Converging Health Systems Frameworks:

Towards A Concepts-to-Actions Roadmap for Health

Systems Strengthening in Low and iddle !ncome
Co"ntries
George Shakarishvili, Rifat Atun, Peter Berman, William Hsiao, Craig Burgess,
and ary Ann Lansang
Debates around health systems have dominated the international health
agenda for several decades. A wealth of contributions has been made to
define, describe and explain health systems through multiple conceptual
frameworks proposed to date. The array of health systems frameworks
arguably provides an opportunity for identifying different appropriate
approaches to meeting various country-specific challenges. At the same
time, multiplicity of health systems frameworks also creates confusion at the
country level as to which conceptual model to refer to for designing health
systems strengthening interventions. Additionally, most debates have
focused on conceptualizing health systems obectives, functions and
performance measurement approaches, with rather less focus on identifying
practical approaches to collective actions to strengthen health systems. The
paper reviews multiple health systems frameworks available to date. The
review finds that the frameworks, despite variations in terms of focus, scope,
categorization and taxonomy, contain sufficient complementary elements to
develop a comprehensive synergistic model. The paper proposes a converged
conceptual framework for health systems as a departure point for further
discussions. A frameworks-to-actions roadmap for collective approach to
health systems strengthening is also proposed as the basis for developing a
translational reference for harmonized planning and implementation of
health systems strengthening interventions.
!#TR$%&CT!$#

The adoption of the U !illennium "e#laration and the !illennium
"evelopment Goals $!"Gs% signifi#antl& #hanged the lands#ape of
international development assistan#e during the last de#ade' The am(itious
nature of the health) and nutrition related !"Gs has also led to a gro*ing
momentum *ithin the field of glo(al health' +n the earl& ,---s this
momentum *as marked (& the esta(lishment of several high)profile glo(al
health initiatives $GH+s% su#h as the Glo(al .und to .ight A+"S, Tu(er#ulosis
and !alaria $G.AT!%, the Glo(al Allian#e for /a##ines and +mmuni0ation
$GA/+%, the US' President1s 2mergen#& Plan for A+"S Relief $P2P.AR%, the
US President1s !alaria +nitiative $P!+%, the Stop TB Partnership, the Roll
Ba#k !alaria Partnership and others, *ith the primar& o(3e#tive of redu#ing
the (urden of ma3or diseases of pu(li# health importan#e' The esta(lishment
of these initiatives *as asso#iated *ith the e4pe#tation that strengthened
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health s&stems *ould (e an inevita(le #onse9uen#e of in#reased health se#tor
spending'
A re#ent WH7 e4pert #onsultation on health s&stems and glo(al health
initiatives #on#luded, ho*ever, that *hile in#reased resour#es do (ring
positive :spillover; effe#ts to (roader health#are s&stems, the #ategori#al
programs supported (& these initiatives also produ#e unintended side)effe#ts
su#h as redu#ing s&stems1 #apa#it& to address the (roader health#are needs of
the population'
1
Anal&ti#al eviden#e generated during the last fe* &ears also
suggests that signifi#ant progress in s#aling up disease #ontrol interventions is
a##ompanied (& a fairl& #omple4 range of positive and negative effe#ts on
other servi#es and the s&stem in general'
2
Re#ent studies in Benin, 2thiopia
and !ala*i reported some eviden#e of disease)spe#ifi# investments
#ontri(uting to stronger health s&stems, (ut also found that s&stemi#
*eaknesses, espe#iall& in the areas of human resour#es and pro#urement
s&stems, (e#ame more e4posed as a result of s#aling up disease)related
interventions'
3
Another assessment in !o0am(i9ue, Uganda and <am(ia
reports that the ma3or H+/ donors=P2P.AR, Glo(al .und and World Bank1s
!AP=have helped esta(lish A+"S)spe#ifi# parallel s&stems and pro#esses
distin#t from those for other health programs'
4
There are also #on#erns a(out
the a(ilit& of health s&stems to effe#tivel& and effi#ientl& a(sor( rapidl&
in#reasing resour#es through spe#ifi# programs'
5
Additionall&, gro*ing
empiri#al eviden#e indi#ates that in spite of the availa(ilit& of effe#tive
interventions for man& priorit& health pro(lems, progress to*ards agreed
health goals remains slo*, suggesting that the primar& (ottlene#k to a#hieving
the !"G health targets are *eak and fragmented health s&stems, *hi#h are
una(le to deliver the volume and 9ualit& of needed servi#es'
6
These and other findings have #ontri(uted to a shift in thinking a(out
the intera#tions (et*een disease)spe#ifi# programs and health#are s&stems'
Strong and effe#tive health s&stems are in#reasingl& #onsidered a prere!uisite
to redu#ing the disease (urden and to a#hieving the health !"Gs, rather than
the outcome of in#reased investments in disease #ontrol' As a #onse9uen#e,
health s&stems strengthening $HSS% has risen to the top of the health
development agenda'
The gro*ing demand for HSS investments in #ountries, and gro*ing
#ommitments of glo(al health initiatives and #olla(orating agen#ies to support
HSS, demonstrate a re#ognition of the need to a##ompan& the s#ale)up of
stand)alone programs *ith (roader health s&stem strengthening' .or
e4ample, G.AT! re#eived funding re9uests of US" >?, million and US"
?,,@A million for HSS in Rounds B and C, respe#tivel&, and the Te#hni#al
Revie* Panel $TRP% re#ommended US" @DA million $RB% and US" D>E
million $RC%'
7
The GA/+ Allian#e announ#ed an in#rease of its finan#ial
#ommitment to HSS (& US" @-- million, (ringing its total HSS (udget to
US" C--m (& ,--C'
8
The World Bank1s lending for pro3e#t spe#ifi#all& #oded
to in#lude health#are reforms $onl& part of all HSS)related lending% in#reased
from US" @?A million in ,--? to US" B@> million in ,--B'
9

A#kno*ledging the in#reased importan#e of HSS in a#hieving (etter
health out#omes, glo(al health partners have (een enhan#ing their
#ommitments to HSSF The A,
nd
World Health Assem(l& issued a resolution
urging the mem(er states to :keep the issue of strengthening health s&stems
(ased on the primar& health #are approa#h high on the international politi#al
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agenda;H
10
The World Bank revised its Health, utrition and Population
strateg& in ,--B, *here HSS is given one of the highest priorities, and is
presentl& in the pro#ess of operationali0ing it'
11
Also in ,--B, ".+" laun#hed a
ne* health strateg&, *hi#h *ill :#ontinue to support multilateral approa#hes
to national health initiatives, as long as the& strengthen national health
s&stems';
12
The Glo(al .und initiated #onsultations *ith te#hni#al partners on
updating the HSS funding frame*ork for Round C and is #urrentl& revising it
(ased on the TRP Round C and Round > te#hni#al reports'
13
+n ,--C GA/+
#ommissioned an anal&sis of its HSS e4perien#e *ith the aim of produ#ing
