Nepal Capacity Enhancement Seminar

Health systems experts Christopher Potter and Richard Brough have years of experience working in and analyzing organizations around the world. They shared their insights and the systems building tool they developed, the capacity pyramid, with Nepal’s Ministry of Health and Population staff and development partners earlier this year. Through a one-day seminar, supported by MLI and attended by more than 50 participants, the capacity pyramid was introduced as a way to help improve the health system’s functional capacity.

While health officials and donors in developing countries often focus on training and provision of equipment as ways to expand and improve services, Potter and Brough argued that other aspects of health systems management are equally or even more important. The basis of a health system, said Potter, who directs the global health module within Cardiff University’s Masters in Public Health program, are the “soft” aspects of capacity development and enhancement including local context, prevalent institutional culture and power dynamics. Understanding issues in those areas will make the entire system more efficient, he explained. Potter urged participants to consider an approach that encompasses the entire organization or thematic area. “In my experience in many countries, people were trained pretty well—they had skills, they had abilities, but the system they were working in often prevented them from using those skills effectively,” he said in an interview.

Under the capacity pyramid, first set out in a 2004 paper, structures, systems and roles constitute the stable bottom of the system, staff and infrastructure on the next level, skills on the following level, with tools making up the top tier. Supplying skills and tools is “easy to do” explained Brough, head of strategic planning and development at the Infectious Diseases Institute at Makerere University in Uganda. But, he said, “If you ignore those lower levels, inputs at the higher levels are likely to be relatively ineffective.”

The pyramid enables managers to consider all the elements of capacity enhancement and identify problems early on. Potter and Brough like to view the pyramid as a prism. “It helps to break light up as a prism would break light up into its different constituent parts. Using it gives an opportunity to look at the system…it enables them to think through the different elements that are required to actually produce a health program in the field,” Potter said.

Many developing countries have similar organizational problems, such as lack of skilled supervisors, ineffective logistical systems and out of date bureaucracies, that can be identified and mitigated with a thorough analysis and concerted effort to improve efficiency. “Very often what’s needed in developing countries is a much better appreciation of the system,” Potter said. “Unless the system is understood, very often the interventions are ineffective.”

Potter used as an example the provision of training to health workers for a procedure that involves new equipment, but the equipment doesn’t arrive until months later. By that time, 20% of the staff has changed leaving few people who know how to use it and the equipment arrives without spare parts or training manuals. “That’s what we mean by systematic problems,” he said. Identifying the problem and forging a system that gets components working together would greatly improve health services delivery, he said.