Value and Challenges of Health Systems Strengthening
Value
There is strong global consensus on the need to strengthen health systems. “Weak health systems” are often cited as core drivers of high mortality and morbidity from disasters, poor health outcomes of a population, and the spread of outbreaks and epidemics. Health sectors in crisis-affected states are often overwhelmed with external actors with jostling agendas during acute and immediate postcrisis periods. It is imperative to prioritize during this time the effectiveness and integrity of the state’s health system, both during and after the crisis.
Health development specialists concerned with addressing specific diseases or health conditions should also have a keen interest in health system integrity and functioning; the success of disease-specific interventions depends largely on the health system’s capacity to implement them. For example, conflict- and crisis-affected states with weak institutions struggled in recent years to make progress in health-related Millennium Development Goals such as lowering infant and maternal mortality, and reducing the prevalence of human immunodeficiency virus/acquired immunodeficiency syndrome, tuberculosis, and malaria. In contrast, stable countries with effective health systems made relatively rapid progress. Current struggles to end the Ebola outbreaks in the Democratic Republic of Congo, where trust in the health system is low after years of neglect of the health needs of the population, continued armed conflict, and political turmoil, illustrate this problematic dynamic. Initiatives to improve health security will hinge on the effectiveness of health systems.
Challenges
Despite its acknowledged importance, there are still significant variations in definitions, implementation frameworks, and accepted evidence for health systems strengthening (HSS). Many health systems lack the capacity to measure or understand their own weaknesses and constraints, which limits policy-makers’ ability to identify and address the most critical needs.
A History of Health Systems Strengthening
The definition, conceptualization, boundaries, and responsibilities of health systems have featured in global health debates for more than four decades. The nature and focus of these descriptions often served the interests of those proposing them, reflecting biases in economics, political models, and other domains.
Modern concepts in HSS have been strongly influenced by the Alma-Ata Declaration of 1978, which declared health as a human right and proposed that states and global health authorities focus on primary care as the foundation of health systems. The Declaration adjured governments to address “essential health care based on practical, scientifically sound, and socially acceptable methods and technology made universally accessible to individuals and families.” It avoided specifying which health services met these criteria, but aimed to shift the focus of health systems away from specialist-driven boutique and hospital-based care for those who could afford it to community-based health services.
Critics of Alma-Ata felt its goals were too idealistic and vague. The year following Alma-Ata, the Rockefeller Foundation convened a follow-up summit in Belagio, Italy, to identify what core services health systems needed to provide. Termed “Selected Primary Care,” the summit specified four health services that should be universally available—growth monitoring, oral rehydration, breastfeeding, and immunization, but did not address which authorities would be responsible for implementation.
Thus, although Alma-Ata addressed the philosophical reasons states should be responsible for health systems, and the breadth of coverage and community focus, it did not specify health services for prioritized delivery or how it should be funded. Similarly, although Selected Primary Care identified a narrow set of universal programs to provide the maximum community value, it did not describe how and where these services would be provided, or by who.
Later models addressed the functional components of health systems. Frenk and Murray (2000) proposed that health systems are composed of four functions: financing, provision of health services, generation of nonfinancial resources (workforce, knowledge, infrastructure), and stewardship. They also specified three goals of health systems: improved population health; responsiveness of the health system to the expectations of the population; and financial fairness, including risk from medical bankruptcy. Mills and Ranson (2001) elaborated on these components, identifying relationships among stakeholders as important factors for success.
In 2008, Roberts et al. (“Getting Health Reform Right”) attempted to create a predictive, operational model of health systems to guide policy makers in health system reform ( Fig. 17.1 ). The World Bank adopted this model as the “Flagship Framework,” conceiving health systems as a control panel with five control knobs—financing, payment, organization, regulation, and persuasion—that can be adjusted to achieve desired outcomes. For example, policymakers might consider changing the ‘finance’ control knob from a general tax to social insurance scheme to meet certain goals. The model predicts the effect setting changes would have on health outcomes, including patient satisfaction and risk protection. This model provided two notable benefits. First, it moved beyond a descriptive framework to a mechanism for tailored action. Second, it offered researchers a better conceptual platform to analyze performance differences among health systems.
About the same time as Roberts’ publication, the World Health Organization (WHO), concerned about the widening gap between the growing number of effective medical interventions and the low capacity of health systems to deliver them, proposed the “building block” model of health systems. This framework describes health systems as comprised of six “building blocks” or inputs: service delivery; health workforce; information; medical products, vaccines, and technologies; finance; and leadership, governance, and stewardship. The goal was to help researchers and policymakers more effectively categorize health system problems and discussions. The WHO model also sought consensus on four core outcomes or goals of health systems: improved population health; responsiveness (later often termed “customer satisfaction”); social and financial risk protection; and improved efficiency. Later models recategorized “improved efficiency” as an intermediate process goal rather than an end unto itself. Despite a high degree of consensus on these goals, the WHO’s building block model ( Fig. 17.2 ) has been criticized for its apparent inability to explain why various health systems produce different results. Some have suggested this is because although “building block” implies discrete, well-defined entities, the dynamic relationship between them is less easily understood.
