What health systems do? Functions as a starting point to assess health systems performance

Health system assessment (HSA) tools are often built around static health system building blocks, which lead to largely descriptive narrative and lack of linkages to health system outcomes. The development of a common framework that would also focus on performance outcomes is long overdue. We analysed the key HSA frameworks and tools based on them, with the purpose of identifying a common approach that would allow to link health system components to specific outcomes. The presentation will focus on using the health system functions as the basis of conducting the performance assessment. In a second step, the presentation will elaborate on the intermediate and final health system goals as part of the HSPA framework. It will explain their links to the four functions and thus, discuss their relevance for performance assessment.

Evaluating and strengthening the health system of Curaҫao to improve its performance for future outbreaks of vector-borne diseases

Background Vector-borne diseases (VBDs) such as dengue, chikungunya, and Zika pose a significant challenge to health systems in countries they affect, especially countries with less developed healthcare systems. Therefore, countries are encouraged to work towards more resilient health systems. This qualitative study aims to examine the performance of the health system of the Dutch Caribbean island of Curaҫao regarding the prevention and control of VBDs in the last decade by using the WHO health system building blocks. Methods From November 2018 to December 2020, a multi-method qualitative study was performed in Curaçao, applying content analysis of documents (n = 50), five focus group discussions (n = 30), interviews with experts (n = 11) and 15 observation sessions. The study was designed based on the WHO framework: health system building blocks. Two cycles of inductive and deductive coding were employed, and Nvivo software was used to analyse the data. Results This study’s data highlighted the challenges (e.g. insufficient oversight, coordination, leadership skills, structure and communication) that the departments of the health system of Curaҫao faced during the last three epidemics of VBDs (2010–2020). Furthermore, low levels of collaboration between governmental and non-governmental organisations (e.g. semi-governmental and private laboratories) and insufficient capacity building to improve skills (e.g. entomological, surveillance skills) were also observed. Lastly, we observed how bottlenecks in one building block negatively influenced other building blocks (e.g. inadequate leadership/governance obstructed the workforce's performance). Conclusions This study uncovers potential organisational bottlenecks that have affected the performance of the health system of Curaҫao negatively. We recommend starting with the reinforcement of oversight of the integrated vector management programme to ensure the development, implementation and evaluation of related legislation, policies and interventions. Also, we recommend evaluating and reforming the existing administrative and organisational structure of the health system by considering the cultural style, challenges and barriers of the current health system. More efforts are needed to improve the documentation of agreements, recruitment and evaluation of the workforce's performance. Based on our findings, we conceptualised actions to strengthen the health system's building blocks to improve its performance for future outbreaks of infectious diseases. Graphical abstract

Hypertension in Guatemala’s Public Primary Care System: A Needs Assessment Using the Health System Building Blocks Framework

Background Uncontrolled hypertension represents a substantial and growing burden in Guatemala and other low and middle-income countries. As a part of the formative phase of an implementation research study, we conducted a needs assessment to define short- and long-term needs and opportunities for hypertension services within the public health system. Methods We conducted a multi-method, multi-level assessment of needs related to hypertension within Guatemala’s public system using the World Health Organization’s health system building blocks framework. We conducted semi-structured interviews with stakeholders at national (n = 17), departmental (n = 7), district (n = 25), and community (n = 30) levels and focus groups with patients (3) and frontline auxiliary nurses (3). We visited and captured data about infrastructure, accessibility, human resources, reporting, medications and supplies at 124 health posts and 53 health centers in five departments of Guatemala. We conducted a thematic analysis of transcribed interviews and focus group discussions supported by matrix analysis. We summarized quantitative data observed during visits to health posts and centers. Results Major challenges for hypertension service delivery included: gaps in infrastructure, insufficient staffing and high turnover, limited training, inconsistent supply of medications, lack of reporting, low prioritization of hypertension, and a low level of funding in the public health system overall. Key opportunities included: prior experience caring for patients with chronic conditions, eagerness from providers to learn, and interest from patients to be involved in managing their health. The 5 departments differ in population served per health facility, accessibility, and staffing. All but 7 health posts had basic infrastructure in place. Enalapril was available in 74% of health posts whereas hydrochlorothiazide was available in only 1 of the 124 health posts. With the exception of one department, over 90% of health posts had a blood pressure monitor. Conclusions This multi-level multi-method needs assessment using the building blocks framework highlights contextual factors in Guatemala’s public health system that have been important in informing the implementation of a hypertension control trial. Long-term needs that are not addressed within the scope of this study will be important to address to enable sustained implementation and scale-up of the hypertension control approach.

