Essay: Health System Strengthening

The application of public health sciences in the provision of primary health care and community health services, coupled with increased focus on immunization, family planning, gender and sexual reproductive health, maternal, newborn and child health, nutrition, research, development and innovation has created general awareness about the state of health systems in the country and globally’ (Frenk J 2010).
In addition, the aspect of accountability and advocacy for increased funding to health sector over the years by civil society organizations, CSOs, has both accelerated and maintained the reform issues of the 1990s. The disparity between health systems in developing and developed world continued to form part of the discussion.
Due to its relationship and important linkage to different service delivery mechanisms, Health system strengthening (HSS) has been an important aspect for researchers, donors and policy makers locally, nationally and globally. Health care reforms of the 1990s triggered by economic liberalization has resulted in the generalization of volumes of literature, increased assessments of the implications, emphasis on appropriate polices, application of the correct set of tools and safety of employees during or while on duty have been a subject of great interest on the national and global stage for some years from the reforms in the 1990s.Some of these papers presented or documented focuses on specific parts and/or units of health systems, whereas some focuses more on health systems as a whole. Some is descriptive, some is comparative by way of benchmark studies, and some is predictive. But most of this work has an underlying social objective—to improve and support health system performance and enhance human well-being. “Health system strengthening is often seen as an essential means and a major pathway to achieve this end”. (USAID, 2015)
Where do ideas that reach policy makers and planners as proposals for health system strengthening and reform actually originate? More often than we may care to admit, they come from informal exchanges among policy makers (nationally, regional blocks and internationally), anecdotal comparisons across countries, or “expert” advice proceeding “from preconceived notions to foregone conclusions” (WHO, 2013) these are solutions looking for problems.
Health-related goals are prominent globally, nationally, and locally. As one example, four of the eight Millennium Development Goals (MDGs) include outcomes specifically related to health outcomes. MDGs 4, 5, and 6 were monitored with specific indicators related to health status for the population especially children, women in relation to communicable diseases (maternal, newborn and child health or gender and sexual reproductive health). MDG 1, which focuses on poverty, is also closely related to health. Child under nutrition is one key indicator for MDG 1, which is, itself, influenced by health financing. For example, “there is widespread evidence that the lack of financial risk protection for health-related household expenditures is an important cause of impoverishment in developing countries” (Xu et al., 2007). For middle-income countries, like United States of America and a number of European Countries where progress toward the MDGs is already well advanced, other health-related priorities are also prominent. “They include controlling the burden and incidence of none communicable diseases(NCD), life style diseases/conditions, assuring and access to health care for aging populations, and providing financial protection” (Chawla et al., 2007).
The observation in relation to healthcare funding and access to services in wide spread globally and Uganda where this study is undertaken is no exception. In all societies, people also expect support, quality, and respect from their health care system. Health systems are a means, developed by societies, to help achieve ends such as system inputs, the performance and the benefits the system can deliver depend largely upon the knowledge, skills experience and level of training and mentorship, investments on the health systems and motivation of those individuals responsible for delivering health services. As well as the balance between the human and physical resources, much as some operations are established within a resource limited setting, it is always essential to maintain an appropriate mix between the different types of health promoters and caregivers to ensure the system’s success. Due to their obvious and always unique differences, it is imperative that intellectual or human capital is handled and managed very differently from physical capital. The relationship between human resources and health care is very complex, and it merits further examination and study. Both the number and cost of health care consumables (drugs, prostheses and disposable equipment) are rising astronomically along the global supply chain, which in turn can drastically increase the costs of health care with considerable implications on access (quantity supplied and quantity demanded of service). In publicly-funded systems, expenditures in this area can affect the ability to hire and retain effective practitioners and the case is not very different with privately governed institutions in relation to human resources for health (HRH) attraction and retention.
In both government-funded and private for profit and not for profit facilities, health systems can be a vehicle for accelerating progress on health-related goals, but they can also be a source of constraints, impeding progress. Health system performance can be thought of as the results produced by health systems (collection of in-puts, structures, strategies, activities and resources) the ends societies seek to achieve. The challenge faced by policy makers and the analysts who support them is, therefore, to figure out how to improve health system performance to achieve better results.
