Turning the world upside down

Independent crossbench member of the House of Lords There are many examples of successful knowledge transfer from poorer to richer countries – as well as the other way round. Methods developed in Africa for treating conditions as different as HIV/AIDS and clubfoot are now being used worldwide. Lenses created for poor people in India are used in cataract operations around the world. Mexico's Oportunidades programme, which was designed to bring services to the poorest parts of its population, was explicitly copied by New York City in 2007. I have entitled this paper Turning the World Upside Down because it makes three arguments which together turn on their head some of the most common assumptions about strengthening health systems in poorer or developing countries. These three arguments are that: 1. There is a new set of approaches to health services and systems being developed in poorer countries which are every bit as important as the introduction of ideas and practices from richer countries. 2. There is a need for a process of co-development – and mutual learning between countries and their development partners – which recognises that richer countries themselves have substantial problems and can learn a great deal from poorer ones. 3. System strengthening without building in continuous improvement is a waste of money and effort. T his short paper does not attempt to cover all aspects of health systems strengthening but takes as its starting point the WHO analysis that there are six essential elements that need to be addressed – service delivery, financing, governance, health workforce, information systems and supply management. The paper deals with two of them: service delivery and health workforce. The same principles and arguments as are used here with these two can, however, be applied to the others. The paper builds on this analysis to argue that successful implementation of effective system strengthening requires systems thinking and attention to the way that all the elements of the system work together. There are now tried and tested ways of doing this. It uses examples relevant to each of the three health-related MDGs – on tackling HIV/AIDS, malaria and tuberculosis; childhood death; and maternal mortality – and makes reference to poverty and the empowerment of women. The paper starts by looking at innovation in low-income countries and considers how the relationship between high-income and low-income countries affects health systems strengthening. Leaders in low-income countries, without either …