systems thinking for making health system work for all · systems thinking for for making health...

NO. IHAT/EBTS/OO2 June 2019

Systems' Thinking for Making Health SystemWork for All

E-Book Technical Series (EBTS) on Heal� System in Nigeria

Initiative for Health Accountability and Transparency

Systems Thinking for for Making Health System Work for All

It is our pleasure to welcome our followers to this edition of our E-Book Technical Serieson Health System in Nigeria following successful roll out of our maiden edition onTransforming Primary Health Care for Universal Health Coverage, and very positivereception and feedback. We welcome you to this edition on Systems' Thinking forMaking Health System Work for All.

Dr Mohammed Jibril Abdullahi is aHealth System and Primary Health CareSpecialist, Convener and ChiefExecutive Of�cer of Initiative for HealthAccountability and Transparency (IHAT),A Health NGO mobilizing forAccountability and Equity in Health andPublisher of E-Books Series on HealthSystem in Nigeria.

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Editorial Note Initiative for Health Accountability and Transparency (IHAT) was founded to be a STRONG AND INFLUENTIAL VOICE in the Health System, Promoting Accountability,Better Health-Equity and an End to Social Exclusion. While there are substantial efforts in the country to deliver essential healthcareservices to those who need them, progress have been slow despite availability of costhealth interventions that can prevent much of the burden of diseases. Lack of suf�cient progress is often due to varying degrees of health system failure which requires systems’ solutions, but in many cases the responses are oftentemporary remedy which have been generally considered inadequate.

In furtherance of our mission, Initiative for Health Accountability and Transparency haschosen this chronicle on Systems Thinking for Making Health System Work for All todeepen the understanding of conceptual and practical foundations of health systemsimprovement initiatives.

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Systems Thinking for Making Health System Work for All

1. What system and systems’ thinking are. 2. What system thinking means for the health system - why it is

Important to understand Health Systems Thinking Approach. 3. Illustrative Examples of Health System Strengthening Initiatives in

Nigeria 4. Practical guidelines in applying the systems perspective to design and

evaluate health systems interventions. 5. Challenges and opportunities to applying systems thinking in practical

settings and real-life situations.6. .Video clip on Systems Thinking

Contents

The Contents of this edition of E-Book Technical Series include:

Initiative for Health Accountability and Transparency is a Health Non-Governmental Organization founded to promote accountability, healthequity and mobilize towards ending social exclusion. We are Accredited by the Medical and Dental Council of Nigeria (MDCN) asContinuing Professional Development provider on Health Leadership,Management and Governance. For our course, visit http://learn.ihatresources.org Website: www.ihatresources.org; Email: [email protected] Twitter: @ihatnigeria; Facebook: https;//fb.me/ihatnigeria Contact: Suite C310, Garki Mall, Kabo Street, Damaturu Crescent, Garki2,Abuja. Phone:+2349027950751, +2348161342585, +2348072338232

About Us

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Introduction The need for robust health systems is more acute than ever and healthsystem strengthening is rising on political agendas and becoming a priorityof health reforms in many countries.

As countries commit to achieving Universal Health Coverage, it is imperativeto focus on the vehicle for delivering quality health services, improvement inhealth outcomes, achieving Universal Health Coverage, and putting an endto health inequity and social exclusion.

While there are efforts globally to deliver cost-effective interventions to thosewho need them, progress have been slow in many developing countriesdespite availability of cost health interventions that can prevent much of theburden of diseases.

Basically, lack of suf�cient progress is due to slow and ineffective coverage,widening health inequities and inadequate and underutilized cost-effectiveinterventions. In many cases, the fundamental problem lies with the failureof the health systems and its ability to deliver interventions to those whoneed them.

Weaknesses and obstacles exist across the system, including overallstewardship management issues; critical supply-side issues such as humanresources, infrastructure, and service provision; and demand side issues suchas people’s participation, knowledge and behaviour

It is often a case of systems’ failure which requires systems’ solutions but inmany health systems, the responses are often temporary remedy whichhave been generally considered inadequate.

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Strong health systems are fundamental if we are to improve healthoutcomes and accelerate progress towards the Sustainable DevelopmentGoal of Universal Health Coverage and reducing maternal and childmortality, and combating HIV, malaria and other diseases.

Systems’ thinking is crucial for any health system strengthening effort andhas huge and untapped potential:

First, systems’ thinking is important for understanding the complexity of theentire health system.