Current Concepts in Health Systems Strengthening
Below are three current definitions of HSS by well-respected organizations that work in this field. For this chapter, we will focus on the WHO as it has the broadest influence.
USAID Health Systems Strengthening Definition
The United States Agency for International Development (USAID) defines a health system as consisting of all people, institutions, resources, and activities whose primary purpose is to promote, restore, and maintain health. Strengthening a health system means initiating activities in the six internationally accepted core HSS functions—human resources for health; health finance; health governance; health information; medical products, vaccines, and technologies; and service delivery. A well-performing health system is one that achieves sustained health outcomes through continuous improvement of these six interrelated HSS functions.
UNICEF Health Systems Strengthening Definition
“UNICEF [United Nations Children’s Fund] defines HSS as actions that establish sustained improvements in the provision, utilization, quality and efficiency of services delivered through the health system, and encourage the adoption of healthy behaviors and practices. These actions may also influence the health system context, including key performance drivers such as policies that impact on health in all sectors, governance, financing, management, capacity for implementation, social norms and country participation in initiatives designed to maintain national and global health security. They also implicitly improve health security by strengthening the system’s resilience and its preparedness to respond efficiently and effectively in the context of emergencies.”
World Health Organization Health Systems Strengthening Definition
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Health systems strengthening:
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the process of identifying and implementing the changes in policy and practice in a country’s health system, so that the country can respond better to its health and health system challenges;
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any array of initiatives and strategies that improves one or more of the functions of the health system and that leads to better health through improvements in access, coverage, quality, or efficiency.
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Health system:
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all the activities whose primary purpose is to promote, restore, and/or maintain health;
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the people, institutions, and resources, arranged together in accordance with established policies, to improve the health of the population they serve, while responding to people’s legitimate expectations and protecting them against the cost of ill-health through a variety of activities whose primary intent is to improve health.
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As mentioned earlier in this chapter, the WHO uses a framework that identifies six building blocks/essential functions that form the foundation of a health system (which requires a functioning governing system) ( Table 17.1 ).
| Six Building Blocks | Key Components |
|---|---|
| Leadership and governance (stewardship) |
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| Health workforce (resources) |
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| Medical products, vaccines and technology |
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| Heath information (data and data systems) |
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| Health financing |
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| Service delivery |
|
By strengthening these building blocks, the overall goal is improved health because of better access, coverage, quality, and safety. Responsiveness to changing health requirements, social and financial risk protection, and improved efficiency are additional outcomes.
World Health Organization Systems Thinking
After implementing the six building blocks as a framework, many critics suggested that this framework neglected the important role of communities, essential to delivering health care where the official system stops. Therefore, the WHO initiated an additional approach to strengthening health systems by applying “system thinking.” This 10-step approach facilitated seeing and understanding the health system as a whole instead of one building block alone and encouraged potential synergies among different interventions.
The aim of systems thinking is to reveal the underlying characteristics and relationships of interconnected systems and fields as diverse as engineering, economics, and ecology combined with nonlinear, unpredictable, and resistant developments sometimes worsening a problem.
Within misunderstood systems, interventions—even the very simplest—often fail to achieve their goals because of the often unpredictable behavior of the system around them. As any health intervention has a direct or indirect effect on other health programs belonging to the functional areas of the building blocks, those ripple effects need to be recognized as soon as possible, to identify potential consequences—which may be symbiotic at best, competing and negative at worst ( Fig. 17.3 ).
Health System Resilience
This is defined as “the capacity of health actors, institutions, and populations to prepare for and effectively respond to crises; maintain core functions when a crisis hits; and, informed by lessons learnt during the crisis, reorganize if conditions require it.” However, additional themes are identified that require further defining of the concept to simultaneously achieve sustainable transformations in public health practice and health service delivery, and improve their preparedness for emergencies.
Health Systems Strengthening in the Context of Fragility
The importance of understanding the strength and vulnerabilities of a health system seems to differ significantly in the context of fragility and conflict. In complex humanitarian emergencies, a key focus is needed on threats to the interface between public health provision and community processes that see community, civil society, private sector actors, and the state as key agents within a complex system adjusting to the prevailing drivers of fragility.
Health Systems Strengthening and Disaster Management
Disaster management is being globally encouraged to improve disaster preparedness, along with growing international commitment to strengthening health systems. The WHO has published a new health emergency and disaster risk management (EDRM) framework. In addition to the previously describe six building blocks, this framework adds three components: Risk Communication; Community Capacities for Health EDRM; and Monitoring and Evaluation.
