Transcript No Slide Title

Development of a Country Health System
Typology to Guide System
Strengthening Efforts
David Heller*, Ritu Sadana**, Timothy Evans**
*University of California, San Francisco;
**Cluster for Evidence and Information for Policy, the World Health Organization
Background
•
What is a country health system typology?
•
How could a typology inform health system strengthening? How might
it best do so?
•
What typologies are available as tools for system improvement? How
have they been applied?
•
How do WHO staff and others believe a typology should be optimally
structured, conveyed, and applied?
•
On the basis of the above, can a country health system typology be
constructed to identify the strengthening goals, and strengthening
approaches, that would best serve each country?
What is a Health System Typology?
•
Defined most broadly, it is any means by which countries can be
differentiated into discrete categories on the basis of health system
factors
"A system of categorization which groups countries into some of
their key features" (McPake and Machray, 1997)
• Any numerical index describing any aspect of a health
system therefore implies a typology, though it is not a typology itself.
For example, infant mortality rate (IMR) could be used to group
countries into types on the basis of agreed threshold values (e.g.
more than 100 per 1000 is a "high-type" country
What is a Health System Typology?
•
Likewise, any explicit, measurable descriptor of any health
system component implies a typology, even if the descriptor is not
numerical.
For example, Anne Mills (Mossalios et al., 2001) describes four approaches
to overcoming health system capacity constraints. Countries could be
grouped based on the extent to which they have implemented each
approach
•
WHO staff and academic experts were interviewed regarding the ideal
structure, content, and format of a system-strengthening typology. Their
responses suggested a diverse set of elements to incorporate, most of which
were implicit typological criteria like the examples above
How could a Typology inform Health System
Strengthening?
In at least four
•
ways:
Method 1: Identifying the most salient differences among
country system structures and actions, to allow further
study of which interventions fare best in which contexts
Disadvantage: this approach provides no insight on which interventions are appropriate
to each country, nor how to tailor their implementation
How could a Typology inform Health System
Strengthening?
• Method 2: Defining indices that reflect the
performance of a country's health system or each of
its components, to indicate which system elements
most need to be strengthened in each country
Disadvantage: many common indices correlate poorly with performance (e.g.
physicians per capita). Also, no insight on the best means of improving each
deficiency within the country context
How could a Typology inform Health System
Strengthening?
•
Method 3: Defining specific tools for strengthening health
systems relevant to all countries, to indicate for any given
country which approaches it should employ, has
employed, and has not yet employed
Disadvantage: although it could suggest specific health system interventions needed,
especially in conjunction with a country evaluation of performance weaknesses, this
approach does not account for how reform implementation depends on country context
How could a Typology inform Health System
Strengthening?
• Method 4: Defining the health system characteristics
that dictate how to properly implement each health
system strengthening tactic in a given country, to
indicate for each country the specific actions it must
take to optimize system strengthening within the
country context
Disadvantage: although this is in principle the optimal model, it may be
impossible to place each country into precisely one category that dictates all
of the system strengthening approaches it must take
What Typologies are Available?
•
Academic literature, technical publications, and WHO strategy documents
reviewed. 162 documents retrieved, and roughly half reviewed in detail. 158
typologies collected. Mostly academic and technical publications from
developed nations
•
Only a handful are "typologies" as such. Many others are nonetheless true
typologies in that they both define a means of describing a health system,
and define the boundaries of categories in which each country may fall
• The majority, however, are implicit typologies: they
either define a numerical index that could be used to classify health
systems, or define a set of system features whose presence, absence, or
behaviour could divide health systems into categories
• The majority address specific components of the
health system, rather than the system overall.
What Typologies are Available?
• The majority of the typologies are descriptive only: they do
not evaluate system shortcomings and strengths, nor do they identify
system strengthening tactics, or suggest how to apply them. These
typologies can inform system strengthening through approach 1 above
• Other typologies are evaluative: they provide numerical indices
or other benchmarks that allow comparisons of health system performance.
These address progress on system goals such as health quality and equity,
but also secondary aims such as level of out-of-pocket financing. These
typologies inform system strengthening through approach 2: aiming
interventions at a country's areas of weakness
• Of the few that are prescriptive, most merely specify
generic system strengthening approaches; they do not
indicate which are most appropriate for any given country context. These
typologies inform approach 3: evaluating countries' progress on
implementing strengthening reforms
What Typologies are Available?
•
Notably, only five of the 158 define country factors that dictate which
system strengthening approaches are optimal.
These five typologies are the only known attempts at approach 4 above: a means of
placing each country into only one category, which dictates which interventions
should be taken and how. Also, all five group countries according to similar criteria:
the state's stability, capacity, wealth, or attitude towards the poor
•
The majority of the typologies have not been widely used in health system
strengthening efforts. Those that have are most often evaluative (allowing a
country to focus on weak areas) or broadly prescriptive (allowing a country
to assess its progress in implementing reforms)
• Thus, the literature could inform a broad typology
that assesses each country's shortcomings and
recommend the interventions to address them, if a
structure for such a model could be agreed
How Should a Typology be Structured?
•
The prior discussion begs this question. Which of the four
typology approaches above, if any, would be most
useful? Most feasible?
