Health Systems Assessment Approach: A How-To Manual - PHRplus

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Chapter 1. Health Systems Strengthening: An Introduction Table 1.1 Government Policy and Health Programs Governmental Policy Levers Size of the total government health budget Financing mechanisms for funding the health care system (e.g., donor support, taxes, user fees, social insurance contributions) Allocation of the government health budget Regulation of civil society organizations Political support to raise awareness for specific health messages and behaviors (e.g., clear government support for specific health messages such as prevention of HIV, contraceptive use, or TB treatment) Adoption of specific health standards or guidelines Regulation of pharmaceuticals Business regulations and taxation Relevance to Health Programs Sets the overall limit on what a government can spend Determine what flexibility the government has for financing health care and identify potential financial barriers that may exist for accessing care (e.g., fees, their levels, and exemptions) Reflects how the government uses its tax resources to, for example, deliver services, employ staff, subsidize providers, regulate the sector, provide information, and configure the sector in terms of preventive vs. curative services, personnel vs. supplies, investment in human resources (training) vs. physical resources (hospital) Affects which programs are prioritized and what populations will benefit (rich vs. poor, urban vs. rural) Can facilitate or constrain the functioning of private voluntary organizations (PVOs), nongovernmental organizations (NGOs), and community organizations with regard to service delivery and the capacity such groups have to influence and advocate for health services Can be powerful for stigmatized or polemic health initiatives and promoting high impact health interventions (e.g., hand washing) Can improve the quality of care, expand or constrain the number of providers, and facilitate implementation of approaches such as Integrated Management of Childhood Illness (IMCI). Can improve medicine quality assurance and rational use of medicines Can influence the ability to bring medicines and supplies into the country Can influence the degree to which the private sector participates in health care—for example, import taxes can affect pharmaceutical sales; business regulations can hamper private providers from setting up practices; limitations on advertising can limit promotion of branded health products An example of strong government stewardship in health can be found in Uganda, where the government’s proactive approach to preventing HIV/AIDS is likely to have reduced the incidence of the disease. The government provided an enabling environment by encouraging community-based initiatives and supporting mass communication campaigns, which promoted prevention and behavior change. 1-3
Health Systems Assessment Approach: A How-To Manual Furthermore, stewardship in health encompasses (1) activities that go beyond the health system to influence the main determinants of health (e.g., education, poverty, environment), and (2) other issues that are external to the health system, but which either foster or constrain its effectiveness. For example, a government may decide to tax imported medicines to increase general tax revenues or to protect local producers, but in doing so, will increase prices to consumers and impair access to these medicines. Stewardship in this area seeks to influence the broader environment in which the health system operates. Emerging research evidence demonstrates that health is a key component to good development policy (Saunders 2004). The presence of poor health conditions in a country slows economic growth directly as societies lose potential workers and consumers to disease and disability. Attention to reducing child mortality and morbidity results in healthier children who can attend school and eventually contribute to economic growth when they become wage-earners. When child survival is the norm, parents tend to have fewer children and are able to invest more in their children’s education and health. Priorities in health policy also need to be elaborated at the national and local levels through health goals that address improving the health of the poor and reducing the gap between the poor and non-poor for an impact on child survival (Gwatkin 2000). Although the establishment of policy lays an essential foundation for a government’s intention, its value depends on the evidence and effects of policy implementation. As such, health system assessment should take account of the degree of government decentralization and the levels and authorities that are the key decision makers in health. Which levels have authority over planning, budgeting, human resources, and capital investment? Is the health sector represented at the district council level? Does the district have a role in policy development, resource allocation, and human resource planning? These dimensions underscore the need to approach health system performance and strengthening by understanding the interaction and linkages that exist between health financing, service delivery, and management of human resources in the health sector. 1.2.1 Performance Criteria Understanding the health policies of the national government, and its international commitments, allows for informed development of advocacy for improved health care access, equity, and quality. In addition, national policies affect the system’s ability to deliver efficiency, thereby affecting the overall sustainability of the system and its ability to function into the foreseeable future from a financial and organizational perspective. These performance criteria are defined and further explained in Annex 1A. 1.2.2 Sustainability A stronger health system is fundamental to sustaining health outcomes achieved by the health system. Sustainability typically cannot be guaranteed through changes at the local level only. For example, health providers can be trained at the local level, but if these providers cannot be 1-4
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Health Systems Assessment Approach: A How-To Manual - PHRplus

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