Of building stamina, Resilience: Jogging as an allegory of building resilient and sustainable systems for health

Introduction

So today I was back on the asphalt. And this time around I actually run my best time in 2020! I guess that’s something to be proud of and celebrated, right? I know it doesn’t measure up with the jogging exploits by a couple of my friends who are already doing under 5 minutes/km, and for longer distances too. But it was a huge moment for me.

And it wasn’t after a long while this time around – I have been fairly consistent with my Saturday jogs since February. This time around, as was my last couple of jogs, I couldn’t help thinking about what jogging does to me. In particular, the how and why of building stamina. That inevitably led me to think of something that’s been on my mind for a while now – building resilient and sustainable systems for health, or RSSH as we call it in my line of work. It’s been a theme I’ve heard over and over again in many a meeting on health since I started my career and more so now during my work in global health. It’s not surprising why I fell upon RSSH. About exactly this time last year I attended WHO/AFRO’s Africa Health Forum in Cape Verde and the discussions were rife with this topic. More still, currently the global community is faced with one of the most unprecedented health emergencies that has sent shockwaves not just in health sectors across the globe but also sent stock markets tumbling and catalyzed a global recession. COVID-19 is another reminder of why we need resilient and sustainable systems for health.

My jogging has in this instance been a form of an RSSH allegory. But what exactly crossed my mind in terms of my jogging vis-à-vis RSSH?

Jogging is good for me

Well, that’s supposed to be obvious, right? I mean, all of us agree physical exercise is important for the body and there’s plenty of evidence to that effect. Even holy writ says it has some benefits. For me jogging is a kind of escape from my immediate reality. When I’m on the asphalt my mind somehow enters a magical and serene sphere where I can hear myself thinking. It is as if I can literally hear a pin drop! But it helps me recharge too. I mean, I spend so much time working and by the end of the week I am worn out. Jogging helps me re-energize. It builds my stamina (more on this later). Builds my endurance. Keeps my BP in check. It clears my mind and sharpens my alertness. The list goes own. It makes me whole, I guess.

The same can be said about the resilience of our health systems. We all know it’s critical, nay, a non-negotiable so far as securing better health outcomes is concerned. The global health community think it’s imperative to achieving universal health coverage (UHC) or ending AIDS, TB and malaria by 2030. The evidence points to it, even anecdotally we know with better systems for health there’s a higher chance we’ll get better health for everyone. Incidentally, in my immediate previous life as an institutional strengthening expert, we often argued having strong organizational systems is one sure way to having better functioning organizations – its true of NGOs and its true of public organizations. But that’s a piece for another day.

Measuring as a means to improving my jogging experience

So I know jogging is good for me, but how do I get the most out of it? How do I know I’m making progress? Well, I measure, course-correct and keep improving on the strategies I am employing. I keep track of my jogging experience to know it’s benefiting me. In terms of process indicators, for example, this could be around how long I take for the same distance. When I first run on my current track it took me 40 minutes to cover a 5.8km stretch. At some point I hit 38 minutes. Last week my run was back to 40 minutes. Today it was 36.9 minutes. Terrific! But what exactly is going on here? Plenty. One can argue that I’ve built my stamina. I’m stronger. In terms of outcomes, one could argue perhaps that a stronger stamina has helped with getting rid of excess fat, cholesterol and kept my BP in check. Speaking of which, lately my doctor has given me cause to monitor my BP so I’ve had to create a BP profile. My reading today was the lowest in weeks! Because of measuring, now I know a stronger stamina is good for me given it’s helping me became resilient. That’s evidence right there.

Likewise, measuring the process of building resilient health system – which by the way is a building block within health systems work – is just as critical. Anyone who’s been around RSSH work long enough soon realizes it can be likened to a maze – with so much to be done one can easily get lost in the work. It can also be like a jigsaw puzzle – so many pieces to put together it’s difficult to figure out the end from the beginning or even identify a beginning point. Oftentimes it’s difficult to actually show what we are achieving.

I’d argue that a good beginning point in this journey of a thousand miles would be to invest in strengthening health information systems which has a multiplier effects on the entire health systems. With better information systems, we can measure the achievements of the health sector. We’d have a much better idea on morbidities and their causes, distributions geographically or across the year, trends, etc. Likewise for mortalities, we’d have a better visual of their causes, frequencies, trends, etc. Better information would also give us an idea of what’s working, what’s failing, and what’d benefit from better management, identify information gaps, the quality of health care services, etc. And the impact on decision-making, including course-correction, is just as enormous.

