What if one of the most familiar ideas in global health is pointing us in the wrong direction?
We talk constantly about the last mile – of vaccine delivery, primary health care and remote communities. But last from whose perspective?
For a mother giving birth, or a health worker travelling a difficult road, this is the first mile. And that distinction matters.
From a systems perspective we usually ask: How do we integrate programmes, align budgets, and deliver our interventions all the way to the last mile?
But starting with citizens, the questions become: Why did we miss this family? Why is this health worker absent, and this facility struggling to deliver care?
Working alongside governments in Mozambique, Nigeria, Pakistan and the DRC, we've found that solving practical delivery problems can change how entire health systems work.
In Tete Province, Mozambique, different programmes visited the same communities with separate teams, vehicles, plans and budgets, while others went unreached. You could call this an integration problem. But citizens ask a simpler question: why aren’t we being reached?
In the DRC, community health workers visited families, yet some children still missed vaccination. We asked: How could one programme use what another already knew?
And in Sindh, Pakistan, where health facilities struggled to deliver basic care, it was about making sure senior leaders knew exactly which facilities were struggling, why, and what could be fixed by next week.
These experiences have shaped how we think about SystemSolving. Start with the problem as people experience it. Find the friction. And work with governments to solve it.
“Integrate health services” is an instruction almost nobody can act on.
But “how can different programmes reach more communities with the resources they already have?” is a question people can work together to answer. It moves people from defending structures and interests, to working out what problems need solving.
That doesn’t always mean creating something new. New tools and systems have their place, but often the answers are already there. The challenge is making better use of them.
One programme may have vehicles, another may know where missed children live, while a third has trusted community workers. District managers may already have effective planning tools.
So we ask: What stops us from using them? The obstacle may be a budget, mandate, reporting requirement or even an incentive. Sometimes it is simply the permission to work together.
The problem isn’t always a lack of resources. Often, it’s a lack of connection. But more connection isn’t always better. The trick is knowing exactly what needs to come together to solve the problem – and what doesn’t.
Even connecting things is not enough. The real test comes through delivery: trying things, learning what works and adapting. Shared success builds confidence, and gives governments something tangible to improve and scale.
This is where practical health sovereignty becomes real. It’s not just about governments controlling their own financing and governance. It’s about being able to identify and solve local delivery problems. Our job is to help governments do that, so progress lasts.
We started by asking how to reach the last mile, but now we approach it from the first. When you solve from a citizen’s perspective, something changes. Missed children become visible. Wasted journeys become obvious. A donor funded programme becomes a resource rather than a silo. Integration stops becoming an objective and becomes the result of solving the right problems.
We didn’t set out to integrate health systems. We started with the people they were failing to reach. And before we knew it, the system had begun to change.
SystemSolving in practice
Start with the problem. Build on what works. Connect only what helps. Learn from the results. Build government’s ability to solve and scale.
This is how Acasus works alongside governments: solving immediate delivery problems while building the skills and systems to keep improving services at scale.