What is a health system?

What is health system

strengthening?

IHPSR Presentation 2

www.hpsa-africa.org

@hpsa_africa

www.slideshare.net/hpsa_africa

Introduction to Health Policy and

Systems Research

Outline

• Definition of a health system

• Conceptual frameworks that help us to

think about health systems

• Considering policy for health system

strengthening

‘A health system consists of all

organizations, people and actions whose

primary intent is to promote, restore, or

maintain health.’

WHO, 2007, p.2

http://www.who.int/healthsystems/strategy/en/

A health systemHealth

• Beyond sickness

– mental and physical

health

– social wellbeing

• Beyond the individual

– actors/agents

promoting health and

wellbeing

– domestic/national

AND international

factors impacting on

health and health

system agents

A complex adaptive

system

• A set of interacting

elements

• More than the sum of the

parts

• Acts in ways that are not

fully predictable, e.g.

feedback loops

• Influenced by history

• Self-organising

• Resistant to change

Complex adaptive system

Health system frameworks …

WHO, 2007

7

Antwerp model: Van Olmen et al. 2010

Figure 1 The health system dynamics framework in its generic form

Frenk, 1994

COLLECTIVE MEDIATOR

HEALTH CARE

PROVIDERS

ORGANISATION

POPULATION

ORGANISATION

RESOURCE

GENERATORS

OTHER SECTORS

Basis for

eligibility

Degree of

control

Degree of

control

Degree of

control

Taxes, Demands

for services

Services with health

effects

Subsidies,

Information,

Ideologies

Potential personnel,

money, data

Schemes for

interpreting human

experience

Formal health services

Community participation

Competition for

responsibilities and

resources

Human resources, Payment

mechanisms, Scientific information,

Technology

Health systems are dynamic and

interconnected systems at whose heart are

people

‘It is the multiple

relationships and

interactions among the

building blocks ... that

convert these blocks into

a system’

de Savigny & Adam, 2009

People

governance

Information

financing

service delivery

human resources

medicines &

technology

Macro, meso and micro levels

Health system: hardware and software

‘Health system’ as a focus

in global health …

• Not new ...

… but

• in a ‘see-saw’ with focus on disease

control programmes

Changing global trends in thinking about

how to improve health systems

• 1970s: whole system focus > comprehensive PHC,

Alma Ata 1978

• 1980s: focus on interventions > selective PHC,

GOBI-FFF

• 1990s: health system reform – focus on overall

financing+organisation (efficiency+equity)

• mid-1990s–2000s: focus on priority diseases, e.g.

HIV/AIDS > Global Fund plus

• 2000s: health system strengthening

2000s move towards health systems

strengthening because …

‘Effective interventions exist for many priority health

problems in low income countries; prices are falling, and

funds are increasing. However, progress towards

agreed health goals remains slow. There is increasing

consensus that stronger health systems are key to

achieving improved health outcomes.’

Travis et al., 2004

Health system strengthening goes beyond dedicated

disease/condition-specific programmes

Travis et al., 2004

Good health at low cost:

Thai experience

Sustained action to address access barriers over time

Patcharanarumol et al., 2011

Whole system change: achieving good health at low cost

Good governance, effective

institutions and bureaucracies,

planning and leadership e.g. Thai case:

use of evidence in

decision making

Fair and

sustainable

financing

Effective primary care as entry point to referral network

New cadres, large numbers, new roles; payment mechanisms (values)

Drug supply, low cost technologies (ORS)

PHC

UHC

Balabanova et al., 2011

Why and how sustained action over time?

Hardware

interventions to

tackle access

barriers

Software:

values-driven &

dedicated

health

professionals

How and

why?

3) Decision-making processes that have ensured consistent vision and persistent development towards goals

How and

why?

1) HS features:1. public sector

strengthened

2. integrated service

provision

3. limited reliance

on external

resources

1. Values-based and

charismatic political

leadership

2. Elite and interest

groups support

3. Competent, values-

based and

distributed technical

leadership

4. Generation and use

of evidence in

decision-making

5. Decentralised

authority

6. Flexible

implementation

7. Communication and

feedback, learning

through doing

2) Community

factors: 1. community

awareness &

acceptance of

health

programmes

2. public trust &

confidence in

DHS

3. public status of

health

professionals

How and

why?

Socio-cultural values;

positive experiences

Pro-poor, pro-

rural ideology

How and

why?

Pro-poor ideology; Use of

evidence; Economic context

Health system

Health policies are deliberate

actions to strengthen health

systems and improve

performance

Polices are more than documents!

Not just the output of

decision making but rather

the entire process of

decision-making across the

full range of people and

organisations that translate

policy

documents/statements into

policy-as-experienced

• It is important to understand:

– the politics of influencing

‘policy agendas’

and

– the organisational

dynamics through which

policies take effect:

actors, relationships

and driving forces

Caveat

No easy answers to improve a

health system!

Politics and values matter …

• The US: Obamacare

• The UK:

– born out of a political moment

• with particular underpinning values

– but undergone endless reforms over its life

• Could current changes compromise

initial values?

• Will they improve system performance?

Copyright

Funding

You are free:

To Share – to copy, distribute and transmit the work

To Remix – to adapt the work

Under the following conditions:

Attribution You must attribute the work in the manner

specified by the author or licensor (but not in any way that

suggests that they endorse you or your use of the work).

Non-commercial You may not use this work for commercial

purposes.

Share Alike If you alter, transform, or build upon this work,

you may distribute the resulting work but only under the same

or similar license to this one.

Other conditionsFor any reuse or distribution, you must make clear to

others the license terms of this work.

Nothing in this license impairs or restricts the authors’

moral rights.

Nothing in this license impairs or restricts the rights of

authors whose work is referenced in this document.

Cited works used in this document must be cited following

usual academic conventions.

Citation of this work must follow normal academic

conventions. Suggested citation:

Introduction to Health Policy and Systems Research,

course presentation, Presentation 2. Copyright

CHEPSAA (Consortium for Health Policy & Systems

Analysis in Africa) 2014, www.hpsa-africa.org

www.slideshare.net/hpsa_africa

This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no.

265482). The views expressed are not necessarily those of the EC.

The CHEPSAA partners

University of Dar Es SalaamInstitute of Development Studies

University of the WitwatersrandCentre for Health Policy

University of GhanaSchool of Public Health, Department of Health Policy, Planning and Management

University of LeedsNuffield Centre for International Health and Development

University of Nigeria Enugu Health Policy Research Group & the Department of Health Administration and Management

London School of Hygiene and Tropical MedicineHealth Economics and Systems Analysis Group, Depart of Global Health & Dev.

Great Lakes University of KisumuTropical Institute of Community Health and Development

Karolinska InstitutetHealth Systems and Policy Group, Department of Public Health Sciences

University of Cape TownHealth Policy and Systems Programme, Health Economics Unit

Swiss Tropical and Public Health InstituteHealth Systems Research Group

University of the Western CapeSchool of Public Health