Converging Health Systems Frameworks

Not all “health systems strengthening” initiatives actually strengthen health systems. Having good frameworks to conceptualise health systems and guide action are essential, as the linked article by Shakarishvili and colleagues (2010) explains.

A health systems framework is defined as a “bird’s eye view over the health system” (p.4). It describes and explains the health system and its objectives, structural and organisational elements, functions and processes. Many of the available frameworks are really health care system frameworks, describing only the narrower system which delivers health care. Health outcomes are the results of many factors that could be considered part of a larger health system within which the health care system sits. However, the complexity of those larger set of relationships makes these larger health systems much more difficult to represent.

Global health initiatives which target specific diseases or problems have grown in importance in recent years. Shakarishvili and colleagues describe how the idea that the resources channeled through these initiatives would strengthen health systems as they targeted specific diseases, has evolved to an understanding of how they might also undermine health systems. For example, evidence suggests that the setting up of parallel systems (such as multiple supply chains for the same products) can undermine the residual system. Specific disease control programs (such as a separate HIV program) can absorb disproportionate shares of scarce human resources, weakening the rest of the system. They suggest that the understanding that has evolved is that health systems are a prerequisite of successful disease control rather than an outcome of increased investment. Health systems strengthening needs to be a focus, not a by-product, of initiatives.

In recent years, all major stakeholders in global health have been trying to revitalise their approaches to health systems strengthening. In order to achieve this revitalisation, it is argued that there is a need for greater clarity to guide health systems strengthening efforts, and a health systems framework to define, describe and explain health systems. However, there are lots of competing frameworks, which may generate conceptual confusion and hinder such efforts. The paper aims to develop a converged conceptual framework to simplify and provide clarity for those working at country level.

The paper classifies existing health system frameworks into a typology:

• Descriptive frameworks: these describe components of health systems but do not focus on how they work. Some examples attempt to describe whole national systems; others focus on sub-components which could relate to levels of care, disease focused programs or operational components (such as drug procurement and distribution).
• Analytical frameworks: these provide greater depth in analysing some major aspect of a system (for example the flow of funds); or focus more comprehensively (functional frameworks) across multiple aspects of operation.
• Deterministic and predictive frameworks: these include actuarial, economic and macro policy models that make predictions about future performance of health systems with respect to, for example, health expenditure or human resource requirements.

A converged health system framework aims to simplify the task of describing health system functioning and prescribing appropriate reforms. It should be capable of addressing institutional, functional, operational, structural and other types of health system challenges. It should be useful for multiple purposes such as programming, policy making and research. Finally, it should allow for complex interactions between elements of the health system, and between the health sector and external factors.

To aid development of a converged framework, the authors identify areas of complementarity in existing frameworks. There is broad consensus that:

• The goals of the health system include improved health status, protection against financial risk, responsiveness to needs, satisfaction of consumers’ expectations.
• The overarching principles of the health system include equity, efficiency, sustainability, quality, access, coverage, safety and choice.
• The processes or ‘control knobs’ of the health system include organisation, regulation, integration, decentralisation, resource generation and resource allocation. In descriptive frameworks, these processes are described. In analytical/predictive frameworks they are points of intervention whose impacts are to be predicted.
• The functions or ‘building blocks’ of the health system include structural and institutional aspects, service delivery, health information systems, health workforce, technologies and commodities, demand generation, governance and financing. These can be quantitatively considered as inputs (for example, number of staff, amount of funding). They can also be qualitatively considered as the means of achieving progress with respect to their function .

In order to use a common conceptual framework at country level, a ‘roadmap’ is needed that builds from the conceptual framework to an operational framework, a country health system strengthening strategy and a broader health system strengthening policy and program that further incorporates implementation, evaluation and learning (as described in the figure below). Countries can then follow this process to develop and refine frameworks, strategies, policies and programs that are coherent and appropriate.

Image source: Based on Figure 1 in Shakarishvili G, Atun R, Berman P, et al. Converging health systems frameworks: towards a concepts-to-actions roadmap for health systems strengthening in low- and middle-income countries. Global Health Governance. 2010;IV(1) p14

In your setting, how much influence do you think conceptual health systems frameworks (and HSS frameworks) have on national strategy or policy? Please type your response in the comments section below.

References

Shakarishvili, G., Atun, R., Berman, P., Hsiao, W., Burgess, C. and Lansang, M. 2010, ‘Converging Health Systems Frameworks: Towards A Concepts-to-Actions Roadmap for Health Systems Strengthening in Low and Middle Income Countries’, Global Health Governance, vol. 3, no. 2, pp. 1-17.