Systems Thinking

The keys to health: financing and organization.

By Maryalice Yakutchik • Photography by Chris Hartlove

If anything positive could come from the Ebola epidemic, it might be that it amped up the conversation about health systems. West Africa’s epidemic exposed what happens with weak or nonexistent ones, says Sara Bennett, PhD, associate director of the Bloomberg School’s Health Systems Program. She defines health systems in terms of the various functions that they need to organize. These would include financing, governance and service delivery. In this Q&A, she shares insights about how Ebola’s hard lessons might be applied to health systems in ways that can avert the next crisis.

How would a strong health system have responded during the Ebola crisis?

In a strong system, people would have sought care earlier, quicker.  When there’s trust by communities in the government and the health system, people more readily go to health facilities and say, “I’m sick.” That wasn’t happening as it should in the affected countries. Perhaps even more critical is that in strong systems, surveillance would have leapt in, identified the initial cases, found out their networks and who they might have infected, and contained this at a much earlier stage. Obviously, one of the big problems is that there wasn’t a proper response until the epidemic had spread some distance.

How can Ebola’s hard lessons be applied going forward?

In those countries that were at the heart of this epidemic, there are real shortages of health workers.  In Liberia, for example, with a population of 4.2 million people, there were fewer than 100 doctors and only about 1,400 nurses and midwives. Building up a health workforce is absolutely key to sustaining the community-level health services that help build trust in the health system and in government. I think surveillance systems in low- and middle-income countries have been relatively neglected until now. Beyond that, we need to pay attention to developing capacity … for monitoring health status, investigating health problems and mobilizing partnerships with the community.

With the Ebola crisis waning, how can we advance health systems for the long term?

That’s the $6 million question. If we blame the [magnitude of the] Ebola outbreak on weak health systems, and now we’ve put in millions of dollars to try and contain the outbreak, we’ve put a sticky plaster—What do you call it in America? A Band-Aid?—on the problem. But if we don’t address the underlying problems about weak health systems, we could find ourselves back in the same place in five or 10 years’ time.

"When there's trust by communitites in the government and the health system, people more readily go to health facilitites and say, 'I'm sick.'"

Can you tell us about your work in transitioning from short-term response to long-term strengthening of health systems?

One of the things I’ve been working on is an evaluation of the transition of an HIV/AIDS prevention program in India that was scaled up rapidly in the mid-2000s to avert a catastrophe. Initially the program was fully funded by the Bill & Melinda Gates Foundation and implemented through a system that ran in parallel with government efforts. The Gates Foundation then undertook, over a seven-year timeframe, to transition the emergency response into the government system. It required an awful lot of planning, dedicated budget lines and dedicated transition management officers to think through, “Well, how do we build capacity in government? How do we ensure the government’s got the necessary budget lines to support this program of work?” 

Too many donors wait until the last minute and then realize they can’t transition effectively in the last months of a program.

Which countries have recently developed strong, sustainable systems?

A lot of the success in Ethiopia has involved developing structures for service delivery at the community level by using paid and relatively well-trained community health workers. I sense a very strong political commitment to strengthening the health services in Ethiopia.

In Rwanda, there’s perhaps more interest in and emphasis on health financing, but very much community-based—for example through community-level health insurance schemes. They’ve also instituted results-based payments—paying health care providers according to whether they’re achieving specific indicators. 

Is there a blueprint for countries wanting better health systems? 

No, I don’t think that there is, and I doubt that there ever will be. There’s a lack of specificity around how best to strengthen health systems, for lots of reasons. Part of the problem is that we haven’t got the same kind of strength of evidence base that you would have if you looked narrowly at a particular childhood illness or a childhood disease. The second issue is that appropriate health systems vary from country to country based on social, political and economic factors.

You’re also working with International Health Chair David Peters on a new WHO policy for "people-centered health services."

The new focus on people-centered health services is in part coming out of a recognition that health services may be off-putting to patients who increasingly have a very impersonal experience of seeking care. Also, there’s an acknowledgment that the services currently being offered are very expensive, particularly when you think about the growing burden of chronic diseases.

Policymakers are looking for new models of service delivery that will be both more cost-effective and humanize the experience of care. For example, self-management programs, perhaps supported by information technology, can help keep patients out of hospitals and allow more effective engagement of family members.