A CONCEPTUAL FRAMEWORK FOR SYSTEMS STRENGTHENING
Since "systems strengthening" means different things to different
people, it is necessary to begin by defining the kind of health system
which is to be strengthened. In an article entitled "Building the
Infrastructure for Primary Health Care: an Overview of Vertical and Integrated
Approaches," authors Smith and Bryant concluded that:
district health systems based on primary health care provide an excellent
practical model for health development, including an appropriate health
system infrastructure. Within this model the concerns with accelerating
the application of known and effective technologies and the concerns with
strengthening of community involvement and intersectoral action for health
are both accommodated. The district health system provides a realistic
setting for dialogue and planning involving both professionals and non-professionals
concerned with health and social development. (1)
Health reform is a complicated process which usually includes simultaneous decentralization of the health system, a transition from vertical to integrated programs, an emphasis on a minimum/essential package of services, and the development of public/private and community partnerships. With so many things going on at the same time, one is sometimes left with an impression that the health reform process is more chaotic than systematic.
In this context, a conceptual framework may be helpful to maintain the overall vision of a developing integrated health system. One possible framework which has been adapted from a 1987 WHO technical report (2) to reflect country-specific terminology. This framework consists of a 3-dimensional cube which includes a matrix of program interventions and support components at various system levels. Examples of this framework are shown for the countries of Haiti and Zambia.
The first dimension is that of the package of PHC services or interventions. This may include the eight essential elements of primary health care as outlined at Alma Ata in 1978. These are Immunization; Maternal and Child Health and Family Planning; Nutrition and Supplemental Feeding; Curative Care; Essential Medicines; Water and Sanitation; Endemic Disease Control; and Health Education. Many variations and "minimum packages of care" are possible. For example, Zambia has developed them as six program thrusts - safe motherhood, child health, malaria, tuberculosis, HIV/STD and water/sanitation.
The second dimension is that of the system support components required to facilitate and support the delivery of the PHC interventions. Typically these systems include such things as planning and management; information systems; logistic and supply lines, infrastructure and equipment; training and continuing education, financing and user fee systems; community participation and partnerships, Iinformation, Education and Communications (IEC), and Operations Research.
The third dimension recognizes
that the above support systems are required, to some degree, at each level
of the health system , i.e., household; community; health center; district;
region and central level. Within each level, the integration of PHC services
and the integration of support components needs to occur. The degree of
integration will, however, vary with the system level, e.g. full integration
of services and support components at the health center level by a few
multipurpose health workers. There are often differing views about whether
health system reform should be a top-down, bottom-up or middle-out process.
In general, experience has shown that there is no one best approach, and
that each country must find its own mix of development strategies. In this
case, the integrated health system framework may be useful to help people
visualize that health reforms will result in a cohesive integrated system
while simultaneously working at various levels of the health system, e.g.,
community level partnerships, district level strengthening of DHMTs and
national level development of a health information system.
There are often quite differing views about how to go about strengthening
a health system. Should the health development process be top-down, bottom-up
or middle-out? What should be the operational unit for organizing the management
of PHC? Should health districts be developed before, after or at the same
time as the provincial support systems? Which support components or program
interventions might serve as catalysts for system development?
Selective PHC and Child Survival projects have emphasized oral rehydration
therapy (ORT) and immunizations as the "twin engines" to develop
PHC systems. However, there is a growing consensus that this strategy has
only been a qualified success. A 1993 proposal for a revision of A.I.D.'s
Child Survival strategy for Africa recommended that:
There is growing consensus that while immunization and ORT efforts
were very successful during the 1980's, coverage levels have now plateaued
or are even decreasing. Child survival interventions cannot be sustained
without a functioning health system. More attention must be given to reinforcing
the support components of integrated health systems. Each level (national,
regional, and district) of an integrated health system must include subsystems
to support the health interventions. (3)
The merits of a systems strengthening approach are not theoretical, but have already been demonstrated by several USAID-funded projects. The SANRU Basic Rural Health Project from Zaire and the SESA Maternal Child Health and Child Survival project from Cameroon will serve as good examples of systems strengthening projects.
1. Smith, D.L. and Bryant, J.H. Building the infrastructure for primary health care: an overview of vertical and integrated approaches. Soc.Sci.Med. 26:909-917, 1988.
2. Hospitals and Health for All. WHO Tech.Rep.SeriesNo. 774:1987.
3. Revised Child Survival Strategy for Africa, HHRAA/SARA project, 1993.