a#tiona(le, eviden#e)(ased re#ommendations to improve the HSS appli#ation
pro#ess, an HSS funding frame*ork and me#hanisms for providing te#hni#al
assistan#e'
14
USA+" has su(mitted the first ever HSS report to the Congress
outlining the agen#&1s HSS priorities
15
'
Supporting the glo(al health #ommunit&1s in#reased fo#us on HSS, the
GC leaders re#entl& endorsed the report of the GC Health 24perts Group,
*hi#h provides a frame*ork for HSS and for fighting the spread of
#ommuni#a(le diseases, and reiterated the #ommitment to provide US" A-
(illion over the #oming five &ears for health and disease #ontrol programs'
16
A
spe#ial High 6evel Taskfor#e on +nnovative +nternational .inan#ing for Health
S&stems $Taskfor#e% *as set up in ,--C :to #ontri(ute to filling national
finan#ing gaps through mo(ili0ing additional resour#es, in#reasing the
finan#ial effi#ien#& of health finan#ing, and enhan#ing the effe#tive use of
funds';
17

+n earl& ,--> the Chief 24e#utives of the G.AT! and GA/+ informed
the GC Taskfor#e of their intention :to (egin 3ointl& programming GA/+
Allian#e and G.AT! resour#es to*ards health s&stems strengthening';
18
+n
!ar#h ,-->, the G.AT!, GA/+ and World Bank, *ith te#hni#al support from
WH7, laun#hed inter)agen#& #onsultations on aligning HSS funding
frame*orks *ith the aim of developing me#hanisms for 3oint HSS funding and
programming'
TH' #''% F$R (R'AT'R CLAR!T) $# H'ALTH S)ST'S A#% H'ALTH
S)ST'S STR'#(TH'#!#(
Politi#al and finan#ial support to HSS, #om(ined *ith the international health
#ommunit&1s in#reased attention to HSS in developing #ountries, has #reated a
strong impetus for glo(al health partners to #olla(orate and (etter #oordinate
their HSS strategies' The e4pression of gro*ing needs for HSS investments
from #ountries, the #ommitment from ke& donor agen#ies to meet those
needs, and the WH7)fa#ilitated pro#ess to strengthen s&nergies among
te#hni#al partners=have produ#ed in#reased momentum for enhan#ing the
overall effe#tiveness and effi#ien#& of HSS interventions glo(all&'
To date, there has (een a proliferation of multiple approa#hes to
thinking a(out health s&stems and there are man& *a&s in *hi#h the term
:health s&stem strengthening; is used'
19
Argua(l&, su#h #on#eptual diversit&
around HSGHSS, the la#k of #oordinated operational me#hanisms, and la#k of
glo(al division of la(or for HSS finan#ing and programming #an #reate
#onfusion at the #ountr& level, in#rease transa#tion #osts and redu#e overall
effe#tiveness and effi#ien#& of health s&stem strengthening efforts'
20
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+n order to enhan#e #olle#tive a#tion at #ountr& level for strengthening
health s&stems, (etter #ommon understanding is needed on anal&ti#al
approa#hes to health s&stems, along *ith some #onsensus on #on#epts, terms,
and #ategories for health s&stems strengthening' !ore #larit& in anal&ti#al,
te#hni#al, and operational thinking for glo(al and #ountr& partners *ould help
support aligned and harmoni0ed HSS strategies' This #ould ultimatel& lead to
developing a common conceptual framework for health systems
strengthening and a common operational roadmap for &,,. The former
#ould support a #ommon understanding of the s#ope of HSS, *hat #onstitutes
health s&stem strengthening, ho* the progress in HSS is to (e measured and
ho* HSS investments #an (e anal&0ed' The latter *ould help #larif& ho*
different national and glo(al health a#tors relate to HSS from the operational
perspe#tive'
.or more #larit&, an important distin#tion should (e made (et*een
health s&stems $HS% frame*orks, a #ommon #on#eptual HSS frame*ork, and
a #ommon operational roadmap for HSS' The first is a (ird1s e&e vie* over the
health s&stem' +t defines, des#ri(es and e4plains the health s&stem, its
o(3e#tives, stru#tural and organi0ational elements, fun#tions and pro#esses'
The se#ond is a#tion)oriented and outlines the #ourses of a#tion ne#essar& for
enhan#ing the s&stem1s o(3e#tives, fun#tions and pro#esses, and for
strengthening the s&stem1s overall performan#e' The first should serve as a
te#hni#al referen#e for designing the se#ond' The third defines me#hanisms
for #oordinating and harmoni0ing glo(al and #ountr& partners1 HSS
investment strategies and poli#ies, program support s&stems I pro#esses, and
operational, te#hni#al I anal&ti#al tools' +t is informed (& (oth=the HS and
HSS frame*orks' The #hallenge is that multiple HS frame*orks have (een
proposed, *hi#h are diverse in terms of their fo#us, s#ope, ta4onom&,
linguisti#s, usa(ilit& and other features $see Ta(le ?%'
21
Su#h diversit& of health
s&stems frame*orks #ontri(ute to the la#k of #larit& around the #on#ept'
Ta*le +: An ill"strative list of proposed concept"al frameworks for
health systems
An !ll"strative List of "ltiple Health Systems Frameworks:
J A#tors frame*ork $2vans, ?>C?%
J .und flo*s and pa&ment frame*ork $Hurst, ?>>?%
J "emand)suppl& frame*ork $Cassels, ?>>D%
J Performan#e frame*ork $WH7, ,---%
J Control kno(s frame*ork $Hsiao, ,--@%
J Reforms frame*ork $Ro(erts, Hsiao, Berman, Rei#h, ,--E%
J Pu(li# management frame*ork $5haleghian, "as Gupta, ,--E%
J Capa#it& frame*ork $!ills, Rasheed, Tollman, ,--A%
J Building (lo#ks frame*ork $WH7, ,--B%
J 2ssential pu(li# health fun#tions frame*ork $PAH7, ,--C%
J S&stems frame*ork $Atun, ,--C%
Sour#eF R' Atun, ' !ena(de, :Health S&stems and S&stems Thinking; in R' Co#ker, R' Atun,
!' !#5ee, &ealth ,ystems and the +hallenge of +ommunicable Disease
"espite (eing diverse, various health s&stems frame*orks are #omplementar&,
in that the& offer s&nergisti# vie*s to the health s&stem and pla#e high fo#us on
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its various elements' The dis#ussion (elo* provides an anal&ti#al overvie* of
various HS frame*orks' +t also e4plores *hether it is feasi(le to #onverge
multiple HS frame*orks to develop a #ommon s&nergisti# model' A #onverged
HS frame*ork *ould (e a more effe#tive te#hni#al point of referen#e for
designing a common HSS #on#eptual frame*ork than an& single HS
frame*ork alone' The #ommon #on#eptual HSS frame*ork in turn *ould aid
#ountr& and glo(al partners in designing harmoni0ed and aligned #ountr& HSS
strategies'
,,

$,'R,!'- $F H'ALTH S)ST'S FRA'-$R.S
The availa(ilit& of an arra& of #on#eptual frame*orks for health s&stems
argua(l& provides an opportunit& for identif&ing different appropriate
approa#hes to meeting various #ountr&)spe#ifi# #hallenges' At the same time,
multipli#it& of health s&stems frame*orks also #reate #onfusion at the #ountr&
level as to *hi#h #on#eptual model to refer to for designing health s&stems
strengthening interventions'
23
Additionall&, different definitions, methods,
tools and strategies promoted (& different donors and te#hni#al and
implementing agen#ies, as a result of appl&ing different health s&stems
frame*orks into pra#ti#e, ma& hinder #olle#tive a#tion for (etter out#omes'
24

Health s&stems frame*orks var& in purpose, in the *eight the& pla#e
