Session 1
Global Health Priorities
Health Systems Science & Health Systems
Health systems frameworks are shaped by the context in which they are produced, emerging with specific discourses. They are not neutral descriptions but are purposive and shaped by the agendas of their authors. These agendas can range from supporting the strengthening of comprehensive health services and empowerment of communities, to advocating for the integration of specific disease programs or stimulating market driven health systems. By understanding the underlying discourse of these frameworks we can more clearly understand their origins and differences.
In the 2000s, health systems thinking was shaped by three major and interconnected developments: 1) Private foundations and Global Health Initiatives (GHI) became prominent actors in the global health landscape and came with targeted strategies to address specific priorities, especially those prioritized by the Millenium Development Goals (MDGs). Through their funding leverage they increased funding streams and directed priority setting processes at a global level. 2) At the same time, the WHO shifted its focus to the performance of health systems. 3) Some time later, the health systems research community recognised the increasing complexity of health systems.
With the proliferation of the donor landscape and the increased pressure of good governance in recipient states, there has been a call to increase ownership and improve the harmonization of aid procedures, resulting in the Paris – Accra Declaration. The Paris – Accra Agenda focused it attention to aid effectiveness and the resulting attempt to speed up progress towards the MDGs lead to the notion of results based financing to become popular. This notion gained strong support from the World Bank and Norway.
The global financial crises between 2008 and 2010 drastically shifted the priorities of the USA and Europe away from international aid. This led to seeking for “best buys” or value for money through producing rapid results. To facilitate this monitoring and evaluation of performance regained new attention resulting in new frameworks and sets of indicators and monitoring strategies.
Converging Health Systems Frameworks: Towards A Concepts-to-Actions Roadmap for Health Systems Strengthening in Low- and Middle-Income Countries
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Atun (2008) further developed HS frameworks through a “systems thinking approach” by accounting for the context in which the health system functions, specifically, the demographic, economic, political, legal and regulatory, epidemiological, socio-demographic and technological contexts (“DEPLESET”). He proposed a framework that can appreciate interrelationships and repeated events, for seeing patterns of change rather than static snapshots.
Descriptive Models: These models are mostly useful for understanding health systems by providing basic descriptions of the systems themselves, their financial and human resources devoted to improving health, how existing programs operate, and the key stakeholders involved and may include institutional arrangements. It tells us the components of a health system, but not how the health system works.
Areas of commonality in existing Health Systems Frameworks:
Health Goals: These are independent variables and remain constant irrespective of the health system framework, changes in the health system and its surrounding environments. There is some consensus that health system goals should include 1) improved health status, 2) protection against health related financial risk, 3) responsiveness to needs, and 4) satisfaction of consumers’ expectations.
Overarching Principles: There is also some consensus on the presence of some “over arching principles” or “characteristic features” which include equity, efficiency, sustainability, quality, access, coverage, safety, choice and other cross-cutting aspects.
Processes or Control Knobs: Multiple frameworks differ in how they define this dimension. Some frameworks refer to “processes” by emphasizing actionable constituents of concepts grouped under this category. Others refer to “control knobs” to describe means for implementing adjustments. This dimension combines concepts such as behaviour, organization, regulation, integration, decentralization, resource generation, resource allocation and payment. These are concepts that describe what happens within the health system as a course of action and how it happens, or describe them as power mechanisms in the hands of health system actors in which their application result in certain adjustments to the system (e.g. resource allocation can affect hospital mergers).
Building Block or Functions: Building blocks describe the structural and institutional aspects which they correspond to, whereas “critical health system functions” emphasize the functional aspects of health systems. This dimension includes concepts such as service delivery, health information, health workforce, technologies and commodities, demand generation, governance and financing. From the structural/institutional perspective, these are quantitative concepts referring to inputs, (e.g. “technologies and commodities” may refer to a specific piece of equipment or a type of drug procured, “health information” to an M&E system with indicators, data analysis software, reporting templates etc.). From the functional perspective these are qualitative concepts describing the means of achieving the progress in implementing the corresponding function (e.g. “technologies and commodities” may refer to activities aimed to strengthen supply-chain management system, “health information” may refer to institutionalizing the data collection system, technical capacity building etc.).
Multiple frameworks also explore the vibrant context, entailing demography, epidemiology, politics, economy, technology and other elements, within which the health system is placed, and suggest that any dynamics in the state of each of these external factors may affect health systems (and vice-versa) and consequently may determine priorities for health systems strengthening interventions.