Applying a Health Systems Assessment in a fragile setting.
Turning the results of health systems assessments (HSA) into practical policy actions is vital for countries to make progress towards universal health coverage. But critically, in order to do this, HSA information should be linked to performance dimensions such as equity, efficiency and responsiveness.
Since health systems strengthening is a critical means to achieve universal health coverage (UHC), a regular analysis of how the health system is performing takes on increased prominence.
With performance as key, health systems functions - stewardship, delivering services, financing and generating resources - should be included in health systems assessments going forward.
These were key messages to come out of the second face-to-face meeting of the UHC2030 Health Systems Assessment Technical Working Group on 6-7 November 2018, in Geneva.
Strong turnout at the meeting from country representatives, and other partners, including OECD, GFTAM, GIZ, UNICEF, World Bank, WHO, FHI360, IPPF, and GAVI highlighted the importance of multi-stakeholder engagement and consultation, facilitated by UHC2030.
Why do we need to rethink health systems assessment approaches?
Many countries, especially those that are aid-dependent, are faced with a growing burden of multiple and sometimes contradictory health system assessments. This often means high transaction costs with few results actually being put into practice. As a global health community, we need to ask ourselves, is this the best way to organise our approach?
The UHC2030 HSA Technical Working Group was formally constituted in 2017 with the rationale of studying various HSA tools in order provide a more harmonized and aligned HSA approach. Ultimately, it should be driven and owned by the country, rather than triggered by the needs of those who are paying for or conducting the assessment.
The Technical Working Group reviewed existing HSA tools to gain insight into the various approaches used to assess a health system, and the objectives behind such processes. It became clear that an analysis of health systems performance was unevenly done in countries.
The Technical Working Group saw the value in not only harmonizing and aligning HSA approaches but also in creating a more explicit link between HSA data and health systems performance assessments (HSPA). The participants of the HSA TWG reached a consensus to regroup the content of the reviewed HSA tools in accordance to health systems functions; stewardship, delivering services, financing and generating resources..
What was discussed at the 2nd face-to-face meeting?
Currently, the HSA Technical Working Group is focused on Deliverable 1 of the HSA Technical Working Group. (See below for the full list of the groups deliverables).
The 2nd face-to-face meeting discussed the proposed shift from Health Systems Assessments to Health Systems Performance Assessments. Participants reflected on the merits and potential challenges of the health system functions, examined the appropriateness and suitability of proposed sub functions and considered potential qualitative and quantitative performance indicators.
Toomas Palu, World Bank UHC2030 Co-Lead and Gerard Schmets, WHO Coordinator of Health Systems Governance, Policy and Aid Effectiveness both pointed out the importance of international partners providing support to countries in conducting and contextualising HSPA as well as planning and implementing system changes as a result.
Dr. Banu Ayar from the Ministry of Health in Turkey shared information about the first HSPA conducted in Turkey, noting the importance of high-level political support and the need for multi-stakeholder engagement. “Health systems performance assessments are critical to inform policy decision-making,” she said.
Country-specific issues such as the health system structure and national cultural and religious influences are of critical importance. Professor Jesse Uneke, Director of the African Institute for Health Policy and Health Systems in Nigeria, deliberated on the challenges when conducting the Nigerian HSA in 2008. Nigeria’s context is complex and diverse with 36 states, over 250 ethnic groups and various religions. The Nigerian health system operates in a complex and rapidly changing environment with ageing and urbanization influencing the burden of disease; and many efforts now focus on building capacity at the state level to design a bottom-up HSA approach, first considering the context in each state.
Keep it practical
A country panel of representatives from Ghana, Belgium, Turkey and Nigeria highlighted the importance of linking HSA results with implementation and the need for policy makers to support this process. They all reiterated why the proposed approach of the UHC2030 HSA Technical Working Group should support countries to make their findings tangible and easy to translate into policy actions. The main goal is for countries to use HSA information for assessing their own health system’s performance, and take action as a result.
Representatives from civil society organisations such as IPPF and FHI360, several institutions such as GFTAM, OECD, GIZ, GAVI and WHO regional offices of AFRO, EURO and PAHO all suggested and welcomed an operational approach which is easy to use and not too academic, with fewer indicators to reduce the burden of collecting data.
In her closing remarks, Dr. Agnes Soucat, WHO Director of Health Systems Governance and Financing, re-affirmed the importance of the approach. “Harmonized systems assessment and the specific deliverable of the HSA Technical Working Group are vital in the SDG era where strengthening health systems is a foundation for climbing towards UHC.”
Presentations from the meeting
• Dheepa Rajan
• Marina Karanikolos
• Ellen Nolte, London School
• Katja Rohrer
• Kira Koch
• Marina Karanikolos
• Dheepa Rajan
• Pascal Meeus
• James Duah, Ministry of Health
• Jesse Uneke
• Banu Ayar
Background to the HSA Technical Working Group
What are the deliverables?
Deliverable 1: Development of a recommended UHC2030 annotated template to conduct health systems (performance) assessments, including taxonomy, working definitions, a set of core indicators.
Deliverable 2: Development of UHC2030 process guidance on HS(P)A, integrating performance assessment and based on the principles of country ownership and leadership.
Deliverable 3: Development of a UHC2030 knowledge base around HS(P)A and support to cross-country learning.
Deliverable 4: Advocacy to gain stakeholder buy-in on UHC2030 TWG deliverables to promote a more accountable HS(P)A environment.