Measuring health systems strength and its impact: experiences from the African Health Initiative (original) (raw)
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BMC health services research, 2013
Integrated into the work in health systems strengthening (HSS) is a growing focus on the importance of ensuring quality of the services delivered and systems which support them. Understanding how to define and measure quality in the different key World Health Organization building blocks is critical to providing the information needed to address gaps and identify models for replication. We describe the approaches to defining and improving quality across the five country programs funded through the Doris Duke Charitable Foundation African Health Initiative. While each program has independently developed and implemented country-specific approaches to strengthening health systems, they all included quality of services and systems as a core principle. We describe the differences and similarities across the programs in defining and improving quality as an embedded process essential for HSS to achieve the goal of improved population health. The programs measured quality across most or all...
BMC health services research, 2017
Achieving the United Nations Sustainable Development Goals in sub-Saharan Africa will require substantial improvements in the coverage and performance of primary health care delivery systems. Projects supported by the Doris Duke Charitable Foundation's (DDCF) African Health Initiative (AHI) created public-private-academic and community partnerships in five African countries to implement and evaluate district-level health system strengthening interventions. In this study, we captured common implementation experiences and lessons learned to understand core elements of successful health systems interventions. We used qualitative data from key informant interviews and annual progress reports from the five Population Health Implementation and Training (PHIT) partnership projects funded through AHI in Ghana, Mozambique, Rwanda, Tanzania, and Zambia. Four major overarching lessons were highlighted. First, variety and inclusiveness of concerned key players (public, academic and private)...
BioMed Central, Health Services Research, 2018
Background: The completion of an implementation research project typically signals the end of research. In contrast, the Ghana Health Service has embraced a continuous process of evidence-based programming, wherein each research episode is followed by action and a new program of research that monitors and guides the utilization of lessons learned. This paper reviews the objectives and design of the most recent phase in this process, known as a National Program for Strengthening the Implementation of the Community-based Health Planning and Services (CHPS) Initiative in Ghana (CHPS+). Methods: A mixed method evaluation strategy has been launched involving: i) baseline and endline randomized sample surveys with 247 clusters dispersed in 14 districts of the Northern and Volta Regions to assess the difference in difference effect of stepped wedge differential cluster exposure to CHPS+ activities on childhood survival, ii) a monitoring system to assess the association of changes in service system readiness with CHPS+ interventions, and iii) a program of qualitative systems appraisal to gauge stakeholder perceptions of systems problems, reactions to interventions, and perceptions of change. Integrated survey and monitoring data will permit multi-level longitudinal models of impact; longitudinal QSA data will provide data on the implementation process.
A common evaluation framework for the African Health Initiative
BMC health services research, 2013
The African Health Initiative includes highly diverse partnerships in five countries (Ghana, Mozambique, Rwanda, Tanzania, and Zambia), each of which is working to improve population health by strengthening health systems and to evaluate the results. One aim of the Initiative is to generate cross-site learning that can inform implementation in the five partnerships during the project period and identify lessons that may be generalizable to other countries in the region. Collaborators in the Initiative developed a common evaluation framework as a basis for this cross-site learning. This paper describes the components of the framework; this includes the conceptual model, core metrics to be measured in all sites, and standard guidelines for reporting on the implementation of partnership activities and contextual factors that may affect implementation, or the results it produces. We also describe the systems that have been put in place for data management, data quality assessments, and ...
Measuring the Impact of Health Systems Strengthening: A Review of the Literature
The purpose of this literature review is to summarize current efforts in measuring health system performance and to highlight the indicators and performance benchmarks most frequently used by the global community. The review also aims to serve as a resource for health system experts working on building consensus around a core set of indicators for monitoring and evaluating health system performance. The literature review is particularly useful in the context of the Millennium Development Goals and the “Countdown to 2015” initiative, as well as in the context of current U.S. Government presidential initiatives, bilateral programs, and host-country planning processes.
