The key element of any health system is the people who run it. Nowhere is this more true than in countries in the midst of, or recovering from, conflict. Indirect or direct threats faced by health workers exacerbate a population’s challenges in seeking and receiving health care.

In conflict settings, health workers may be forced to flee to safe havens as refugees, internally displaced people, or leave the country as migrants—if they have the means to do so. Some of the most capable are absorbed into international agencies. Those who remain frequently have insufficient resources to perform their jobs and must carry on as best as they can under daunting circumstances.

This situation has worsened in recent years with a growing number of direct attacks on health workers in fragile states, such as those against polio vaccinators [10] in Pakistan and Nigeria. These blatant violations of the Geneva Conventions [11] inhibit an already difficult environment for the delivery of health services and the recovery or development of the health system.

In Kenya, cancer is ranked third as a cause of mortality and morbidity after communicable and cardiovascular diseases.

The Ministry of Health, supported by the USAID [16]-funded, Management Sciences for Health (MSH)-led, Health Commodities and Services Management [17] (MSH/HCSM) Program, led the development and launch of the First National Guidelines for Cancer Management in Kenya, in collaboration with World Health Organization (WHO), Africa Cancer Foundation, and other stakeholders.

The Cancer Guidelines are intended to help increase access to cancer screening, early diagnosis, referral and management of diagnosed cases.

In Kenya, cancer-related services have previously been available only in the top private hospitals and the public teaching and referral hospitals, which have restricted access to a few well-to- do individuals who can afford the related costs. The guidelines de-mystify cancer management and have outlined the core health system requirements needed to offer services in the different tiers of health care, including: community, primary care, county referral and national referral hospitals.

TB CARE I Indonesia [21], The Global Fund to Fight AIDS, Tuberculosis and Malaria [22], and Indonesia’s National TB Program (NTP) organized a mass-mobilization World TB Day event on March 24, 2013, called "Run 4 TB".

This 5K race drew thousands of runners, bikers, walkers, and observers.

(Photo credits: KNCV/TB CARE I)

In recent years, commitments from the government and major donors have led to improved tuberculosis (TB) control in Indonesia, with reductions in both prevalence and incidence. The nation’s economic status has also improved; however, this has caused many donors to reduce their contributions to the nation’s health programs.  Compounding this financial challenge is the rising prevalence of drug resistant strains of TB that further tax the health system with the cost of expensive services and medicines needed to care for these patients.

Management Sciences for Health (MSH) under USAID [26]’s TB CARE I project [27], is assisting the Ministry of Health’s National TB Program (NTP) to develop ways to increase domestic financing for Indonesia’s TB control initiatives. Possible solutions include: increased contributions from national health insurance and government budgets, corporate social responsibility programs, and improvements in cost-effectiveness and efficiency.

In a postoperative ward of Kibagabaga Hospital, the district hospital serving Rwanda’s capital city of Kigali, Eric Bizimana sits up in bed. Bizimana, 25, had sought care after severe pain in his right leg forced him to stop work as a barber. He was diagnosed with a bone infection called osteomyelitis. Antibiotics alone couldn’t clear the infection. Without an operation to remove the diseased bone, Eric faced the possibility of losing his leg.

Eric was one of the 40 patients who enter Kibagabaga for surgery every day. In Rwanda’s tiered healthcare delivery system, patients are referred from local health centers up to the district hospital when their conditions require more complex care. Most babies are delivered at health centers, for example, but a woman suffering complications or who was expected to need a C-section would be referred to the district level.

Private sector companies, like McDonald's and General Electric, have successfully been using internal universities or academies for decades. So how can programming for health service managers be better, more cost effective and more sustainable? Embed programming within special “Leadership Academies” based in ministries of health.

“We’re going to try to drive through that?”

After spending nearly two years working in South Sudan, I was on my way with two colleagues to one final meeting. The USAID [16]-funded second phase of the Sudan Health Transformation Project [36] (SHTP II), led by Management Sciences for Health (MSH), ended activities on July 31, 2012, and three of us needed to travel 360 kilometers (220 miles) to a results dissemination meeting. A flight booking mishap meant we had no choice but to drive --- during rainy season.

With a key bridge washed out.

And it rained --- down poured --- for over an hour the morning we left.

After passing several toppled trucks, overtaking pickups irrevocably mired in mud, and crossing through a river, we came across the point where I uttered the above quote (“We’re going to try to drive through that?”).

Each year, as many as 64,000 people die from tuberculosis (TB) in Indonesia. Although the Ministry of Health’s (MOH) National TB Program (NTP) has made great progress over the last few years, the country is still one of twenty-two high TB-burden countries in the world. Indonesia is also one of the twenty-seven countries considered to have a high burden of multi-drug resistant TB (MDR-TB). In 2011, the nation reported 6,100 cases of MDR-TB.

Donor funding has been a major factor in the success of Indonesia’s TB program over the last few years, especially The Global Fund to Fight AIDS, Tuberculosis and Malaria [22] (Global Fund) grants.  Indonesia has, however, progressed economically and is now a relatively low priority for Global Fund grants, which are expected to end or reduce significantly by 2015.

Despite Indonesia’s economic growth, the sustainability of the TB program will be a major challenge without support from this critical donor, especially during the funding transition period.

“J’mappelle Mompati. Comment t’appelles tu?”

Overcoming my confusion at being greeted by a French-speaking man in Botswana, I smile, take his proffered hand and reply in my rusty, stilted French, “J’mappelle Naume...”

Mompati is Mahalapye Hospital’s dynamic public relations officer. Now that he has my full attention, Mompati wastes no time in telling me about his work linking the hospital and the surrounding community through events and the media. We exchange contacts and he hands me a few copies of his newsletter before dashing off to his duties.

Mahalapye is a small town in the Central District of Botswana on the edge of the Kalahari Desert. Situated along the main road between the capital, Gaborone, and the second largest city, Francistown, Mahalapye is a convenient stopover place.

The hospital has been recently renovated and serves 300 outpatients a day and up to 200 inpatients.

Sophia is a humble woman. She has been working as a nurse for 10 years, and is currently one of five nurses posted at Rwesande health center IV in the hills of western Uganda.

When I arrived I was impressed by the number of services the health center offers, and the general appreciation felt around the compound. Rwesande health center IV has a maternity ward to safely deliver babies; counseling areas for family planning, reproductive health, and HIV; a general ward, a surgery theater, and health education space.

Family planning counseling and services now available

As Sophia shows me her meticulously-kept record books I can see the pride she takes in her work. She explained how women are now coming and asking for family planning services.

Not too long ago clients were not coming, and the nurses didn’t have proper training on methods to offer clients.