1. Strengthening the health
systems in SSA: the role
of health policy and
systems research &
analysis (HPSR+A)
Prof BSC Uzochukwu (MBBS, MPH, FWACP)
3rd African Epidemiological Association Conference,
Yaoundé, Cameroon.
4 – 6 June, 2014

2. Introduction
• Health outcomes are unacceptably low across much of SSA
• Rapid progress towards MDG targets and UHC is greatly
hampered by weak, poorly functioning health systems
• Much of the burden of disease can be prevented or cured
with known, affordable technologies, yet the gaps in health
outcomes continue to widen
• The problem is getting these affordable technologies on
time, reliably, in sufficient quantity and at reasonable cost
– to those who need them

3. Introduction…
The reality is straightforward.
The power of existing interventions is not
matched by the power of health systems to
deliver them to those in greatest need, in a
comprehensive way, and on an adequate scale.

4. What is a health system?
“all organizations, people and actions
whose primary intent is to promote,
restore or maintain health”, including
efforts to address the determinants of
health, besides direct activities to improve
health (WHO).

5. Health Systems…
• It’s more than the pyramid of publicly owned
facilities that deliver personal health services.
• It includes, for example, a mother caring for a
sick child at home, private providers, informal
providers, behaviour change programmes,
vector-control campaigns, health insurance
organizations; inter-sectoral action etc.

6. The six building blocks of a health system
People
Governance
Information
Financing
Service
delivery
Human
resources
Medicines
&
technology
Elements of health systems interact together to form a complex system, and the health
system interacts with the wider context within which it is situated. These interactions
affect the achievement of goals for health systems.

7. A good health system delivers quality services to all
people, when and where they need them
The Health System
Leadership,
governance &
accountability
Deliver effective, safe,
quality health services Sufficient, fairly
distributed,
competent,
responsive &
productive health
workforce
Functioning health
information
system
Equitable access to
essential medicine
and medical
products
Raises adequate
funds for health &
avoids financial
catastrophe
Community
participation
People
People

8. Health systems are shaped by hardware
and software elements

9. Health Systems Strengthening
• There is increasing recognition that disease specific
interventions implemented in vertical silos are
unsustainable, and growing interest in strengthening health
systems
• “ We will not be successful in our efforts to end deaths
from AIDS, malaria and tuberculosis unless we do more to
improve health systems around the world…”
(President Obama, May 5, 2009).
“The responses of many health systems so far have been
generally considered inadequate and naïve. . . . a system’s
failure requires a system’s solution – not a temporary
remedy.”
(WHO World Health Report, 2008).

10. Health Systems Strengthening…
• Involves improving the six health system building
blocks and managing their interactions in ways that
achieve more equitable and sustained improvements
across health services and health outcomes.
• In recent years there have been some major new
initiatives to support health system strengthening
• These developments have been accompanied by a
growing recognition of the role of research in
improving health systems and health care delivery

11. What is Health Policy and Systems
Research & Analysis (HPSR+A) ?
• “an emerging field that seeks to understand and improve
how societies organize themselves in achieving collective
health goals, and how different actors interact in the policy
and implementation processes to contribute to policy
outcomes.”
• By nature, it is a multidisciplinary and inter-disciplinary field
of research, a blend of economics, sociology, anthropology,
political science, public health and epidemiology.
• Central to health systems strengthening because it tries to
draw a comprehensive picture of how the health system and
broader determinants of health can shape and be shaped by
policies.

12. Recognising the diversity of HPSR+A
Epidemiology
& Clinical
Sciences
Policy &
Practice
Social Sciences
HPSR+A

13. • Global Forum, Bamako,
2008
• First HSR symposium,
Montreux, November 2010
• UK funders meeting,
London, December 2011
• Second HSR symposium,
Beijing, October 2012
• Third HSR symposium Cape
Town Sept/Oct 2014: ‘The
Science and Practice of
People-centred Health
Systems’
• Mills HPP 2011
• PLOS medicine papers
2011
• London meeting
background
document, Dec 2011
• Reader, February
2012
• WHO global health
systems research
strategy background
document, March
2012
Lots of interest in HPSR+A!