The health-related and other goals that are the purpose of health systems have been framed in a number of ways by different authorities, with many or multiple similarities drawn and some differences identified; this paper however will not enter further into that segment and debate. There is, however, a widespread consensus that multiple goals are important and that this attribute of having multiple goals increases the complexity of measuring health system performance and of designing strategies to improve performance to required level of service delivery satisfaction.
If health spending and or expenditure were the only variable influencing performance, countries would line up along a diagonal from lower left to upper right. Instead, they are distributed throughout the chart. This variability, we would argue, reflects the variation in health system performance. “It further demonstrates or illustrates that many more variables other than health spending/expenditure influence how health systems perform”.(Mainz.J. 2003), Wagstaff & Claeson., (2004), examined that quality, policies and institutions, are measured by World Bank’s Country Policy and Institutional Assessment (CPIA) Index, influences the returns to additional government health spending. The two listed above found that in countries with better policies and institutions, each additional dollar spent by government on health yields a higher return, as measured by its impact on reductions in under-five and maternal mortality, child underweight, and mortality from tuberculosis. Expenditure analysis on health was just able to demonstrate that were there are strong institutions and well research policies the impact on investments resulted into achievement of health goals, but there could be other variables hence this study on health systems.
“Health systems analysis can therefore be seen as both an essential and main component of health system reform, defined as a significant and specific approach and commitment to improve the performance of the health care system” (Roberts et al., 2003). The analysis and assessment and resulting reform is significant because it provides a more direct and alternative strategic, comprehensive view of the health system, and purposeful because it is based on a core foundation and basis of logic and evidence and an explicit analytical framework.
“There are multiple measures of health system performance, HSP, just as there are multiple health system goals. to be more specific and direct, according to the framework adopted by the World Bank in its Flagship Program on Health Sector Reform and Sustainable Financing” (Roberts et al., 2003),
2.1.1 Human resources for health
The concept of human resources for health, HRH constitutes one of the building blocks for health systems strengthening. In Uganda, human resources for health have multiple and complex managerial and logistical/operational challenges of attraction and retention, ethics of health professionals, low morale and poor pay and reward schemes. The implications of weak or poor health systems on the quality of service delivery and health status of the population created demand for continuous quality improvement in the aspect of human resources for health especially (planning and development) with strong advocacy for more funding towards staff capacity development through establishment of colleges of health sciences, health training and service institutions for all sets of multidisciplinary professionals, medical and clinical officers, laboratory technicians and technologists, pharmacy technicians and pharmacists, nurses and midwives.
The literature reviewed for impact of health systems strengthening on health service delivery demands need for more or prioritization on continuous medical education, on site mentorship, orientation and couching to ensure required development of needed skill gaps within the health sector. Succession planning, remains a critical challenge in the face of a very young population structure hence need for more layers and structures of health professionals to manage and implement ever expanding service base that includes prompt response to epidemic and disaster management.
The development of human resources for health and the component of sustainability strategy still has a long route to travel especially with the most recent trend of highly trained and qualified Ugandan health professionals travelling to South Africa, Europe and western capital to look for greener pastures. This requires a lot of incentives and budget provisions to either reverse the negative trend or create fresh dynamism to return or work home. This if not promptly managed, will lead to a disaster like situation with high incidence of new infections, multidrug resistance health conditions, mortality and morbidity.
