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7 Things Everyone Should Know About DFID's Approach To Health Systems Strengthening

Yesterday the UK Parliament's International Development Committee heard oral evidence about the UK Department for International Development's (DFID's) efforts to improve health systems in low- and middle-income countries (LMICs). But why do health systems matter? And what is health systems strengthening anyway? Here are the top things you need to know.

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1. The WHO defines health systems as comprised of six 'building blocks' / Via WHO

While it's hard to separate these building blocks out, it's been a helpful way to think about the different areas that may need attention in order to improve health systems.

The six building blocks are: service delivery, health workforce, health information, medical products, vaccines and technologies, health financing, and leadership and governance.

2. But the 'building blocks' approach has its critics / Via de Savigny D, Adam T: Systems Thinking for Health Systems Strengthening. Edited by de Savigny D, Adam T. Geneva, Alliance for Health Policy and Systems Research; WHO; 2009.

While separating out the building blocks gives useful focal points for health systems strengthening, some have argued that this gives the incorrect impression that one can just focus on one block or another -- that somehow they are disconnected.

But it's clear that they are not -- health systems strengthening requires an integrated approach that adopts true systems thinking. It's no good having more vaccines available, for example, if there aren't enough doctors and nurses to administer them.

Others have argued that these six building blocks are too disconnected from the people that use health systems, and that there needs to be a focus on putting people back into health systems.

3. Systems thinking? What's that?! / Via Paina, L. and D. Peters (2011) Understanding pathways for scaling up health services through the lens of complex adaptive systems. Health Policy and Planning, 26(5).

Good question. As this graphic shows, systems have certain characteristics that make them unique and hard to influence (or to strengthen!). Path dependency, for example, is a key characteristic of a system -- it's one of the reasons the UK (and some other countries) still drive on the left, while the majority of nations drive on the right. Once there is a lot of investment in the infrastructure, the costs of changing courses becomes difficult -- and the further down the path one is, the more difficult it is to change. This is as true for health systems as it is for driving. / Via Wikimedia Commons

At 5:00am on 3 September 1967, Sweden became one of the few countries to successfully switch from left-hand driving to right-hand driving. Known as H-Dagen (or H Day), it was a serious and concerted effort that had been voted down a number of times, which just shows how difficult it is to switch tracks once one is locked into a way of doing something. On the brighter side, it also shows that it's possible! The picture above shows Kungsgatan in Stockholm as vehicles changed sides of the street.

Other systems dynamics that might influence change include: feedback loops (which may unexpectedly exacerbate a problem), scale-free networks, emergent behaviour (where individual behaviours come together to create a different overall behaviour, like herding behaviour in many animals), and phase transitions.

4. Right, so now we know what health systems are -- but why are they important?

View this video on YouTube

Didn't watch the video? Let me recap -- the video explains what all is involved in vaccinating children. First, we need the science to determine whether a vaccine is effective at solving a particular problem. We've got lots of this type of science in health, we know what sorts of technologies seem to work.

But having an effective technology isn't enough if it can't get to the people who need it, or if they can't afford it, or if it's broken along the way -- that's where health systems (and health systems strengthening) come in. As the video explains there is vaccine production in a variety of countries. These vaccines need to be purchased and then distributed to the countries where they are needed. Once they arrive in country, there need to be further distribution mechanisms -- often while kept in cold storage. Let's say that they arrive at a local clinic, in addition to keeping cold they then have to be administered by a trained health care provider of some sort.

Overall something as 'simple' as administering a vaccine is actually rather complicated, and effective health systems are necessary to ensure each step.

5. What are some common problems with health systems?

There are a number of potential problems that a health system might face.

A big one is financing. Research and development, medicines, diagnostics, staff, training, and the health facilities and their operating costs -- these are all things that must be paid for by someone. In some countries, like the UK, there is a strict separation between who pays for health products and services and who receives them. In the US -- and in many low- and middle-income countries -- this is not always the case.

In the US there are many private health insurance providers, but people who don't have insurance must pay for services 'out of pocket'. High out of pocket expenditures is typical in many LMICs. For example in Bangladesh, according to its most recent health accounts, roughly 64% of the total health expenditure (THE) of the country in 2007 came from out-of-pocket payments. This can be disastrous for poor people.

Yes, Dorothy, that is a lot! That's one of the reasons health systems need to be improved.

Another common problem is inefficiency. There are many types of health systems inefficiency, but one common phrase is 'vertical' versus 'horizontal' programmes. 'Vertical' programmes generally target a specific disease or health issue. If it's a disease like malaria, a vertical programme would target several health strengthening interventions to improve, for example, distribution of bednets, provision of anti-malarials, etc. That might make a health system very good at combating malaria, but what about everything else? What if malaria isn't the only problem?

Another big challenge faced by many health systems is access to services. You may think that has mainly to do with not being able to afford health services. And it is true that one of the main arguments for interventions in health systems is that they often leave the poor behind, providing the best services to those who can afford them and locating quality services in safe neighbourhoods.

But beyond finances, there are lots of ways that access may be helped or hindered. / Via Future Health Systems

Geographic access can be a big challenge in many LMICs. In this picture, a pregnant woman in central Uganda takes a boda boda, or motorcycle taxi, several kilometres to her local health clinic where she can receive appropriate ante-natal care.

Finally, another big challenge might be the quality of health products and services on offer. Because of price pressures and a number of other factors, counterfeit medicines are rife in many LMICs. And the knowledge of health practitioners isn't always great -- this can lead to misdiagnosis and harmful prescription of drugs.

6. Ok, how is DFID approaching health systems strengthening then? / Via UK Department for International Development (DFID)

In it's 2013 Health Position Paper, DFID notes that health system strengthening is just part of its approach. It says it works through multi-lateral organisations, like the GAVI Alliance on vaccine provision, to strengthen systems. It also works with a wide range of providers.

[DFID] Aims to maximise health gains through targeted, cost-effective health interventions that are delivered through strengthened, more efficient and effective health systems (including both public and private providers) and that engage communities in the promotion and protection of their own health. It incorporates work on the broader determinants of health, for example: improved access to water and sanitation and improved hygiene behaviour; increased girls' education; women's leadership and political participation; strengthened political systems; and greater resilience to the impacts of climate change, natural disasters and conflict.

7. Is DFID's approach working?

In today's oral evidence in front of the International Development Committee, there seemed to be a consensus that many of the things DFID was doing to support health systems development were appropriate.

Simon Wright from Action for Global Health went as far as suggesting that DFID has been a champion of health systems strengthening but needs to do more at the international level to improve policy and encourage other donors to support this approach.

However, there was some criticism that a 'results focus' had prioritised simple and quick interventions -- like distributing bednets -- at the expense of actual health systems strengthening.

Prof Kara Hanson from the London School of Hygiene and Tropical Medicine and Research Director of the RESYST Consortium also suggested that, while DFID has the desire to base its decision making on the evidence, in practice this doesn't happen as often as it should. Of course that's not unique to health systems strengthening, as the recent ICAI review of how DFID learns pointed out.

Experts at the inquiry also noted that health systems strengthening actually goes well beyond health. There are many areas of government that effect health -- for example sanitation, trade and agriculture -- and DFID should support other governments to adopt a joined up approach to governance of the health system which brings in these sectors.