Second, systems’ thinking is essential for applying the understanding todesign and evaluate interventions can improve health and health equity.

Third, systems’ thinking can open powerful pathways to identifying andresolving health system challenges, and as such

Forth, Systems’ thinking works to reveal the underlying characteristics andrelationships of systems

This edition of our E-Book Series offers a fresh and practical approach tostrengthening health systems through "systems thinking". This powerfulconcept is used to deepen the understanding of the health system andstimulate fresh thinking among stewards of health systems, decode thecomplexity of a health system, and then applies the understanding to designbetter interventions to strengthen systems, increase coverage, and improvehealth.

Why it is Important to Understand the Health System

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What is a System? There are common examples of systems in the human body and inengineering. A system consists of a group of interconnected andinterdependent elements or parts forming a complex whole.

By the World Health Organization de�nation, a health system “consists of allorganizations, people and actions whose primary intent is to promote,restore or maintain health”

It also includes the laws, policies, strategies, plans and programs etc.

The goals of the health system are “improving health and health equity inways that are responsive, �nancially fair, and make the best, or mostef�cient, use of available resources”

The four (4) key functions of the health system

Stewardship: Encompasses the task of de�ning the vision and direction ofhealth policy, exerting in�uence through regulation and advocacy, collectingand using information.

Creating or Generating Resources: Any level of a health system needs abalanced variety of resources to function. The resources needed includephysical assets, consumable supplies, human resources andknowledge/information

Financing: Financing deals with the mobilization and allocation of funds tocover the health needs of the people, it covers revenue collection, fundpooling and purchasing

Service provision: Involves the mix of inputs needed for the productionprocess leading to delivery of health intervention. Good service provision ischaracterized by access to service, continuity of service, comprehensivenessand coordination of care

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The performance of the health system is determined by the way thesefunctions are organized

Objectives of the Health System

The Health System Has 3 Main Objectives:

1. Improve the health status of the population by lowering the morbidityand mortality rates and reducing inequalities

2. Protect the population against the �nancial risk of health problems3. Respond to the citizens demands and needs

Stewardship in the Health System

Health Systems Thinking Why Systems Thinking is a “Sound Choice”

“Healthcare delivery has commitment, resources, and powerful low costinterventions. However, the power of the interventions is not matched by thepower of health systems (capacity) to deliver them to those in greatest need,on an adequate scale, in time….”

Stewardship in the Health System refers to the wide range of functionscarried out by governments as they seek to achieve national health policyobjectives. At the national level, health system stewards, include the policy-makers and leaders responsible for providing strategic direction to thesystem and its concerned stakeholders.

These are typically from government (e.g. senior Ministry of Health of�cials, adistrict commissioner, a hospital administrator), but may also include otherstakeholders, e.g. civil society and the private sector. System stewards are"information providers and change agents, linking the general public,consumer groups, civic society, the research community, professionalorganizations and the government in improving health of the people in aparticipatory way.

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Health Systems Thinking Approach Health Systems Thinking Approach is the application of scienti�c or logicalinsights to understand the elements that in�uence health outcomes;models the relationships between those elements; and alters design,processes, or policies based on the resultant knowledge in order to producebetter health.

It is the use of systems perspective to understand how health systembuilding blocks, contexts, and actors act, react and interact with each otherin designing, delivery and evaluating health services and interventions.Systems thinking places high value on understanding context and lookingfor connections between the parts, actors and processes of the system

Systems are dynamic architecture of interactions and synergies and systems’thinking works to reveal the underlying characteristics and relationships ofsystems.

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Systems Thinking for Strengthening the Health System

Advantages of the Approach1. It provides a deliberate and comprehensive suite of tools and

approaches to map, measure and understand health system dynamics.2. It connects intervention design and evaluation more explicitly, both to

each other and to the health system framework.3. Systems’ thinking can accelerate the strengthening of systems better

able to produce health with equity and deliver interventions to those inneed.

4. Application of systems thinking does not mean that resolving problemsand weaknesses in the health system will come easily, but it will identifywith more precision, where some of the true bottlenecks andchallenges lie, thus helping to:

5. Explore these problems from a systems perspective;6. Show potentials of solutions that work across sub-systems;7. Promote dynamic networks of diverse stakeholders;8. Inspire learning; and9. Foster more system-wide planning, evaluation and research.