on spe#ifi# #on#epts and health s&stems elements, and in the terminolog& and
ta4onom& the& use for defining, des#ri(ing, e4plaining and #lassif&ing health
s&stems o(3e#tives, fun#tions and pro#esses' Cumulativel&, there ma& (e
value)added in the development of multiple frame*orks, *hen the
information #ontained in them provides more #omprehensive overall pi#ture
of the health s&stem than an& single frame*ork individuall&'
7ne important point to mention at the outset is that man&
#ontri(utions to the dis#ussion a(out health s&stems a#kno*ledge that
out#omes are the result of man& determinants' +n man& #ases, health s&stem
frame*orks are reall& a(out the health care system, *hi#h is often the main
domain that poli#& makers #an affe#t and *hi#h is a#kno*ledged to sit *ithin
a larger health system. A num(er of authors make referen#e to a *ider set of
determinants and pro#esses and sometimes in#lude elements of it in their
health s&stem frame*orks, (ut the #omple4it& of this *ider #anvas has proved
diffi#ult to manage #omprehensivel&'
-ultiple &, .rameworks
"ra*ing on earlier *ork (& 2vans *ho identified four main sets of
a#tors in health #are s&stems=the population to (e servedH health #are
providersH third)part& pa&ersH and government as regulator=Hurst and
#olleagues defined health s&stems in terms of fund flo*s and pa&ment
methods (et*een population groups and institutions'
25
The& identified seven
ma3or su(s&stems of finan#ing and deliver& of health #are, namel& three
voluntar& insuran#e s&stems $private reim(ursement, #ontra#t and integrated
models%, three #ompulsor& insuran#e) or ta4)funded models $pu(li#
reim(ursement model, #ontra#t and integrated models% and the dire#t,
voluntar& out)of)po#ket pa&ment model'
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7ther #ommentators have des#ri(ed health s&stems in terms of the
e#onomi# relationship (et*een demand, suppl& and intermediar& agen#ies
*hi#h influen#e the suppl&)demand relationship'
26

There are several frame*orks that have fo#used on anal&sis of health
s&stem reforms' That developed (& 5ut0in ena(les e4ploration of health
s&stems reform through a finan#ing lens'
27
+n earlier studies he and !#Pake
also suggested a @)step approa#h to evaluating health reforms $i% ke&
#onte4tual fa#tors driving reformH $ii% the reform itself and its o(3e#tives, and
$iii% the pro#ess (& *hi#h the reform *as $is (eing% implemented'
28
The approa#h developed (& .renk fo#used on the dimensions of health
s&stem reform and interrelationships among health s&stem #omponents'
29
He
#on#eptuali0ed the health s&stem as a set of relationships among five ma3or
groups of a#torsF the health #are providers, the population, the State as a
#olle#tive mediator, the organi0ations that generate resour#es, and the other
se#tors that produ#e servi#es that have health effe#ts' He also identified four
poli#& levels at *hi#h health s&stem reform operatesF s&stemi#, programmati#,
organi0ational and instrumental
!ills and Ranson #on#eptuali0ed health s&stems in terms of four ke&
fun#tions and four ke& a#tors'
30
Their frame*ork or :map; depi#ted the
interpla& (et*een these four fun#tions $regulation, finan#ing, resour#e
allo#ation, servi#e provision% and the ma3or stakeholders involved in ea#hF
government or professional (odies responsi(le for regulationH the population
$in#luding patients%H finan#ing agents responsi(le for #olle#ting and allo#ating
fundsH and servi#e providers'
Ro(erts, Hsiao, Berman, and Rei#h $,--@% #on#eptuali0ed a health
s&stem as :a set of relationships *here the stru#tural #omponents $means%
and their intera#tions are asso#iated and #onne#ted to the goals the s&stem
desires to a#hieve $ends%;'
31
The frame*ork identifies five ma3or :#ontrol
kno(s; of a health s&stem *hi#h poli#&)makers #an use to a#hieve health
s&stem goalsF finan#ing, ma#ro)organi0ation, pa&ment, regulation and
edu#ationGpersuasion' This frame*ork has (een used as the (asis for the
World Bank +nstitutes .lagship Program on Health Se#tor Reform and
Sustaina(le .inan#ing, no* renamed Health S&stem Strengthening'
Three fre9uentl& #ited health s&stems frame*orks have (een proposed
(& WH7' The ,--- World Health Report
32
defined a health s&stem as one that
in#ludes all a#tors, institutions and resour#es *hose primar& intent is to
improve population health in *a&s that are responsive to the populations
served, and seeks to ensure a more e9uita(le distri(ution of *ealth a#ross
populations' +t outlined four ke& fun#tions of a health s&stem *hi#h drive the
*a& that inputs are transformed into health s&stem out#omesF resour#e
generation, finan#ing, servi#e provision and ste*ardship'
Another #ontri(ution from WH7 *as the ,--B report :2ver&(od&1s
BusinessF Strengthening Health S&stems to +mprove Health 7ut#omes; *hi#h
proposed pra#ti#al *a&s to organi0e health s&stems into A operational
:(uilding (lo#ks;F servi#e deliver&, health *orkfor#e, information, medi#al
produ#ts and te#hnologies, finan#ing, and leadership and governan#e'
33
The
(uilding (lo#ks approa#h is a useful means for lo#ating, des#ri(ing and
#lassif&ing heath s&stem #onstraints, for identif&ing *here and *h&
investments are needed, *hat *ill happen as a result, and (& *hat means the
#hange #an (e monitored'
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!ore re#entl& pu(lished (& WH7 Kprimar& health#are1 frame*ork
$,--C% identified four (road poli#& areas for essential #hangesF $i% dealing
*ith health ine9ualities (& moving to*ards universal #overage, $ii% putting
people at the #entre of servi#e deliver&, $iii% integrating health into pu(li#
poli#ies a#ross se#tors, and $iv% providing in#lusive leadership for health
governan#e'
The World Bank Strateg& for Health, utrition, and Population Results
defined health s&stems in terms of fun#tionalit&, defined (& health servi#e
inputs $resour#e management%H servi#e provision $pu(li# and private%H health
finan#ing $revenue #olle#tion, risk pooling, and strategi# pur#hasing%H and
ste*ardship $oversight%'
34
The Bank1s #on#ept of ste*ardship resem(les that of
the WH7, in that it involves esta(lishing the poli#& frame*ork to govern the
entire health s&stemH the institutional frame*ork in *hi#h the man& a#tors in
health must intera#tH #oordination *ith non)health se#torsH and the
generation of data for de#ision)making'
+n the :s&stems thinking; approa#h to health s&stems anal&sis, Atun
$,--C% further e4panded other HS frame*orks to take into a##ount the
#onte4t *ithin *hi#h the health s&stem fun#tions, namel&, the demographi#,
e#onomi#, politi#al, legal and regulator&, epidemiologi#al, so#io)demographi#
and te#hnologi#al #onte4ts $:"2P62S2T;%'
35
He also introdu#ed the #on#ept of
:health s&stem (ehavior; and fo#used on #omple4 intera#tions (et*een health
s&stems elements and (et*een these and #onte4tual fa#tors' He proposed
:s&stems thinking for seeing the *hole;=a frame*ork for seeing
