Health Systems Strengthening The University of Melbourne

The reconceptualisation of global health

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How should global health be understood in an era marked by the rising burden of non-
communicable diseases (NCDs), climate change and other environmental crises, integrated
chains of production and consumption, a power shift towards emerging economies, intensified
migration and instant information transition? (Frenk et al, 2014, p.94)

This question, asked by Julio Frenk and colleagues in an article published in The Lancet, is our
starting point for our journey into health systems strengthening. How we conceptualise health,
and health systems, shapes how we act in health systems strengthening.

…global health should be reconceptualised as the health of the global population, with a focus
on the dense relationships of interdependence across nations and sectors that have arisen with
globalisation (p.94).

In discussing global health, the authors critique the understanding and practices associated with
the older term ‘international health. They suggest that it was focused on control of epidemics and
the problems of poor countries; an excessively technocratic (expert-driven) approach to
solutions, and an understanding of aid that viewed problems as located in poor countries with
solutions located in rich countries.

Importantly, for our concerns in this course, they state that ‘international health’ as a discipline
overemphasised control of particular diseases (for example, malaria or pneumonia) through
narrow interventions and programs, but did not pay much attention to broader health systems.

Two key points are used to support the ideas for the reconceptualisation of global health
proposed:

1. Global health should not be ‘foreign health’ but the health of the global population
2. Global health should not be about dependence but about interdependence, and exploring
interdependence through:

 Cross-border movement of elements of the natural environment.

 Consumption of globally marketed goods and services.
 The global spread of information, knowledge, and culture (such as patterns of use of
technologies that lead to antimicrobial resistance).
 Transnational rules such as trade treaties and the International Health Regulations.

They depict managing inter-dependence as highly cross-sectoral, with many actions far outside
the traditional boundaries of the health sector.
The globally inter-dependent nature of health risks produces a ‘triple burden’ of health concerns
globally: the unfinished agenda of infectious disease control; the global epidemic of non-
communicable disease, and the health risks caused by globalisation itself, such as those
associated with the import of food, or the migration of health workers.

Recognising that this agenda can only be addressed at the global level, but that a global
government is not a realistic option, Frenk and colleagues suggest that what is required is to
slowly build a ‘global society’ in which global citizens

accept to share the risks, rights, and duties related to protection and promotion of the health of
every member of this society (p.96)

How do you respond to this? Do you see the challenges of the health system in your setting
to be predominantly local and independent, or global and interdependent in nature?
Reflect on this as we look at the next three steps and explore the history of health systems
strengthening.

REFERENCES

FRENK, J., GÓMEZ-DANTÉS, O. AND MOON, S. 2014, FROM SOVEREIGNTY TO

SOLIDARITY: A RENEWED CONCEPT OF GLOBAL HEALTH FOR AN ERA OF

COMPLEX INTERDEPENDENCE. THE LANCET, 383(9911), PP.94-97.

 The path to Universal Health Coverage

The WHO’s World Health Report (2010) is the most recent of the World Health Reports to focus
on health systems, and it lays out the vision for Universal Health Coverage (UHC) which reflects
current thinking about health system objectives. The report defines UHC as: “all people have
access to services and do not suffer financial hardship paying for them” (page ix).

The report recognises, as do Frenk and colleagues (2014), that health is dependent on many
factors outside the health sector. However, it argues that “timely access to health services - a mix
of promotion, prevention, treatment and rehabilitation - is also critical” (page ix).

The report documents how far the world is from achieving UHC and estimates that:

 Closing coverage gaps in skilled birth attendance, for example, could save 700,000 lives
in low income countries.
 Globally, about 150 million people suffer financial catastrophe as a result of health care
costs.

Three pillars are identified as being needed to support a UHC strategy:

1. Raising sufficient funds to ensure the availability of health services that meet the major
health needs of the population. In order to do this, it is suggested that countries need to:
o Increase the efficiency of revenue collection
o Reprioritise government budgets to give money to health
o Explore innovative financing opportunities like taxes on air tickets, foreign
exchange transactions or tobacco
o Access development assistance (aid) for health
2. Reducing reliance on out of pocket payments (where people pay directly for health
services they use) as a way to finance health services. Instead of charging fees for health
services, the report recommends using tax or insurance schemes to finance health
services. This reduces financial risk for individuals and shares risk across the population.
Poor people will need subsidised health services, and payment through tax or insurance
should be compulsory for those who can afford it, or people with low risk will opt out of
the payment system.
3. Reducing inefficient and inequitable use of resources during the process of delivering
health care. The main strategies proposed to achieve this are:
o Selecting and procuring appropriate medicines
o Selecting appropriate technologies and services
o Motivating health workers
o Improving hospital efficiency
o Reducing medical errors
o Eliminating waste and corruption in the health system
 o Critically assessing what services are needed
o Reducing inequalities in coverage

All these ideas and strategies will receive substantially more attention throughout the course,
especially in the week focused on financing.

Our view of what constitutes a health system, and the scope of health systems
strengthening, has greatly widened over time. In the strategies discussed above, are there
things you would consider ‘outside’ the scope of health systems strengthening? Reflect on
this as we take a deeper look in the next two videos of the history of health systems
strengthening.

The emergence of Primary Health Care

In your country setting, how were your health systems influenced by the Primary Health Care
movement (if at all)? If you know something of this history in your own setting, please tell us all
about it briefly below.

