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Key issues in health
system development
ICHS 3
www.hpsa-africa.org
@hpsa_africa
www.slideshare.net/hpsa_africa
Introduction to Complex Health
Systems
Outline
1. Dimensions of health system
performance
2. Understanding the Thai experience
STARTING POINTS: HEALTH
SYSTEM PERFORMANCE
WHO, 2007
4
M.E. Kruk, L.P. Freedman / Health Policy 85 (2008) 263–276 265
the scope of this paper, metrics need to be locally
relevant, reliable and valid as well as feasible to imple-
ment. Process indicators should be causally linked to
outcomes and sensitive to change in policy. Devel-
oped and developing countries may thus adopt very
different indicators in measuring the performance of
health systems and different indicators may be rele-
vant depending on the unit of analysis (e.g., facility,
district, nation). There are now several major initiatives
to standardize and harmonize the collection of health
metrics globally and to make recommendations on the
most useful measures. These include the UN’s Intera-
gency Group on Indicators that recommends measures
to track progress on the Millennium Development
Goals across countries, the WHO-based Health Met-
rics Network that is helping countries to develop health
information systems, and a new research Institute for
Health Metrics and Evaluation at the University of
Washington, among others [9–11].
This paper presents a systematic literature review
of health system performance indicators or measures
currently being used in the field, with a focus on devel-
oping countries. Given the complex and locally specific
nature of health systems and the corresponding need
to customize indicators for different settings, we did
not set out to compare the quality or feasibility of the
indicators reviewed here, which span many countries.
Rather, in this review, we describe the indicators that
have been applied in the field to measure health system
performance and highlight those indicators that were
found to be in most common use.
To organize this review, and based on the definition
of the goals of a health system discussed above, we
created a framework for health systems performance
(see Fig. 1). The three major dimensions of perfor-
mance in our framework are effectiveness, equity, and
efficiency and the inputs are policies, funding and
organization. This framework is informed by extensive
Fig. 1. Framework for health systems performance measures.
Kruk and Freedman, 2008
Improved
health
Social &
financial
risk
protection
Access & coverage
Donabedian: “proof of
access is in use of service,
not presence of a facility”
Degree of fit between
between the health
system and the
population it serves
A vailability
A cceptability
A ffordability
From availability to effective
coverage
for whom service
available
can use service
who are willing to use
services
who use service
who receive ‘effective’
care
People:
Shrinking proportion >>>
Responsiveness
how people are treated and the
environment in which they are treated
when seeking health care
a particular focus on inequitable
treatment associated with social status
www.who.int/responsiveness/en
Health care responsiveness (percentage of respondents who responded either
“good” or “very good”) comparisons across countries
Outpatient experiences Inpatient experiences
S
Africa
Brazil Israel Euro* S
Africa
Brazil Israel Euro*
Time 58 65 69 72 66 69 77 81
Dignity 71 93 92 90 74 90 90 89
Communication 69 81 87 87 67 76 87 82
Autonomy 60 70 80 83 61 66 79 72
Confidentiality 74 90 88 89 73 80 83 82
Quality of basic
amenities
68 80 90 91 70 80 60 87
Support 68 70 91 92
Summary 67 80 83 87 68 76 81 83
*European countries included were: Austria, Belgium, Denmark, Finland, France,
Germany, Greece, Ireland, Italy, Luxemburg, Netherlands, Portugal, Sweden, and United
Kingdom
World Health Survey data, 2003 (Pelzer, 2009 BMC Health Services
Research)
2352 participants (1116 men and 1236 women)
What is a health system’s
broader societal value?
The knowledge of a safety net for times of
vulnerability
‘Public value’• producing things of value to groups of citizens
• operating in fair, efficient & accountable ways
THE THAI EXPERIENCE
Health performance
• Achieved MDGs
early 2000s
• Over 40 years:
– LEB gone up, IMR
gone down, MMR
gone down, strong
annual reduction in
ChMR over 20yrs
• Reduction in IMR
and ChMR
inequalities
Value for money:
Relatively low IMR for
relatively low per capita
health expenditure
(compared to other
countries)
Health care performance
• Cause specific mortality decreases for intervention-addressable conditions (PyCare, MCH, pub health), except for peri-natal care
• High coverage with many interventions critical for child survival
• ‘Satisfactory’ essential obstetric care (no policy on unsafe abortions)
• Equity in utilisation
• Low out of pocket payments with low levels of catastrophic health expenditure
Factors explaining
experience
Health care performance gains over time
due to
Sustained action to address access barriers
over time
Sustained action to address access barriers over time:
Balabanova et al. 2011
Source: de Savigny and Adam (2009)
What building blocks were
addressed?
