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The Importance of Sustainability in Health Systems

In this article, we provide an overview of health systems and highlight the Sustaining Ability case study.
Masura Begum, age 35 of Purba para, Charitabari is receiving referral slip for relief. Mita Alam of CBM local partner GUK is seen signing the slip after making physical visit to masura magums house.
© CBM/Gonzalo Bell

In this article, Professor Allen Foster (LSHTM) provides an overview of health systems and Dorothy Boggs (LSHTM) highlights the Sustaining Ability case study.

Healthcare system overview

Rehabilitation services need to be integrated into general health services rather than exist as stand alone vertical programmes.

A healthcare system can be considered as the organisation of people and resources to meet the health needs of the population through the delivery of health services.

  • “Organisation” implies leadership, planning and management;
  • “People” means all stakeholders including health care professionals;
  • “Resources” include infrastructure, information systems and money;
  • “Health needs of the population” means a public health approach prioritising the most important interventions to improve health; and
  • “Services” includes all interventions be they promotive, preventive, therapeutic or rehabilitation, as well as non-clinical care such as waiting times and respect.

Figure 1 diagrammatically shows the six components on which a health system is built. The health needs of the population are at the centre.

Figure 1 – Health System Building Blocks

Health services

Health services are delivered at different levels:

  • Community – through community health workers or outreach services
  • Primary – a health care clinic
  • Secondary – usually a hospital
  • Tertiary – a specialist hospital, usually including training

The delivery of services may be through government, non-government or private health care providers and financed by different mechanisms; for example, patient fees, health insurance or government subsidy.

For the health system to work well it is important that ALL stakeholders participate in the planning of services to avoid duplication, and to encourage ownership and responsibility. This is not easy to accomplish.

Table 1 gives an outline of the components of a health system applied to rehabilitation services.

Table 1 – Building Blocks and Application to Rehabilitation Services

Governance Leadership to advocate with decision makers for rehabilitation services.
Leadership to advocate with decision makers for rehabilitation services.
Work Force All health staff involved in the delivery of rehabilitation, at all service levels.
Provision of good quality training for rehab. staff.
Clear job descriptions, with who does what.
Encourage working in teams.
Financing Commitment by government to provide staff and facilities for rehabilitation services.
Inclusion of rehabilitation interventions within health insurance schemes e.g. hearing aids.
Medicines & Technology Appropriate technology (devices and aids).
See GATE (See Step 3.8 Overview of assistive products).
Information Use of IT to provide good information for decision making, evidence and research about rehabilitation needs and services.
Service delivery Focussed on the person’s needs and capabilities.
– Access – Good equal access; equity – gender; age; residency; ethnicity etc
– Coverage – High coverage for essential services, linked to equity
– Quality – Provide a quality service (both clinical and non-clinical).
– Promote quality improvement projects (QUIPs).
– Safety – Promote a culture which identifies adverse events and seeks to improve while avoiding the “blame game”.
Improved Health Impairments minimised
Functioning improved
Participation enhanced
Better health and life.
Monitor results.

Table 2 gives an outline of health service facility levels applied to rehabilitation services.

Table 2 – Application of Rehabilitation Services at Health Facility Service Level

Community Role of Community Based Rehabilitation (CBR) (See Step 3.16 Community based inclusive development)
Primary Integration of essential simple rehabilitation interventions into Primary Health Care. Primary Health Care Workers (PHCW) can provide basic promotive, preventive and therapeutic services which prevent diseases leading to impairment and disability. PHCW can identify and refer people who need secondary level rehabilitation services.
Secondary Provision of common rehabilitation services required by many people. The second level is where the core services for sensory and motor impairments can be delivered together with rehabilitation services.
Tertiary Provision of specialist rehabilitation services. Training of the rehabilitation work force.

Sustaining Ability Case Study


It is therefore clear that Rehabilitation Services must be delivered through each level of the health system, in order to be effective, and this requires many components to be in place (e.g. expert staff, funds, patients and so on).

A second important issue to consider is that Rehabilitation Services must be sustainable. LSHTM’s ICED and Handicap International evaluated what factors are important to ensure sustainability of Rehabilitation Services by developing the Sustainability Analysis Process (SAP) through a joint four year “Sustaining Ability” study in five post-conflict countries.

Sustainability Analysis Process (SAP)

The SAP evaluation is undertaken as a participatory process with in-country key stakeholders through a series of workshops. This process allows stakeholders to agree a common vision of sustainability, and how to define sustainability indicators that can be used to monitor progress towards this vision within the context of the national rehabilitation system (See Figure 2 for rehabilitation service indicators from Nepal’s 2014 SAP workshop).2 Stakeholders are a multi-sector (including, but not only, the health sector) and multi-level (civil society, institutional, local, national) group of actors, which is why alignment is so important for rehabilitation.

Figure 2: SAP Component 2 Rehabilitation services indicators, Nepal SAP 2014

SAP lessons learned for sustainable health system strengthening3,4

  1. The Structure of the rehabilitation system stakeholder network characteristics is key
    • Need to look at evolution over time to understand changing nature of relationships between stakeholders
    • Stakeholders’ capacity must work as a system, rather than a sum of stakeholders
  2. Creating consensus on a common vision of sustainability requires additional system level interventions
    • Identify and support stakeholders who promote systems thinking above individual interests

SAP conclusions

  • Importance of a ‘sustainability champion,’ this could be a government or civil society organisation and/or a person to lead and coordinate next steps
  • Shift in thinking from project level –> system level is essential for all stakeholder
  • The development of national rehabilitation action plans/strategies along the contiguum should be prioritised with close synergies to WHO health systems initiatives
  • SAP can facilitate sector planning
  • It is important to initiate and support development of data collection activities to monitor and measure indicators

Next steps for Sustaining Ability

As of 2017, Handicap International has coordinated 18 physical rehabilitation SAP workshops in three languages across the following 14 countries: Nepal (x3), Somaliland (x2), Cambodia, Liberia, Sierra Leone, Burundi, Haiti, Laos, Bolivia, Chad, Afghanistan, Myanmar, Jordan and Palestine (West Bank & Gaza).

Handicap International continues to support ongoing Sustaining Ability activities in the countries where they work with the aim to more closely align the methodology with WHO health systems initiatives and to share results widely to inform global rehabilitation sectors and UN cluster systems in emergencies.

© The London School of Hygiene & Tropical Medicine
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