Within many health care systems worldwide, increased attention is being focused on human resources management (HRM) and now widely termed human resources for health (HRH) with scope covering planning and development. Specifically, human resources are one of three principle health system inputs, with the other two major inputs being physical capital and consumables. Human resources, when pertaining to health care, can be defined as a multidisciplinary professional team comprising of the different kinds of clinical and non-clinical staff responsible for public and individual health interventions or epidemic response and control. As arguably the most important of the health System inputs, the performance and the benefits the system can deliver depend largely upon the knowledge, skills, competencies, operational efficiencies, level of supervision and support structures and mechanism, motivation or facilitation of those individuals responsible for delivering health services. As well as the balance between the human and physical resources, it is therefore, also essential to maintain an appropriate mix between the different types of health promoters and caregivers to ensure the system’s success. In most countries including Uganda, under the public private partnership, PPP, establishment of linkages and referral networks, task shifting, decentralization under the ministry of local government, establishment satellite facilities created environment for access to services delivery. “Both uniqueness and sensitivity between human and physical resources, it’s always essential to manage and coordinate similarities and differences independently. For over two decades, similarities and differences between the human resources and health care has always been swallow and sometimes confusing and/or complex, and these requires special focus, interest and follow up through observation, examination, assessment and study” (Edmund D. P (2006),).
In addition, it can be noted that with or without application of the economy of scale, the number and cost of health care consumables (drugs, prostheses and disposable equipment) are rising astronomically, which in turn can drastically increase the costs of health care. In publicly-funded systems, like the Ugandan public health systems, expenditures (expenses in this area can affect the ability to attract and retain an effective and required level of healthcare professional team to sustain continuous and quality delivery set up . In both government-funded and employer-paid systems, Human resources for health policies governing practices, operations and procedures must be well structured and regulated in order to find the appropriate balance of workforce supply and the ability of that health work force to practice effectively and efficiently. A health worker and/or practitioner without adequate and required set of tools is as inefficient as having the tools without the practitioner. This means the two must always be matched and balanced from time to time. When examining health care systems in a global context, many general human resources issues and questions arise. Some of these issues of greatest significance to health systems that will be discussed and assessed in further details include the size, composition and distribution of the health care workforce, workforce training and capacity development issues, staff attraction and retention, ratio of health staff to patients, the migration of health workers, the level of economic growth and development in a particular country and socio- demographic, geographical and cultural factors. The variance in size, distribution and composition within a county\’s health care workforce is of great significance. For example, the number of health workers available in a country is a key indicator of that country\’s capacity to provide service delivery and intervention scale up in the management and control of epidemic. “These are factors to mention when establishing the demand and access for health services in a particular country:- cultural characteristics, sociode-mographic characteristics and economic factors” (Bekey & Schwartz, 1972). .
Human resources for health planning and development provide opportunity for continuous quality improvement through refresher and orientation trainings hence staff motivation, attraction and retention. It is essential that human resources personnel consider the composition of the health workforce in terms skills, experience, specialization and training levels . New options for the education and in-service training of health care workers are required to ensure that the workforce is aware of and prepared to meet a particular country\’s present and future needs. ‘A properly trained and competent workforce is essential to any successful health care system’. Edmund D. P (2006).
Both the un predictable in-ward and outward migration of health care workers is an issue that arises when examining global health care systems. In resource limited setting, the situation is even more complicated and cross cutting; namely from the quality of training to absorption to attraction and retention and healthcare infrastructure needs. Research suggests that the movement of health care professionals closely follows the migration pattern of all professionals in that the internal movement of the workforce to urban areas is common to all countries. Health sector professional workforce/team migratory trend can create additional imbalances that require better work force planning, attention to issues of pay and other rewards and improved overall management of the workforce. In addition to salary incentives, developing countries use other strategies such as housing, infrastructure and opportunities for job rotation to recruit and retain health professionals, since many health workers in developing countries are underpaid, poorly motivated and very dissatisfied. In all, most attraction and retention challenges are linked to employment terms and conditions. The migration of health workers is an important human resources issue that must be carefully measured and monitored. In the annual country operational planning, every country or institution must create clear and achievable goals and objectives in relation to human resources for health (HRH), planning and development in terms of attraction and retention, internal capacity development to constitute orientation and ongoing refresher trainings/continuous medical education. There must too be provision for internal growth and development, performance management which promotes coaching and mentorship, job placements, salary benchmarks and reward schemes. In most cases, motivation is beyond monetary terms and systems that encourage research and development is a major emphasis in today’s global content and through exchange programs and transfer of technology which is a common practice involving memorandum of understanding between Universities in developed countries and those in developing countries. The institutional organogram and reporting lines, authority and responsibilities should always allow free and regular follow of information.
