HSR 2016: From Health Systems to Systems for Health

By Taylor Williamson, health governance specialist

What would you do to access health care?

Would you take a bus for three hours to a clinic? Arrange child care with friends and family? If you missed that bus, would you take a ride from the police?

The Fourth Global Symposium on Health Systems Research opened with a story of what one woman from a rural indigenous community endured to get a simple biopsy in British Columbia, Canada. Out of this story emerged a common theme: Researchers must consider systems for health, not just health systems.

What does “systems for health” mean in practice? The obvious answer, at least for public health experts, is to address the social determinants of health: culture, power, resources, and distance. These explain poor health outcomes as a function of roads, social support, inequality, or culture, but may not take into account the interactions between social determinants, decision making processes, or political factors that contribute to whether or not a woman can get a biopsy.

How do we break out of this trap?

We must shift focus in several areas: from the supply of primary care to client needs; from national-level working groups to community-led forums; and from health policy to political drivers of health.

First, we must place clients at the center of our analytical efforts. As Ben Ramalinga from the Institute of Development Studies said, health systems research should “start from the end user back, not the organization forward.” We have to think more in-depth about why a client leaves their home, goes to a health clinic, accesses services, and returns home. This focus is a departure from the primary health language of the Alma Ata Declaration, orienting us away from the supply of health services and toward various aspects that drive service demand — such as provider interactions, child care, transportation, language, and culture. Using the client’s perspective also addresses concerns about intersectionality, viewing clients as whole people with competing privileges and disadvantages.

Second, multi-sector engagement must move from national to community levels. Ministries of Health hold one part of the puzzle — the supply of services — but other ministries, such as agriculture, education, and transportation, hold similarly important pieces. While engagement and discussion between ministries may occur in high-level technical working groups, it rarely occurs at the local level. Too often, clinic hours and locations do not align with transportation and education investments. Even if a client lives within 5 kilometers of a health center, how do we know that they don’t have to walk 10 kilometers along the road? “As the crow flies” is not good enough. Similarly, school-based health programs can improve access to prevention services, but only if paired with knowledgeable health workers and child-friendly services. The USAID-funded Nepal Health for Life (H4L) project provides one option for these types of integrated, locally negotiated fora. Project staff work with Village Development Committee (VDCs) to develop health plans that address not only supply challenges at health facilities, but also multi-sectoral barriers to demand.

Finally, we must research how political incentives drive both the supply of, and demand for, health services. Researchers can provide clear evidence on the importance of addressing social determinants for health. But, as we learned from Justin Parkhurst from the London School of Economics, evidence is interpreted through the lens of social goals. Social goals, such as opinions on tax rates, competing roles of the private and public sector in health, and the importance of social protection, are ideological. Evidence not aligned to those goals is likely to have little impact. Health systems researchers impose their own values when they focus on World Health Organization priorities — such as improving health status, financial protection, and responsiveness — rather than country-specific priorities. In the United States, cost control is a primary concern of government and insurers; evidence that does not take cost into account will fall on deaf ears. Understanding what political leaders want their health systems to achieve, and engaging with those leaders, requires knowledge of how political systems drive health decisions.

These approaches are both old and new. We have talked about the importance of social determinants, multi-sectorality, and politics for decades. The Fourth Global Health Symposium, however, has encouraged us to dig deeper to understand how social determinants interact with one another, what makes multi-sectoral forums successful, and how policy makers use health systems evidence.