interrelationships and repeated events rather than things, for seeing patterns
of #hange rather than stati# :snapshots;' The s&stems frame*ork identified
four levers availa(le to poli#&)makers *hen managing the health s&stemF
ste*ardship and organi0ational arrangements, finan#ing, resour#e allo#ation
I provider pa&ment s&stems, and servi#e provision' The intermediate goals
identified in the frame*ork $e9uit&, effi#ien#& $te#hni#al and allo#ative
effi#ien#&%, effe#tiveness and #hoi#e% are fre9uentl& #ited in other frame*orks,
sometimes as end goals in themselves' The S&stems frame*ork has (een
e4tended to develop a S&stemi# Rapid Assessment $S8SRA% toolkit *hi#h
allo*s simultaneous and s&stemati# e4amination of the (road #onte4t, the
health #are s&stem and the features of health programs $su#h as
#ommuni#a(le disease #ontrol programs%'

+lassification of &, .rameworks
Hsiao and Siadat introdu#ed a useful #lassifi#ation of health s&stems
frame*orks (& grouping them into des#riptive, anal&ti#al, and deterministi#
and predi#tive #ategories'
36
This #lassifi#ation is summari0ed in the Ta(le ,
(elo*, follo*ed (& dis#ussionF
Ta*le /: Classification of Health Systems Frameworks
0erspective1Type Researchers1$rgani2ations
Descriptive
,ub-systems /arious

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Roemer $?>>?, ?>>@%
*ational 2uropean 7(servator& $HiTS%
WH7 Regional Sites
Analytical
.und .low Hurst $?>>,%
72C"
Anell and Willis $,---%
"o#teur and 74le& $,--@%
.unctional 6ondono and .renk $?>>B%
WH7 $,---%
!ills and Ranson $,--?, ,--A%
The World Bank $,--B%
The Glo(al .und $,--C%
,tatistical +orrelation i4on and Ulmann $,--A%
Anand and BLrnighausen $,--E%
Deterministic and predictive
Actuarial models 7ffi#e of the A#tuar&, C!S
'conomic models 8ett , "ra(ak, +ntriligator, et al $?>B,%
.eldstein).riedman $?>BA%
-acro-policy model Hsiao $?>>B%H $Ro(erts, et' al' ,--@%
Sour#eF Hsiao and Siadat ,--C'
Descriptive -odels/ Basi# des#riptive models appl& to (oth su()s&stems and
national s&stems, *hile more #omple4, anal&ti#al #on#epts to health s&stems
appl& at the national level' The (asi# des#riptive models are most relevant for
general understanding of health s&stems' The& essentiall& provide a (asi#
des#ription of the s&stems themselves, their finan#ial and human resour#es
devoted primaril& to improving health, e4isting programs and ho* the&
operate, the ke& stakeholders involved and ma& in#lude the (asi# institutional
arrangements' +n other *ords, the des#riptive approa#h tells us the
#omponents *ithin the s&stem, (ut not ho* the s&stem *orks' +t does not
e4plain *h& an& parti#ular s&stem *ould perform (etter than another'
At the su()s&stem level, the des#riptive models #an (e further su()
divided into several #ategoriesF :Servi#e "eliver& Su()S&stems;, *hi#h entail
the notion of health s&stems fo#used on providing servi#es at different level
$e'g' primar& #are, or se#ondar& and tertiar& #are%H :"isease Su()S&stems;,
*hi#h en#ompass disease)spe#ifi# programs su#h as H+/GA+"S, TB, malaria
or va##ine preventa(le diseasesH :7perational Su()S&stems;, su#h as those
fo#used on various operational elements $e'g' pro#urement and distri(ution
me#hanisms% and others'
Some national level s&stems #an also (e vie*ed through a (asi#
des#riptive model' A #lassi# e4ample is one defined (& Roemer *ho des#ri(ed
a health s&stem as, :the #om(ination of resour#es, organi0ation, finan#ing and
management that #ulminate in the deliver& of health servi#es to the
population;' This frame*ork des#ri(es in detail the various resour#es $e'g'
human resour#es, infrastru#ture, health #ommodities, and kno*ledge% and
health programs providing servi#es $e'g' government, volunteer agen#ies,
private agen#ies% as *ell as the e#onomi# support, management and servi#e
deliver& me#hanisms at pla&
37
A further e4ample of the (asi# des#riptive
model at the national level is that of the 2uropean 7(servator& on Health
S&stems and Poli#ies1 Health S&stems in Transition $HiT% #ountr& profiles that
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provide detailed des#riptions of ea#h 2uropean health #are s&stem as *ell as
the various reform and poli#& initiatives under*a&'
38
Analytical -odels/ Anal&ti#al models go (e&ond des#ri(ing *hat e4ists and
go into greater depth in anal&0ing some ma3or aspe#ts of a s&stem and its
#omple4 operations' T*o t&pes of anal&ti#al models=fund flo* and fun#tional
models are des#ri(ed (elo*F
The fund flo* models des#ri(e and anal&0e the fund flo*s (et*een
patients, government, insurers, hospitals, #lini#s, et#' The utilit& of the fund
flo* model is limited in that it des#ri(es 3ust one part of the national health
s&stem, *ithout #onsidering the intera#tion of the s&stem1s various
#omponents'
.un#tional models des#ri(e and anal&0e the fun#tional #omponents of a
s&stem su#h as inputs $finan#ial, human resour#es, fa#ilities%, ste*ardship,
governan#e, and regulation, et#' .un#tional models provide a more anal&ti#al
vie* in e4amining all ma3or fun#tions and programs, at all levels' "ifferent
fun#tional models have (een proposed, ho*ever man& #ontain a similar set of
overar#hing #ategoriesF finan#ing $revenue #olle#tion, pur#hasing, pooling%,
servi#e provision and deliver& $pu(li# and private%, resour#e allo#ation,
resour#e generation, and regulation' The fun#tional frame*orks offer a more
holisti# and sophisti#ated anal&sis of health s&stems than do fund flo*s or
purel& des#riptive models' Ho*ever, the fun#tional models do not tell us *hat
*orks and *hat does not, ho* poli#& #an improve the fun#tions, and further
do not reveal the intera#tion among the various health s&stem fun#tions'
Deterministic and 0redictive -odels/ "eterministi# models differ from
anal&ti#al models in one ke& aspe#t' The& tr& to ans*er a more fundamental
9uestionF *hat fa#tors influen#e ho* *ell the fun#tions perform in a health
s&stemM Ultimatel&, deterministi# models have to ans*er the 9uestions ) *h&
do some health s&stems *ork (etter than othersM Ho* #an poli#&makers
make a national health s&stem perform (etterM
7ver the past fe* de#ades, spe#ialists from several dis#iplines have
developed deterministi# models of national health s&stems' 2#onomists,
a#tuaries and pu(li# poli#& s#ientists have (een most a#tive in this effort' A
fe* s&stem d&nami# spe#ialists have also attempted to model the health
s&stem' !ost efforts have (een dire#ted at modeling the national health
s&stem to allo* predi#tions a(out future health e4penditures or human
resour#e re9uirements' Hsiao and Siadat su()divide the deterministi# model
in the a#tuarial, e#onomi# and ma#ro)poli#& models and argue that the ma#ro
poli#& model provides the most #omprehensive approa#h for poli#&makers to
e4amine the ke& elements of a health s&stem that #an (e managed to
strengthen it' The& provide a detailed des#ription of the :#ontrol kno(s;
frame*ork as an e4ample of the ma#ro)poli#& model' This model parti#ularl&
fo#uses on the needs of poli#&makers *ho *ant to kno* *hat poli#&