16. The New Interest in HPSR+A
• Owes much to recognition of its importance for the
success of health interventions and programmes,
and the changing macroeconomic environment of
international health.
• Realization that the Millennium Development Goal
targets would not be achieved due to weak health
systems despite increased funding for health
during the period 2000–2008

17. Scope of HPSR+A
We seek to understand
• what health systems are & how they function
• what needs to be done to strengthen them
• how to influence policy agendas on health
system development
• how to develop and implement policies in ways
that strengthen health systems

18. The terrain of HPSR+A
Health Policy:
Contents & Instruments
Actors, Politics & Power
Health Systems:
Hardware: Structure;
Organisation;
Technology;
Resourcing
Software: Values;
Norms; Actors &
Relationships
System functioning
&
Policy Change/System
Strengthening
Global and
national forces

19. What priorities in developing
research & analysis?
• Balance in questions asked
• not only what works (best)? but also why and how?
(interventions work, systems are now and change over time)
• Less description, more appropriate exploration
and deeper analysis
• more careful thinking about study design & more
understanding of range of alternatives
» case studies, mixed method studies, longitudinal work
• use of theory
• More understanding of how to ensure rigour

20. Key research approach and methods:
Epidemiological studies vs. HPSR+A
Deductive:
Hypothesis & method-
driven
Emphasis on measurement
through surveys, data
records & statistical
analysis;
some qualitative data
FIXED RESEARCH DESIGNS
Inductive: theory building &
testing ; problem- or
question-driven
Emphasis on qualitative
data collection approaches
&
Interpretive analysis
FLEXIBLE RESEARCH
DESIGNS
Epidemiological studies HPSR+A
Positivist:
Validity &
reliability of data
& analysis
Relativist:
Trustworthiness of
interpretive
judgements

21. As epidemiologists, let’s think outside the box!!
• Despite benefits of disease-targeted
programmes for improved outcomes
for communicable diseases,
evidence on optimum system
designs is weak.
• Because epidemiological studies
on their own cannot strengthen
the health system, we need to
think outside the box
• Think about what keeps a
programme or service going…The
underlying building blocks for that.

22. Health systems thinking approach

23. Addressing ill-health: programmatic vs. systems
orientations
Constraint Disease-programme
thinking approach
Health system thinking
approach
Inappropriately
skilled staff
Continuous education and
training workshops to
develop skills in focal
diseases
Review of basic medical and
nursing training curricula to
ensure that appropriate skills
included in basic training
Poor TB data Introduction of TB register Improvement in health
information systems
Physical
inaccessibility:
distance to facility
Outreach for focal diseases Capital investment and siting
of facilities
Financial
inaccessibility:
inability to pay,
informal fees
Exemptions/reduced prices
for focal diseases
Development of risk-pooling
strategies- Health insurance

24. Some HPSR+A studies that have
strengthened health systems
1. Rwashana AS, Williams DW, Neema S (2009). System
dynamics approach to immunization healthcare
issues in developing countries: a case study of
Uganda. Health Informatics Journal, 15(2):95–107.
Systems analysis of an immunization programme
captured and analyse complex interactions between
behavioural, technical, policy and cultural issues. This
enabled decision makers to focus on the root causes of
shortcomings and not the symptoms alone

25. 2. Sheikh K, Porter J (2010). Discursive gaps in the
implementation of public health policy guidelines in India:
The case of HIV testing. Social Science & Medicine, 71(11):
2005–2013.
Focused on actors’ decision-making
Recognising the deliberative nature of implementation, and
strengthening discourse and communications between involved
actors may be critical to the success of public health policies in
Indian and comparable LMIC settings. Effective policy
implementation in the long term also necessitates enhancing
practitioners’ contributions to the policy process, and equipping
country public health functionaries to actualize their policy
leadership roles.

26. 3. D Blaauw, E Erasmus, N Pagaiya, V Tangcharoensathein, K
Mullei, S Mudhune, C Goodman, M English & M Lagarde
Policy interventions that attract nurses to rural areas: a
multi country discrete choice experiment. Bull World
Health Organ 2010;88:350–356 |
doi:10.2471/BLT.09.072918
DCEs to help policy-makers choose more effective
interventions to address staff shortages in rural areas.
Intervention packages tailored to local conditions are more
likely to be effective than standardized global approaches.

27. 4. Martha Morrow, Quy A Nguyen, Sonia Caruana, Beverley A
Biggs, Nhan H Doan and Tien T Nong
Pathways to malaria persistence in remote central Vietnam:
a mixed-method study of health care and the community.
BMC Public Health 2009, 9:85 doi:10.1186/1471-2458-9-85.
Malaria control cannot be achieved through community
education alone in this region. Whilst appropriate awareness-
raising is needed, it is most urgent to address weaknesses at
systems level, including bed-net distribution, health provider
staffing and skills, as well as equipment and supplies.