Globalization and Health, 2014
Background: The study aimed at developing a set of attributes for a 'good' health system performance assessment (HSPA) framework from literature and experiences in different contexts and using the attributes for a structured approach to lesson learning for low-income countries (LICs). Methods: Literature review to identify relevant attributes for a HSPA framework; attribute validation for LICs in general, and for Uganda in particular, via a high-level Ugandan expert group; and, finally, review of a selection of existing HSPA frameworks using these attributes. Results: Literature review yielded six key attributes for a HSPA framework: an inclusive development process; its embedding in the health system's conceptual model; its relation to the prevailing policy and organizational setup and societal context; the presence of a concrete purpose, constitutive dimensions and indicators; an adequate institutional setup ; and, its capacity to provide mechanisms for eliciting change in the health system. The expert group contextualized these attributes and added one on the adaptability of the framework. Lessons learnt from the review of a selection of HSPA frameworks using the attributes include: it is possible and beneficial to involve a range of stakeholders during the process of development of a framework; it is important to make HSPA frameworks explicit; policy context can be effectively reflected in the framework; there are marked differences between the structure and content of frameworks in high-income countries, and low-and middleincome countries; champions can contribute to put HSPA high on the agenda; and mechanisms for eliciting change in the health system should be developed alongside the framework. Conclusion: It is possible for LICs to learn from literature and the experience of HSPA in other contexts, including HICs. In this study a structured approach to lesson learning included the development of a list of attributes for a 'good' HSPA framework. The attributes thus derived can be utilized by LICs like Uganda seeking to develop/adjust their HSPA frameworks as guidelines or a check list, while taking due consideration of the specific context. The review of frameworks from varied contexts, highlighted varied experiences which provide lessons for LICs.
Assessing health system performance in developing countries: A review of the literature
Health Policy, 2008
With the setting of ambitious international health goals and an influx of additional development assistance for health, there is growing interest in assessing the performance of health systems in developing countries. This paper proposes a framework for the assessment of health system performance and reviews the literature on indicators currently in use to measure performance using online medical and public health databases. This was complemented by a review of relevant books and reports in the grey literature. The indicators were organized into three categories: effectiveness, equity, and efficiency. Measures of health system effectiveness were improvement in health status, access to and quality of care and, increasingly, patient satisfaction. Measures of equity included access and quality of care for disadvantaged groups together with fair financing, risk protection and accountability. Measures of efficiency were appropriate levels of funding, the cost-effectiveness of interventions, and effective administration. This framework and review of indicators may be helpful to health policy makers interested in assessing the effects of different policies, expenditures, and organizational structures on health outputs and outcomes in developing countries.
Frontiers in Public Health
The African region is experiencing peculiar demographic, economic, social and environmental challenges that place pressures on the health systems. While the need to explore ways to address identified health systems challenges is far from easy, there are substantial evidence that having robust frameworks and metrics to direct efforts and priorities of countries could be rewarding. In view of persisting regional health systems' challenges the World Health Organization African regional office proposed the adoption of a comprehensive health system strengthening action framework that provides an opportunity to translate global health policy into operational strategies for Africa's health sector policies, strategies and operations. The adoption of the action framework could support the realization of regional health objectives and priorities, and guide movement toward sustainable developments in countries.
Health systems performance in sub-Saharan Africa: governance, outcome and equity
BMC Public Health, 2011
Background: The literature on health systems focuses largely on the performance of healthcare systems operationalised around indicators such as hospital beds, maternity care and immunisation coverage. A broader definition of health systems however, needs to include the wider determinants of health including, possibly, governance and its relationship to health and health equity. The aim of this study was to examine the relationship between health systems outcomes and equity, and governance as a part of a process to extend the range of indicators used to assess health systems performance. Methods: Using cross sectional data from 46 countries in the African region of the World Health Organization, an ecological analysis was conducted to examine the relationship between governance and health systems performance. The data were analysed using multiple linear regression and a standard progressive modelling procedure. The under-five mortality rate (U5MR) was used as the health outcome measure and the ratio of U5MR in the wealthiest and poorest quintiles was used as the measure of health equity. Governance was measured using two contextually relevant indices developed by the Mo Ibrahim Foundation. Results: Governance was strongly associated with U5MR and moderately associated with the U5MR quintile ratio. After controlling for possible confounding by healthcare, finance, education, and water and sanitation, governance remained significantly associated with U5MR. Governance was not, however, significantly associated with equity in U5MR outcomes. Conclusion: This study suggests that the quality of governance may be an important structural determinant of health systems performance, and could be an indicator to be monitored. The association suggests there might be a causal relationship. However, the cross-sectional design, the level of missing data, and the small sample size, forces tentative conclusions. Further research will be needed to assess the causal relationship, and its generalizability beyond U5MR as a health outcome measure, as well as the geographical generalizability of the results.
Health Policy and Planning, 2012
In recent years, there have been several calls for rigorous health policy and systems research to inform efforts to strengthen health systems (HS) in lowand middle-income countries (LMICs), including the use of systems thinking concepts in designing and evaluating HS strengthening interventions. The objectives of this paper are to assess recent evaluations of HS strengthening interventions to examine the extent to which they ask a broader set of questions, and provide an appropriately comprehensive assessment of the effects of these interventions across the health system. A review of evaluations conducted in 2009-10 was performed to answer these questions.