10. Increase the likelihood that health system strengthening investmentsand interventions will be effective.

11. Provide opportunity for the actors and components of the system totalk to each other from within a common framework – communicating,sharing and problem-solving.

WHO Health System Building Blocks WHO’s framework of health system essentially describes six clearly de�nedHealth System Building Blocks that together constitute a health completesystem. The building blocks serve as a convenient device for exploring the healthsystem and understanding the effects of interventions upon it - interventionmight �ow through, react with, and impact on these sub-systems in a crucialmanner, thus providing opportunity to apply systems thinking in a positiveway.

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The dynamic architecture and interconnectedness of the healthsystem building blocks

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Building Blocks of the Health System

1. Service delivery: including effective, safe, quality personal and non-personal health interventions that are provided to those in need, whenand where needed (including infrastructure), with a minimal waste ofresources;

2. Health workforce: responsive, fair and ef�cient given availableresources, circumstances, and available in suf�cient numbers;

3. Health information: ensuring the production, analysis, disseminationand use of reliable and timely information on health determinants,health systems performance and health status;

4. Medical technologies: including medical products, vaccines and othertechnologies of assured quality, safety, ef�cacy and cost-effectiveness,and their scienti�cally sound cost-effective use.

5. Health �nancing: raising adequate funds for health in ways that ensurepeople can use needed services, and are protected from �nancialcatastrophe or impoverishment associated with having to pay for them;

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Leadership and governance: ensuring strategic policy frameworkscombined with resources; effective oversight, coalition building,accountability, regulations, incentives and attention to system design.

It is critical that the role of people is clearly understood, not just at the centreof the system as mediators and bene�ciaries but as actors in driving thesystem itself.

This includes their participation as individuals, civil society and stakeholdernetworks, and also as key actors in�uencing each of the building blocks, ashealth workers, managers and policy-makers. Placing people and theirinstitutions in the centre of this framework emphasizes WHO’s renewedcommitment to the principles and values of primary health care – fairness,social justice, participation and sectoral collaboration.

The People

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The building blocks alone do not constitute a system. It is the multiplerelationships and interactions among the blocks – how one affects andin�uences the others, and is in turn affected by them – that convert theseblocks into a system. As such, a health system may be understood throughthe arrangement and interaction of its parts, and how they enable thesystem to achieve the purpose for which it was designed.

Aims and Desirable Attributes of the Building Blocks

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1. i. Decentralization and Devolution of PHC to the States/LGAs ii. PHC Governance Reform - PHC Under One Roof iii. PHC Managerial System through the Committee System iv. Civil Society Participation iii. Licensure, Accreditation, Registration of Providers iv. Training and Continuing Professional Development on Leadership andManagement v. Budget and Project Tracking vi. Patients' Bill of Rights (PBoR)

2.Financing i. User Fees ii. Conditional Cash Transfers (demand side) under the SURE P MCH iii. Pay-for-Performance (supply side) - under the World Bank supportedNigeria State Health Investment Project (NSHIP) iv. National Health Insurance and ongoing decentralization. v. Provider �nancing modalities vi. Sector Wide Approaches (SWAps) and basket funding .

3. Human Resources i. Integrated Training on Service Delivery. ii. Quality improvement Initiatives iii. Performance Management iv. Incentives for retention or remote area deployment

4. Information i. Shifting to electronic (versus manual) medical records ii. Integrated data systems & enterprise architecture for HIS design iii. Coordination of national household surveys (e.g. timing of data collected)

Some Types of System Level Interventions Implemented in Nigeria

Governance

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5. Service delivery i. Training of service providers on Life Saving Skills (LSS and its variants),Integrated Management of Childhood Illnesses (IMCI) ii. Strengthening of Referral linkages - procurement and distribution ofambulances and creation of community transport system. iii. Approaches to ensure continuity of care iv. Integration of services versus centrally managed programmes v. Community outreach versus �xed clinics vi. Community Directed Distribution Initiatives - Ivermectin, ITN, FPCommodities, Food/Nurition Supplements including the School FeedingProgramme. vii. Solar Lighting in Provider Facilities

6. Medical products, vaccines and technologies i. Essential Drug Programme and Drug Revolving Fund ii. Supply of Delivery and Mama Kits under the Midwives Service Scheme iii. Supply chain management iv. Integrated delivery of products and interventions .

