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The Gateway to Inclusive Health Systems? Localization

December 7, 2023

Localization 2.0: Three Ways to Move from [Old] Rhetoric to Future Results

A one-size-fits-all approach to development doesn’t work. It ignores how unique cultural, social, and economic factors affect health outcomes. Localization, which can take these factors into account, promotes a strategy in which policymakers, civil society organizations, and practitioners work together to provide services that are relevant, accessible, and culturally acceptable to specific communities. While co-design, co-implementation, and co-monitoring practices aren’t new, responding to evolving health systems needs and our partners’ capacity requires us to shift our approaches to be locally informed, owned, driven, and sustained. We must examine our practices, adapting them to align with the dynamic of a local health system’s landscape.

Building Bridges Between Policymakers and Communities

Traditional localization efforts involve various actors across different levels of health systems. However, meaningful engagement of communities to inform national policies merits more comprehensive and nuanced approaches. Building institutions, networks, and platforms represents a strategic initiative for bridging the disconnect between policymakers and communities. This empowers local and national stakeholders to take the lead in creating and implementing interventions that harmonize policy and practice.

Striking a balance between local agency and national alignment is pivotal to ensure interventions address community nuances while adhering to regulatory and policy frameworks. In Ukraine, the Local Health Systems Sustainability (LHSS) project improved the telemedicine system during the conflict by strengthening national integration and addressing local cultural and health system challenges.

The Abt Global-led team formed an interagency working group that united stakeholders and experts through a transparent policy dialogue platform, fostering trust and a shared telemedicine vision informed by health workers’ and patients’ inputs through interviews and feedback. The technical workplan group facilitated a comprehensive telemedicine assessment, suggested legislative amendments, and developed organizational and technical models. The work ultimately led the government to adopt and approve the telemedicine strategy now providing access to medical services through more than 1,250 providers and 325 health facilities across Ukraine.

Powering Research Through Local Perspectives

Communities should play a multifaceted role in health systems, participating not only in the design and implementation of their own agendas and interventions but also generating the evidence that informs them. Equitable research—including monitoring, evaluation, and learning (MEL)—ensures that local perspectives and priorities direct both research and program agendas. What does this mean at a practical level? Incorporating community insights in framing research questions and methodologies and more importantly sharing and interpreting data locally.

In Mozambique, the USAID-funded Efficiencies for Clinical HIV Outcomes (ECHO) project is set to exceed ambitious 95-95-95 clinical targets through a powerful combination of hyperlocal MEL approaches and data-driven adaptive management that’s bringing policy and practice together. The 95-95-95 target means that 95% of all people living with HIV know their HIV status, 95% of all people with diagnosed HIV infection receive sustained antiretroviral therapy (ART), and 95% of all people receiving ART have viral suppression by 2025.

Localized data analysis and decision-making enables differentiated service delivery models at the community level. The models generate the results and proof needed to inform national policy changes that have expanded access to ART and led to dramatic declines in treatment dropouts. In a single quarter, the number plunged 94 percent, from 10,210 to 632, in Tete, and 70 percent, from 2,175 to 648, in Niassa. More patients staying on treatment means more people living happy, productive, and healthy lives with a greatly reduced chance of passing HIV to others. 

Reimagining Localization Through Systems Thinking

By adopting a systems-oriented lens, localization emerges as a vehicle to ensure not only the effectiveness but also the sustainability and responsiveness of interventions. Blending systems and localization approaches enables a comprehensive framework for addressing the complex dynamics within health systems. Understanding this forms the basis for interventions designed for specific contexts and anticipates the potential for unintended consequences.

In Nepal, localized systems-tailored strategies championed by Abt through USAID's Strengthening Systems for Better Health (SSBH) Activity led to success and sustainability. As Nepal transitioned to federalism and shifted from centralized structures to regional and local empowerment, SSBH engaged with local partners to help develop community-driven health solutions. SSBH's partnership with municipal governments used data-driven decisionmaking to achieve remarkable results:

  • Institutional delivery of newborns rose from 76% to 84%.
  • The number of pregnant women who had four antenatal care visits increased from 56% to 73%.
  • Delivery of newborns by skilled birth attendants jumped from 65% to 93%.

SSBH's commitment to locally led, holistic, data-driven planning and strengthening of health interventions enhanced equitable and accountable governance and improved health outcomes. Localization also proved indispensable during the COVID-19 crisis, bolstering the emergency response while bridging efforts across the federal, provincial, and municipal levels in Karnali and Lumbini provinces.

As health systems face evolving and complex challenges, we don’t need to invent new solutions so much as plan to innovate and expand on what we know works. These adaptations have the potential to make health systems more resilient, equitable, and community-centered—ensuring better health for all.

Stay tuned for the next reflection in this series, where we delve deeper into other approaches for addressing health system quality and resilience.

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