To promote good health for all, effective health systems are critical. Rather than focus on a specific disease or program, there is growing consensus that we need to widen the range of support — to build the capacity of health staff, promote community engagement, ensure monitoring and evaluations systems are functional, and so on.
Despite the recognition that building effective health systems is a fundamental task, the strategies to achieving this are not always clear. Health systems are complex entities, functioning at multiple levels, composed of disparate elements and acutely influenced by context — including geography, politics, finance, the influence of other sectors, and national, regional and international dynamics. All these factors coalesce to produce specific health outcomes.
We believe that adopting a multi-level framework will help us navigate this complexity and identify areas for action. This framework emerged from synthesizing findings across five country case studies, exploring what has driven progress in maternal and child health (Nepal, Mozambique, and Rwanda), and neglected tropical diseases (Cambodia and Sierra Leone).
The framework highlights three critical levels for analysis:
1. The macro level is broadly defined as the level of national policies and strategies, where decisions about priorities and policies are made, interventions are designed and resources allocated.
2. The meso level is where policies are operationalized and implemented as specific programs, affected by the organizational context and the strength of competing interests.
3. The micro level represents the interface of health systems and users, where services are delivered and where the role of individuals and communities becomes critical.
The levels are not mutually exclusive and some drivers of progress cut across all levels. Furthermore, the framework can evolve, with certain drivers acting at different points in times.
So what does this multilevel framework tell us about the drivers of good health outcomes? How were positive health outcomes achieved?
Effective governance and financing at the macro level
All five case studies show that these are vital ingredients, with effective governance including strong leadership, effective and well-coordinated partnerships, strategic policy making and mechanisms for accountability. In post-war Mozambique, for instance, primary health care was positioned as a key government priority; and in Rwanda, President Kagame personally championed improved health services. Strategic policymaking, informed by evidence and best practice, was crucial in all five countries.
The picture is more mixed on accountability, but in Sierra Leone the Free Health Care Initiative — working closely with the Anti Corruption Commission— has taken steps to reduce corruption and weaknesses in the health sector across the different levels.
Finally, increased investment in health was critical in all countries. While domestic expenditure has increased, external support remains paramount, with all five countries benefiting from external aid.
Effective implementation at the meso level
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Critical to positive health outcomes at the meso level were the integration of specific programs into existing health systems, partnerships with other sectors and task-shifting. In Sierra Leone, NTD activities have been integrated into existing health campaigns, for example de-worming tablets distributed during the Maternal and Child Health Week. Partnerships between the health and the education sectors have been crucial in Cambodia for distributing NTD drugs across the country. In Mozambique, task shifting — where nonphysician health staff are trained as medical and surgical technicians — may have contributed to reduced costs and increased service provision in remote areas.
Effective user and provider engagement at the micro level
Community health workers and community engagement have been critical for increasing access to health. In Nepal, 48,000 female community health volunteers have raised awareness of maternal health practices and services in remote areas. In Sierra Leone, 29,000 Community Drug Distributors have been central to the success of the NTD program, going house to house to explain the purpose of NTD control, as well as distribute drugs. Locally known and chosen by communities, they are crucially able to gain people’s trust.
Despite ongoing challenges at all levels — including the sustainability of funding, fragile partnerships with other sectors and sustaining the motivation of voluntary health workers — these examples provide a number of insights to health planners and programmers about how to strengthen health systems.
Cross-cutting recommendations
1. Increase awareness of the different levels of a health system: often a malfunctioning in one level could lead to inefficient or ineffective programming in another.
2. Promote close collaboration with key policy makers from the start, to create strong leadership and political commitment from the top — critical if a program implemented at the meso or micro level is to be both successful and sustainable.
3. Accountability mechanisms cross-cut all levels, so build the capacity of key stakeholders at all levels to develop, run and sustain such mechanisms.
Macro-level recommendations
1. Establish and effectively coordinate partnerships with stakeholders working in similar areas to learn from best practices, create comparative advantages and ensure minimal duplication.
2. Encourage national level policy makers to address inequalities of access based on geography and different socio-economic and wealth groupings through strategic policies.
3. Pool and effectively manage external funding, while at the same time supporting initiatives to increase local income generation — for example, through better collection of taxes.
Meso-level recommendations
1. When planning and designing an intervention, consider partnering with other sectors to achieve better coverage and scale.
2. Think through ways of institutionalizing such partnerships in order to replicate and sustain the initiative.
3. Integrate health programs into existing health infrastructure and programs to increase access, make programs more effective, and make best use of scarce resources.
Micro-level recommendations
1. From the outset of a program, identify ways of involving community members in problem and priority solution identification; awareness raising and community mobilization activities; and delivery of services.
2. Incentivize volunteers and explore ways to incorporate them into the formal health sector — for example, through task shifting.
3. Ensure appropriate supervision is provided to community-based health workers.
Many of these recommendations are not new, but need to be continuously reaffirmed against recurring challenges. Taking a multilevel approach — as shown by the study — allows us to navigate the complexities of health systems, being aware that they are in a constant state of flux and influenced by context, sectoral dynamics and political interests.
Without seeking to offer a blueprint, findings from these case studies can help policy makers and implementers think through the ingredients necessary at different levels — and adapted to the particular context — in order to expand access and, ultimately, to promote good health outcomes for all.
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Healthy Means is an online conversation hosted by Devex in partnership with Concern Worldwide, Gavi, GlaxoSmithKline, International Federation of Pharmaceutical Manufacturers & Associations, International Federation of Red Cross and Red Crescent Societies, Johnson & Johnson and the United Nations Population Fund to showcase new ideas and ways we can work together to expand health care and live better lives.