7. Multiple building blocks i. Infrastructural renewal at all levels of healthcare ii. Health Sector Reforms - Basic Health Care Provision Funds iii. LGA health system strengthening iv. Implementation of Water, Sanitation and Hygiene (WASH) initiative

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Intervening at high leverage points in the system A health system is vulnerable to certain leverage points at which anapparently small intervention can result in substantial system-wide change.For instance, a seemingly minor event (e.g. freezing health worker salaries)may tip the system into large crisis (e.g. provoking a health worker strike).

In selecting interventions, it is important to identify leverage points.However, often at times, interventions are selected based on intuition andthe prevailing development paradigms. Available evidence suggests that high leverage points are located in twosub-systems – governance and information. These are two of the healthsystem’s building blocks, that receive the least attention from health systeminterventionists. Missing information �ows are often identi�ed as the mostcommon cause of system malfunction, and incapable or overstretchedgovernance structures can contribute to less than optimal performance andcohesion among the building blocks and the system as a whole.

As part of national efforts to accelerate progress towards the attainment ofof the MDGs, particularly between 2000 and 2015, Nigeria initiated severalhealth system strengthening initiatives. Examples of some �agshipprogrammes include the following:

1. Millennium Development Goals Debt Relieve Grant supportedMidwives Service Scheme and the Subsidy Reinvestment andEmpowerment Programme Maternal and Child Health (SURE P MCH)

2. Millennium Development Goals Debt Relieve Grant supported PrimaryHealth Care Infrastructural Renewal

3. Millennium Development Goals Debt Relieve Grant supported NHISfree MCH programme

4. Millennium Development Goals Debt Relieve Grant supported MCHAmbulance programme

Illustrative Examples of Health System Strengthening Initiatives in Nigeria

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1. Infrastructural Renewal - to improve geographical access to increaseservice utilization, select primary health care facilities were rehabilitated andnew ones built in under-served areas. 2. Human Resources Intervention - to improve skilled birth attendants,midwives and community extension workers were deployed to selectprimary health care facilities. Midwives constitute the backbone of Maternaland Child Healthcare in Nigeria. 3. Supply of Equipment and Essential Drugs - to improve quality of care,essential equipment including delivery and mama kits, drugs and supplieswere distributed to select facilities 4. Health Financing - to improve �nancial access, free MCH services andConditional Cash Transfer were implemented in select facilities 5. Capacity Building - to improve the skills and knowledge of providers,midwives, community health workers and doctors were trained on LifeSaving Skills and Integrated Management of Childhood Illnesses 6. Community Linkage, Engagement and Empowerment - to improvecommunity participation and ownership, community managerial processwere instituted in the wards and communities 7. Strengthening the Referral Linkage - to improve access to emergencycare, ambulances were procured and distributed to select referral healthfacilities under the SURE P MCH.

Speci�c interventions implemented under the illustrated initiatives includethe following:

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Health Workers Health Facility

Renewal

Training onEBOC Ambulances

PatientsDrug Supplies

CommunityPatnership

Conditional CashTransfer

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Practical Guidelines in Applying the Systems Perspective to Design and Evaluation of Health Systems Interventions

The Ten Steps to Systems Thinking

WHO has provided a single people-cantered framework combining sixclearly de�ned building blocks or sub-systems that, taken together,comprise a complete health system? Understanding the relationships anddynamics among these sub-systems is crucial in the design and evaluationsystem-level interventions and interventions with system-wide effects.

“Ten Steps to Systems Thinking” has been developed to provide guidance onapplying the systems perspective.

I: Intervention DesignStep 1: Convene stakeholders: Multi- disciplinary and multi-stakeholderinvolvement is critical throughout the “Ten Steps to Systems Thinking”.Identify and convene stakeholders representing each building block, plusselected intervention designers and implementers, users of the healthsystem, and representatives of the research community To legitimate the convening process, this should start with or be endorsed ata high of�cial level in the Ministry of Health. At a minimum, at least oneknowledgeable representative of each sub-system (or building block) isrequired, plus at least one representative of the research community andone from a funding partner.

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Step 2: Collectively brainstorm: This step is critical in identifying all possiblesystem-wide effects of the proposed intervention. It is important to ensurethat right mix of stakeholders is convened to discuss the proposedintervention, they anticipate and hypothesize all rami�cations of theintervention within each building block, while also thinking through themany interactions among the sub-systems. Front-line implementers (possibly those representing the service deliveryand health workforce building blocks) will deliberate on possible system-wide effects of the proposed intervention respecting systems characteristics(feedback, time delays, policy resistance, etc.) and systems dynamics.