What building blocks were addressed?
Tackling access barriersHardware:
• Physical availability:
– provincial > district hospitals (phased imp)
– human resources:
• Bonding to rural areas for doctors and nurses, plus
• Expansion of nurse training & intro of less qualified cadres with career paths by MOPH (not MoEd)
(some provincial EDLs)
• Financial risk protection
– Piecemeal & gradual extension to 70% of population by 2001
– Universal coverage 2002
– Increased government spending over time
Software:
• ‘Pro-rural’ values
• Dedicated and committed health professionals across the system
• Social recognition of health professionals
Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedicated
health
professionals
How and
why?
Health system
Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedicated
health
professionals
How and
why?
1) Decision-making processes that have ensured consistent vision and persistent development towards goals
How and
why?1. Values-based and
charismatic political
leadership
2. Elite and interest
groups support
3. Competent, values-
based and
distributed technical
leadership
4. Generation and use
of evidence in
decision-making
5. Decentralised
authority
6. Flexible
implementation
7. Communication and
feedback, learning
through doing
Pro-poor, pro-
rural ideologyHealth system
Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedicated
health
professionals
How and
why?
2) HC features:
1. public sector
strengthened
2. integrated
service
provision
3. limited reliance
on external
resources
How and
why?
Pro-poor ideology; Use of
evidence; Economic context
Health system
Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedicated
health
professionals
How and
why?
3) Community
factors:
1. community
awareness &
acceptance
of health
programmes
2. public trust &
confidence in
DHS
3. public status
of health
professionals
How and
why?
Socio-cultural values;
positive experiences
Health system
Sustained action over time: why and how?
Hardware
interventions to
tackle access
barriers
Software:
values-driven
& dedicated
health
professionals
How and
why?
1) Decision-making processes that have ensured consistent vision and persistent development towards goals
How and
why?
2) HS features:
1. public sector
strengthened
2. integrated
service
provision
3. limited reliance
on external
resources
1. Values-based and
charismatic political
leadership
2. Elite and interest
groups support
3. Competent, values-
based and
distributed technical
leadership
4. Generation and use
of evidence in
decision-making
5. Decentralised
authority
6. Flexible
implementation
7. Communication and
feedback, learning
through doing
3) Community
factors:
1. community
awareness &
acceptance
of health
programmes
2. public trust &
confidence in
DHS
3. public status
of health
professionals
How and
why?
Socio-cultural values;
positive experiences
Pro-poor, pro-
rural ideology
How and
why?
Pro-poor ideology; Use of
evidence; Economic context
Health system
Note
• SYSTEM development matters!– Action went beyond specific interventions,
services or programmes
– Intersectoral actions
• New challenges to be addressed
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Introduction to Complex Health Systems, Presentation
3. Copyright CHEPSAA (Consortium for Health Policy &
Systems Analysis in Africa) 2014, www.hpsa-africa.org
www.slideshare.net/hpsa_africa
This document is an output from a project funded by the European Commission (EC) FP7-Africa (Grant no.
265482). The views expressed are not necessarily those of the EC.
The CHEPSAA partners
University of Dar Es SalaamInstitute of Development Studies
University of the WitwatersrandCentre for Health Policy
University of GhanaSchool of Public Health, Department of Health Policy, Planning and Management
University of LeedsNuffield Centre for International Health and Development
University of Nigeria Enugu Health Policy Research Group & the Department of Health Administration and Management
London School of Hygiene and Tropical MedicineHealth Economics and Systems Analysis Group, Depart of Global Health & Dev.
Great Lakes University of KisumuTropical Institute of Community Health and Development
Karolinska InstitutetHealth Systems and Policy Group, Department of Public Health Sciences
University of Cape TownHealth Policy and Systems Programme, Health Economics Unit
Swiss Tropical and Public Health InstituteHealth Systems Research Group
University of the Western CapeSchool of Public Health
