Health System Strengthening for
Greater Health Impact
We all say we do it and do it well, but
what is it?
How strong is the evidence base?
Dan Kraushaar
Management Sciences for Health
We now have more and better “what”,
“why” and “how much”
•
•
•
•
•
Understanding of the problem
Proximal and distal of causes
Evidence on intervention efficacy and effectiveness
Improved modeling
Much improved normative guidance
Fragmented HSS efforts have created evidence
on how to improve inputs and processes
Inputs
Leadership &
governance
Financing
Information
Health workforce
Delivery
Medical products,
vaccines and
technologies
processes
outputs
outcomes
impact
The evidence base on system
strengthening for health impact is weak
• The black box of health system strengthening for
health impact remains a black box.
• Weak health systems remains the primary barrier
• Lack of an agreed upon conceptual framework
• Lack of appropriate evaluation designs and limited
scientific method applied to HSS efforts
• Consequently limited evidence of what works, why
and under what conditions
Two promising practices
1. Causal pathway analysis as a means of linking
health system strengthening interventions to
health outcomes.
2. Systematic application of key policy and
managerial levers applied against concretely
defined system bottlenecks.
Most effective programs have defined HSS
efforts based on causal pathway analysis in
some way or another
System
requirements
Evidence based
interventions &
coverage levels
Problems
and causes
Measurable
goal
Allowing for system strengthening, program design
and management along that defined causal path.
HSS against
specific
health system
bottlenecks
Right inputs
& processes
Higher
coverage
Reduced
problems,
goals attained
That, coupled with use of five policy and management
levers for improved system performance
• Five key features of the health system which can
be manipulated by policy makers and managers.
• When systematically applied have shown to
influence the structure and function of the health
system.
• They are a promising approach to improving
health system performance for greater health
impact.
*Modified from Hsiao, William C. (2009). Inside the Black Box of Health Systems: What Are the Policy Control Knobs?
What are those levers?
Health system
bottlenecks
1. Changing how resources are
mobilized and allocated and how risks
are pooled
2. Changing the organization of
financing and the appropriate
involvement of public and private
sectors
3. Changing the payment and incentive
structures for providers and consumers
and modifying costs of inputs
Applied
against
system
bottlenecks
can improve
system
performance
Health Information
Health Financing
Medical Products,
Vaccine, and
Technologies
4. Use of the coercive power of
government through policy & regulation
5. Influencing beliefs, preferences and
behavior of people, organizations and
providers
Leadership and
Governance
Health Workforce
Health Services and
Delivery
Source: Roberts, Marc, William Hsiao, Peter Berman, and Michael
Reich. Getting Health Reform Right - A Guide to Improving
Performance and Equity. New York: Oxford University Press,
2008. Oxford Scholarship Online. Oxford University Press.
Convincing evidence
• Retrospective analysis of effective programs
• Bill Hsiao, Harvard: 22 country analyses
• Specific examples of country programs
• Multiple examples the past few days
Thailand national FP program
Lever
Policy and management action
1. Mobilize, allocate and
manage resources
1. Massive and preferential increase in FP funding
sustained by gov’t over time. Subsidies to private sector
2. Organization, roles of
public and private sectors
2. Expanded community level gov’t facilities. Encouraged
private provision. Created midwifery cadre and established
midwifery schools for community FP delivery. Expanded FP
logistics. Integrated FP into MCH system. Encouraged
private sector.
3. Changing the payment
and incentives and costs
3. Free services. FP currently covered by 30Bht scheme?
4. Policy and regulation
4. Policy allowed for private sector innovation. Allowed
research on FP methods.
5. Influencing beliefs,
preferences and behavior
5. Studied KAP of providers and consumers. Identified
resistance points. Educated and trained all levels of
providers. Multi media campaign.
HSS in Jordan (Dr. Hamsa’s presentation)
Lever
Policy and management action
1. Mobilize, allocate and
manage resources
1. Emergency financial allocations for mag sulfate. Cost
analysis. Preferential financing.
2. Organization, roles of
public and private sectors
2. Improved logistics and supply. Altered purchasing
processes. Improved monitoring and supervision.
Creation of motherhood committees. Improved program
execution.
3. Changing the payment
and incentives and costs
3. Improved accountability through use of motherhood
committees.
4. Policy and regulation
4. Improved policies on use of mag. Sulfate. Clinical
guidelines.
5. Influencing beliefs,
preferences and behavior
5. Competency based training. Use of expert clinicians. Use
of data and access to global evidence to influence provider
attitudes and behavior. Self directed learning.
Thinking Causally and
application of policy levers:
What are the benefits?
1. Evidence based.
2. Justifies multiple yet calculated policy and managerial actions
based on predicted outcomes in a way that is empirically testable.
3. Defines policy and managerial tools for changing system
performance.
4. Identifies the vital few interventions and the critical path to impact.
5. Helps identify the most appropriate indicators along that critical
path.
6. Helps policy makers and managers focus on outcomes and impact
vs inputs and processes using the 5 levers for HSS.
What needs to be done?
• More systematic application of causal pathway
analysis.
• Greater attention evidence
• More rigorous analysis of health system
bottlenecks based on causal analysis.
• More systematic application of policy and
management levers.
• Creation of empirical evidence through more
systematic evaluations to determine
effectiveness of this approach