While significant strides have been made in global interventions designed to improve maternal and child health and reduce mortality and ill-health related to HIV/AIDS, tuberculosis, and malaria, these gains have not been sufficiently broad-based and sustainable. National level progress has not necessarily translated into improvements for the most vulnerable groups, and in some instances progress has reached a plateau or even reversed (WHO, 2010). Consequently, there’s been a shift in the global health agenda from focusing on disease-specific approaches to emphasizing health system strengthening (HSS) to improve the effectiveness of health ministries. Increasing evidence demonstrates that health systems capable of delivering services equitably, efficiently, and in a coordinated manner are essential for achieving improved health outcomes. This evidence is leading many global health initiatives to incorporate HSS in support of country and regional programs.

A “health system” is described as all of the organizations, institutions, resources, and the people whose primary purpose is to improve health (WHO, 2010). WHO has placed additional emphasis on health systems as the means to deliver effective and affordable care, to facilitate meeting the Millennium Development Goals, and to achieve increased health equity, especially for the poor (The Global Fund, 2009). In order to function, a health system needs staff, funds, information, supplies, transport, communications, and overall guidance and direction and it needs to provide services that are responsive, financially fair, and that treat people with respect. Strengthening health systems means addressing key constraints in each of these areas with the goals of improving access, quality and utilization of services, as well as, developing effective approaches for monitoring and evaluating the various levels of system inputs, processes, outputs and outcomes (Global Fund, 2009; WHO, 2010).

HSS Building Blocks

WHO and global partners have been developing a framework for measuring HSS that is comprised of six core components or “building blocks” (WHO, 2010). Leadership/ governance and health information systems are cross-cutting components that provide the basis for the overall policy and regulation of the other system blocks. Financing and the workforce are key input components, while medical products/technologies and service delivery reflect immediate system outputs. The framework focuses on the health sector and does not include interactions with other sectors, nor does it take into account factors that influence health behaviors, underlying social and economic determinants of health, such as gender inequities and education, or links and interactions across the six components. However, by distinguishing these components, the framework provides structure for this complex system that allows identification of indicators and measurement strategies for monitoring and evaluation.

Indicator Selection

Indicators were selected for the six component areas of the framework, initially by a small working group of agency representatives and technical experts, then reviewed more broadly by country level experts and supported with case studies and reviews of country experiences (WHO, 2010). The final selection of indicators was guided by the need to detect changes and progress in strengthening health systems that relate to both the level and distribution of inputs and outputs. Whereas the primary focus is on low- and middle-income countries, experiences from higher income countries have also been used to guide the development of the indicators and measurement approaches.

Note: For graphics and detailed discussion of the WHO Health Systems Framework, more detail on the process and criteria used in developing the WHO toolkit of indicators for HSS, and comprehensive lists of indicators with definitions, see the following resource links: WHO (2010) and The Global Fund (2009).

For the purpose of this database, fourteen core indicators have been selected from the comprehensive WHO HSS toolkit that relate directly to reproductive health in terms of policy, access, management and quality of services, training, commodities, and the registration and reporting of vital statistics for births, deaths and maternal mortality. The use of these standardized indicators will allow comparisons within and between countries, regions, sectors, and programs, as well as tracking changes over time. Some of the indicators will present challenges for measurement and reporting, requiring the development and institutionalization of effective country, regional, and program level protocols, management, and training. Wherever possible, collection of relevant corresponding data is recommended for disaggregation of the indicators (e.g., by sub-populations, location, sector and types of facilities and programs, demographic and socioeconomic factors). The value of these indictors, as with all of the indicators in the WHO HSS toolkit, will be enhanced and better understood through continued research and utilization of the information that they generate.

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References:

The Global Fund, 2009, Monitoring and Evaluation Toolkit: HIV, Tuberculosis and Malaria and Health Systems Strengthening, https://www.measureevaluation.org/resources/training/capacity-building-resources/m-e-of-hiv-aids-programs-in-india-english/session-1/GFATM%20M_E_Toolkit.pdf

USAID, 2009, Measuring the Impact of Health Systems Strengthening: A Review of the Literature, Washington, DC. https://www.researchgate.net/publication/274064201_Measuring_the_Impact_of_Health_Systems_Strengthening_A_Review_of_the_Literature

WHO, 2010, Monitoring the Building Blocks of Health Systems: A handbook of Indicators and their Measurement Strategies, Geneva.
https://www.who.int/healthinfo/systems/WHO_MBHSS_2010_full_web.pdf

“Global Action for Health System Strengthening, Policy Recommendations to the G8.” Task Force on Global Action for Health System Strengthening.  Japan Center for International Exchange, 2009.