Enhancing Health Systems Performance Initiative

Enhancing Health Systems Performance Initiative (EHSPI)

Background
Since the publication of the WHR2000, the regional consultations have argued that the links between the measurement of performance and the development of policy requires strengthening. In addition, a substantial number of countries expressed interest in active collaboration with WHO to assess the performance of their own systems and to use the evidence to formulate policies to improve performance. To meet the country requests, the Director-General decided to group these efforts under the rubric of the Enhancing Health Systems Performance Initiative (EHSPI) which we also propose to use to meet the suggestions of the regional consultations.

Almost 30 countries* have expressed an interest, and we are currently working with twenty countries from all income ranges and all WHO regions. They have expressed a mix of reasons for engaging, including:

assessment of the performance of their own health systems, or sub-systems, using the WHO framework;
assessment of their own performance using better data than was available to WHO;
development of national skills in the required methodologies;
contributing to the development of more practical tools for translating evidence into practical policy, particularly related to the four functions;
the search for greater contact with and opportunities for learning about health systems in other countries.

EHSPI - Purpose and Scope
EHSPI has both national and global objectives. At a national level, the aims are to:

enable policy makers to have a better understanding of their health system's performance, and to feed this information into a national debate. This requires an assessment of performance and the analysis of the policy implications;
link evidence to actions to improve performance;
develop greater national capacity to monitor and improve performance.

The country level work interacts with two global objectives:

the further development of the conceptual framework and methods;
development of a better international evidence-base for policy advice.

Applying the framework at the country level involves measuring attainment in terms of the three intrinsic health system goals, assessing how well the four core health system functions are being carried out, and analysing the policy implications. These steps can be considered to be part of a diagnostic phase. The 'implementation' type activities envisaged by the Initiative refer to specific actions aimed at improving performance would be carried out and tested, with WHO's assistance where requested. In addition, there are also 'reflection' type activities in which people involved in different aspects of performance assessment at the country level can meet together with counterparts in other countries and with WHO. This allows feedback and further development of the framework, indicators and methods, as well as to stronger links to policy.

Implementation: Linking evidence to policy
A number of participant countries have chosen to hold national seminars to introduce a wider range of decision-makers, analysts and researchers to the performance assessment approach, and to discuss preliminary findings from the baseline analysis of inputs, outcomes and functions. These seminars are an important opportunity to take stock and synthesize information from a disparate set of actors, and have in some cases led to the identification of a second set of analytic activities. Follow this link for a list of country seminars.

In addition, WHO is providing direct policy support to a small number of countries, incorporating the information being generated from these efforts.

Sub-national Performance Assessment
Some countries, particularly those with some form of decentralisation, have suggested that the performance assessment framework used by WHO at the national level could be helpful in assessing and improving the performance of sub-national units. It could then become a tool for more effective stewardship and management at the national level. We are currently discussing ways to develop and test a sub-national assessment tool with six countries. (For more on subnational performance assessment, see the paper entitled "Sub-national performance assessment: objectives, challenges, and strategies" by Travis P, Mechbal A, Murray C, forthcoming on this website).

Developing Information Systems to Monitor Performance
Several countries have stated from the start that they want to link the baseline assessment with longer term efforts to improve their information systems. This is particularly important if additional indicators of the performance of the different functions of the system are routinely measured. It would pose additional strains on health information systems, and makes it all the more important to examine if some of the required information could be obtained by occasional surveys as a supplement to the other activities of a health information system.

Building capacity in health systems performance assessment and analysis
For health systems performance assessment to be sustainable at the country level, capacity for undertaking both the diagnostic and implementation phases must be built. A variety of strategies can be suggested, ranging from straightforward briefings on using the methods, through technical support to analysts in-country or at WHO, to formal training workshops. All methods have been piloted - for example, there have been training workshops in Indonesia and South Africa (in English) for participants from around the world, in China, and one for French speakers is scheduled for early 2002 in Côte d'Ivoire.