If you don’t know enough about your health system’s history, now would be a good time to do a
little of your own reading about how the Primary Health Care movement, Alma Ata Declaration
and subsequent debates have shaped your health system - understanding this history is key to
recognising why your health system might look the way it is today (and what may or may not be
feasible to implement in future).
The UHC cube shown in the previous video describes three key dimensions of Universal Health
Coverage:

(1) cost coverage (proportion of health costs covered by tax, insurance or other prepayment
mechanisms);

(2) service coverage (the number and type of health services provided) and

(3) population coverage (the proportion of the population who have access to these services).

Expanding coverage along one dimension (for example, increasing the number and type of
services covered) typically means that coverage in the other two dimensions (for example, cost
coverage and population coverage) may decrease, unless additional resources are put into the
system. In addition, there is a quality dimension – meaning that nominal coverage of costs,
services or population may be undermined by gaps in quality which mean that effective coverage
is lower than the three dimensions suggest.

Many debates in health systems strengthening ultimately revolve around the relative
prioritisation of these dimensions in health strategies, policies and programs. While all
dimensions are important, some countries focus on covering the whole population with a very
basic package of services, but many services, and most costs, are not covered. Others provide
much better service and costs coverage to particular groups within the population (for example,
children under five), but their overall population coverage and service coverage is poor.
 An overview of different health systems frameworks
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While there are many frameworks to describe health systems, the two most influential are
WHO’s Building Blocks framework and the World Bank/Harvard’s Control Knobs framework.

The World Health Organization’s “Building Blocks” framework

In 2007, WHO published a framework, commonly known as the “WHO building blocks”, to
focus attention on the need to strengthen health systems, and to guide a common conceptual
understanding of what constitutes a health system, in order to go about strengthening it.

According to this framework (see ‘the WHO system framework’ image below), six building
blocks constitute a health system or in other words, there are six essential functions of the health
system. These building blocks are: + service delivery; + health workforce (human resources); +
information (data and data systems); + medical products, vaccines and technologies; + financing;
and leadership and + governance (stewardship).

These six building blocks need to be strong to achieve the overall goals of a health system, which
were improved health; responsiveness (that is, how well the system responds to changing
health needs or other changes in the system); social and financial risk protection; and
improved efficiency. Intermediate goals are access, coverage, quality and safety.
Image source: The WHO’s Health System Building Blocks Framework. World Health Organization.
Everybody’s Business: Strengthening health systems to improve health outcomes—WHO’s Framework
for Action. Geneva: WHO, 2007, page 3.) Re-used with permission.

A more detailed description of the WHO framework can be found in the ‘see also’ section below.

The building blocks framework, while widely used, also received criticism for not
acknowledging how the building blocks were inter-connected and interacted with each other; and
for ignoring the consumers and communities at the centre of the health system.

In 2009, in a seminal publication on systems thinking, WHO published an adapted version of the
building blocks framework. This placed “people” at the centre and showed the
interconnectedness of the different blocks (see figure below).
Image source: Interconnection between building blocks. World Health Organization. Systems thinking for
health systems strengthening. Edited by Don de Savigny and Taghreed Adam. WHO, 2009, page 32). Re-
used with permission.

For more information on this, please refer to the web links provided in the ‘see also’ section
below.

The World Bank Flagship Program “Control Knobs” framework

Roberts et al (2008) published a framework to assess health systems performance and guide
health systems strengthening efforts. This approach was jointly developed by the World Bank
Institute (WBI) and the Harvard University School of Public Health and is taught in the WBI-run
Flagship Program on Health Sector Reform and Sustainable Financing.

The focus of this framework is to identify areas of policy action to modify health systems and
improve their performance. This framework identifies five “control knobs” that can be
adjusted/changed to strengthen health systems (see figure below).
Source: The Control knobs for health sector reform (Source: Roberts, M.J., W.C. Hsiao, P. Berman, and
M.R Reich. 2003. Getting Health Reform Right. New York: Oxford University Press, page 27). Re-used
with permission.

Briefly, the five control knobs are:

 Financing: this control knob deals with the mechanisms which mobilise money to fund
healthcare and how it is allocated. In other words, how much money is available, who pays for
health sector activities, and how are the funds distributed?
 Payment: this control knob looks at how providers are paid and the incentives or disincentives
this creates to influence performance.
  Organization: this control knob looks at how healthcare delivery systems are organized and
managed.
 Regulation: these are the coercive requirements imposed by the state to direct the behaviour of
health care providers and organisations.
 Behaviour: this control knob is around influencing the behaviour of providers and consumers
through population-based interventions, since these are grounded in social and cultural
structures and therefore influenced by beliefs, perceptions, attitudes and cultural norms.

Health system goals according to this framework are improved health status, customer
satisfaction and risk protection (fairly similar to the WHO framework) and intermediate goals are
access, quality and efficiency.

From your own experience, are there other functions or components of a health systems
that these frameworks do not cover? Do you think they address all the most important
aspects? Use the comments section below to share your thoughts.
 Converging Health Systems Frameworks
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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.
 Thinking Systematically
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While health systems frameworks such as the ‘control knobs’ and ‘building blocks’ may be a
useful starting point to understanding the core elements and functions of health systems, a more
complex understanding of what constitutes a health system, and how actors and processes in the
system interact, is vital when developing health systems strengthening approaches.

As you watch the animation in the next step, the first in a series throughout this course which
explores complexity within health systems, think about the value of simplification and ‘rules of
thumb’ when working on complex issues, but also the risk of failing to see the true complexity of
a system and account for it.