instruments *ill allo* them to measura(l& affe#t desired out#omes' This
ma#ro poli#& model *as developed through a pro#ess of s#ientifi# in9uir&
involvingF o(servation, h&pothesis formulation, predi#tion, test and
e4perimentation' .irst, the authors *orked #losel& *ith more than t*o do0en
nations in their planning of ma3or health s&stem reforms' The authors
o(served the pro(lems that #onfronted these #ountries and s#rutini0ed *hat
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poli#& instruments poli#&makers #ould use to produ#e health s&stem
improvements' These instruments had (een tried (& other nations, produ#ing
a great deal of a##umulated eviden#e on their appropriateness and impa#ts'
.rom the o(servations and availa(le eviden#e, the authors developed
h&potheses to formulate the model' Su(se9uentl&, this model has (een tested
in man& #ountries interested in strengthening their health s&stems'
2valuations and e4periments are (eing #ondu#ted'
A C$#,'R('% H'ALTH S)ST'S FRA'-$R.3
Should there (e an effort to develop a #ommon health s&stems
frame*orkM Would a #onverged frame*ork *ould (ring a pragmati# added
value to international health assistan#eM +s there suffi#ient #ommon ground in
the #urrent varied set of health s&stems frame*orks to #om(ine their
#omponents to #reate a #onverged, #omprehensive modelM These 9uestions
are e4plored (elo*' An initial sket#h of the #omplementar& areas of multiple
health s&stems frame*orks, is also proposed'
As sho*n a(ove, a ri#h literature e4ists #ontri(uting to understanding
*hat a health s&stem is, *hat are its #omponent parts, *hat fa#tors drive its
performan#e, ho* #an poli#& makers go a(out improving the health s&stem,
and ho* #an one predi#t the effe#ts of health s&stem #hange on its results'
This ri#h literature has given rise to a variet& of vie*s, (ut no single vie*' This
variet& of vie*s represents different purposes as *ell as different differen#es
in prin#iples, fo#us, and empiri#al o(servation'
!u#h resour#es and energ& have (een spent on te#hni#al dis#ussions
a(out the merits of some frame*orks over others' e* health s&stems
frame*orks are proposed, presuma(l& (e#ause their authors per#eive that
the& fill a gap in kno*ledge or understanding' But it is diffi#ult to demonstrate
that empiri#all&'
Arguments in favor of a #onverged health s&stems frame*ork suggest
that it *ould simplif& the tasks of the health se#tor a#tors (& providing a user)
friendl&, &et #omprehensive tool that #an (e applied as a te#hni#al point of
referen#e for designing health s&stem strengthening strategies' +t #ould (e
applied for addressing institutional, fun#tional, operational, stru#tural and
other t&pes of health s&stems #hallenges' +t #ould (e applied to various
purposes su#h as programming, poli#&)making or resear#h' +t *ould allo*
#onsideration of the #omple4 intera#tions among various elements of the
health s&stem, and (et*een the health se#tor and e4ternal fa#tors' And it
*ould fa#ilitate more effe#tive #olle#tive a#tion at #ountr& level to implement
health s&stems strengthening a#tivities'
Areas of +omplementarity in 'xisting &ealth ,ystems .rameworks/
&ealth ,ystems "oals/ Among the health s&stems frame*orks revie*ed, there
is an overall #onsensus that the health s&stem is a #omple4, multidimensional
domain of a#tors and a#tions, *hi#h produ#e out#omes that so#ieties value'
7ne of the dimensions en#ompasses the health s&stem1s goals' These are
independent varia(les, in that the goals remain #onstant $although the levels
of their attainment are indeed d&nami#% irrespe#tive of the t&pe of the health
s&stem, or #hanges *ithin the s&stem and its surrounding environments' With
some differen#es in definitions used, there seems to (e a good #onsensus
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among the health s&stem frame*orks that the health s&stems goals should
in#lude F $i% improved health status, $ii% prote#tion against health related
finan#ial risk, $iii% responsiveness to needs, and $iv% satisfa#tion of #onsumers1
e4pe#tations' There are important areas of de(ate a(out ho* so#ieties arrive
at a #onsensus a(out health s&stem goals and to *hat e4tent goals are
universal'
$verarching 0rinciples/ There also seems to (e a #onsensus on the presen#e
of some :overar#hing prin#iples; or :intermediate o(3e#tives; or
:#hara#teristi# features; *hi#h in#lude e9uit&, effi#ien#&, sustaina(ilit&,
9ualit&, a##ess, #overage, safet&, #hoi#e and other #ross)#utting aspe#ts' The&
#an (e targeted (& health s&stem strengthening interventions, (ut the& are
results of these interventions, and often of multiple interventions and health
s&stem pro#esses that take pla#e #on#urrentl&' .or e4ample, strengthening
e9uit& re9uires ad3ustments of several #omponentsGareas, *hi#h #umulativel&
determine the level of this #omposite #on#ept, su#h as ) planning, resour#e
generation, resour#e allo#ation, pa&ment methods, planning et#'
0rocesses1+ontrol 2nobs/ /arious frame*orks differ in the *a& the& define
&et another dimension of the health s&stem, although the dimension itself is
present in most frame*orks' Some refer to this dimension as :pro#esses;,
putting emphasis on the a#tiona(le #onstituents of the #on#epts grouped
under this #ategor&' 7thers des#ri(e them as the means for implementing
ad3ustments, la(eling them :#ontrol kno(s;' This dimension #om(ines
#on#epts su#h as organi0ation, regulation, integration, de#entrali0ation,
resour#e generation and resour#e allo#ation' +n other *ords, these are the
#on#epts *hi#h either des#ri(e *hat happens *ithin the health s&stem as a
#ourse of a#tion and ho* it happens $e'g' resour#e allo#ation #an (e a
:pro#ess; in itself, and it ma& (e implemented through #ross)su(sidi0ation, or
through #hanging providers1 reim(ursement me#hanisms%, or des#ri(e them
as po*er me#hanisms in the hands of health s&stem a#tors, appli#ation of
*hi#h ma& result in #ertain ad3ustments to the s&stem $e'g' resour#e allo#ation
#an also (e a :#ontrol kno(; = an instrument through *hi#h #ertain pro#esses
*ithin the health s&stem, for e4ample hospital mergers, #an (e affe#ted%'
%uilding %locks1.unctions/ Similarl&, various frame*orks seem to also
address a dimension *hi#h is referred to either as :(uilding (lo#ks; to
des#ri(e stru#tural and institutional aspe#ts of the #on#epts to *hi#h the&
#orrespond, or :#riti#al health s&stem fun#tions; to emphasi0e fun#tional
aspe#ts' This dimension in#ludes #on#epts su#h as servi#e deliver&, health
information, health *orkfor#e, te#hnologies and #ommodities, demand
generation, governan#e and finan#ing' .rom the stru#turalGinstitutional
perspe#tive these are 9uantitative #on#epts referring to inputs, $e'g'
:te#hnologies and #ommodities; ma& refer to a spe#ifi# pie#e of e9uipment or
a t&pe of drug pro#ured, :health information; to an !I2 s&stem *ith
indi#ators, data anal&sis soft*are, reporting templates et#'%' .rom the
fun#tional perspe#tive these are 9ualitative #on#epts des#ri(ing the means of
