Building better: How can we support countries to analyse and assess health systems performance?

A more harmonised approach to health systems assessments, making clearer links between health systems functions and performance, can help countries develop evidence-based health strategies and plans – including to respond to and recover from COVID-19.

The COVID-19 crisis highlights the need for robust health systems to protect population health. To help countries strengthen health systems, health systems performance assessments are necessary to guide policy dialogue, decision-making and health strategy development and implementation. They will be increasingly valuable to inform how countries adapt to and recover from the current pandemic.

Many tools exist to assess the breadth and depth of the health system at different levels. However, countries face two challenges. First, many of these tools focus on organisational or structural elements of health systems (such as the health system building blocks), with much descriptive information about inputs and less reflection on interaction between the different inputs and results. This makes it hard to meaningfully interpret some assessments: what do they tell us about how well health systems are functioning, or their performance in terms of outputs and outcomes? Second, a multitude of different assessments cover different but overlapping aspects of health systems. This is often exacerbated in countries that receive substantial external assistance for health, with different partners supporting or promoting different assessments. How can we help countries and partners better harmonise their assessments, and draw coherent insights and learning from their results?

The UHC2030 Technical Working Group (TWG) on Health Systems Assessments was formed in 2017 to bring together diverse stakeholders to address these challenges. The TWG examined how to harmonize different assessment approaches, recognizing their unique objectives and angles taken, so that assessment results have more policy relevance and offer greater insights into system performance.

Based on these joint efforts, the group proposes that countries and partners can strengthen and harmonise performance assessments through a three-pronged approach:

i) apply one or more (existing) health system assessment (HSA) tools within a country context;

ii) understand how HSA information is linked to system performance using the Health system performance assessment (HSPA) framework for UHC;

iii) extract and organise HSA data using the HSPA for UHC template, a simple aid to focus the country user on areas which most impact performance.

i) Health systems assessment tools

The TWG reviewed existing HSA tools and recognized their value as established approaches to collecting data for a system-wide assessment. The group agreed not to design a new tool, but to show how existing tools’ data collection and analysis efforts can be oriented towards an appraisal of health systems performance, thus bringing in more harmonized and aligned tool application.

ii) The HSPA for UHC framework

The HSPA framework for UHC conceptually depicts how HSA information links with system performance. It is based on four health system functions to reflect what a system needs to effectively “do” to achieve health systems goals: governance, financing, resource generation and service delivery. (Note: these four functions overlap with and incorporate the six health system building blocks, but re-organised to emphasise the link to outputs and outcomes, and therefore, performance.)

iii) The HSPA for UHC template

The HSPA template aims to be a practical aid, based on the HSPA framework, for country users to organize information collected during a HSA and think through system performance.  Currently being developed and tested, it will help users to extract performance-relevant qualitative and quantitative information (“indicative measures” which may appear in different HSA tools) and consider where the challenges and strengths lie which impact on overall performance. 

How does this improve harmonization and alignment?

HSA tools are practical by design, providing guidance for data collection and analysis, but often lack an explicit conceptual framework to think through functionality of the system and its impact on performance. This is relevant for all countries. The HSPA framework bridges this gap, and the three-pronged approach can help address:

• Fragmentation. The HSPA framework and template orient HSA information towards performance, so reports generated through application of HSA tools can include a health system performance analysis regardless of the tool used. This allows for comparative performance analysis using information from different HSAs, including trends analysis over time, and promotes more coherent assessment. 
• Ownership. An implicit principle in the approach is that performance assessment is driven by countries’ policy priorities and planning cycles. The framework and template can help countries make better use of HSAs, even where these may have been commissioned by different partners, and to lead the overall process. 
• Performance bottlenecks. By providing an umbrella performance framework with explicit focus on functions, outcomes and goals, the HSPA approach can help all stakeholders to jointly reflect and act on root causes of system under-performance.

In sum, the approach offers opportunities to more meaningfully analyse health systems performance in a more joined-up way, and provide a basis for more coherent and effective action.

The Health System Performance Assessment conceptual framework will be presented at the virtual Health Systems Research Symposium satellite session “Health System (Performance) Assessment – how to stop Performance from drifting away?” (10 February 2021, 16:00 – 18:00 Central European Time/19:00-21:00 Gulf Standard Time). A conference copy of a comprehensive book laying out the HSPA framework for UHC and the HSPA template will be available for participants. The final publication will be made available in April 2021.

In the meantime, WHO and UHC2030 partners are identifying opportunities to promote the HSPA approach and support countries to use it to accompany their health system assessments, to inform national health reviews and health systems strategies. This is especially timely as countries consider how to strengthen health systems to adapt to and recover from COVID-19 in the medium-term.

For more information please contact Dheepa Rajan and Julia Sallaku.

Photo: WHO/Lindsay Mackenzie

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