better systems, better health
The Health System Assessment Approach OVERVIEW A first step in strengthening health systems is to understand their strengths and weaknesses—which components work well, which don’t, and which interventions will produce quality, affordable health services that improve health outcomes. Health Systems 20/20 has led the use of health system assessments (HSAs) utilizing the USAID Health Systems Assessment Approach (HSAA), which it co-developed, and is updating in 2012.
IMPACT Originally designed to help USAID missions identify target areas for their health programs, HSAs now are in high demand by country ministries of health and other donor programs. The HSAA has been used to carry out 25 HSAs in Africa, Asia, Europe, the Caribbean, and South America to diagnose national (or, in a few cases, subnational) performance of health system functions. The HSAA looks at health governance; financing; service delivery; human resources; medical products, vaccines, and technologies; and information systems to inform health sector planning. Because the HSAA’s stakeholder engagement emphasis builds strong country participation and ownership, many countries have put the results to use.
For example, based on the HSA’s identified need to strengthen technical coordination of health, Senegal’s Ministry of Health created a department of planning, research, monitoring, and evaluation. To strengthen regional health districts’ ability to provide services, the ministry transformed regional offices into regional departments of health with more authority over the management of health workers, financing, and service delivery. To expand financial coverage, Senegal drafted a law to enable pooling of funds for free-care services and health insurance. Finally, Senegal used HSA findings to inform its new 10-year strategic plan.
In Saint Lucia, HSA findings raised concerns about how the costs of operating a new national hospital being built with European Commission (EC) funding would affect the rest of the health system. The HSA highlighted the urgent need for detailed hospital cost data, both to make informed programming decisions regarding the hospital in the short-term and to seek efficiencies within the entire health system over the long run. Health Systems 20/20 assisted the Ministry of Health (MOH) estimate the unit costs of current hospital services, and provided training to MOH leaders on how to do costing studies. Impressed with MOH leadership of the HSA process and cost projections, the EC allocated additional funding to equip the hospital. In working with the HSAA methodology, Health Systems 20/20 has identified criteria essential to HSA success. In particular, transferring of the methodology is a long-term process and the capacity of local institutions must be built—in qualitative data collection and analysis—so they can support HSA implementation. Stakeholders, especially at the MOH, must be engaged in every phase to ensure ownership and buy-in of recommendations. In Vietnam in 2008, Health Systems 20/20 partnered with the Health Strategy and Policy Institute (HSPI), a semiautonomous entity under the MOH, to develop HSPI’s capacity to conduct HSAs. Initial assessments were done in two provinces to provide needed data for provincial-level programs not addressed by national-level assessments. Results were used to improve the quality and use of routine health data. The HSPI went on to lead, with minimal Health Systems 20/20 assistance, HSAs in six additional provinces, and will eventually do 16 more, using the HSAs as a means of monitoring progress at the provincial level over time. Health Systems 20/20 is USAID’s flagship project for strengthening health systems worldwide. By supporting countries to improve their health financing, governance, operations, and institutional capacities, Health Systems 20/20 helps eliminate barriers to the delivery and use of priority health care, such as HIV/AIDS services, tuberculosis treatment, reproductive health services, and maternal and child health care. Abt Associates leads a team of partners that includes: Aga Khan Foundation | Bitrán y Asociados | BRAC University | Broad Branch Associates | Deloitte Consulting, LLP | Forum One Communications | RTI International | Training Resources Group | Tulane University School of Public Health
FEATURES The HSAA uses an indicator-based framework to do a rapid assessment of the health system. It does not include primary quantitative data collection. Instead, the assessment relies on secondary data, document review, stakeholder interviews, and limited facility visits to gather information, from which it identifies systems strengths and weaknesses, synthesizes that information, and transforms findings into recommendations and strategies for action. Findings and recommendations are validated and prioritized in country stakeholder workshops, before the assessment report is finalized and officially sanctioned. These features—examination of all health system functions, continuous and close engagement with country stakeholders, rapid results—distinguish the HSAA from other assessments of health system functions. For example, National Health Accounts studies focus on financial resource tracking and often require extensive primary data collection, while Marginal Budgeting for Bottlenecks looks only at resource allocation, and the Lives Saved Tool identifies priority solutions using pre-set models. In addition, the HSAA considers interactions among the various components of the health system and produces cross-cutting recommendations. Version 2.0 of the HSAA manual will be published in summer 2012 and can be downloaded from www.healthsystemassessment.com/health-system-tools. New features include broader examination of the private health sector and increased emphasis on capacity building and stakeholder involvement. Because stakeholder engagement is an integral component of the HSAA, Health Systems 20/20 published Engaging Stakeholders in Health Systems Assessments: A Guide for HSA Teams to complement the HSAA manual. For further information, please contact Michael Rodriguez at Michael_Rodriguez@abtassoc.com. DISCLAIMER:The author’s views expressed here do not necessarily reflect the views of the United States Agency for International Development or the U.S. Government. For more information about Health Systems 20/20 please contact: Health Systems 20/20 | Abt Associates | www.abtassociates.com 4550 Montgomery Avenue | Suite 800 North | Bethesda, MD 20814 | USA E-mail: info@healthsystems2020.org | www.healthsystems2020.org July 2012