a#hieving the progress in implementing the #orresponding fun#tion $e'g'
:te#hnologies and #ommodities; ma& refer to a#tivities aimed to strengthen
suppl&)#hain management s&stem, :health information; ma& refer to
institutionali0ing the data #olle#tion s&stem, te#hni#al #apa#it& (uilding et#'%'
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+t should (e noted that the :(uilding (lo#ksGfun#tions; and the
:pro#essesG#ontrol kno(s; are not e4#lusive $i'e' a stand alone :(lo#k; or an&
of its #omponents, ma& also (e present under another :(lo#k;%' .or e4ample,
te#hnologies #an (e a :(lo#k; in itself, (ut also #an (e a #omponent of servi#e
deliver&'
The ta(le (elo* summari0es the four #omplementar& dimensions identified in
various health s&stems frame*orksF
Ta*le 4: Complementary Areas of ,ario"s Health Systems
Frameworks
%imensions Components
"oals/ N Better Health
N .inan#ial Prote#tion
N Responsiveness
N Satisfa#tion
$verarching 0rinciples/
34ntermediate $bectives,
+haracteristic .eatures5
N 29uit&
N 2ffi#ien#&
N Sustaina(ilit&
N Oualit&
N A##ess
N Coverage
N Safet&
N Choi#e
0rocesses1+ontrol 2nobs/ N Resour#e Creation
N Resour#e Allo#ation
N Pa&ment
N 7rgani0ation
N +ntegration
N Regulation
N Behavior
%uilding %locks1 +ritical
.unctions/
N Servi#es
N Health Workfor#e
N Health +nformation
N Te#hnologies I Commodities
N "emand Generation
N .inan#ing
N Governan#e
.urther to the a(ove dimensions *here various health s&stems frame*orks
seem to (e #omplementar&, multiple health s&stems frame*orks also share
vie*s on a num(er of additional provisions that are proposed as essential
#onstituents of the health s&stem' .or e4ample, as mentioned a(ove, several
frame*orks e4plore a vi(rant #onte4t, entailing demograph&, epidemiolog&,
politi#s, e#onom&, te#hnolog& and other elements, *ithin *hi#h the health
s&stem is pla#ed, and suggest that an& d&nami#s in the state of ea#h of these
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e4ternal fa#tors ma& affe#t health s&stems $and vi#e)versa% and #onse9uentl&
ma& determine priorities for health s&stems strengthening interventions'
Also, high importan#e is given to the #omple4 nature of relationships
(et*een various aspe#ts of the health s&stem, su#h as pro#esses, fun#tions and
stru#tures' And it is emphasi0ed that these intera#tions too, in addition to the
state of the individual aspe#ts, are ultimatel& #onne#ted to the goals'
Almost all frame*orks des#ri(e the :Pro#essesGControl 5no(s; and the
.un#tionsG;Building Blo#ks; at their aggregate levels, *hile for translating the
health s&stems frame*ork into a health s&stems strengthening frame*ork it
*ould (e pra#ti#all& appli#a(le to disaggregate these #on#epts at an
operational level $e'g' :servi#e deliver&;, (oth as a :(uilding (lo#k; and as a
:fun#tion; #an (e disaggregated into fa#ilit& improvement, te#hni#al #apa#it&
(uilding, referral s&stem developmentP et#'%' "isaggregation of all
:Pro#essesGControl 5no(s; and :.un#tionsG;Building Blo#ks; at the
operational level su()#omponents *ould produ#e a pra#ti#all& appli#a(le
ta4onom& that #an (e used as a point of referen#e for sele#ting interventions
to strengthen #orresponding stru#tural, fun#tional, pro#ess and #ontrol
elements of the health s&stem' Su#h #lassifi#ation *ould (e espe#iall& useful
for enhan#ing #olle#tive a#tions for health s&stems strengthening, as it #ould
serve as a (asis for developing 3oint inter)agen#& performan#e measurement
and resour#e tra#king frame*orks'
FR$ FRA'-$R.S T$ ACT!$#S: A R$A%A0 F$R A C$$#
A00R$ACH T$ HSS
The proposal for a #onverged HS frame*ork should not (e #onsidered &et
another effort to design an additional #on#eptual approa#h to e4plaining
health s&stems, (ut rather as an element of a concepts-to-actions roadmap for
(etter #olle#tive a#tion to strengthen health s&stems in developing #ountries'
+t #ould (e the first step to*ards developing a translational approa#h for
pra#ti#al utili0ation of theoreti#al #on#epts for designing a#tion)oriented HSS
strategies' .igure ? (elo* provides a graphi#al illustration of su#h a roadmap'
+mplementing the roadmap entails 3oint #ontri(utions from the glo(al and
national partners for developing a set of #ommonl& shared te#hni#al and
anal&ti#al tools, and for aligning a#tors1 HSS approa#hes, organi0ational
pro#esses, programmati# and finan#ial s&stems' Some elements in#luded in
the roadmap are alread& a *ork in progress under the +HPQ, Harmoni0ation
of Health in Afri#a and other glo(al and regional partnership initiatives'
Among them, the re#entl& initiated #olla(orative effort of the World Bank,
Glo(al .und and the GA/+ Allian#e, *ith te#hni#al support and fa#ilitation
from WH7, is aimed at preparing a #ommon platform for 3oint funding of HSS
interventions in developing #ountries, in line *ith the Paris "e#laration, the
A##ra Agenda for A#tion $AAA% and the +HPQ prin#iples' +n addition to
designing the 3oint funding platform, this initiative also #ontri(utes to the
ongoing efforts of a *ider range of international health a#tors fo#used on
harmoni0ing various HSS operational elements, pra#ti#all& appli#a(le for
effe#tive #olle#tive a#tion for HSS, su#h as HSS performan#e measurement
and evaluation s&stems, HSS TA provision, HSS #lassifi#ation s&stem,
anal&ti#al HSS needs assessment methodolog&, and a range of s&stems and
pro#esses for 3oint HSS funding and programming'
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Fig"re +: A Translational Frameworks-to-Actions Roadmap for
HSS
C$#CL&S!$#
"e(ates around health s&stems have dominated the international health
agenda for several de#ades' A *ealth of #ontri(utions has (een made to
e4plain health s&stems through multiple definitions, frame*orks and models'
!ost de(ates have fo#used on #on#eptuali0ing health s&stems o(3e#tives,
fun#tions and performan#e measurement approa#hes, *ith rather less fo#us
on pra#ti#al solutions for #olle#tive a#tion to strengthen health s&stems in
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developing #ountries' This revie* of availa(le health s&stems frame*orks
identifies a #ommon ground and e4plores the feasi(ilit& of #onverging
multiple HS frame*orks as a #ommon te#hni#al point of referen#e for
#olle#tive a#tions to strengthen health s&stems in developing #ountries' A
#on#epts)to)a#tions roadmap is also proposed as the means for translating
#on#epts and theories into pra#ti#al interventions' .urther de(ates, and a
#oordinated e4amination of the prin#iples of #ongregating #on#eptual
approa#hes to HS and HSS, ma& assist the glo(al and national partners to
enhan#e their harmoni0ation and alignment efforts at (oth=the #ountr& and
the glo(al levels, redu#e transa#tion #osts and to a#hieve overall (etter HSS
out#omes more effe#tivel& and effi#ientl&'
George Shakarishvili is a medical doctor, Master of international
public health and a Doctor of social policy with about 15 years of
practical eperience in international health and development!
