How leaders have leveraged windows of opportunity to strengthen health systems

Gro Harlem Brundtland, who has been both prime minister of Norway and director general of the WHO, once famously wrote that the global health community has a bias. It, she said, “tends to overlook the politics of health reforms” and prefers “to focus on technical solutions.”

However, mustering the political will to strengthen a health care system is often a momentous task – and can be as challenging as, or more challenging than, developing technical solutions. With that in mind, we've collected three examples of how NGOs, civil society, and government health leaders have leveraged windows of opportunity to secure political commitments for critical health reforms.

While each of these examples varies in its details, they share one key trait – all three illustrate how important it is to take advantage of windows of opportunity to build the political will to transform health outcomes.

In Peru, the tipping point came in 2006, as the nation was swept up in a highly contested race for president – a period that coincided with a major strengthening of the country’s democratic institutions and civil society.

Civil society leaders, including the leaders of the biggest non-governmental organizations working in the country, joined forces and created the Iniciativa Contra la Denutricion Infantil (the Childhood Malnutrition Initiative, IDI) to put stunting reduction at the top of the nation’s health priorities amid the election.

“We figured we needed the highest level of political commitment, it needs to come from the president of Peru,” said Milo Stanojevic, the former country director for CARE, which helped launch the initiative. “One of the journalists suggested to me, ‘They have to commit to a target.’ We agreed to having them reduce chronic malnutrition by five percentage points in children under five, in the next five years. We called it ‘The Five by Five by Five Campaign.’ We approached the 19 candidates in the [presidential] election and once we had a couple of the candidates sign, we went around [to the others] and said ‘look, so-and-so has signed, don’t you want to sign too?’ [Shortly after], we had nine signatures and went public with a press conference … and malnutrition became a key priority for the country.”

Even after all political candidates signed the pledge, the IDI continued its work, drafting a concise 10-point policy document for the first 100 days of the newly elected president's term. Upon taking office, the new president publicly pledged to achieve a nine percent reduction in stunting over the next five years. Over the next 10 years, the country cut its stunting rate by more than half.

“I believe that an important factor in stunting reduction is that it was included in the political agenda as a priority. That made the difference when compared with the approach to other public health problems (…). The fact we had a president that talked about child health and its link with the country development was crucial,” a nutrition and child development official at the Ministry of Development and Social Inclusion told Exemplars researchers.

In Liberia, the 2014 Ebola epidemic demonstrated the dangers posed by the country’s weak health system and left government officials and their partners open to sweeping reforms. CHW advocates found an ally in Liberian President Ellen Johnson Sirleaf, who was eager to both improve the country’s dismal health outcomes and secure her legacy. Johnson Sirleaf and other health leaders quickly positioned the proposed national CHW program as a response to Ebola. In December 2014, the president announced, “We are going to make the final push to fight Ebola now by supporting community workers to get the job done.”

By May 2015, as the last Ebola cases were being identified, the Ministry of Health convened representatives from 14 ministry departments, 13 of the country’s 15 County Health Teams, and 30 partner organizations to agree on a vision and roadmap for strengthening community health. Just over one year later, in July 2016, the new CHW program – the National Community Health Assistant Program in Liberia – was officially launched. Johnson Sirleaf expedited the program's implementation with the goal of deploying 1,000 CHWs before she left office in January 2018. As it turned out, by the end of her term, more than 2,000 CHWs had been recruited, trained, and deployed.

Johnson Sirleaf’s successor inherited a functioning CHW program that provides hundreds of thousands of Liberians with lifesaving care to this day.

Lastly, in Brazil, a broad civil society movement called the Movimento da Reforma Sanitária, or Sanitary Reform Movement, leveraged the end of two decades of military rule to transform health outcomes. The movement was led by the Brazilian Health Studies Center, known by its acronym in Portuguese, CEBES, and the Collective Health Postgraduate Association, also known by its acronym in Portuguese ABRASCO, along with allied groups including the Catholic church and labor unions.

First, the movement successfully pressed for health to be included as a human right provided by the state, in Brazil’s new 1988 constitution. This provided a key foundation for a series of future reforms that transformed the health sector and the health of Brazilians – including establishing Brazil’s national health system, financed by general taxes to which the entire population is entitled, and the adoption of Brazil’s Family Health Program (Programa Saúde da Família, later renamed as the Family Health Strategy), which established one of largest CHW programs in the world.

Beyond these examples,The International Journal of Health Policy and Management has also produced an analysis on how political will for pro-health equity policies can be created, informed by eight case studies.