Complexity and Lessons Learned From the Health Sector for Country System Strengthening

This is a background paper for the November 2012 USAID Experience Summit on Strengthening Country Systems.

Health systems are increasingly becoming viewed as complex and dynamic, requiring new approaches and ways of thinking about them as interconnected components of a whole rather than as discrete elements. This is occurring in both industrialized  and non-industrialized countries. Health Systems Strengthening (HSS) has taken a prominent role in U.S. Governmental strategy to provide aid to foreign countries, as a mechanism for leveraging finite resources. It is one of the seven key principles of the Global Health Initiative (GHI)  and a primary focus of the upcoming USAID-convened Strengthening Country Systems Experience Summit. From the U.S. Government’s perspective, high-performing health systems contribute to the delivery of cost-effective interventions and technologies for combating disease, and ultimately help countries save lives. Health systems strengthening is a way to add value while achieving priority health outcomes.

In high-income countries, there is a growing recognition that public health problems are complex issues, deeply rooted in society, while health care systems have grown in complexity over the past 30 years. Yet solutions to public health problems continue to be developed as independent, siloed, “one-off” efforts that rarely result in producing their intended large-scale impacts. Systems thinking and systems change approaches are growing in both perceived relevance and perceived necessity for achieving sustained, significant transformation in health care  and in other sectors.

Similarly, in the developing world, HSS is not a new concept. The 1993 World Bank report titled World Development Report 1993: Investing in Health raised HSS as a possible strategy within the context of the health sector reform movement. Nearly 10 years later, the World Health Organization (WHO) increased the visibility and prominence of HSS with its World Health Report 2000—Health Systems: Improving Performance. Due to a growing amount of attention on both system transformation and HSS over the past 10 years, a systems approach is poised to become the prominent lens through which potential solutions to global health challenges are viewed and addressed. However, HSS, and other country strengthening efforts, still require a significant amount of justification and education to generate sufficient buy-in and engagement with relevant stakeholders. It has not yet attained an “orthodoxy” where the social norms of U.S. government agencies require inclusion of a systems approach in all aspects of addressing a particular problem, but a systems approach to addressing public health problems is quickly gaining in visibility, understanding, and support.

While there has been a great deal of attention paid, and resources allocated, to HSS efforts on the part of the U.S. Government, there has been very little evidence generated relating to measurable outcomes. This is in keeping with systems change efforts in high-income countries as well, where results have been less than promised or hoped for in many cases. This background paper is intended to:

• Take what little direct evidence there is for elements that contribute to or hinder successful HSS efforts
• Link USAID experience to what is known about system transformation more generally
• Make recommendations about ways to move forward incorporating systems thinking for HSS
• Apply lessons learned in the areas of HSS to other country system strengthening (CSS) initiatives