Progress towards Every Newborn Action Plan (ENAP) implementation in Iran: obstacles and bottlenecks

Background Neonatal mortality accounts for more than 47% of deaths among children under five globally but proper care at and around the time of birth could prevent about two-thirds of these deaths. The Every Newborn Action Plan (ENAP) offers a plan and vision to improve and achieve equitable and high-quality care for mothers and newborns. We applied the bottleneck analysis tool offered by ENAP to identify obstacles and bottlenecks hindering the scale-up of newborn care across seven health system building blocks. Methods We applied the every newborn bottleneck analysis tool to identify obstacles hindering the scale-up of newborn care across seven health system building blocks. We used qualitative methods to collect data from five medical universities and their corresponding hospitals in three provinces. We also interviewed other national experts, key informants, and stakeholders in neonatal care. In addition, we reviewed and qualitatively analyzed the performance report of neonatal care and services from 16 medical universities around the country. Results We identified many challenges and bottlenecks in the scale-up of newborn care in Iran. The major obstacles included but were not limited to the lack of a single leading and governing entity for newborn care, insufficient financial resources for neonatal care services, insufficient number of skilled health professionals, and inadequate patient transfer. Conclusions To address identified bottlenecks in neonatal health care in Iran, some of our recommendations were as follows: establishing a single national authorizing and leading entity, allocating specific budget to newborn care, matching high-quality neonatal health care providers to the needs of all urban and rural areas, maintaining clear policies on the distribution of NICUs to minimize the need for patient transfer, and using the available and reliable private sector NICU ambulances for safe patient transfer.

Evaluating and Strengthening the Health System of Curaҫao to Improve its Performance for Future Outbreaks of Infectious Diseases.

BackgroundVector-borne diseases (VBDs) such as dengue, chikungunya, and Zika pose a significant challenge to health systems in countries they affect, especially countries with less developed healthcare systems. Therefore countries are encouraged to strengthen their healthcare systems to achieve more resilient systems. This qualitative study aims to examine the performance of the health system of the Dutch Caribbean island of Curaҫao with regards to the prevention and control of VBDs in the last decennium by using the WHO health system building blocks.MethodsFrom January 2019 to February 2020, a multi-method qualitative study was performed in Curaçao., applying content analysis of documents (n = 50), five focus group discussions (n = 30), interviews with experts (n = 11), and fifteen observation sessions. The study was designed based on the WHO framework: health system building blocks. Two cycles of inductive and deductive coding were employed, and Nvivo software was used to analyse the data.ResultsThis study’s data highlighted the challenges (e.g., insufficient oversight, coordination, leadership skills, structure, and communication) that the departments of the health system of Curaҫao faced during the last three epidemics of VBDs (2010–2020). Furthermore, low levels of collaboration between governmental and non-governmental organisations (e.g., semi-governmental and private laboratories) and insufficient capacity building to improve skills (e.g., entomological, surveillance skills) were also observed. Lastly, we observed how bottlenecks in one building block negatively influenced other building blocks (e.g., inadequate leadership/governance obstructed the workforce's performance).ConclusionsThis study uncovers potential organisational bottlenecks that have affected the performance of the health system of Curaҫao negatively. We recommend starting with the reinforcement of oversight of the integrated vector management program to ensure the development, implementation, and evaluation of related legislation, policies, and interventions. Also, we recommend evaluating and reform the existing administrative and organisational structure of the health system by taking the cultural style, challenges, and barriers of the current health system into account. More efforts are needed to improve the documentation of agreements, the recruitment, and evaluation of the workforce's performance. Based on our findings, we conceptualised actions to strengthen the health system's building blocks to improve its performance for future outbreaks of infectious diseases.