, even for national health insurance (JKN) members. Theoretically, the patterns should be more regressive. It turns out that higher-income people prefer premium healthcare, which is not fully covered by private insurance and JKN. They also prefer to not use JKN so they can instead get quicker services.

Halimah Mardani, Senior Analyst

What was your life like before ThinkWell and why did you decide to join ThinkWell?

Before joining ThinkWell, I worked in the National Team for the Acceleration of Poverty Reduction (TNP2K), the Office of the Vice President of the Republic of Indonesia, for more than seven years. I decided to join ThinkWell to expand my scope of work to an international level and bring knowledge about Indonesia to the world. Through ThinkWell’s Strategic Purchasing for Primary Health Care (SP4PHC) project, which takes place in five countries, I have gained a lot of international knowledge and experience.

What’s been the most meaningful lesson that you’ve learned during your health career?

I have learned about health issues from discussions with communities, health workers in remote areas, heads of community health centers (Puskesmas), and health offices in districts/cities. They have bright ideas that accommodate central policies while being grounded in their local specifics. I’ve also learned how to translate the results of a study for health policymaking purposes.

What’s a health statistic or fact that you can’t get out of your head? Why should everyone know it?

Indonesia is an archipelago country with the fourth largest population in the world. Dealing with 514 leaders of districts is very challenging, especially in the era of decentralization. Although several health policies have been decided at the national level, policy implementation is within the authority of the regions. Given the contextual differences across the regions, implementation is difficult.

Andhika Nurwin Maulana, Senior Analyst, Data Management and Analysis

What was your life like before ThinkWell and why did you decide to join ThinkWell?

Previously, I worked on health sector and public financial management issues. I joined ThinkWell due to its broader experiences in public financing and focus on the health sector and health financing.

What do you view as the greatest challenge to improving health and wellbeing in your country?

Working in the health sector always has unique challenges, but politics around making funding more effective, efficient, and sustainable financing for a better health services is a big challenge.

Trihono, Technical Advisor, Health Financing

What was your life like before ThinkWell and why did you decide to join ThinkWell?

Before joining ThinkWell, I worked at National Institute of Health Research & Development. I decided to join ThinkWell to support better health policy and its implementation. I believe ThinkWell supports evidence-based research and policy recommendations for better health policies.

What’s been the most meaningful lesson that you’ve learned during your health career?

Advocacy to policymakers is not easy. It needs consistent and continuous efforts to inform, advocate, and make recommendations.

What makes you hopeful about health progress in Indonesia?

We are facing many health problems that need strong leadership from the Indonesia’s Ministry of Health. Our new health minister always asks for inputs related to health development from many stakeholders. I believe that ThinkWell’s evidence-based suggestions will be able to help revise policies.