28. 5. Rifat Atun, Diana E C Weil, Mao Tan Eang, David Mwakyusa.
Health-system strengthening and tuberculosis control.
Lancet 2010; 375: 2169–78
HPSR was used to resolve the bottlenecks to TB control:
Bottlenecks in relation to governance, financing, supply chain
management, human resources, health information systems,
and service delivery in Bangladesh, Cambodia, India, Tanzania,
Thailand, and Vietnam

29. 6. Douglas Wilson, Victoria Howell, Christina Toppozini,
Krista Dong, Michael Clark, and Rocio Hurtado. Against
All Odds: Diagnosing Tuberculosis in South Africa. The
Journal of Infectious Diseases 2011;204:S1102–9
Context-appropriate systems for the diagnosis of
tuberculosis are entirely dependent on effective and
responsive management of human resources and an
uninterrupted supply of clinical materials.

30. 7. Ben Rolfe, Sebalda Leshabari, Fredrik Rutta and Susan F
Murray. The crisis in human resources for health care
and the potential of a ‘retired’ workforce: case study
of the independent midwifery sector in Tanzania.
Health Policy and Planning 2008;23:137–149
Because of their location and emphasis on personalized
care, small-scale independent practices run by retired
midwives could potentially increase rates of skilled
attendance at delivery at peripheral level.

31. 8. Jennifer Bryce, Cesar G Victora, Jean-Pierre Habicht, Robert
E Black and Robert W Scherpbier. Child survival: results of
a multi-country evaluation of Integrated Management of
Childhood Illness. Health Policy and Planning, 20
(supplement 1):i5–i17.
This analysis highlights the need for a shift if child survival
efforts are to be successful. Delivery systems that rely solely
on government health facilities must be expanded to include
the full range of potential channels in a setting and strong
community-based approaches.

32. 9. Reham Khresheh and Lesley Barclay. Implementation of
a new birth record in three hospitals in Jordan: a study
of health system improvement. Health Policy and
Planning 2008;23:76–82
Quantitative and qualitative audit data demonstrated
improved clinical reporting, organizational development
and sustained commitment to the new record from
clinicians, managers and policy leaders.

33. 10. Uzochukwu BSC, Onwujekwe OE, Soludo E, Ezuma N,
Obikeze EN and Onoka CA (2010). Implementing
Community Based Health Insurance in Anambra State,
Nigeria. www.crehs.lshtm.ac.uk
Make efforts to secure widespread backing among groups
(both within and outside the Ministry of Health), take into
consideration power dynamics between local community
actors when designing policies to be implemented at the
local-level and ensure that policy guidelines are clearly
communicated to those responsible for implementing the
policy and to community members.

34. Problems with HPSR+A
• Funding for HPSR in developing countries and by
developing country researchers is meagre.
– Evidence suggests that such funding is at most
0.02% of health expenditure
• A multidisciplinary and inter-disciplinary field of
research, as such it lacks an obvious institutional home
in universities and other research institutes
– The lack of a fixed home means poorly defined career
structures for researchers in this field.
• Lack of capacity to do HPSR in Africa

36. End note
• HPSR has much to contribute to our understanding of health systems and
policies and such knowledge can be applied to improve the health of the
worst-off of SSA population
• The application of HPSR+A has contributed to problem resolution, and a
widely applicable scientific body of knowledge is emerging.
• Its potential to achieve health system change hinges on it becoming more
people-centred in how it is conceived, conducted, and utilized.
• Epidemiologists need to begin to think outside the box since
epidemiological studies alone cannot produce evidence to strengthen the
health systems
• But we need to build capacity for HPSR+A especially in Africa and
epidemiologists are invited

37. ACKNOWLEGEMENT
CHEPSAAConsortium for Health Policy
& Systems Analysisin Africa

38. Thank youCHEPSAA members:
• School of Public Health and Family Medicine, University of Cape Town, South Africa
• School of Public Health, University of Western Cape, South Africa
• Centre for Health Policy, University of Witwatersrand, South Africa
• Institute of Development Studies, University of Dar es Salaam, Tanzania
• School of Public Health, University of Ghana, Legon, Ghana
• Tropical Institute of Community Health, Great Lakes University of Kisumu, Kenya
• College of Medicine, University of Nigeria Enugu, Nigeria
• London School of Hygiene & Tropical Medicine, United Kingdom
• Nuffield Centre for International Health and Development, University of Leeds, United Kingdom
• Karolinska Institutet, Sweden
• Swiss Tropical and Public Health Institute, University of Basel, Switzerland