Greater than the Sum
By Dykki Settle
WHO defines six building blocks of a health system: service delivery, health workforce, information, commodities (products, vaccines and technologies), financing and leadership/governance. The health systems approach puts the emphasis not just on the components of the health system, but the relationships within and between the building blocks. Core to health systems strengthening (HSS) is the idea that none of these building blocks can stand alone, all are necessary for better health outcomes. Changes in one area have repercussions elsewhere. Improvements in one area can't be achieved without contributions in another.
Information and communication technology (ICT) has a powerful role to play in illuminating these relationships, mitigating unexpected negative impacts to the health system, and maximizing positive ones. ICT can be most powerful in the essential role of health systems surveillance, supporting efforts to monitor and measure the strength of health systems and the success of HSS activities.
While not a panacea for all that ail health systems, information technology is a key component to health system strengthening. Photos courtesy of IntraHealth
Health systems strengthening must be attentive, iterative and responsive to change. This can only be achieved through routine surveillance of health and health systems. The concept and discipline of health surveillance, well established and explored by the disease surveillance community, is taking advantage of the growing availability and support of ICT in low-resource environments to monitor and respond to all aspects of health.
Health surveillance begins with routine systems to measure the problems and the relative success of solutions, reaching beyond the health system itself to the broader determinants of health. Closing the Gap in a Generation, the final report of the WHO's Commission on Social Determinants of Health, calls for countries and global organizations to establish national and global health equity surveillance systems. These systems will routinely collect, collate and disseminate information on health, health inequities and health determinants in a coherent fashion.
The routine surveillance of health systems is a necessary counterpart to health equity surveillance. In October 2008, WHO convened a meeting of technical partners in Bellagio, Italy to develop a plan for a global initiative to strengthen country health system surveillance (CHeSS). The goal of the initiative is to improve the availability, quality and use of health system data to inform country health sector reviews and planning processes and strengthen assessments of health systems performance. The initiative will be planned and implemented in line with the principles of the International Health Partnership (IHP+) common evaluation framework, which, in turn, is based on the Paris Declaration on aid effectiveness.
Country health system surveillance will draw data from a wide variety of routine information systems for the six building blocks. These include logistics and facility information systems for health commodities, health management information systems for service delivery, human resources for health (HRH), and a variety of other component systems. The comprehensive nature of the CHeSS approach creates an opportunity for deeper development of specialized health systems surveillance systems within and between the six building blocks.
For example, within the complex domain of HRH and human resource information systems (HRIS), emerging approaches to develop the science and methodologies of workforce surveillance - defined by as the routine, dynamic and systematic collection and analysis of HRH data for the provision of rigorous evidence and information which leads to action - provide an excellent example of the power of linking data from the six building blocks to generate a comprehensive surveillance model on system components, health outcomes and health equity.
Health worker performance and retention is affected by all aspects of the health system. Reasonable workload and expectations, availability of medical supplies, clean water and power, proximity of health facilities to urban areas and major roads, availability of health information, supportive supervision and leadership, and of course, timely compensation are all essential contributors to health worker motivation and the successful delivery of health services. Using effective and well planned ICT, information from all six building blocks can be brought together to provide dashboards, maps, and other tools that will help policy and decision makers proactively identify and respond to health worker retention and performance challenges.
These approaches apply across all sectors of health care. A report from Cordaid on strengthening human resources for health for faith-based organizations (FBOs) highlights the use of geographic information systems (GIS) by Tanzania's Christian Social Services Commission (CSSC) to address a variety of FBO health workforce issues. Efforts such as this lay the foundation for health workforce surveillance at the country level.
Effective understanding of health inequities and the health systems that must sustainably address them cannot be accomplished without strong technology support. Efforts by private, public and non-profit sectors alike are closing the gaps in ICT infrastructure, local technology skills, and national ICT policies and support in regions and countries around the world. These increasing information resources will only be effective for addressing health challenges if they are used by the health community. Improving our understanding of the complex interrelationships of community, national and global health through a systems approach and proven surveillance methodologies will accelerate our efforts to reach the MDGs and achieve the collective vision of better health for all.
Recently, the global health informatics community, under the leadership of the Health Metrics Network, WHO, Rockefeller, Canada's International Development Research Centre (IDRC) and others has begun to embrace and corral the complex interrelationships of the different health system building blocks through a discipline called enterprise architecture. Enterprise architecture is a systems engineering approach to define reusable blueprints for information flow based on business processes. These blueprints can be used by countries and communities to help plan their health system strengthening activities, ensuring a proactive design that will take the necessary information flows and system relationships into account. The architecture framework and process also provide a common language and set of tools to support south-to-south sharing and regional development of system blueprints.
Last September, Rwanda's Ministry of Health unveiled a $32 million plan to make health-care services delivery effective through ICT. The funding will support district health centers, develop community-based information systems and computerize the national health-care system. Rwanda's eHealth coordinator, Dr. Richard Gakuba, is working with WHO, the Health Metrics Network and a wide variety of international partners to develop and implement the plan through an enterprise architecture approach.
Enterprise architecture has implications beyond ICT implementation, however. The same approaches used to develop information systems can be used to better plan and strengthen the health system as a whole. Ethiopia is in the implementation stages of a multi-year, health-sector-wide, business process re-engineering activity that promises to realize significant gains in efficiency and effectiveness. This work applies many of the principles of enterprise architecture to health system design and reform and may serve as a model for other countries and global organizations embarking on health system strengthening efforts.
Finally, ICT for health systems strengthening does not exist in a vacuum. It exists within broader country efforts to strengthen ICT infrastructure and resources for the community. A recent article in the UK's Independent highlights how the village of Macha in Zambia, two hours from the nearest paved road, is getting connected to the Internet by the UK charity Computer Aid and its local partner LinkNet. The local hospital, malaria research center, and nurse training center are all tied in to the community network and nurses are taking advantage of the new connectivity right alongside local farmers and community leaders. Placing the health system in the context of the community it serves helps provide the most successful and sustainable results.
Getting to Maybe: How the World is Changed provides an excellent overview of complexity theory, systems dynamics and how they relate to social innovation, along with many examples from global health and international development. As the largest collective social innovation effort with the most important potential outcomes, the global health community has the most to gain and offer from a greater understanding the complex dynamics of our work.
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World Health Organization. About health systems.
Dykki Settle is the director of health Informatics for IntraHealth International, and leads the health workforce surveillance team for the CapacityPlus project.
Dear Sir/Madam
I found this article very impressive and informative. It will grately help program managers and activists in this field.
Thank You
— Yaynshet on 2010-01-27