What is a Health System?

Health Systems
Human Resources for Health
Health Systems Research
Global Health Partnerships

Health Systems

Overview

A health system weaves together all the organizations, institutions, and resources that are devoted to producing health actions with formal care (doctors, clinics, hospitals and pharmacies) and informal care (traditional healers and community-based workers), as well as with related areas such as research. In addition, a health system includes policies and regulations, as well as related practices outside the health area such as food and workplace safety, and reliable roads and vehicles for transporting medical goods-anything that seeks to promote or protect health.

Goals of a Health System

A health system has three overarching goals:

• maintains or improves people's health;
• aims to provide services that respond to legitimate public expectations (both medical and non-medical); and
• ensures all households receive a fair share of public services and are protected equally from financial risk.

The first goal can be considered the "defining goal;" the goals that follow are shared across or touch other public systems such as education.

Essential Functions

A health system has four essential functions. The first function, provision of health services, is supported by the three that follow it.

1. Provision of health services: Provide health services ranging from personal health care (diagnosis, rehabilitation, etc.) to services such as mass education and sanitation.
2. Resource generation and management: Provide resources to make the system work (medical staff, facilities, drugs and equipment, knowledge).
3. Financing: Collect revenues and allocate financial resources to various activities.
4. Stewardship: Ensure a level playing field through stewardship (organization, priority setting, performance assessment, advocacy, policy and regulation, and consumer protection).

Components of a Health System

Although individual countries will manage their health systems differently, each system generally has seven components.

1. Organizational structure

This provides the overall blueprint for the system. It looks at questions such as centralization or decentralization of services and decision making, and the three levels of care in the health system:

• primary care - first point of contact (outreach workers, rural health outposts)
• secondary care - first level of referral (district or sub-district-level hospitals)
• tertiary care - second level of referral (large specialist-care hospitals usually located in urban centres)

2. Service delivery

Health systems will vary in terms of service delivery with respect to these issues:

• private providers (both for-profit and non-profit providers) versus public providers
• size and scope of traditional medicine or informal health care
• level of responsiveness to public expectations (respect, choice and quality, community involvement)

3. Human resources for health

The World Health Organization (WHO) has broadly defined human resources for health (HRH) as "the stock of all individuals engaged in the promotion, protection or improvement of population health." This involves both training and managing a health workforce, and addresses issues such as volume, composition, distribution, skills mix, retention, and renewal of health workers.

4. Financing and insurance systems

Financing and insurance systems deal with the level of government spending on the health system, the government's share in total health spending, and the reliability of external funding sources, including donors. It also deals with issues such as user fees and health insurance schemes.

5. Health information systems

Having effective and reliable systems for the collection and analysis of data is crucial for health systems: it is the foundation for evidence-based decision-making. Health information includes vital statistics (births and deaths), patient records, disease control, household surveys, etc.

6. Procurement, logistics, and supply systems

Countries need efficient access to essential medicines, equipment, and supplies. This involves a range of areas-from appropriate policies and projections to cost-effective procurement and distribution to good stock management.

7. Health systems research

Countries need good research to identify weaknesses in their health systems in order to address them effectively. Health systems research can provide decision makers, policy advocates, and health services managers with the information they need to ensure that their strategies, programs, and services address and overcome system barriers with the end result of improving health outcomes. Building research capacity within a health system is a critical requirement for it to be responsive to the ever-changing health care needs of the people they serve.

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Human Resources for Health

Overview

Human resources for health (HRH) is one of the seven components in a health system. It refers to all the people who promote, protect, and improve people's health. This includes medical workers in public and private (non-profit and for-profit) systems that do clinical work, as well as those working in public health and research. It also includes non-medical workers involved in management and support.

Based on WHO estimates, 57 countries face critical shortages of health workers, the equivalent of a global deficit of 2.4 million doctors, nurses, and midwives. The two regions facing the greatest shortfall are sub-Saharan Africa and Southeast Asia. For every formally qualified doctor or nurse, there are at least three or more health workers, including "invisible" workers at the family level, traditional healers, and a range of health workers without formal qualifications.

Human Resources are Vital for Health Systems

A health system needs the right number of service providers with the right skills, knowledge, and motivation in the right place at the right time in order to promote health and prevent illness.

There is no single formula to get the right "mix" of health workers. Many issues need to be taken into consideration in human resource planning to get a system that works. The following are a few of the key elements considered in the planning process:

• burden of disease, as well as government policies, on essential services to prevent and treat these diseases;
• gender dimensions (e.g. ensuring access to female health workers in areas where culture and religion restrict women's mobility); and
• equal access for rural and disadvantaged populations.

Issues and Challenges

• Scarcity

In North America, there are about 10 health professionals (doctors, nurses, and midwives) for every 1,000 people; in sub-Saharan Africa, however, the ratio is only 0.8:1,000. The ratio identified as being critical for reaching the Millennium Development Goals related to health is 2.5:1,000.