•
A typology that places each country into exactly one category, which
dictates which system interventions to select and how to do so
(Approach 4) would be the simplest and most informative choice
•
Yet existing typologies of this kind are sparing. A fair amount has
been written and applied on the assessment of system weaknesses,
and possible remedies for each, but not on how a country's unique
context shapes the choice and implementation of each remedy
Expert Interviews: Towards an Optimal Typology
Framework
• Academic experts and HQ WHO staff (but not regional
staff, health ministry officials, or WRs) interviewed on the
following:
• How can a typology best be communicated to facilitate system
strengthening?
• What components should it contain?
• What existing typologies facilitate system strengthening? What
are their formats and content?
• How should a typology be judged: what purpose ought it serve,
and how can its efficacy be evaluated?
•
Roughly 45 interviews requested, and 20 completed
Expert Interviews: Key Findings
•
The interview comments mirrored
ways:
•
•
•
the literature search in several
The few typologies that address the entire system
use the same common criteria as those in the
literature: state stability, capacity, wealth, and
attitude towards the poor
An overwhelming consensus that a useful typology
would describe in detail the structure and
performance of specific aspects of the health
system, which would in turn dictate which
interventions are most appropriate
Interviewers acknowledged that this approach cannot indicate how to
execute system strengthening. However, many voiced skepticism
that a more informative typology (i.e. Approach 4) is possible
Expert Interviews: Notable Quotes
•
An explicit typology of countries themselves, which places each one into a
discrete category which prescribes specific options for intervention, is impossible.
I attempted in several of the working papers of the CMH effort to produce such a
typology, but found it really hard, due to scanty evidence…in fact I didn't like doing
it (Anne Mills)
•
A typology should reflect if the country is showing returns on existing efforts; it
should be judged on its ability to meet real needs, such as HRH…the typology
should clarify what constitutes, for example, stewardship- and must be informed
by data found in each country (Nicole Valentine)
•
In order to bolster a health system, one must know: the capacity of the
government to deliver policy, and its interest in meeting peoples' needs. Are there
institutional weaknesses? How much governing capacity? Are the politics propoor? (Paolo Piva)
•
A typology of any sort, especially one with only a handful of discrete types, is
probably of limited value, especially to country health ministers. From a more
detailed profile, however, one could construct a set of interventions proven helpful
in each country context. Only then can a rigorous typology be constructed
(Barbara McPake)
Expert Interviews: What Format best reflects Needs?
•
Review of literature, and interviews, suggest that Model 2 above is
most appropriate
•
This model does not, however, readily advise on how to tailor the
recommended intervention to country context. This approach would
require Model 4: Unfortunately, literature review, and especially
expert opinion, suggest that such a typology may not be available
with sufficient rigor to be useful
•
However, a Model 2 typology, by evaluating which
interventions are needed in each country, and
profiling country context, could form the basis for
the eventual development of a Model 4 typology,
because it would allow study of which means of
intervention work best in which contexts, and which
contextual factors matter most.
Expert Interviews: What Format best reflects Needs?
A model 2 typology enjoys two further
advantages over a model 4:
1.
It would be more relevant to country health ministers, donors,
and others involved in strengthening, because it would provide
more detailed and more country-specific
information, and would indicate not only how to approach
system strengthening based on country context, but which
interventions are available to select, and how to prioritize them
(as McPake and others have suggested)
2.
Yet, if constructed with a small number of quantitative indices, it
would be simple enough to allow researchers to
complete comparative studies of interventions in
different country types, which could eventually produce a more
elegant Model 4 typology.
A Typology Can be Created, Based on these Data, to
Select Interventions Appropriate to Country Need
•
Proposed typology addresses each of the six core functions of the health
system individually, as well as health outcomes, and country context
•
For each such function, it suggests which available typologies, based on
literature and interviews, best describe the structure and performance of
that function in a given country, so that areas for improvement can be
identified
•
Besides the evaluation indices and strengthening approaches it describes
as essential for each core function, the model suggests other approaches
discovered that could be helpful
•
The assimilation of these eight sub-typologies produces a
single country typology that can guide a detailed, countryspecific system strengthening response
Can We Achieve the Ultimate Goal: a typology that
places each country into a single category to ensure
a context-appropriate approach to strengthening?
•
As discussed above, this approach may prove difficult: the balance of
interviews suggest a rigorous version of this model is unavailable, and the
literature offers few examples
•
Yet, also as discussed above, a handful of context factors are cited in all
such typologies created, and in all interviews in which this model was
discussed
• These factors are state capacity and capacity
constraints; state stability; GDP; and state interest in the
poor
•
Several typologies to classify countries on this basis are readily used in
system strengthening efforts: the "fragile state" model, the typology of
system constraints developed by Hanson et al., the World Bank system
delivery model, and others
The Proposed Model:
A Typology to Address All Needs
• On one axis, a typology of countries based on state
capacity and capacity constraints; state stability;
GDP; and state interest in the poor
• On the other, a detailed set of sub-typologies to
evaluate system deficiencies and therefore needed
interventions
• With this model, we know both what to do to
bolster a given health system, and how to
do it