Health systems strengthening in global and national contexts

Abstract

Despite advances in medical research, the burden of disease in most countries remains high. Further, health inequalities continue to grow and emerging infectious diseases are still wreaking havoc across countries. To respond to contemporary public health challenges, a new systems thinking paradigm has emerged that highlighted a holistic approach towards health systems, resulting to an emerging field - health policy and systems research (HPSR). HPSR seeks to understand and enhance how societies organise themselves in achieving collective health goals, and how different actors interact in the policy and implementation processes. However, research gaps remain particularly in applying this paradigm to strengthen health systems performance across countries. This thesis contributes to HPSR by: a. examining the underlying concepts of health systems strengthening; b. determining how health systems contribute to better health outcomes, particularly on reducing infant mortality rates and improving life expectancies at birth, and c. understanding mechanisms to use findings from health systems strengthening assessments to inform global and national-level health policymaking processes. In 2015, 40% of the Global Fund investments go toward health systems strengthening (HSS). The global health threats posed by recent viral epidemics such as Ebola and Zika even further increased calls to invest in and develop better health systems. These health systems investments were also in most cases subjected to performance-based funding, but contrary to other monitoring and evaluation methods used for other health programs, health systems monitoring and evaluation demand a new analytical frame due to its complexity, along with the very different country capacities, uneven data sources and data availability and quality, including the varied contexts that drive priority areas for health systems. As such, monitoring these initiatives remain to be highly contentious despite its importance to inform health resource allocation. In particular, studies often highlighted different conceptual and methodological challenges associated with health systems assessments worldwide. To address these issues, I first introduced a new HSS framework based on existing monitoring and evaluation frameworks collected from my field experience, systematic reviews, and thematic analyses of existing HSS documents and database. Based on the developed HSS framework, existing HSS indicators were also examined to guide further analysis. Further, I quantitatively assessed health systems performance using a new composite indicator based on previous efforts for a global health systems performance index. To do this index, I used data collected from the Demographic Health Surveys, the World Bank Indicators, and the World Health Organisation (WHO) Global Health Surveys. In particular, I used fixed-effects and random-effects regression analyses to determine how each health system characteristic affects health outcomes, particularly infant mortality rates and life expectancies. Specifically, I examined how global core health indicators can be used to assess each health systems building block (governance, financing, service delivery, health workforce, medical products and technologies, and health information systems. From global health systems assessments, I then examined the use of health systems monitoring and evaluation to assess one of the building blocks – governance – in Cambodia and the Philippines. In this thesis, I found about 3000 health systems indicators that countries can choose from to guide their current or future health systems performance assessments, while tailoring them into their specific country needs and contexts. In addition, I found a significant gap in country capacities to be able to monitor health systems performance, implying the need for better surveillance and reporting systems particularly in low- and middle-income countries. Further, I also quantified the contributions of each of the health systems building blocks to overall infant mortality rates and life expectancies and found that health systems can only effectively improve health outcomes if all of the building blocks are well-functioning. Using these information, I created an index for health systems performance assessments that can be used for global monitoring and evaluation. Using this index, I found that many countries in Africa and Southeast Asia remain to have the least performing health systems, as well as health outcomes. The index was able to account for the different health systems building blocks, while controlling for socioeconomic factors and other health determinants. When applied in assessing health governance in Cambodia and the Philippines, I found that decentralization significantly contributed to improve Cambodia’s infant mortality rates, while finding a lesser effect for the Philippines. Given these findings, I concluded that health systems performance can be quantitatively assessed with these assessments providing comprehensive yet easily understandable overview of health systems performance in both national and global levels; hence, facilitating use in health systems decision-making processes.