Another issue that arises when examining global health care systems is a country\’s level of economic development. There is evidence of a significant positive correlation between the level of economic development in a country and its number of human resources for health. Countries with higher gross domestic product (GDP) per capita, like USA, UK and other European member countries spend more on health care than countries with lower GDP and they tend to have larger health workforces. This is an important factor to consider when examining and attempting implementing solutions to problems in health care systems in developing countries.
Socio-demographic elements such as age distribution of the population, service and information gaps also play a key role in a country\’s health care system. In the most recent, Uganda population and housing census, the population of young people below the age of 35 years is 70% of the total country’s population; this means more resources should be allocated to health care especially primary health care and community health, agriculture and education. On the other hand, an ageing population leads to an increase in demand for health services and health personnel. An ageing population within the health care system itself also has important implications: additional training of younger health workers of different categories( laboratory technologists, pharmacists, nurses, community development workers and counselors will always be in short supply to meet the ever growing service and resource gaps, this is an essential factor too for a rapidly changing population. It’s an aspect for succession planning and task shifting which is indeed a major scope of human resources for health. This too requires funding or health care financing facility and which must be monitored over a specific period of time. The geographic location is yet a major issue or dimension and in the case of Uganda, professional always prefer urban work stations. An attractive employment package with better terms and conditions are needed for an effective rural health care service delivery.t be required to fill the positions of the large number of health care workers that will be retiring. It is also essential that cultural and geographical factors be considered when examining global health care systems. Geographical factors such as climate or topography influence the ability to deliver health services; the cultural and political values of a particular nation can also affect the demand and supply of human resources for health. The above are just some of the many issues that must be addressed when examining global health care and human resources that merit further consideration and study.
The impact of human resources on health sector reform when examining global health care systems, it is always a critical consideration and an essential factor to consider examining the impact of human resources on health sector reform. Whereas the specific health care reform and measures varies from country to country, some trends can be identified. The common known outcomes are efficiency, equity, access, affordability, outcomes in the case of clinical services and quality objectives while others value is to do with value for money, access to care, retention in care, equality, affordability, profitability, cost effectiveness and so on.
Within the last two decades, multiple or more than the previous efforts have been employed in an attempt to increase efficiency. Outsourcing of services has been used to convert fixed labor expenditures into variable costs as a means of improving efficiency. Contracting-out, performance contracts and internal contracting are also examples of measures employed.
Many human resources initiatives for health sector reform also include attempts to increase equity or fairness. Strategies aimed at promoting equity in relation to needs require more systematic planning of health services. Some of these strategies include the introduction of financial protection mechanisms, the targeting of specific needs and groups, and redeployment services. One of the goals of human resource professionals must be to use these and other measures to increase equity in their countries. All these strategies consider the fact that resources are scarce and must be used sparingly for the greater good of the population.
Human resources in health sector reform also seek to improve the quality of services and patients’ satisfaction. Health care quality is generally defined in two ways: technical quality and socio cultural quality. “Technical quality refers to the impact that the health services available can present have on the health conditions of a population, whereas “Socio- cultural quality measures the degree of acceptability of services and the ability to satisfy patients\’ expectations” (Hodge, Gostin & Jacobson, 1999).
Human resource professionals employed within the urban and rural facilities face multiple barriers along the service delivery supply chain network in an effort to offer high quality care service to the population. Example of the most regular obstacles are small operational budget and late release of funds, lack of team work and partnership due to political interference, corruption and a culture of lack of accountability, high demand for services by the population than the resources available (both human and physical to offer the required quantity demanded at the highest technical standard possible and within a given timeframe). Technical operational efficiency requires regular maintenance which includes monitoring and support supervision which in most cases not up to standard and when it’s done, this is always beyond regulated time frame or provision.