In this section, we're going to talk about designing and evaluating programs from a health system strengthening perspective and how it can be different to the design and evaluation of typical programs. In typical health programs, we might think about a program as producing outcomes in a community, perhaps with the help of the local health system, but with the end goal of improving health outcomes in a population. On the other hand, in health system strengthening programs, we're thinking about our program as acting on and producing outcomes in the health system itself. The difference is subtle, but it's an important shift in perspective. You could almost think about the health system itself as a program with its own inputs, outcomes, and outputs. If we're designing a health system strengthening program, it needs to fit in with this bigger ongoing program called the health system. The outputs of our own program should be about trying to improve the functioning of that bigger program, the health system. Another analogy could be that the health system is like an engine or a piece of machinery. It has a lot of moving pieces, and at any given time it can be functioning well, running smoothly, consuming fuel, and producing energy efficiently, or some part of the machine could be broken or clogged up, forcing the whole machine to run inefficiently. In this analogy, a health system strengthening program is like the work that a mechanic does; operating on one part of the system. We're trying to improve one COG or piece of the machinery. If we can improve that one COG, it will have consequences for the whole engine. The overall output will be better. I like this analogy because it captures the dependency of the success of our program on other programs or parts of the system. We might improve our one COG in the machine and get it to work well. But unless other parts of the machine are working well too, we're not going to see much of an impact. The point of a machine or of a health system is that you need a lot of component pieces to work well and to work well together. In the next few slides, I'm going to talk about three general aspects of program design and evaluation that we need to think about when we take a health system strengthening perspective. First, we need to think about the goals and objectives of our program. Specifically, orienting our objectives towards improving the health system and only indirectly improving population health. Second, we need to think about the dependencies of our program. How the impact of our program might not be seen unless other components of the health system are strong too. Lastly, we need to think about the implementation of our program, who we need to involve, and how long it will take. The goal of a health system strengthening program will ultimately at some level, align with the goals of the local health system itself. The goals of a health system are to improve population health. But within that overarching goals, there are several outcomes that we typically think of. The four objectives you see here come from one of the WHO's Health Systems Framework, which says that the goal of a health system should be to improve health. Both the level of health and the equity of health outcomes. Be responsive, in other words, provide care in a timely appropriate fashion in a way that's responsive to community needs. There should be social and financial risk protection. In other words, it should be financially fair and protect people from catastrophic financial losses, and there should be efficiency. The health system should make the best use of the available resources. Although the goal of your program will align with those overall health system goals and your program will contribute towards them, the point of a health system strengthening program is that it does this indirectly by improving the functioning of the health system itself. So the goals for your program should be articulated in terms of these improvements to the health system, not the other outcomes we were just looking at. Some examples of this might be to increase the availability of equipment and supplies at health systems, to improve the working environment and productivity of health care workers, or to increase demand for services. These are just some examples. In other lectures, we'll talk about health system components and the sorts of domains that you could target as part of a health system strengthening program. Another way of thinking about this is to go back to the matrix that we looked at in an earlier lecture. If you're running a health system strengthening program, the goal of your program should be to improve the local government health system, not to build or improve a parallel system. Your program should be system focused rather than disease-specific. In other words, the improvements you make to the health system should make the system as a whole stronger, not create silos in niche areas. A second thing that a health systems strengthening perspective brings is an awareness of the dependencies required for the health system to function properly, and therefore for your own program to achieve an impact. As we discussed before, the health system, like a machine or engine, needs many different pieces to be functioning well in order for the overall system to be functioning well. If you're trying to improve a part of a health system, you may be successful improving that part but you may not see an overall change in health outcomes because other aspects of the health system that are needed for impact do not function well. That doesn't mean you shouldn't run your program. We absolutely need health system strengthening programs to improve all aspects of health systems performance. But if you want to see an impact from your program, for example, in an evaluation, you need to be mindful that your program may depend on other processes functioning well for this to happen. These other processes may not be part of your own program, but then nonetheless required to see the impact of your program. In the same way, your program may be a dependency of another program. In other words, your program may unlock the potential of a different program that previously improved the functioning of other aspects of the health system. The third thing to think about when taking a health system strengthening perspective is how the implementation of your program might be different from typical programs. One key aspect of health system strengthening programs is that they almost always require a close partnership with the Ministry of Health. This goes without saying, but if you are going to be working to improve the health system, the people who run the health system need to be involved. You will need their input at all stages. If the Ministry of Health is not supportive and participating meaningfully in your program, it's unlikely that it will achieve traction or be sustainable in the long run. Other stakeholders may also need to be involved, including community members, the private sector, or other implementing partners. You also want to think about the timing of your program. Participatory processes can take time, building consensus, and getting people's buy-in is something that can't be rushed. It can take a while to identify which aspects of the health system need improvement and how best to go about it. The effects of your program may take a while to be seen. A health system program will typically be working upstream on the underlying processes in the system, and it may take years before the effects of this are seen on front line health system functioning and population-level health outcomes. A final point worth making is that health system strengthening programs are highly context-specific. These types of programs are necessarily tailored to the health system in the country. Each health system around the world is very different. There are different types of health systems. Some decentralized, some more centralized, and some health systems are stronger than others, for example, with greater workforce density or more advanced HMIS systems. What this means is that you can't take a cookie cutter approach to health system strengthening. You need to design programs that meet the local health system where it's at, and strengthen the things that most need to be strengthened in the country in which you're working. When you're considering a health system strengthening program, you need to ask, is your program goal relevant in this context? Will your program logic hold true in this context, and are your activities feasible in this context? We'll talk more about program design in Module 2. For now, just keep in mind that a health system strengthening perspective involves thinking differently to how you would for a typical program.
