The call for ‘health system strengthening’ (HSS) has become something of a mantra in global health circles in recent years. But what do we mean by HSS and how might policymakers go about enacting it?
My colleagues Dr Katharina Hauck, Dr Ranjeeta Thomas and I are working on an iDSI project where we take the position that an important form of HSS focuses on service delivery ‘platforms’. These platforms can take many forms, such as a network of community nurses, a health centre, or even a hospital. Their common feature is that the delivery of a range of services depends to some extent on the platform. For example, a local health centre might provide antenatal maternity services, routine child health and vaccination programmes, and a variety of other ambulatory services.
The costs and effectiveness of each of those services are likely to be influenced by how well the health centre (the platform) functions as a whole. As a result, the services that use the platform are to some extent interdependent.
Conventional approaches towards the evaluation of health services consider treatments independently. They assume that the costs and benefits of a treatment remain unchanged whatever the characteristics of the platform, and are not associated with those of any other treatments that use the platform. Yet it is clear that both costs and benefits – but particularly costs – often depend heavily on how well a delivery platform is functioning and what other services are relying on the platform’s resources.
Our research models three types of investments in HSS that focus on delivery platforms. The first type looks at an existing platform and examines whether additional funds should be spent on improving the overall functioning of the platform or expanding the range/volume of services it supports. Using the funds for HSS will improve the quality (or reduce the costs) of existing services but will to some extent reduce the scope for introducing new services. This trade-off is at the core of many HSS decisions and we show how it can be addressed analytically.
It is often the case that a platform is unable to function as well as it should because of some physical constraint, such as limited human resource capacity. For example, a hospital may be unable to deliver some highly cost-effective treatments because of a shortage of medical personnel. The second type of HSS therefore examines the benefits of removing such constraints by investing funds in the right way, here by the hiring of additional medical personnel. Again, such actions will come with a cost, especially if the new ability to focus on more cost-effective treatments means sacrificing lower value treatments that are currently provided by the platform. The key policy decision is whether the costs of removing the constraint are outweighed by the benefits.
The third type of HSS is the consideration of an entirely new platform, often to affect a radical new way of delivering a treatment. An example might be the creation of a home-based testing programme for HIV/AIDS that relies on a new network of community health workers to test people in their homes, as an alternative to the current system of opportunistic testing at clinics. The decision whether or not to proceed with this option may depend on what other services could be delivered by the community workers, such as testing for hypertension, diabetes or tuberculosis, to make the home-visit worthwhile.
Our research therefore examines the trade-off between HSS and expansion of treatment coverage that is often encountered and has many policy implications concerning the nature and timing of health system reforms. We were excited to present our initial findings at HTAsia Link 2018 and look forward to publishing as the work develops.