"resently, he serves as a Senior Advisor for #ealth Systems
Strengthening at the Global $und in Geneva!
%ifat Atun is Director of Strategy, "erformance and &valuation
'luster at the Global $und! &e oined the "lobal .und from the 4mperial
+ollege, #ondon, where he was 0rofessor and Director of the +entre for
4nternational &ealth -anagement.
"eter (erman is the #ead &ealth &conomist at the )orld (ank in
)ashington, D'!
)illiam #siao is a 0rofessor of 'conomics at the &arvard ,chool of 0ublic
&ealth.
'raig (urgess is a ,enior Technical $fficer at the "A(4 Alliance in
"eneva.
Mary Ann *ansang is Director of +nowledge Management ,nit at
the Global $und!
"#$%A# &'A#T& "$(')*A*+', /76U!2 +++, 7' , $SPR+G ,-?-% httpFGG***'ghg3'org
?D
1
World Health 7rgani0ation, :!a4imi0ing positive s&nergies (et*een health s&stems and Glo(al Health
+nitiatives'; Availa(le atF httpFGG***'*ho'intGhealths&stemsGPosS&n@rd24pConsRHR'pdf'
2
7pen So#iet& +nstitute, :Glo(al H+/GA+"S initiatives in <am(iaF issues of s#ale)up and health s&stems
#apa#it&'; Availa(le atF
httpFGG***'ghinet'orgGdo*nloadsG<am(iaRGH+R.inalR+nterimRReportR.inalR!a&-C'pdfH /i#tor !*apasa
and Sohn 5ad0andira, :2ffe#t of glo(al H+/GA+"S initiatives on human resour#es at su(national level in
!ala*i'; Availa(le atF
httpFGG***'ghinet'orgG#ountr&studiesRafri#aRmala*iRstud&,'asp'
3
5ate Stillman and Sara Bennett, :S&stem)*ide effe#ts of the Glo(al .undF interim findings from three #ountr&
studies'; Availa(le atF httpFGGpdf'usaid'govGpdfRdo#sGPA".?>A'pdf'
4
andini 7omman, !i#hael Bernstein, and Steven Rosen0*eig, :Sei0ing the opportunit& on A+"S and health
s&stems'; Availa(le atF httpFGG***'#gdev'orgGfilesG?AED>RfileRSei0ingRtheR7pportunit&R*e('pdf'
5
Ph&llida Travis et al, :7ver#oming health s&stems #onstraints to a#hieve the !illennium "evelopment Goals,;
The #ancet @AE, no' >E@B $,--E%F >--)>-A'
6
4bid.
7
The Glo(al .und' :Round B and Round C Te#hni#al Revie* Panel reports'; Availa(le atF
httpFGG***'theglo(alfund'orgGenGtrpGMlangTen'
8
Clare "i#kinson, :Glo(al health initiatives and health s&stems strengtheningF the #hallenge of providing
te#hni#al support'; Availa(le atF hlspinstitute'org GfilesGpro3e#tG,?A,DCGTSRforRHSSRSune-C'pdf'
9
World Bank' :HP 6ending "ata'; Availa(le atF
httpFGGsiteresour#es'*orld(ank'orgG2UTHPSTATSGResour#esGHPTheme'4ls'
10
World Health 7rgani0ation, 6orld &ealth Assembly )eport $GenevaF WH7, ,-->%'
11
World Bank, &ealthy development/ the 6orld %ank strategy for health, nutrition and population results
$Washington, "CF The World Bank, ,--B%'
12
"epartment for +nternational "evelopment, 6orking together for better health $6ondonF ".+", ,--B%'
13
World Health 7rgani0ation' :The Glo(al .undVs Strategi# Approa#h to Health S&stem Strengthening';
Availa(le atF httpFGG***'*ho'intGhealths&stemsGgf,?'pdfH The Glo(al .und' :Report of the Te#hni#al Revie*
Panel on the Round C Proposals'; Availa(le atF httpFGG***'theglo(alfund'orgGenGtrpGMlangTen
14
The Glo(al Allian#e for /a##ines and +mmunisation, &ealth ,ystems ,trengthening Tracking ,tudy,
,ynthesis )eport $GenevaF GA/+ Allian#e, ,-->% $Unpu(lished do#ument%H The Glo(al Allian#e for /a##ines and
+mmunisation, :Strengthening Te#hni#al Support'; Availa(le atF
httpFGG***'gaviallian#e'orgGresour#esG,-->-??ARGA/+RTe#hni#alRSupportRReportR.inal'pdf'
15
United States Agen#& for +nternational "evelopment, :Sustaining Health GainsF Building S&stems' USA+"
Report to the Congress'; Availa(le atF
httpFGG***'usaid'govGourR*orkGglo(alRhealthGhsGpu(li#ationsGhssRreport'html'
16
!i&ata 5a0uo, :GC 6eaders Wel#ome .rame*ork for A#tion on Glo(al HealthF KTakemi Working Group1s1
Presen#e .elt'; Availa(le atF httpFGG***'3#ie'orgG-C-B->RSankei2'pdfH Sapan Center for +nternational
24#hange, :GC Hokkaido To&ako Summit .ollo*)UpF Glo(al A#tion for Health S&stem Strengthening Poli#&
Re#ommendations to the GC'; Availa(le atF httpFGG***'3#ie'or'3pG3apanGpu(Gpu(lstG?E@E'htmH +nternational
Health Partnership and Related +nitiatives, :/ideo#onferen#e ote)for)the)Re#ordF +nternational Health
Partnership and Related +nitiatives !eeting of WH71s "ire#tor)General and "evelopment Partners'; Availa(le
atF httpFGG***'internationalhealthpartnership'netGpdfG+HPQ
W,-"evRPartnersR/CR!inutesR2R-@R-DRSuneR,--C'pdf
17
High 6evel Taskfor#e on +nnovative +nternational .inan#ing for Health S&stems, :Terms of Referen#e and
!anagement Arrangements, vE'; Availa(le atF ***'internationalhealthpartnership'net'
18
The Glo(al .und and The Glo(al Allian#e for /a##ines and +mmunisation, :Soint 6etter to P! Gordon Bro*n
and WB President Ro(ert <oeli#k, from Sulian 6o()6ev&t $GA/+% and !i#hel 5a0at#hkin $TG.%'; Availa(le atF
httpFGG***'internationalhealthpartnership'netGpdfG+HPW,-UpdateW,-?@GTaskfor#eGlondon
W,-meetingGne*GGA/+W,-andW,-G.AT!W,-letter'pdf'
19
Bruno !ar#hal, Anna Cavalli, and Gu& 5egels, :Glo(al Health A#tors Claim To Support Health S&stem
StrengtheningX+s This Realit& or Rhetori#M; 0#o, -edicine A, no' E $April ,C, ,-->%'
20
Bala(anova ", !#5ee !, !ills A, Walt G, Haines A' What #an glo(al health institutions do to help strengthen
