Health Systems Strengthening - True or False?
01/25/2010
Catherine Connor debunks misconceptions about health systems
True or False?
• Health systems can't be measured.
• We don't know what works to strengthen health systems.
• Strengthening health systems will be a money pit, an expensive, open-ended investment that won't show measurable results.
Health system strengthening is red hot and referenced in PEPFAR II, Obama's Global Health Initiative, WHO's "Everybody's Business," the World Bank's new Health, Population, and Nutrition Strategy, and USAID's Report to Congress. But the stampede to health systems still leaves key questions in the dust for many stakeholders. Without answers, health systems strengthening is appealing, but not actionable. Luckily this challenge has inspired years of collective work and thinking to generate some answers.
Health systems can't be measured. FALSE.
Significant progress has been made in terms of the accuracy, availability and consensus on indicators of health system performance: outcomes (life expectancy, infant and child mortality rates), outputs (immunization, utilization and coverage rates), and inputs (financing, human resources, policies, regulations). But how do we judge whether a country's indicators reveal good or bad performance? A practical, accepted way is to compare one country with a group of peer countries. The U.S. reform effort is driven in part by how poorly its health system performs when evaluated against comparable countries - shorter life expectancy despite spending much more on health, for instance. Malawi may be alarmed to see that it has significantly higher child mortality in comparison with peer countries that are spending less on health. However, these measures are only as good as the country data from which they are drawn, and data quality is highly variable in developing countries. Quality data are a public good. There is significant work to be done to improve data quality from vital statistics, household surveys, public and private facilities, NGOs, government and donors.
We don't know what works to strengthen health systems. FALSE.
There was early consensus on what's broken in health systems (Lancet 2004; 364) and the surge of disease-focused funding since 2000 has shone a brighter light on system weaknesses, but what works? There is an emerging consensus beginning with the Montreux Challenge meeting in 2005, Making Health Systems Work; the WHO working paper series on making health systems work since 2006; USAID's Health Systems Assessment Approach in 2006; and recommendations from the Task Force on Innovative Health Financing for Health Systems in 2009. We know that strengthening health systems is working across the health system building blocks (service delivery; human resources; information; medical supplies, vaccines, and technology; health financing; and governance). USAID has more than a decade of health system strengthening investments in "best buys": 1) health information systems (HIS), infectious disease surveillance, DHS, and vital statistics; 2) logistics and supply chain management; 3) removal of financial barriers to access services (insurance, vouchers, targeting); 4) rational planning and management of human resources for health; and 5) institutionalizing quality improvement methods. However, rigorous evaluations are rare. There is still much to learn about what works.
Strengthening health systems will be a money pit.
FALSE, if there is accountability and real coordination. Two challenges to show results to funders: attribution and causality. Regarding causality, it is difficult to show that health systems strengthening investment X caused health systems impact Y. Attribution is related to causality. Picture a mother in rural Zambia, healthy and holding her second child who's fully immunized and she, with her IUD, confident that she can care for him without worrying about an unplanned pregnancy. What caused this result and who gets the credit? The U.S. government trained the health workers and supplied the contraceptives. WHO supplied the vehicles. GAVI helped finance the vaccines. The EU and UNICEF paid for the household survey. Inputs should be complementary. Implementers must be held accountable for individual inputs and outputs. Credit for outcomes should be shared. This is the most important challenge -for health systems strengthening to be done efficiently and to have an exit strategy, donors and their implementing partners have to walk the talk of coordination and country ownership.
Learn More
Click here to see how a particular country's health system is performing.
Catherine Connor is deputy director of Health Systems 20/20.
Catherine’s take on HSS is well timed and well noted. As one observer put it long ago, all programs are integrated at the level of a patient visit. One lesson from UNAIDS might be helpful if it were applied, one framework for evaluation - and one coordinating body for the activity. Health economics should be pushing us beyond the obvious - free care does eliminate some barriers to care. but, it does not mean that all care should be free, or that all groups in a society will benefit. the interaction between public care (free or nearly free) and not free care in the public sector is another important area to look at, and to work on.
I’m grateful to this article for making a few good points about how HSS lifts all boats.
— chris McDermott on 2010-02-23