The same applies to measuring other aspects of the health systems. Take investments in health for example. Are public expenditures in health increasing/falling, say, reaching Abuja declaration targets? Are out of pocket (OOP) expenditures dropping or rising? Are catastrophic expenditures rising or falling? What’s happening to the health of the poor, the marginalized, or those generally left behind vis-à-vis the better able or general population? What’s happening to maternal and child mortality rates? What’s happening to availability of health services, whether in terms of proximity to health facilities, ratio of health workers to clients or being attended to by qualified medical personnel, in terms of availability of medicines and medical commodities, etc?

An excellent case in point that comes to mind at this juncture is Rwanda. The country was on the brink of self-destruction in 1994. Fast-forward to 2020, it is one of the two countries that has been able to achieve the HIV epidemic control targets i.e. 90% of people living with HIV know their status, 90% of these are on treatment and 90% of these have attained viral suppression. As can be seen in the table below, the country has impressive stats to show in terms of maternal or child mortality, OOP, etc. and their life expectancy trends, from 26.45 in 1994 to 69 in 2020 which is one of the top six (6) in Africa, which, although compounded by other factors, is a demonstration of the better health of its people because of prioritizing investments in the health sector.

No cheating!

I was nearly three-fourth of the way down my track, at the Orthodox Church in Bole, when I couldn’t bear the fatigue anymore. I was breathing heavily. I was going up, and my muscles were in 4WD. Any relief was welcome. The temptation to take a break was highest. Instantly I saw another track on my right that was trudging downwards and would take me back to my original track, saving me a painful 100m upward trudge. But I also thought about my target. Every inch of progress I’ve made over the weeks was going out the window with a quick relief! In that moment I wanted to stretch my body to reach new limits. I decided to keep on my original track and face my demon. All this was happening within seconds while on the track.

Imagine therefore my excitement afterwards when I reached the end point and realized I had just run my best time! And to think I’d have easily forfeited that eureka moment had I given in to the urge to go for the short cut? Madness, total madness!

Speaking of cheating vis-vis data, anyone running a program may have encountered the trade-offs I met on the asphalt this morning. You’ve put together an ambitious plan that, if well implemented, would achieve great success with some really good impact. At some point creating the necessary conditions to bend the curve can be tough business entailing tough choices. The temptations to cook up numbers can became so real especially when incentives are at stake. Sometimes this can even be veiled in “adjusting” indicators or targets. It is in those moments remembering that assuring the integrity of the systems we create is just as important to achieving the quality results we are seeking. Sometimes the cost of short-cuts can have huge implications in terms of the quality of services. You only have to look at the temptation to buy quality unassured cheap medicines and the rise of anti-microbial resistance (AMR) to see the damage caused by shortcuts.

Don’t get me wrong here. There’s a place for well-meaning and informed course correction. But the point I’m making is against short cuts that can sometimes jeopardize achieving mission-critical deliverables. Yes, a detour may be an easy way out of tough situations, but what are the broader implications arising from undermining due process?

Conclusion

Well, that was my run this morning. With a rewarding end to keeping on the track week after week. Ends my Q1 2020 runs on a high. And now begins the tough work ahead to beat this record, yet painfully aware that a body in the 40s is not that elastic anymore. In spite of the odds, keeping my eyes on the goal, measuring every aspect of the run, being strategic at every point of the run are all important aspects of ensuring optimal results.

Likewise, measuring and tracking progress is an important aspect of achieving anything worthwhile. This is more so the case for complex phenomena like RSSH. Incidentally, one would argue that a component of RSSH, health information, is in fact a crucial lever to serve the building of other aspects of health systems.

The global health community is once again at the cross-roads, a reminder of the perennial need to build resilient and sustainable systems for health. And you don’t have to be a subject matter expert to appreciate the gist of this conversation. At the height of the COVID-19, you only have to look at the lengths to which China, Europe and the US have had to go to know better systems for health is a must and not just a 'good to have'. At the moment, Africa seems spared of the full wrath of the COVID-19 but it remains to be seen for how long, especially as many countries will be entering winter. I fear what the consequences will be if the policy makers in our countries continue playing willy-nilly with the situation or shirk biting the bullet early enough. As they say, a stitch in time saves nine. I’m digressing. That’s an issue for another day.

The point is, I enjoyed the run today, ended it on a high while enjoying an important conversation with myself on a monumental subject in my field – resilient and sustainable systems for health.