The importance of effective leadership and good governance is increasingly recognized and has been raised at almost all major global health fora in the last decade. Most recently, the current Ebola epidemic in West Africa has demonstrated clearly the central role that leadership—at all levels, plays in determining how successful health systems are in optimizing available resources in order to produce and deliver quality services to the population they serves. Over the past 8 years, discussions on strengthening health systems have drawn a lot of attention to the health systems building blocks as described in the 2007 WHO Framework for Action. A common criticism of this framework however, is that it oversimplifies the complexity of health systems. In particular, this depiction of the system conceals the web of non-linear and dynamic interactions that bring the building blocks as a system together and connect the system with the people who constitute and use it. The greater interest in health systems and recent efforts to strengthen them have revealed the important role that these interactions play in enabling the effectiveness of such systems as well as the devastation that can unfold when these interactions fail. Intervening at the systems level, therefore, requires an understanding of both the processes through which interactions occur and of how systems learn. The responsiveness of these types of systems, therefore, depends upon the effectiveness of the mechanisms through which ‘intelligence’ is transformed into knowledge, and the way in which it is used to inform a coordinated systems response. This transformative process is in essence a process of learning and the efficiency of the system to respond and adapt – its ‘resilience’– is directly correlated to its learning capacity. Learning objectives of this session are: • Familiarize participants with the limitations of the concept of 6 health system building blocks; • Introduce the concept of a “learning health system” to improve the performance of national health systems; and • Discuss the role of effective leadership in designing and managing the health systems.

Ensuring equitable access to quality maternal health care is an essential element of all efforts to reduce maternal morbidity and mortality (MMM). While there is consensus on the most effective clinical interventions to address the main direct causes of MMM, their delivery at the community and institutional levels is still a challenge. Achieving significant and sustained progress in maternal health requires understanding the essential barriers to access and the factors that contribute to poor quality of care as well as the most critical elements of quality of care conceptual frameworks and key strategies to strengthen health systems. Learning objectives: 1. Learn about existing safe and effective interventions to reduce maternal mortality and morbidity (MMM). 2. Understand the importance of health systems-related factors in the determination of MMM and discuss the main changes that need to be introduced to enable health systems to improve maternal health. 3. Identify the research gaps that need to be filled in order to increase the arsenal of clinical and health system interventions for the reduction of MMM. 4. Discuss comprehensive quality of maternal health care (i.e. technical and interpersonal). 5. Discuss underuse and overuse of interventions as an indication of poor quality of care using cesarean section as a case study.

The session will comprise two interactive lectures either side of a short group exercise. In Part 1 the aim will be to explore what we might mean by the term quality care and see how its definition has strategic implications for how we might structure efforts to improve it. This will lead into a brief consideration of how we might assess or evaluate quality care in one core area taking the Institute of Medicine, 2001 definition ‘The degree to which health services for individuals and populations increase the likelihood of desired health outcomes and are consistent with current professional knowledge. ’In Part 2 the aim is to consider the links between improving quality of care and behavior change of health professionals. Often the focus of thinking on quality is on standards, regulation, or accreditation or on quality improvement techniques. However, ultimately delivery of quality services is the result of individual, team and organizational behavior. Once again, however, there is a dependence on information that is both the form of assessment and often an intervention. Learning objectives of this session are: • To engage people in thinking carefully about the different elements of quality and the importance of defining the scope of actions to improve quality • To illustrate how quality may be assessed and the care that should be taken in defining measurement approaches and interpreting results • To recognize that improving quality of care is about change and the behavior of individuals and groups

The best measure of a health system´s performance is its impact on health outcomes. A focus on health systems improvement must include the development of methods for identifying priority health problems and monitoring process and outcomes at the facility and population level. Important steps in this process are: 1) selection of indicators that can serve as measures of policy performance and 2) making maximum use of existing routine and non-routine sources of data.

Tanzania has observed mixed progress in maternal, newborn and child survival specifically with good progress in child survival resulting in attainment of MDG 4 target before 2015, however there has been slow progress in maternal and newborn indicators. The case study explores the reasons for the accelerated achievements in child survival, and for the slower progress in maternal and newborn survival. The team applied the evaluation framework which focused on change in impact (mortality), assessing coverage (outcome), equity, outputs and inputs such as health system investments, whilst accounting for wider changes in context. The four technical working areas for Countdown to 2015 (coverage, equity, financing and health system and policy) were incorporated into this framework. The session will be used to share the findings of the analysis and the use of the case study findings to inform policy and strategy development and implementation to accelerate progress in the area of maternal and newborn survival and sustain the gains in child survival. Learning objectives for this session include: • To share experience on how to apply the evaluation framework to document progress in maternal newborn and child health • To inform participants on how to use the evidence based information to inform policy and programme development to accelerate progress in maternal, newborn and child survival and improve accountability for women and children