Project Director at MEASURE Evaluation Strategic Information for South Africa (MEval-SIFSA), Derek Kunaka, talks about strengthening healthcare systems to meet the new Sustainable Development Goals (SDGs). MEval-SIFSA is a show partner for eHealthALIVE2016 and will be hosting a comprehensive M&E afternoon workshop to give individuals and organisations practical tools for assessing and making evidence-based decisions at critical points throughout a project’s lifecycle.
Tell us about your background and your role at MEval-SIFSA.
I’ve been working in public health since 2004. My expertise is in strengthening health information systems, building strategies around the collection of health data and how healthcare organisations manage that data to improve health outcomes.
I’m currently working for John Snow Inc., a healthcare consulting firm and lead implementer of MEval-SIFSA. I’m the project director of the MEval-SIFSA project, a U.S. government-funded initiative that supports the health system in South Africa to produce useful and high-quality information that contributes to sustainable policy, planning and decision making.
For example, MEval-SIFSA works with the National Department of Health (NDoH) and fellow implementers of the U.S. President’s Emergency Plan for AIDS relief (PEPFAR) to improve strategic information for evidence‐based management of HIV and related health programmes. We also provide technical support to the DoH at all levels by assessing how data is collected, who’s collecting it and who is responding to it.
However, our mainstay is working with districts to ensure that SA’s District Health Management Information Systems Policy and eHealth Strategy are implemented. We also work with various stakeholders to strengthen the use of big data and leverage the collection and sharing of data to support evidence-based decision making.
How would you define a “functioning health system?”
There’s always a debate around how and what determines a “functioning” system. We have a learning model at MEval-SIFSA where we’ve itemised what defines a health system as “functioning.” For us, a strong, functioning system is one that takes you through the entire data management process and evaluates how the data is gathered, interpreted and analysed. But most importantly, a functioning system uses data to maximise a health programme’s impact and improve health outcomes.
Another crucial component to a functioning health system is that it is harmonised and not disparate. This can be achieved through better use of quality data for decision making; but in order for that to happen, investments have to be made into effective programme management. It’s an undeniable fact that whenever you’re running a programme you need to be able to adjust the way in which you’re implementing the programme at critical points throughout its lifespan. The only way you can do that is if you have the appropriate evidence; so the health system needs to help you with that, it needs to provide the evidence that you need to make your adjustments.
Lastly, a functioning health system needs to have demand for data from a variety of stakeholders. Stakeholder demand for data will positively affect the quality of the data that’s coming out of the health system.
Is there currently a sufficient demand for that data from a variety of stakeholders?
The demand is there but it’s still in siloes. I think the way we demand data from our health system is in contrast to what the SDGs give us the opportunity to align partners and stakeholders around common priorities. Different stakeholders are asking for data out of the health system but they have different intentions for it. If we were all working towards one common goal, we could use the data to not only help us meet the SDGs but build a more efficient health system for everybody. But at the moment demand is still motivated by individual or institutional interest and not the broader goal of reaching SDGs and the National Development Plan (NDP) for South Africa.
Is there a specific SDG goal that should be a top priority?
In my opinion, maternal mortality is one of the goals we all need to focus on, especially in South Africa. The health minister has said this on several occasions and on various platforms that maternal health is a key indicator of how well our health system functions. This is where life begins and if we can’t deal with that particular indicator then we can’t deal with other challenges such as HIV and TB because the issues are going to be the same.
Let’s talk specifically about the public sector for a moment. There’s the premise that data should be collected at every point of care, at every site, and those interactions with the health system should be analysed and fed into data sets at a national level. Can you give us a summary of what should be happening in public health but isn’t?
We’re talking about the data flow process and there are so many things to discuss on that because there’s routinely collected data and non-routinely collected data and we’re talking about putting all of that together to come up with a full picture of what is actually happening in the health system.
Implementing a robust health information system is a first big step towards achieving this goal. South Africa has already made great strides in this regard by implementing its District Health Management Information Systems Policy (DHMIS).
So, we’re doing really well collecting data but looking at data across different structures is essential and should be supported. Standardisation is key to developing tools that help countries to collect, analyse and use quality data. We’ve come a long way to establishing standards for eHealth and mHealth, now we need to take the next steps to implementing and enforcing those standards.
What do provincial health ministries need to do to contribute towards reaching SDGs?
