healthy system

What is a health system? A health system consists of all the organizations, institutions, resources and people whose primary purpose is to improve health.1,2 This includes efforts to influence determinants of health as well as more direct healthimprovement activities. The health system delivers preventive, promotive, curative and rehabilitative interventions through a combination of public health actions and the pyramid of health care facilities that deliver personal health care — by both State and non-State actors. The actions of the health system should be responsive and financially fair, while treating people respectably. A health system needs staff, funds, information, supplies, transport, communications and overall guidance and direction to function. Strengthening health systems thus means addressing key constraints in each of these areas. Frameworks for monitoring health systems performance The multifaceted nature of health systems and the spread of direct and indirect responsibilities across multiple sectors, pose challenges in monitoring performance. In response, over the past several years, the World Health Organization (WHO) and its partners have been working to reach a broad-based consensus on key indicators and effective methods and measures of health systems capacity, including “inputs”, “processes” and “outputs”, and to relate these to indicators of “outcome”. It is widely known that there are many potential advantages of a harmonized approach to health systems monitoring and evaluation, including reduced transaction costs, increased efficiency, and diminished pressures on countries. However, there are also identified practical issues to be addressed before greater harmonization can become a reality. The existence of multiple analytical and strategic frameworks for health systems results in considerable potential for duplication, overlap and confusion.3 Existing frameworks include the WHO framework for health systems performance assessment (1); the World Bank control knobs framework (2); and the WHO building blocks framework (3). Such frameworks have varying starting points, resulting in emphases on different outcomes to be tracked. Work is on to develop conceptual frameworks for health systems strengthening and to create a taxonomy that would permit clarification of the indicators, data sources and collection methods, and the analytics underpinning monitoring and evaluation. However, the choice of the strategic framework does not necessarily substantively affect the monitoring and evaluation strategy. There are many commonalities in the various strategic frameworks for health systems that permit a coherent approach to the choice of indicators and measurement strategies. Health systems framework and building blocks This handbook does not attempt to cover all components of the health system or deal with the various monitoring and evaluation frameworks. Instead, it is structured around the WHO framework that describes health systems in terms of six core components or “building blocks”: (i) service delivery, (ii) health workforce, (iii) health information systems, (iv) access to essential medicines, (v) financing, and (vi) leadership/governance (see Figure 1). 1 World Health Organization, 2 The terms “health system” and “health sector” are often used interchangeably with the latter interpreted as restricted to the actions of the government. This handbook focuses on aspects of the health system that are under the responsibility of ministries of health, including the provision of personal health services by both State and non-State actors. 3 For a recent overview see Shakerishvili G. Building on health systems frameworks for developing a common approach to health systems strengthening. Prepared for the World Bank, Global Fund to Fight AIDS, Tuberculosis and Malaria, and GAVI Alliance, Technical Workshop on Health Systems Strengthening, Washington, DC, June 25–27, 2009. Introduction and objectives of the handbook vii The six building blocks contribute to the strengthening of health systems in different ways. Some cross-cutting components, such as leadership/governance and health information systems, provide the basis for the overall policy and regulation of all the other health system blocks. Key input components to the health system include specifically, financing and the health workforce. A third group, namely medical products and technologies and service delivery, reflects the immediate outputs of the health system, i.e. the availability and distribution of care. Inevitably, any type of division of a complex construct such as the health system is fraught with problems. This is also true for the framework, which focuses on health sector actions and underplays the importance of actions in other sectors. It does not take into account actions that influence peoples’ behaviours, both in promoting and protecting health and the use of health-care services. The framework does not address the underlying social and economic determinants of health, such as gender inequities or education, and also does not deal with the substantial and dynamic links and interactions that exist across each component. On the other hand, focusing on these separate components helps put boundaries around this complex construct and permits the identification of indicators and measurement strategies for monitoring progress. Towards a common monitoring and evaluation framework Interest in a common monitoring and evaluation framework was stimulated as a result of the International Health Partnership and related initiatives (IHP+).4 Launched in September 2007, the IHP+ aims to better harmonize donor funding commitments, and improve the way in which international agencies, donors and developing countries work together to develop and implement national health plans. The IHP+ has developed a common monitoring and evaluation framework to enable targeted monitoring and evaluation of health system strengthening efforts (Figure 2). This framework is country-focused and supportive of country needs while also providing a basis for global monitoring.