Health Systems Strengthening: A Literature Review

A core principle of this approach is that weak health systems have limited the effectiveness of governments and their international partners to scale up the availability and use of priority health services. By strengthening the components of health systems, including health financing, human resources for health, health information, service delivery, the medicine supply chain, and leadership and governance, the USG hopes that cost-effective technologies for combating disease and other health problems will be more effectively delivered and sustained. Measuring progress in HSS requires careful planning and sound metrics to assess changes in how health systems function and perform. Health systems frameworks are being used to inform HSS efforts, covering a variety of perspectives and scopes, and focusing on diverse topics such as performance, supply and demand, health reforms, building blocks, and funds and payments. Many health policy analysts argue that health systems are complex adaptive systems with both intended and unintended effects. Each of these frameworks has its own approach to monitoring and evaluation, with different metrics and indicators of health systems functioning. The World Health Organization (WHO) has developed two frameworks for conceptualizing health systems. The first framework, developed by Musgrove and colleagues in the World Health Report 2000, defines health systems as including all actors, institutions, and resources whose primary intention is to promote, maintain, or restore health. This framework identifies intrinsic goals of health systems (health status, financial risk protection, and responsiveness) and four functions of health systems that influence how inputs affect health systems performance (resource generation, financing, service provision, and stewardship). The second WHO framework, developed in 2007, extends Musgrove's framework by organizing health systems into six building blocks: service delivery, health workforce, information, medical products and technologies, financing, and governance and leadership. These building blocks were proposed as an organizing framework to advocate HSS and to provide guidance to WHO, other international organizations, and governments on how to invest in HSS to facilitate the scale-up of interventions essential for achieving the United Nations health-related Millennium Development Goals. The "control knobs framework," developed by Roberts and colleagues in 2004, is another widely cited framework for conceptualizing health systems. This framework identifies health, financial risk protection, and citizen satisfaction as the intrinsic goals of country health systems, and proposes five "control knobs" (financing, payment, organization, regulation, and health behavior) that can influence these goals. The advantage of this framework is that it allows for broad types of strategies for health systems reform to be more clearly identified and considered. These frameworks were developed to conceptualize and analyze health systems and the HSS process. They provide a foundation for understanding the complex relationships between health systems and the external context, and for identifying appropriate indicators to track the HSS process and to specify how program inputs produce improvements in service delivery and health systems performance.