In a resource-constrained environment, it’s crucial to take a strategic approach to reaching the SDGs. Focus on doing the right thing at the right time. Granularity is difficult to achieve manually so significant investments, strategies and automation is necessary to get the disaggregated data to monitor progress to reach the SDGs. The mechanisms to achieving digital granularity are through better community-based information systems; better routine health information systems; and better use of quality data for decision making.
How can the private sector influence reaching these goals?
The private sector has clearly indicated that they want a seat at the table – particularly when it comes to implementing South Africa’s National Health Insurance (NHI) scheme and improving the health system for all. In order for this to happen however, they need to align their interests to meeting the national goals set by the government. The government has extended this invitation to the private sector but because both sectors have different priorities, there’s a lot of mistrust.
The private sector doesn’t want to put in the investment and not benefit from it. On the other hand, the government doesn’t want the private sector to benefit unduly. Finding solutions is good business, but the model must be mutually beneficial with everyone pulling in the same direction to support the country’s health plans and priorities.
Do we have the capacity to respond to the data we’re collecting in either sector?
One of the challenges SA faces is insufficient capacity to analyse the data but the truth is that you will never have enough capacity. The real issue around harnessing big data is less about technology and more about changing mind-sets.
The NDP has given South Africa a common unifying goal to work towards. Stakeholders need to trust each other to achieve the objectives set by the NDP. We’ve made good progress on deciding what the future of healthcare should look like, now we have to enhance the capacity available to get us there.
What are the next steps for South Africa in reaching SDGs?
“Leapfrogging” is a term that is readily used but I think its real meaning and impact is sometimes lost; bypassing unnecessary steps based on lessons learnt from more developed economies that have done the grunt work of introducing new technologies is a huge opportunity for the whole healthcare industry. But we have to bear in mind that technology is changing rapidly and therefore governments must be agile in their adoption of technology. For example, the use of mobile technology and its functionality is constantly growing and evolving but if governments are waiting first to put policies in place about its use, the technology will advance regardless and we won’t be able to leverage the opportunities and momentum it offers us in healthcare.
Interoperability (IOP) is also key to reaching the next stage in South Africa and the 2030 deadline but we shouldn’t make the mistake of confusing IOP with integration. Ultimately, we need to eliminate the duplication of effort and work with systems that talk to each other. I also believe that interoperability could be one way to break down the barriers to trust between the public and private sectors. But as we all know, we’ll have to support normative standards as well as a coordinating body for eHealth if we’re going to get interoperability right.
What other sectors need to provide support and mechanisms to measure progress towards health- related SDGs?
The NDoH is engaging well with the Statistics SA, the National Treasury and the Department of Science and Technology, but we need to work more with other sectors such as Social Development, Agriculture and Mining. If we’re going to tackle TB, we have to engage with the mining community and measure, for example, the impact of HIV and TB on business.
A great example of multi-stakeholder engagement I saw recently was in the Eastern Cape where the MEC for Health hosted a Health Summit to discuss poverty reduction strategies aligned with the NDP and the role each stakeholder will play in meeting those goals.
What would you like to add in closing as essential to reaching SDGs that applies from an individual site all the way up to a national level?
It’s important to acknowledge that measurement and accountability go hand-in-hand. They are equally important to reaching our goals. Now that we’ve strengthened our health systems and have used data to achieve our goals, we have to ask ourselves whether we have adequate measures and policies in place to ensure that we meet our targets. What do we do if stakeholders don’t do what they are supposed to do? Accountability is still a concept that must be instilled and reinforced if we’re going to realise our vision. If we don’t have accountability measures in place, how will we know that we’re moving forward?
Ultimately, the people who receive the service and the people who work in the service, from providers to policy makers, must be held equally accountable for the quality of the health service. For the first time SA has a public protector for health in the form of the Office of Health Standards and Compliance but will they have the influence in the private sector? Do we have a rigorous process for assessing and holding health managers accountable for their ability to manage facilities or budgets or change? Can we realise affordable, accessible healthcare if the people using the health service are not held accountable for their own health?
Accountability is difficult because it means responsibility to deliver and consequences if you don’t but it is absolutely essential to moving the country forward both from a health and social perspective.
This research publication has been supported by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) through the United States Agency for International Development (USAID) under the terms of MEASURE Evaluation-–Strategic Information for South Africa associate award AID-674-LA-13-00005. MEASURE Evaluation-SIFSA is implemented by the Carolina Population Center at the University of North Carolina at Chapel Hill, in partnership with ICF International; John Snow, Inc.; Management Sciences for Health; Palladium; and Tulane University. Views expressed in this publication are not necessarily those of USAID or the United States government.