Step 3: Conceptualize effects: Develop a conceptual pathway mapping howthe intervention will affect health and the health system through its sub-systems In anticipating possible positive and negative effects in the other health sub-systems, it is clear that any major intervention could have importantunknowns. In this step, a smaller design team takes the tabular output anddevelops a concept pathway mapping how the intervention will affect healthand the health system through its sub-systems, with particular attention tofeedback loops. The conceptual pathway of dynamic interactions shows how theintervention will trigger reactions in the system, and how the system mightrespond. Concept mapping and systems dynamic modelling are possibletools to use in this step.

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Step 4: Adapt and redesign: Adapt and redesign the proposed interventionto optimize synergies and other positive effects while avoiding or minimizingany potentially major negative effects. In this �nal design step, the initial concept for the intervention will likelyneed to be adapted or re-designed in light of the �rst three steps to optimizesynergies and other positive effects while avoiding or minimizing anypotentially major negative effects. Based on the expected or hypothesized causal pathway of dynamicinteractions and the table of potential effects brainstormed the stakeholdersmay re-think their intervention design to bundle in additional designelements to mitigate important negative effects, maximize previouslyunappreciated potential synergies or avoid any possible obstacles.

II: Evaluation Design Decide on indicators that are important to

track in the re-designed intervention (from process to issues to context)across the affected sub-systems. Once the indicators have been agreed upon, potential data sources for theindicators should also be agreed upon.

Step 6. Choose methods: Decide on evaluation methods to best track theindicators – process evaluation, effects evaluation, economic evaluation orcontext evaluation.

7. Select design: Choose the evaluation design that best manages themethods and �ts the nature of the intervention

8. Develop plan and timeline: Collectively develop an evaluation plan andtimeline by engaging the necessary disciplines

9. Set a budget: Determine the budget and scale by considering implicationsfor both the intervention and the evaluation partnership

Step 5: Determine indicators:

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10. Source funding: Assemble funding to support the evaluation before theintervention begins.

There are many challenges to applying a systems perspective instrengthening the health system, ranging from prevailing developmentparadigms to issues around intervention implementation.

However, four speci�c challenges in applying a systems perspective havebeen well recognised, and each of the challenges can be converted intoopportunities to strengthen health systems.

1. Aligning policies, priorities and perspectives among donors andnational policy-makers

2. Managing and coordinating partnerships and expectations amongsystem stakeholders.

3. Implementing and fostering ownership of interventions at sub-nationallevel

4. Building capacity at all levels to apply a systems analytic perspective

Challenges and Opportunities in Applying a Systems Perspective

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Aligning policies, priorities and perspectives among donors and nationalpolicy-makers There is a tension in many developing country health systems between theoften-short-term goals of donors who require quick and measurable resultson their investments and the longer-term concerns of health systemsystems stewards. Over the years, the tension has heightened due to thesurge in international aid for particular diseases which has come withambitious coverage targets and intense scale-up speci�c efforts orientedmuch more to short- than long term goals. In many countries, harmonizingthe policies, priorities and perspectives of donors with those of nationalpolicy-makers is an immediate and pressing concern. It is increasingly argued that the selective nature of these fundingmechanisms (e.g. targeting only speci�c diseases and subsequent supportstrategies) may undermine progress towards the long-term goals ofeffective, high-quality and inclusive health system.. Even where this fundinghas strengthened components of the health system speci�cally linked toservice delivery in disease prevention and control – such as speci�c on-the-job staff training, available information suggests that the selective nature ofthe health systems strengthening strategies mostly been unsustainable,interruptive, duplicative, putting great strains on the already limited andover-stretched health workforce. Many of these issues have been recognized internationally, and a number ofdonors have agreed to better harmonize their efforts and align with country-led priorities – as outlined in 2005’s Paris Declaration on Aid Effectiveness.

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Consequently, several funding bodies such as the Global Alliance forVaccines and Immunization (GAVI) and the Global Fund to Fight AIDS,Tuberculosis and Malaria (GFATM) are giving health system strengtheninggreater prominence within their disease-speci�c initiatives. This has givengreater �exibility using their funds to strengthen health systems, even if theystill require that activities are tightly linked to their speci�c health outcomesof interest. The “Ten Steps Systems Thinking” can usefully guide and frame discussionsbetween system stewards and donors, and lay the groundwork for astrengthening initiative that all can agree on.

