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Health System’s Levers

By Nellie Bristol

The word "system" conjures up an image of a rational, organized, well-planned operation where cause equals effect and everyone knows ahead of time what the outcome will be. Health systems, however, defy that concept.

They tend to be more akin to living organisms: amorphous, evolving, reactive. They reflect a country's history, political and social structure, and character as much as they do its health needs.

As an example, the United Kingdom's National Health Service grew out of the devastation of health infrastructure caused by World War II. Free-market-loving Americans embrace the most private-sector-oriented system of any developed country while communist Cuba successfully supports cradle-to-grave care for all.

In spite of the quirks and eccentricities inherent in each country's health system, or maybe because of them, the World Health Organization (WHO) attempts to rationalize systems through the development of norms and definitions. It defines a health system as "all the activities whose primary purpose is to promote, restore or maintain health." The definition is meant to include not only health services, but also factors that contribute to overall health promotion, including health education and relevant social structures.

More specific to health services, WHO delineates six "building blocks" essential to system function: service delivery; health workforce; information; medical products, vaccines and technologies; financing; and leadership and governance. Not only is each individual element needed to ensure adequate access to health services, but so are the connections between them, according to Badara Samb, advisor to the Assistant Director-General, Health Systems and Services at the WHO.

"You cannot take one from the other," he says. "But to make a system is to make them work in harmony toward improvement of a delivery system that allows people access to services."

William Hsiao, Harvard School of Public Health economist, says the building blocks really are more descriptive of health system inputs and that more research is needed into the strategies and organization that make a system function effectively. "In terms of what makes a system work well or not work well, we really don't know too much yet," he says.

Mark Pauly, University of Pennsylvania Wharton School professor of health management, agrees. "Countries usually pick a system that fits their special circumstances, so it's hard to generalize," he says. "I tend to be relatively non-judgmental about systems just because, for one, they're hard to transplant and, for another thing, there is at least, we hope, a kind of dynamic that sort of fits the nature of their problems and also the nature of what their people want."

The country-specific nature of health systems, Pauly argues, makes comparisons on costs and outcomes difficult. "And, of course, on the outcome side, there are other things that affect health other than the health-care system and you can't perfectly control for them," he adds. Ultimately, he says, "A higher standard of living is probably the best way to improve health."

The US Agency for International Development (USAID) has worked with countries on health system strengthening for 30 years. It looks at all aspects of a system, including availability of facilities, transportation options, compatibility of a facility's hours with local living conditions, and whether it's possible to offer services in the community. It tries to react to the degree possible to factors such as mobility and cultural norms of the population. For example, if the movement of women is restricted, it tries to take services as close to them as possible, even to their doorstep if feasible.

It also looks at quality of services, which can depend on the status of facilities and equipment, and staff training and knowledge, but also can depend on factors such as availability of electricity and clean water.

Barbara Stilwell, director of Human Resources for Health and Health Systems Strengthening at IntraHealth International, a global health systems consultant, emphasizes the importance of equity. "A strong health system would be able to provide the same health service to somebody in a remote rural area as it would to somebody in the center of the city," she says. Achieving equitable access and many other elements of a good health system requires good governance, she adds. Systems must not only be able to support quality facilities, but provide qualified personnel and provide them with good management and supervision. Good governance also requires a minister of health, who can make a strong case for health care as part of the national budget, Stilwell says. Health spending as a percentage of GDP globally ranges from 1.7 percent in Equatorial Guinea to a projected 17.6 percent in 2009 in the US.

Better information about health consequences also leads to improvements. WHO points out that enemies of good health in urban areas, including pollution and lack of sanitation, had more profound effects in early 19th century London and Paris then than they do in developing metropolises today. "On one hand, increased knowledge of how diseases are caused and transmitted has led to valiant efforts to reduce contamination, control disease vectors, and educate the population to take care of itself," according to the World Health Report 2000. "On the other hand, even very poor urban dwellers now have better access to effective personal health care [such as vaccines] than much of the rural population ..."

Expanding knowledge and access are crucial roles of health systems and increasingly are on the agenda as the global health community shifts its focus to health strengthening as a major development topic. Disease specific programs, like the Global Fund to Fight AIDS, Tuberculosis and Malaria, the GAVI Alliance and the President's Emergency Plan for AIDS Relief, added health systems growth to their portfolios in recent years in an attempt to address total capacity.

The move is necessary as vertical programs are stymied in attempts to expand access by a lack of health-care workers in the hardest hit countries: the health workforce building block is inadequate. More attention is now being paid to personnel deficiencies and effective workforce management. Systems strengthening could receive another major boost as the World Bank, WHO, GAVI and the Global Fund develop a joint health systems platform using aid effectiveness principles. Recommended by the High Level Taskforce on Innovative International Financing for Health Systems, the goal is to develop a standardized process for the major grant-making organizations to reduce the strain on countries applying for financial help.

Harvard's Hsiao says the trick is to integrate vertical programs into existing systems in a way that complements and enhances them rather than robbing them of scarce resources. Each country must develop an overall financial plan, he says, and vertical programs must be tweaked to fit into them. But, Hsiao says, changing the mindset of some advocates and programs has been difficult. "It's not easy to change organizations' focus and priorities and so it takes time to do that," he says.

Even with greater standardization at the donor level, implementing system changes still must develop out of the countries they are intended to serve. "The country should be in the driving seat for many reasons," said WHO's Samb. "And we really need to make sure that the driver is in command and we're not talking about a diplomatic car where ...the one who is in the back of the car is really in command."

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Nellie Bristol is a freelance journalist, specializing in health policy.