This framework complements the range of public health threats, including new emerging diseases, accidental release or deliberate use of biological, chemical, or radionuclear agents, natural disasters, human-made disasters, complex emergencies, conflicts, and other events with a potentially catastrophic impact on human health.
Toolkit
The WHO Toolkit is based on the experience and lessons of two decades of disasters, to help guidance HSS and improve disaster management capacity.
Supporting Versus Strengthening Health Systems
Difference Between a Health System andthe Health Sector
A health sector is the sum total of all efforts to improve the health of individuals regardless of how those efforts are or are not organized. A health system implies a centralized, deliberately governed effort to organize the health sector. Although many rightfully condemn attacks on very visible elements of the health sector (i.e., clinics), more enduring but sometimes less obvious are elements of the system such as degradation of governance (leadership and decision-making capacity of trusted leadership) and its core instruments such as finance, information support, regulatory authority, policy generation, etc. Notably, some organizations consider supporting health system leadership as a political act that can worsen and fuel conflict, especially in the setting of high levels of corruption. Regardless, the default position should typically be to support a nation’s Ministry of Health unless there are exceptionally clear and compelling reasons for not doing so.
One may also consider the following three areas as separate but related levers for health system support—stewardship, health governance apparatus, and health delivery platform:
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Stewardship
Possibly the most contentious and frequently disrupted element of health systems in conflict-affected states. Although various definitions of stewardship exist, virtually all agree on mandate, legitimacy, and authority to undertake key governing tasks with transparency and accountability. These tasks include setting priorities, deciding on strategies, regulation, and coordination.
The mandate—who gets the authority to make health system decisions—may be contested in states with political turmoil. In postconflict environments where leadership is cycling rapidly, health systems struggle to regain functionality. Priorities change and conflicting strategies emerge to address core problems regarding how, for example, service providers will be paid or services will be delivered in insecure areas. Relationships with nonhealth actors, particularly donors, are often based on personal trust in contexts where institutions are weak.
There may be pressure to choose leadership based on ethnic group affiliation rather than qualification or experience with governance. Health ministries may be a relatively “convenient” place to fill formal or informal quota agreements compared with more powerful offices. Such appointees may require extra support if they lack experience and/or support of the ruling ethnic group.
Legitimacy may be deliberately or inadvertently challenged by accusations of corruption (i.e., graft, cronyism) or perceived inability to benefit the populace.
Authority may be assumed by outside powers that have the resources to manage it. Additionally, the legal foundation of the system can be overturned by unplanned transfer of power.
A hallmark of health systems in crisis is the shearing of the relationship between stewards and the health governance apparatus, where stewards no longer effectively control policy-making or implementation, financing and disbursement, or the ability to assess performance and negotiate with actors in the system or who impact it.
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Health governance apparatus
The health governance platform refers to the tools stewards use to raise and disburse financing; regulate processes; prioritize and organize needs; assess performance and manage relationships with nonhealth sectors.
Crises commonly impact health systems in the following ways.
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Raising and disbursing financing
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Taken out of state’s hands
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Principal agent problem: different agendas and priorities; international donors may decide, or to cut leadership out entirely.
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Shift to security
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Delayed support
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Transaction costs
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Interruptions of regulatory authority
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Erosion of trust
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Cannot pay vendors
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Lost oversight capability
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Actively weaponized
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Policy-making: prioritization and organization
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Peace dividend versus need-based care
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Strong preferences on the part of international community (contracting vs. national health system). These may clash with public expectations.
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Burdens of care may shift dramatically.
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Assessing performance and managing relationships with outside actors
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Creates massive power differentials
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“Capture” by outside interests can be a major goal of unscrupulous actors (counterfeit drugs and tenders).
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Internally, the government may wish to focus exclusively on staying in power.
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Health delivery platform
The health delivery platform is comprised of those health system elements that touch patients: the infrastructure, supply chains, medical services technologies, and health workers who deliver care. Health delivery platform elements are often the most visible in the news—clinics bombed, health workers targeted, and supply chains disrupted.
Theoretical Framework
“Supporting the health system can include any activity that improves services. Support activities improve outcomes primarily by increasing inputs. By contrast, strengthening the health system is accomplished by more comprehensive changes to policies and regulations, organizational structures and relationships across the health system building blocks. Strengthening activities motivate changes in behavior and/or allow a more effective use of resources to improve (multiple) health services. Hence, health system strengthening is about making the system function better permanently, not just filling gaps or supporting the system to produce better short-term outcomes. A wide spectrum of health system strengthening interpretations exists” ( Box 17.1 ).
