Measuring the Success of Health Systems Strengthening

This  is a guest post, written by Christophe Grundmann, Chief of Party, and Katherine Krasovec, Technical Advisor for Nutrition and Child Health at URC.  University Research Co., LLC (URC)* is a global company dedicated to improving the quality of health care, social services, and health education worldwide.

The term “health system strengthening” is vague enough to be interpretable in many different ways and to allow for almost any actions that support the health system. The one certainty is that interventions in multiple areas are required and outcomes are synergistic.

In reality, systems change is complex: the pieces of the system are related to each other and interdependent, thus changing one part of the system will likely change another, often unintentionally. A recent Cambodian example illustrates this perfectly. When the Alliance for Vaccines and Immunization introduced a monetary incentive for Hepatitis B immunizations at birth in target operational districts, it caused the number of BCG immunizations for tuberculosis in those same districts to drop. Furthermore, improving one part of a complex system does not necessarily improve the overall system, and, in fact, may hurt the overall system. The classic textbook analogy is putting the carburetor from a Ferrari into a Volkswagen: it doesn’t make a better car but rather one that no longer works. A comparable health sector example would be ensuring the supply of magnesium sulfate (MgSO4) to a health center. As important as that is, it will not make a difference in outcomes and could be harmful if health staffs are not trained, competent, and confident in the use of MgSO4. Conversely, trained and competent personnel cannot use MgSO4 if it is not available in the health facility when needed.

A Cambodian family heads home after a visit to the health center.  Photo courtesy of URC, USAID Better Health Services project staff.

A Cambodian family heads home after a visit to the health center.
Photo courtesy of Jerker Liljestrand, URC BHS Project

This conundrum poses a challenge for how to measure the outcomes of health systems strengthening over a typical donor-funded project period of five years: is it an improvement in the quality of health service delivery, an increase in the availability of a service or an increase in demand or access? Or could it be some combination of indicators from across the building blocks of the health system as defined by WHO: service delivery; health workforce; information; medical products, vaccines and technologies; financing; and leadership and governance.

The goals of the USAID Better Health Services (BHS) Project implemented by University Research Co.,LLC (URC) in Cambodia dovetail with the mission of the Ministry of Health as stated in the Cambodian Health Strategic Plan 2008-2015: “to provide stewardship for the entire health sector and to ensure a supportive environment for increased demand and equitable access to quality health services in order that all the peoples of Cambodia are able to achieve the highest level of health and well-being.” The project works to this end through a variety of efforts that aim to 1) improve the quality of public health care services, 2) increase the utilization of and demand for such services while pursuing the MOH’s pro-poor goals, and 3) support on-going and new health reform efforts aimed at increasing the transparency and accountability of health services through decentralized, contractual structures.

The project’s impact is evident for individual components of the health system: health financing support is available for the approximately 35% of Cambodian families that the Government has identified as poor in 77% of the country with nationwide expansion expected by 2015; national clinical practice guidelines for adult and pediatric conditions and protocols in key areas like Safe Motherhood, newborn health, and the treatment of severe acute malnutrition have been updated. Systems have been introduced for patient triage and for patient registration into public hospitals; a new web-based health management information system now has almost 100% reporting from public health facilities and more than 250 private polyclinics across the country. Maternal health services in BHS-supported hospitals continue to increase, with 95% now performing active management of the third stage of labor correctly (up from 17% in 2009); and for the first time, family planning is available at referral hospitals. Is this enough to say the Cambodian health system as a whole has been strengthened, when these components have such interlinking and complex linkages?

The purpose of health systems strengthening is to create a functional health system that provides the “socially accepted” level of health services: “socially accepted” because the definition varies significantly from country to country – just look at the differing health systems in the West alone. Perhaps key measures for a functioning health system should include not only performance, but also stability and responsiveness to changing socioeconomic realities. Such capacities can be built by cultivating relationships with the government and other national stakeholders, building trust through ongoing dialogue and openness to exploring options and innovations to strengthen progress toward shared goals. These “soft skills” are difficult to measure but play a central role in health systems strengthening.

To learn more, head over to URC’s website and read more about Health System strengthening in Cambodia