Applying a health systems research perspective to the synergy question

1. Applying a health systems research perspective to the synergy question Peter Berman The World Bank Cape Town July 18, 2009

2. Defining Health System • “A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health”. • A number of different health system frameworks: descriptive, analytical, deterministic/predictive

3. One health system framework

4. Another

5. Diagnosis and Policy Development for the Health System Reform

6. Health Systems Research • Not well-developed concept • Does not mean all research on any aspect of a health system • Health systems research tries to predict or explain the causes of health systems performance (outcomes) • Answers to questions like: • What can we learn from differences in health systems across countries/areas that can help explain differences in performance? • To improve performance, what health system strengthening strategies should I use? What is likely to be their effect?

7. Health systems research methodology • There is no such thing…yet • Health systems thinking primarily is about how we ask questions and what questions we ask, not a methodology for answering them. • Some key elements of health systems thinking: • Focus on outcomes • Explicit analytical basis for linking health system inputs, functions, strategies (control knobs?) to outcomes – causal framework • Multidisciplinary: economics, politics, ethics, management • Design and implementation both important • Wide range of research methods relevant – need to understand rigor and validity

8. The “synergy” question • How do categorical programs, like HIV/AIDS, affect health systems performance? What can be done to assure (more) beneficial effects? • Some tough questions embedded in the question: • What are the desired outcomes of the health system? • What would have happened to the performance of these health systems in absence of the categorical programs (the counterfactual). • In the absence of the most rigorous standards of evidence (like RCTs), what shall be accepted as sound evidence?

9. What most of the research has done so far • Not measured outcomes or performance for the health system • Lacked an explicit causal framework and systematic analysis of multiple steps of the causal chain • Focused on inputs or lower level processes • Often used weaker methods, e.g. key informant interviews, rather than representative measures of outputs/outcomes

10. Is it feasible to do rigorous health system research on the synergy question? • Yes, but its hard, will take time, and will be opportunistic • Are the questions political, ethical, or operational? • More rigorous research may be useful, but not a substitute for more operational focus on improving practice – using sound causal framework