Strategies at different levels of the health system

What are strategies that we can use to strengthen health systems, and how can we select the right one for any particular context?

Selecting the right health system strengthening (HSS) strategy can be complicated. HSS strategies act at different levels of the health system; it may be necessary to combine strategies at different levels and with different approaches to address health system problems.

The connections between the strategies or interventions and their expected impacts on health systems can also be long and complex. For example, introducing a policy on fees for health services at a national level, will have to pass through many intervening links to result in changes in use of services at community level.

As a result, the time periods to see such changes can be long, and it may not be clear for some years whether the expected or hoped for changes occur. The change in user fees will need to be incorporated into budgets, and then into funding for facilities, and then into funding for individual services; users will need to become aware of the changes, and may then change their use of services in response.

Because of the many intervening links, there is the potential for complex inter-connection and interactions with other elements of the health system. Changing user fees may result in changes to the income of service providers, which might change their practices, or their willingness to work in some areas.

This table provides some examples of strategies at different health system levels, and the strengths and weaknesses of operating at each level.

We can also select HSS strategies based on different health system functions. Some examples include:

(1) Health financing strategies. These strategies are increasingly popular and have the advantage of interacting with many other health system functions.

Examples include: Introducing health insurance programs or expanding the coverage of health; conditional cash transfers, which provides direct payments to communities or families that achieve health service targets, such as immunisation coverage; and contracting non-government (for profit or not for profit) providers to provide specific services that the government has difficulty providing (such as HIV counselling).

(2) Workforce strategies, such as: Improving the skills and capacities of health workers, through training and supervision programs. Examples include training of CHWs to provide services such as follow up of TB or HIV patients; improving supervision of health facilities.

(3) Use of information technology to improve data collection or provide information. Examples include use of mobile text messages for reporting; or to provide reminders to patients.

(4) Changes to the organisation of services, such as integrating services for example HIV/AIDS with maternal health services and family planning, to enable easier access.

How can we select the right strategies for HSS?

In selecting a HSS strategy, we can begin by assessing the health system, and trying to identify areas of poor performance. We can then investigate the causes of the poor performance, and seek to identify the underlying key cause or ‘bottleneck’. This may be within the health system, in the community, or in sectors outside health.

Having identified the bottleneck, we can select potential strategies that might address the bottleneck.

In selecting a strategy we should consider:

• whether the strategy addresses the root causes of the bottleneck;
• whether it is based on evidence rather than just the hunches of those involved;
• whether it is feasible and acceptable to those who will implement it;
• whether the implementers have the capacity, such as skills and resources, to implement it; and
• whether the complementary requirements from other health system elements are available to support it.

Implementing HSS strategies

When we come to implementing the HSS strategies, we need to use an approach that recognises the complexities and potential interactions within the health system.

An important principle in implementation is to adopt a learning approach, monitoring changes in the context and in health system operations as implementation progresses, and adapting or revising strategies as needed.

In reflecting on their experience with implementing HSS strategies in Africa, Rwabukwisi et al. (2017) concluded that implementation is a process of continuous learning. Interventions need to be adjusted to account for changes in context, and to address gaps uncovered during implementation. They emphasis the need for ongoing monitoring and for a process of knowledge exchange to inform changes during implementation. You can read the full account of their experiences in the ‘see also’ section below.

Think of a problem in a health system that you are familiar with or that you use. Can you identify a possible cause?

Select one of the strategies mentioned in this step or in the reference papers that you think might address this cause.

What might be some of the intervening links that need to operate in order for the strategy to be effective?

References

Rwabukwisi, FC, Bawah, AA, Gimbel, S, Phillips, JF, Mutale, W & Drobac, P, 2017, ‘Health system strengthening: a qualitative evaluation of implementation experience and lessons learned across five African countries’, BMC health services research, vol. 17, no. 3, p. 826.