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Government-Centered Health System Strengthening: Lessons From the COVID-19 Pandemic in Africa

At the Center for Health Worker Innovation, we provide a platform for our partners and others in global health to share perspectives on the health workforce. To that end, the following piece is authored by Spark Health Africa.
Uganda Ministry of Health national level officials and senior district management team leaders attend a <i>Transformative Leadership and Culture Change</i> workshop led by Spark Health Africa, which is followed by months of intensive on-the-job mentoring and thought partnership.

The divergent paths countries have taken in the face of the COVID-19 pandemic have demonstrated the importance of government leadership to safeguard population health. While no country has eliminated COVID-19, there are definite success stories from both wealthy nations like Germany and New Zealand and less-affluent countries like Vietnam and Rwanda that have largely contained spread and averted the detrimental health impacts seen elsewhere in the world.

At Spark Health Africa we have always emphasized the centrality of government in building resilient healthcare systems. For this reason, our work in health system strengthening focuses on leadership development and work culture change within African Ministries of Health. Our commitment to this agenda has been affirmed by the demonstrations of strong leadership to limit COVID-19 transmission.

Here are some lessons we have learned about the irreplaceable role of government in public health, and the implications for building better and more resilient healthcare systems to tackle COVID-19 and improve health outcomes across disease areas.

Lesson 1: Because governments are ultimately accountable for their citizen’s needs, they have the greatest ownership over creating an enabling environment to build resilient health systems.

It is common for healthcare programming in donor-dependent countries to be fragmented. Different actors tend to carve out their areas of interest and insulate their efforts from the rest of the healthcare system. This siloed approach is not an option for governments. They are stewards over all health programs in the country for the holistic well-being of their population. For this reason, they have the greatest buy-in to cross-cutting health system strengthening.

This stewardship extends to the social and economic determinants of health that threaten the effectiveness of even the best functioning healthcare system. The Rwandan government, for example, rolled out a social protection program as part of their COVID-19 prevention efforts. They did this because they understood that to successfully institute a lockdown they would also need to buffer the most vulnerable against food insecurity due to disrupted livelihoods. Governments have the purview to strengthen the broader environment impacting healthcare systems.

Lesson 2: Governments are the only entity with the authority to mobilize and align diverse stakeholders around a common agenda.

Governments have the power to set a health system strengthening agenda and enforce its implementation with diverse stakeholders. While donor organizations and development partners may be able to finance programs, this is insufficient without the authority to implement and rally collaborators around a common goal.

Diverse stakeholders include the different actors within governments as well. Where we work in Uganda the government swiftly established multi-sectoral district task force teams for an integrated response to the COVID-19 pandemic. COVID-19 District Task Force teams comprise members from the Health Department, Security Services, Transport Department, political leaders and civic society organizations.

We support this government-led initiative by training and providing thought-partnership to Ministry of Health mentors so that they are equipped to catalyze a leadership mindset shift within District Task Force teams. Specifically, these mentors engage in team-building by encouraging the multi-sectoral actors to align around a common agenda and collaborate effectively. The mentors carry this influence over teams because they derive their authority directly from the Permanent Secretary of Health, Dr. Diana Atwine. She has set the mandate for leadership development and reports program successes directly to the Cabinet and Parliament as the government deliberates on how to scale up the Transformative Leadership and Culture Change initiative nationally.

Lesson 3: Only governments can issue population-wide directives and take bold action that has far-reaching impacts

There are actions that governments can take which would be impossible for any development partner to replicate. Some of the most impactful measures to curtail the spread of the coronavirus, such as travel restrictions, lockdowns, and mandatory mask-wearing, could only be instituted by the government.

The South African government, for example, was decisive from very early on in the pandemic. Even when the country only had 61 cases, the message from the President was clear: “This situation calls for an extraordinary response; there can be no half measures.” He followed this commitment up with substantial interventions only possible with a government mandate from a strict lockdown, travel restrictions, and school closure. Concurrently, the government also invested heavily in increasing testing and treatment capacity in quarantine sites.

What should this mean for the future of government and development partner collaboration?

It is up to both the development community and African governments to work towards a government-centered health system strengthening model.

The development community must realize that no amount of funding can supersede the role of government as representing the all-inclusive needs of their citizenry with the full authority and ability to meet this need.

African governments, on the other hand, must confront the fact that poor leadership has also contributed to cracks in the healthcare systems. Lack of government leadership in creating resilient health systems has naturally created a vacuum which has been filled by development partners. Consequently, citizens and the development community will continue to lack trust in African governments that do not lead from the front due to the absence of a clear vision from the top.

While no government response is without its faults, there are valuable lessons to be learned from the strong leadership in countries that committed early and decisively to combat the pandemic. The decisive actions demonstrated during COVID-19 response by a number of African governments can also be used to regain trust, as exemplified by the Ugandan government’s swift arrest of high ranking officials engaged in corruption.

Strong transformative leadership to build resilient healthcare systems is possible within governments if they commit to a mindset and culture shift.

Uganda Perm Sec meeting Aug 2019.jpeg
Spark Health Africa team (left) meet with the Permanent Secretary of the Uganda Ministry of Health Dr Diane Atwiine (3rd from left) and senior Ministry of Health officials. Spark Health Africa has been collaborating with the Ministry of Health on a Transformative Leadership and Culture Change initiative with 10 district health management teams since 2018.

Johnson & Johnson Foundation is a founding partner of Spark Health Africa, which grew out of a collaboration with the Graduate School of Business at the University of Cape Town in 2012 to fulfill a shared goal to cultivate strong leadership practices in public sector health management teams in order to effect work culture change and ultimately improve health outcomes.