health s&stems in lo* in#ome #ountriesM +n press, ,-->'
21
Pan Ameri#an Health 7rgani0ation and World Health 7rgani0ation' :2ssential Pu(li# Health .un#tions as a
Strateg& for +mproving 7verall Health S&stems Performan#eF Trends and Challenges sin#e the Pu(li# Health in
the Ameri#as +nitiative'; Availa(le atF
httpFGG***'*ho'intGpmn#hGtopi#sGhealthRs&stemsGrhsR,--C-D-AGenGinde4'htmlH World Health
7rgani0ation, 6orld health report 7888/ &ealth systems/ improving performance $GenevaF World Health
7rgani0ation, ,---%H World Health 7rgani0ation' 'verybody9s business/ strengthening health systems to
improve health outcomes $GenevaF World Health 7rgani0ation, ,--B%H !ark Ro(erts, William Hsiao, Peter
Berman, and !i#hael Rei#h, "etting health reform right/ a guide to improving performance and e!uity $e*
8orkF 74ford Universit& Press, ,--E%H Anne !ills, .a*0ia Rasheed, and Steven Tollman, :Strengthening Health
S&stems,; in "ean Samison, Soel Breman, Anthon& !easham, George Alle&ne, !ariam Claeson, "avid 2vand,
Pra(hat Sha, Anne !ills, and Phillip !usgrove eds', Disease +ontrol 0riorities in Developing +ountries
$Washington, "CF World Bank, ,--A%, ,
nd
edition, CB)?-,H Rifat Atun, ata !ena(de, :Health s&stems and
s&stems thinking,; in Ri#hard Co#ker, Rifat Atun, and !artin !#5ee eds', &ealth ,ystems and the +hallenge of
+ommunicable Disease $e* 8orkF 7pen Universit& Press, ,--C%H William Hsiao, 6hat 4s A &ealth ,ystem:
6hy ,hould 6e +are: $Cam(ridge, !assa#hussettsF Harvard S#hool of Pu(li# Health, ,--@%H Rifat Atun, Th&ra
de Songh, .ederi#a Se##i, 5ele#hi 7hiri, and 7luso3i Ade&i, :+ntegration of Targeted Health +nterventions into
Health S&stemsF A Con#eptual .rame*ork for Anal&sis; &ealth 0olicy and 0lanning $+n Press%' ,--C
22
Also refer to the .igure ? in Se#tion D'
23
!i#hael Rei#h, 5ei0o Takemi, :GC and strengthening of health s&stemsF follo*)up to the To&ako summit,; The
#ancet @B@, no' >AA, $,-->%F D-C=?DH !ar#hal, Cavalli, and 5egels, :Glo(al health a#tors #laim to support health
s&stem strengtheningXis this realit& or rhetori#M;H "i#kinson, :Glo(al health initiatives and health s&stems
strengtheningF the #hallenge of providing te#hni#al support';
24
Bala(anova, !#5ee, !ills, Walt, and Haines' :What #an glo(al health institutions do to help strengthen health
s&stems in lo* in#ome #ountriesM;H !i#hael Rei#h, 5ei0o Takemi, !ar# Ro(erts, William Hsiao, :Glo(al a#tion
on health s&stemsF a proposal for the To&ako GC summit,; The #ancet @B?, no' >A?D $,-->%F CAD)>'
25
Serem& Hurst, :Reforming health #are in seven 2uropean nations,; &ealth Affairs ?-, no' @ $?>>?%F B=,?H
7rganisation for 2#onomi# C-)operation and "evelopment, The )eform of &ealth +are/ A +omparative
Analysis of ,even $'+D +ountries. $ParisF 7rganisation for 2#onomi# Co)operation and "evelopment, ,--?%'
26
Andre* Cassels, :Health Se#tor reformF Some ke& issues in less developed #ountries,; ;ournal of 4nternational
Development B, no' @ $?>>D%F @,>=@ECH 5at3a Sanovsk&, and Andre* Cassels, :Health Poli#& and S&stems
Resear#hF +ssues, !ethods and Priorities,; in &ealth policy and systems development/ An agenda for research
5at3a Sanovsk& $GenevaF World Health 7rgani0ation, ?>>A%'
27
Soseph 5ut0in, &ealth financing reform/ a framework for evaluation. )evised working document $GenevaF
World Health 7rgani0ation Health S&stems "evelopment Programme, ?>>D%'
28
Soseph 5ut0in and Bar(ara !#Pake, -ethods for 'valuating 'ffects of &ealth )eforms. +urrent +oncerns,
A)A 0aper < =>, $GenevaF World Health 7rgani0ation, ?>>B%'
29
Sulio .renk, :"imensions of health s&stem reform,; &ealth 0olicy ,B, no' ? $?>>E%F ?>=@E'
30
Anne !ills, and 5ent Ranson' :The "esign of Health S&stems'; in 4nternational 0ublic &ealth/ Diseases,
0rograms, ,ystems, and 0olicies, eds' !i#hael !erson, Ro(ert Bla#k, Anne !ills $Gaithers(urgF Aspen
Pu(lishers, ,--D%'
31
Hsiao, ;What +s A Health S&stemM Wh& Should We CareM;H Ro(erts, Hsiao, Berman, and Rei#h, :Getting
Health Reform Right';
32
World Health 7rgani0ation' 6orld &ealth )eport 7888/ &ealth systems/ improving performance $GenevaF
WH7, ,---%'
33
World Health 7rgani0ation, ,trengthening health systems to improve health outcomes $GenevaF WH7, ,--B%'
34
World Bank, &ealthy Development/ the 6orld %ank strategy for health, nutrition and population results
$Washington, "CF The World Bank, ,--B%'
35
Atun R, !ena(de , :Health s&stems and s&stems thinking';
36
William Hsiao, Banafsheh Saidat, :Health S&stemsF Con#epts and "eterministi# !odels of Performan#e' A
Ba#kground Paper prepared for the Workshop on Resear#h Agendas on Glo(al Health S&stems,; "e#' @)D, ,--C'
Availa(le atF httpFGGsiteresour#es'*orld(ank'orgG+THS"GResour#esG@BA,BC)???E????DE-E@G?-??C@E)
?,EAEE>??-D,EGHsiaoSiadat+nSear#h7faCommonCon#eptual.rame*ork.orHSS"raftA,@->'pdf'
37
!ilton Roemer, *ational &ealth ,ystems of the 6orld. /ol' ,. $74fordF 74ford Universit& Press, ?>>@%
38
2uropean 7(servator& on Health S&stems and Poli#ies, :HiT Countr& Profiles'; Availa(le atF
httpFGG***'euro'*ho'intGo(servator&GhitsG,--,-D,DR?'