Evaluation of health systems performance: the role of Health Systems Research


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This presentation was given by Sara Bennett of the Future Health Systems Consortium at the Global Symposium on Health Systems Research.

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  • Start with your audience….what are these things for? Role of HSR in assessments of health systems perrformance varies (I believe) according to purpose
  • Appropriate methods and approaches for Health Systems performance assessment will vary according to aim of the assessment: creation of generalizable knowledge is itself a research function – but even for the other two aims, I will argue that HSR can (and often should) play a role
    DHB – district health barometer
  • Extracted from South African District Health Board
    Green top tercile of rank, yellow middle, red lowest. This works well for indicators of output and outcome, but much less clear for process indicators – what is a good value for ALOS, how does this vary by context?
  • Evaluation of health systems performance: the role of Health Systems Research

    1. 1. Sara Bennett PhD, Johns Hopkins Bloomberg School of Public Health
    2. 2. Why assess health systems performance? “ Performance assessment allows policy-makers, health providers and the population at large to see themselves in terms of the social arrangements they have constructed to improve health. It invites reflection on the forces that shape performance and the actions that can improve it.” Gro Harlem Brundtland Preface to WHR 2000
    3. 3. A wider range of aims in practice Aims Examples  To improve policy and planning  To monitor for accountability  To create generalizable knowledge  To review Kenya’s HSP 94- 2010 so as to inform policy framework through to 2030  South Africa DHB “tool to monitor progress towards strategic health goals”  Thailand, to analyze factors that contributed to changes in health system performance during past 2 decades
    4. 4. Three Challenges to Evaluating Health Systems Performance  How to “benchmark” good performance  Limited knowledge about appropriate values of health indicators  Deciding what to measure:  Cannot measure everything.  When tracking effects of reforms, choice of indicators likely to be influenced by logic models  But how predictable are effects?  How to move from information to action:-  For information to be actionable need to understand WHY results are observed  Need to present evidence in a way that engages users, both policy-makers and civil society
    5. 5. Is first always best? Comparison of South Africa districts on process indicators Fezile Dabi Motheo Mopani Rate Rank Rate Rank Rate Rank Nurse clinical workload 44.2 1 28.9 15 12.5 52 ALOS 2.7 7 4.0 25 4.0 26 Bed Utilization rate 79.7 6 69.1 16 59.2 38 Clinical supervision rate 36.5 39 45.5 31 56.9 20
    6. 6. For example: Determining Appropriate ALOS  Factors Affecting ALOS  Case Mix  Socio-economic & demographic characteristics of the population: age, nutritional status  Care provided post-discharge: care in the community, long term care facilities  Key question: How does ALOS affect patient outcomes?
    7. 7. Frameworks for indicator selection Most health system performance assessments use conceptual frameworks to guide indicator selection:  Donabedian: inputs, processes, outcomes/impacts  WHR 2000: functions (stewardship, creating resources, financing, service delivery); outcomes (responsiveness, fair financing, health)  CHeSS M&E logic model for health systems performance
    8. 8. Health systems as Complex Adaptive Systems  May be difficult to predict impacts:-  Path dependence: health system interventions may have different consequences in different contexts  Emergent behavior: spontaneous organization of actors within the system (eg. organization of informal providers) can lead to unpredictable effects  Phase transitions/tipping points  Need enhanced understanding of these dynamic properties of health systems to ensure performance assessment tracks the right thing
    9. 9. Decision makers need to know the “Why?”  Without knowing “why?” difficult to take corrective action:-  Was the intervention faithful to the original design or was it adapted by local actors?  Complex interventions (as well as complex systems) – what component of intervention caused the observed effects?  Were effects influenced by context: if so what?
    10. 10. How to present the evidence?  How frequently do policy and decision makers need to see evidence?  Are more complex indicators credible, do decision makers understand them?  How does evidence get packaged? Simple dashboards (but are they open to misinterpretation? Face-to-face discussions – but how feasible to do?  Who gets to see it? Publicly accessible? Government officials only?  How best to link to routine government processes eg. health sector reviews?
    11. 11. What can health systems research contribute?  Benchmarking of indicators: what are optimal values of different process indicators, how does this vary by context (level of facility, resource availability etc)  Enhance understanding of complex adaptive systems: modelling and empirical studies to better understand properties  Focused research to understand “Why”: Was intervention implemented as planned? What causal effects occurred?  How best to package and communicate evidence from health systems performance assessments?
    12. 12. Benefits to HSR  HSR challenged by lack of routine data on critical issues:-  HRH availability  Private sector service provision  Health financing trends  Need to build up basic data collection systems (routine facility surveys, household health expenditure surveys etc)  Contribute to understanding of contexts, and enhancing transferability of research findings.