• Inequitable distribution

The health workforce is often unevenly distributed across regions. Improving this distribution means attracting and retaining health workers to work in rural and marginal communities.

• Skill mix

Skill mix issues include the right balance and distribution between frontline workers and professional staff, ensuring that staff at primary-health-care levels can meet local needs and ensuring workers are trained on issues such as health promotion and HIV/AIDS.

• Migration

Skilled health workers continue to migrate from developing to developed countries for varying reasons, including better working conditions, more pay, and expanded opportunities for their children. Moreover, because of aging populations and shifting demographics, richer countries continue to require trained health workers. Some developing countries are now developing innovative strategies to improve retention and to encourage health workers who have left to go home.

• Gender dimensions

Women comprise 80 percent of the global health workforce. Most women health workers are in the informal sector working in positions such as family caregivers. Often they are undervalued and unpaid. Female health workers also face these additional demands:

• discrimination or lack of respect from male colleagues
• balancing professional work with responsibilities in the home
• cultural constraints for the provision of appropriate care for women
• physical threats
• sexual harassment
• working in remote locations away from their families

• Impact of HIV

With increasing patient loads and complex cases, health workers are facing daunting professional challenges that leave them mentally and physically exhausted. Since health workers are on the front line in the detection and treatment of HIV/AIDS, they are also at higher risk of contracting HIV. The HIV/AIDS epidemic has meant managers are constantly balancing the needs of the health systems against such issues as attrition, absenteeism, workload, training, deployment, and retention of health workers.

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Health Systems Research

Overview

Health systems research is one of the seven components in a health system. It provides decision makers, policy advocates, and health service managers with the knowledge and evidence they need to ensure their programs and services actually help improve health.

Although biomedical research is estimated at US$60 billion per year globally, health policy and systems research funds that are external to institutional budgets represent only US$140 million. Of this, only a small portion is spent in developing countries. For this reason, health systems research needs to be demand driven, and accordingly, clearly linked to government health policy. The results of research can help identify gaps or inconsistencies, as well as effective practices. Health systems research can also identify the impact of policies and programs on different population groups, shining light on inequities. Research, along with monitoring and evaluation are also central elements of strengthened accountability.

Investing in Health Research Brings Results

One of the key objectives of CIDA's approach to health sector programming is to promote the development of sustainable health systems, particularly in Africa. One of the best examples of how such support can produce successful results is the Tanzania Essential Health Interventions Project (TEHIP). TEHIP was funded through CIDA and implemented by the International Development Research Centre (IDRC) between 1997 and 2004.

The project helped two districts in Tanzania develop an evidence-based approach to health planning. Instead of relying on national assumptions about health priorities, the districts identified local health priorities, and allocated their budgets accordingly. The project showed how spending money more wisely, according to the greatest needs, could have a dramatic impact on health. In fact, the project reduced child mortality rates in the two districts by nearly 50 percent.

On November 7, 2005, CIDA announced it would provide $7 million to the United Republic of Tanzania to expand TEHIP with a new initiative called the Tanzania Zonal Rollout of Essential Health Interventions project (ZoRo) . ZoRo is now rolling out to the remaining districts in Tanzania the essential health interventions that were designed and tested to strengthen health systems through TEHIP.

CIDA's investment in ZoRo is being combined with financing from other donors to support the Government of Tanzania in rolling out this initiative. This harmonized approach to financing is in line with the Paris Declaration on Aid Effectiveness (PDF, 317 KB, 14 pages), which encourages donors to identify a number of commitments, including local ownership; alignment of aid with national policies, priorities, and country systems; harmonization; results-oriented frameworks; and management and mutual accountability. ZoRo is a good example of CIDA's support being aligned with a country-led initiative to help that country build responsive health systems tailored to its needs.

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Global Health Partnerships

Overview

More and more donors are working together to strengthen health through global health partnerships. Types of partnerships range from funding mechanisms such as the Global Alliance for Vaccines and Immunization (GAVI) to advocacy coalitions such as The Stop TB Partnership. These partnerships provide resources and strategies to help countries reach the health-related Millennium Development Goals by scaling-up programs.

For these partnerships to be truly effective, however, developing countries need strong national health systems. Weaknesses in health systems (shortage of health human resources, ineffective disbursement, lack of national strategies, etc.) undermine attempts to scale-up prevention, treatment, and eradication of disease.


In some cases, global health partnerships (GHPs) have actually added new stresses to health systems in developing countries. Each partnership, with its separate priorities and reporting demands, can overwhelm governments that are already struggling to manage their health systems effectively. The Africa Health Systems Initiative will encourage more harmonization of efforts between African countries and GHPs to find ways to align more effectively with national policies and systems. This will allow for the better coordination of efforts and the more efficient use of scarce resources.

Here are three examples of how donors and global health partnerships have begun to strengthen health systems:

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