What does it really mean to build health systems?

By Jenny Lei Ravelo 02 June 2015

A doctor sees a patient in Ivory Coast. How can various global health stakeholders approach health systems strengthening? Photo by: Ami Vitale / World Bank / CC BY-NC-ND

Over the past year, discussions around dealing with the Ebola outbreak to bringing cases down to zero invariably circled around the need for health systems strengthening.

Dr. Ariel Pablos-Mendez, the U.S. Agency for International Development’s assistant administrator for global health, and Michael Myers, managing director at the Rockefeller Foundation, were perhaps among the first health experts to pin West Africa’s inability to contain the epidemic on weak health systems in the region.

Eventually, discussions on health systems strengthening evolved.

Gro Harlem Brundtland, former director-general at the World Health Organization and member of The Elders, talked about how developing countries should take the lead in strengthening their health systems. These countries know best what they need and should be able to push for these changes to happen, instead of letting international donors — some of which have begun pledging funds to help developing countries strengthen their health systems — and agencies dictate where investments should go.

Further, a number of initiatives have been launched both to shine a light on how strong countries’ health systems really are and to support efforts to address this problem. In March, for instance, Save the Children ranked countries according to their pandemic preparedness. Pharmaceutical giant GlaxoSmithKline PLC meanwhile announced it will invest $9 million to train health workers in Ghana, Kenya and Nigeria.

Building resilient health systems was the theme of the just-concluded 68th World Health Assembly in Geneva, Switzerland, as well.

The need to strengthen and build more resilient health systems seems clear to the global health community. Having this in place minimizes a country’s vulnerability to another infectious disease outbreak, for instance. It could also reduce deaths from preventable diseases — such as malaria, which continues to be the biggest killer of children under 5 in Sierra Leone — or because of a lack of qualified doctors and medicines.

To this day, however, various stakeholders have yet to reach on a common understanding of how to approach health systems strengthening or set in place a robust system that would allow them to systematically and comprehensively tackle the problem.

Different actors, different interventions

The lack of such guidance meant well-meaning actors focused on areas they deemed in need of critical support.

Médecins Sans Frontières Belgium, for example, signed a memorandum of understanding with the Ministry of Health in Sierra Leone to reinforce peripheral health structures to help tackle the three biggest disease killers in the country: malaria, diarrhea and respiratory diseases — which were neglected at the height of the Ebola outbreak. MSF Belgium also hoped the reinforced health structures would eventually allow the medical organization to tackle malnutrition in the country and, post-2015, engage in a negotiation to support the Kenema Government Hospital.

The decision follows the completion of an assessment the international medical group conducted in the southeastern part of the country, where they found serious gaps in health service provision and quality, drug and water supply, and human resources.

The country currently uses what MSF Belgium epidemiologist and medical coordinator Dr. Jacob Maikere calls “push system,” where the central pharmaceutical warehouse is only able to provide hospitals and health centers drugs it currently has in stock, rather than what these facilities need or demand. This underscores the problems Sierra Leone has in its drug procurement system.

The Kenema hospital meanwhile suffered major losses in its medical staff: 52 health professionals, including doctors, community health officers and nurses, died from Ebola.

Other MSF sections, such as the Netherlands and Spain, are also expected to make the same interventions in the western and northeastern parts of the country.

This is the first time MSF Belgium has assessed health system facilities in the country. To measure impact, Maikere told Devex the organization will look at health indicators in its area of intervention. When tackling malaria in Kenema, for example, MSF Belgium will track whether caseloads have improved, remained the same or actually increased.

As part of GSK’s $9 million investment in Ghana, Kenya and Nigeria, meanwhile, more than 9,000 health care workers in those three countries will receive training. Ramil Burden, the company’s vice president for Africa and developing countries, previously told Devex that the move is aimed at providing communities access to better health care workers, who could help change health behaviors and therefore create demand for care and treatments, which eventually creates a market for GSK products.

“By working with community health care workers, we are creating an ecosystem that improves health outcomes and also increases demand in the system,” he said.

These interventions could easily be interpreted as following WHO’s Framework for Action, where the agency identifies six “building blocks” that constitute a strong health system — good service delivery; well-performing health workforce; well-functioning health information system; equitable access to medical products, vaccines and technologies; good health financing; and the presence of leadership and governance measures.

But are they really?

An old problem

A 2009 study published in PLoS Medicine, an international scientific journal, reviewed how health systems strengthening were defined then and the different global health interventions stakeholders deemed necessary to HSS.

The study pointed out that “the term remains a vague concept, with varying definitions and strategies for HSS, and varying ideas about the role attributed to the health system in improving public health.” It also found that most “global health actors” support health systems by focusing on disease-specific interventions or in areas that would benefit their own focus programs.

It further noted that these efforts “can be more accurately described as selective HSS interventions” and while understandable, the lack of coherence between these interventions has turned HSS “into a meaningless container concept.”

The study recommended that “a systemic approach to HSS that is contextual and that fits the countries’ agendas first” is needed.

While not everyone may agree with this recommendation, focusing on countries’ agendas could be a starting point.

For instance in Sierra Leone, the Ministry of Health is looking to strengthen its medical school to fill the gap in health workers: The country needs about 3,300 doctors, but only has 230.

Amanda Glassman, vice president for programs and director of global health policy at the Center for Global Development, meanwhile argued that health systems strengthening, in practical terms, should have “observable effects on the quality and coverage of key health services.”

That could mean providing clinicians incentives in terms of salary increase, greater supervision or feedback, or improving the supply chain to avoid stock-outs, she explained to Devex.

“Each country’s situation will be different. But we should start from the quality and coverage problem that needs to be fixed, rather than broad categories of health system inputs on their own,” she said.

The need for a structure to approach HSS is important, if only to provide stakeholders guidance in terms of their HSS work. This would, for instance, enable donors to really identify how their support is addressing the problem, and provide greater transparency and accountability. It would help health groups strategize their interventions, making sure they really are contributing to a country’s health system.

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About the author

Jenny lei ravelo 400x400
Jenny Lei Ravelo@JennyLeiRavelo

Jenny Lei Ravelo is a Devex senior reporter based in Manila. Since 2011, she has covered a wide range of development and humanitarian aid issues, from leadership and policy changes at DfID to the logistical and security impediments faced by international and local aid responders in disaster-prone and conflict-affected countries in Africa and Asia. Her interests include global health and the analysis of aid challenges and trends in sub-Saharan Africa.


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