**5.1 General principles for design and implementation of strengthening strategies**

Use research and evidence from elsewhere, but combine it with local knowledge and adapt a change or strategy to the local situation:


#### **5.2 Strengthening health services**

Research suggests the following actions could effectively strengthen health services in Yemen:


#### **5.3 Strengthening management and systems**

294 Health Management – Different Approaches and Solutions

A future strengthening strategy will be more effective if it implements changes which have already proven successful for increasing the quantity and quality of health services in

1. Research suggests that the consequences of a strengthening strategy are difficult to predict, and that a strategy successful in one region could be unsuccessful in another. Adapting the strategy so that it can be implemented may require local research and/or

2. Carry out a "barrier analysis" to assess constraints and hindrances to implementation. 3. Consultation can improve the design and planning of a strategy and can speed

4. Involve all levels: each levels of the health and local government system has a role in strengthening health services which needs to be specified, ideally through consultation,

6. Scale up successful pilots using a tested method for scale up (e.g. the Cooley & Kohl,

7. Include feedback to strategy implementers from continual monitoring of progress, of

8. Flexibility and adaptation: have regular formal and informal review points where the

Research suggests the following actions could effectively strengthen health services in

1. Careful and phased implementation of the "GAVI vertical integration" model in PHC beyond the pilot districts. This can be informed from lessons from scale up strategies elsewhere, including strengthening governorate, district and PHC management which may not currently have the capacity to carry out the integration, adapting the model

locally, and using information about implementation to make these adaptations. 2. Removal of financial barriers to health care access, using one or a mixture of the strategies reported to be effective, such as payment exemptions for the poor or social

3. Increase income for health services with effective systems to use and account for the finance, and by a combination of extra government allocations and income generating

4. Increasing the number and skills of health workers, especially in rural areas, by rapidly expanding paramedic training, and possibly by more use of community health workers.

effective, but enough to suggest they should be seriously considered for Yemen: 6. Appropriate licensing of practitioners and health service accreditation, and enforcement

There is less strong evidence to suggest the following strengthening strategies would be

constraints and of new opportunities arising from the changing situation.

**5.1 General principles for design and implementation of strengthening strategies**  Use research and evidence from elsewhere, but combine it with local knowledge and adapt

**5. Practical implications for Yemen from the research** 

implementation, but much depends on the local situation.

and then developed through training and other actions.

2005 three-step approach describe above).

strategy is modified for the changing situation.

5. Pilot test any strategy first, and revise it using feedback from the pilot.

Yemen and elsewhere.

a change or strategy to the local situation:

community consultation.

**5.2 Strengthening health services** 

health insurance schemes.

5. Improving pharmaceutical management

methods.

of penalties.

Yemen:

For these health service strengthening actions to be carried out, actions to strengthen the health system will be needed. These are actions which increase the capability of managers at all levels and how they work together, and improve the management systems such as for management information and human resource management.

For most strategies, managers at all levels need to be developed and given time to plan and implement strengthening interventions (rather than solely manage routine operations), with some managers dedicated full-time to implementing the strengthening intervention. Aspects of leadership associated with successful strengthening changes include: a clearly communicated mandate from top management that gives authority, resources, and accountability to leaders and teams throughout the organization, as well as respected "change champions," and implementation teams.

The evidence suggests that some strategies which require stronger management capacity should not be pursued on more than a pilot basis until the capacity has been developed. Strategies which might be considered later, and which have proven to have some success with adequate management systems are:


#### **5.4 Reduce constraints to health service strengthening**

In planning and implementing a strategy, decision makers would be advised to assess and address the following factors which have been reported in research to enable/hinder implementation of most types of strategies:


Source: Øvretveit, 2006

Table 1. Enabling/Hindering Factor

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