Just like management gurus, we in the health sector can produce our own checklists. What do successful health programmes have in common? Inspired by a visit to Ethiopia’s health extension worker programme, here are my top-ten habits of a successful health programme. What are yours?
- Committed leadership
It is a cliché, but the mobilisation, prioritisation, resourcing and continued support which programmes need to flourish and survive over time cannot happen without technical and political leaders who see it as worth their while to fight for it. This in turns often relates to personal and institutional incentives – what is the return for them? Electoral returns often play a role, and why not? Health is intensely political. Sometimes a crisis can help too, generating momentum for reform and rebuilding.
- Sweating the big stuff
Linked to this, programmes need to address health concerns which are of major social impact for universal access. How else to create the commitment which is needed at leadership and all system levels?
- Fit for purpose funding
That resources have to match the costs of running the programme is obvious (though we all know many, if not most, where this is not the case, with predictable knock on effects on quality, morale and costs for users). However, it is not just the volume of finance but also its modalities that matter. Pooled funding allows control and clear allocation to internal priorities. Fragmented funding does not. Simple as that.
- Ownership and adaptation
Do programmes which are simply transplanted from another setting every work? I cannot think of any examples. It seems to me that all successful programmes are home-grown in some sense. They may be influenced by others (there are few original ideas in the world), but they have been carefully tailored and crafted to match the new context. They have been adopted actively – not through bribery or coercion.
- Clarity on goals and means
Knowing what you are trying to achieve, as well as your boundaries, and having clear tools and guides to help you achieve them is essential. Most health programmes rely heavily on community and lower level staff. Short, practical tools are what they need.
- Knowledge transfer to communities
Demand and need grows exponentially, so a programme which does not increase the ability of its clients to prevent and manage their own health problems is condemning itself to an impossible fight. Prevention and promotion are key, and within that, empowering women is an essential component.
- Linking across and up
Health programmes require effective technical supervision, so radical decentralisation which cuts lower levels off can be disastrous. Health programmes need vertical links but also horizontal ones which connect them to the local community structures (for support and also accountability).
No programme is an island – it functions effectively and sustainably by operating within the available health system resources and contributing to strengthening them. Similarly, it reaches outside the sector to support and influence other sectors which affect population health (which is almost all of them, but some more than others).
- Learning, learning
Knowing where you are going and how well you are doing to get there is another shared feature, but learning involves more than tracking and data; it also requires sometimes painful recognition of failures and the courage to innovate in addressing them – the famous willingness to fail again, but fail better.
- (Reasonable) accountability
Programmes which do not reward effort and performance and penalise their opposites are condemned to entropy. However, effective programmes also know that teams and staff need support and the right conditions to deliver – this is a two-sided bargain.
- Creating a narrative of success (but only half believing it)
To thrive, health programmes have not just to be successful but to be seen to be successful, as this nourishes the commitment which they require. Successful programmes often have outstanding champions – people who know and tell their story well. But they are also not misled by their own narratives into overlooking operational challenges and the need to continually reinvent themselves.
Finally, a bit of luck always helps – operating in an area with economic growth, peace and stability can be very helpful too!