Health System Analysis for Better Health System Strengthening

1. Health System Analysis for Better Health System Strengthening Peter Berman The World Bank Jakarta, Indonesia February 8, 2011 Based on Berman and Bitran forthcoming 2011

2. Health Systems Analysis: • Can be specified and defined as a distinct area of policy analysis and policy development • Has identifiable methods with theoretical and technical basis • There is evidence that it has led to better health system strengthening • As defined, has been widely used by the World Bank and others • Has areas where further development is needed and feasible • More concerted effort and widespread application will likely contribute to better health system strengthening

3. Life expectancies and health expenditure in selected countries: Health System Performance

4. Health System Analysis Defined • Analysis to understand the causes and determinants of health system performance and the likely effects of policy change to improve that performance in order to develop better policies and strategies for reform. • Health system analysis involves: • the gathering of information on health system inputs, processes, and outputs, • the analysis of how they combine to produce the outcomes • other important dimensions of the health system environment such as politics, history, and institutional arrangements. • Health system analysis seeks to derive hypotheses about the causes of poor health system performance and about how reform policies and strategies can improve performance. • It includes proposals about how reforms can be implemented and what their possible effects might be.

5. The Logic of Health Systems Analysis

6. The Methods of Health Systems Analysis {Structure Reflects Health Systems Performance Causal Framework}

7. Different questions, different methods • Three types of health system analysis questions (after Hsiao and Siadat, 2010) • Description • Analysis of causation of performance and mechanisms of determinants of performance • Prediction/modelling • Different methods • For description – measurement of health system components • Comparative health systems work • WHO’s “building blocks”; USAID’s “health system performance assessment” • For analysis – development and testing of causal hypotheses – developing “theories” of determinants of health system performance • Frameworks of hypotheses: e.g. GHRR/Flagship framework • Case studies: e.g. OECD’s reports, World Bank’s HSA • Statistical analysis of larger samples of countries, e.g. WHR 2000 • For prediction of the effects of health system reform policies • Simulation models

8. HSA  Better HSS? “While we believe that more systematic analysis can make a difference in health-sector reform efforts, we are not naïve about the difficulties. Health systems are extremely complex, and they often react in unanticipated ways to policy initiatives…Still, we believe that an increase in both the breadth and the depth of thinking about reform can lead to better performance outcomes…” ( Roberts et al p. vii) “In the design, implementation, and evaluation of its reform, Mexico has made intensive use of the best available evidence, which has been derived from national analysis and knowledge-related global public goods, such as systematic comparisons of the experiences of other countries, measurement methods, and conceptual frameworks.” (Frenk, J., 2006) Examples from Mexico, Ethiopia, Turkey

9. 12 World Bank HSAs

10. Analytical Approach in World Bank HSA

11. Turkey: From Problems to Diagnosis

12. Turkey: From Diagnosis to Reform

14. “Today, the health system in Turkey is transformed, not quite to the point of favourable comparison with the rest of the OECD and most of the European Union, but fast closing the gap in health outcomes, responsiveness, and fair financing.” Baris et al, British Medical Journal, BMJ 2011; 2011; 342:c7456 Table 1  Health system indicators before (2000) and after (2008) the Health Transformation Programme in Turkey1 2 6 7 8 9

15. Some general findings • Objectives and methods of HSA should be selected to meet the specific needs of each situation. • Reports offer policy advice but the specificity and detail of that advice is very uneven • Policy recommendations are often overly ambitious • The evidence base for policy recommendations is not always well articulated and assessment of feasibility not always clear or sufficient. • Good practice is to address explicitly the timing and phasing of recommendations • Insufficient analysis of the policy context • Some parts of HSAs are much more developed conceptually and methodologically than others. There is a need to develop better guidelines and practice experience for the less developed parts. For example: • Governance and institutional analysis • Organizational analysis and service delivery • Health systems analysis of categorical programs

16. Way Forward? • Develop an HSA “practice” with dedicated expertise • Strengthen peer review for reliability and validity • Develop more explicit guidelines and methods, especially in the areas of weakness • Capacity building for Bank staff and clients • “Practice PracticePractice”