Building and supporting partnerships is at the heart of applying a systemsperspective to strengthening health systems, managing and coordinatingthose partnerships – and their expectations – when designing interventionsand appraising evaluation �ndings can pose a daunting challenge. Different partners will have different mandates, priorities and perspectives,all of which may be legitimate. The particular challenge facing healthsystems stewards lies in effectively managing stakeholder participation andcontributions to the design and evaluation of these interventions, ensuringtheir expectations are met and the process is “owned” withoutcompromising objectivity or the needs of the system itself. Many donors are often caught between their need to demonstrate rapidprogress and success in the implementation of funded interventions andtheir commitment strengthening the health systems of recipient countries. Developing and maintaining a culture of open and effective partnershipsamong a variety of national and international stakeholders is sensiblepractice for health system stewards. They can provide effective leadership byemphasizing the systems perspective for interventions in the health system;by fostering open discussions and transparency in expressing competingobjectives and mandates; and by providing the right incentives for datasharing and reconciliation.

Managing and coordinating partnerships and expectations among systemstakeholders.

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Implementing and fostering ownership of interventions at sub-national level One of the main challenges facing health system strengthening efforts ispolicy resistance. The behaviour of "street-level” policy implementers or“street level bureaucrats” – service providers who work at theimplementation end of policies that they have not designed is welldocumented. They use the degree of relative autonomy that they possess to interpretthese policies and to revise the guidelines according to their own prioritiesand wish and frustrate many top-down decision-making processes due tolack of local ownership of the policy. Inadvertently, some stakeholdersessential to implementing an intervention may be left out in its design. Overcoming the resistance of these implementers comes withunderstanding and incorporating their perspective – early and adequately. Incalling for a multi-stakeholder approach to the design and evaluation ofsystem-level interventions, the systems perspective seeks to give voice tothose who are absolutely critical to implementation process. Indeed, multi-stakeholder involvement is a crucial element throughout the“Ten Steps to Systems Thinking”: identifying and involving key stakeholdersconcerned with or affected by the intervention’s implementation is essential.

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Capacity constrains are common in health system strengthening efforts:limited multi-disciplinary technical skills compounded by weak researchpartnerships and collaborations; poor quality and availability of data, lack ofinnovative research methods; and limited skills in building and managingpartnerships. These problems are deepened by the fact that resources for capacitybuilding are still mainly driven by international sources, providing little or noleverage for developing countries on the selection of priorities for research orskill development or on proportional use of resources for capacity building. However, the ability of country teams to undertake research and analysetheir own data is crucial for understanding what works, for whom, and underwhat circumstances – and for monitoring and addressing problems.

Building capacity at all levels to apply a systems analytic perspective

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Referrences

1. WHO SYSTEMS THINKING for Health Systems Strengthening (2009)2. IMPROVING HEALTH SERVICES AND STRENGTHENING HEALTH

SYSTEMS: ADOPTING AND IMPLEMENTING INNOVATIVE STRATEGIESAn exploratory review in twelve countries

3. Primary health care: report of the International Conference o onPrimary Health Care, Alma-Ata, USSR, 6–12 (Health for All Series No. 1).

4. Don De Savigny, Fixing Health Systems5. Caren C. Rossow, Douglas E. Anderson, and James Johnson, Health

Systems Thinking6. 4. National Primary Health Care Development Agency, National

Primary Health Care Development Guidelines and Training Manual2012

7. National Primary Health Care Development Agency, MDG-DRF FundedMidwives Service Scheme (Concept, Process and Progress) 2012,

8. National Primary Health Care Development Agency, Nigeria StateHealth Investment Project (NSHIP), Project Implementation Manual,2016

9. National Primary Health Care Development Agency, SURE P MCHProject Implementation Manual, 2015

10. National Primary Health Care Development Agency, Ward HealthSystem Implementation Guide, 2001

11. Nigeria, Millenium Development Goals, End-Point Assessment Report,2015

WATCH THE VIDEO CLIP ON HEALTH SYSTEM THINKING

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https://youtu.be/vnhVwWmEoHk

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https://youtu.be/vnhVwWmEoHk


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