Health Systems Analysis: A brief overview

Definition and Content of Health Systems Analysis

Health systems analysis tries to understand the determinants of health system performance and develop better policies and strategies to improve that performance.

It involves collecting data on health system

  • Inputs
  • Processes
  • Outputs

Then it analyses how these combine to produce outcomes- their effects on individuals and population well-being.

Health system analysis (HSA) attempts to formulate hypotheses on

  • the causes of poor health system performance
  • how reform policies and strategies can improve performance

It includes proposals regarding how reforms can be implemented and what their potential effects may be.

Key Elements of Health Systems Analysis

A health system performance framework

                This is a representation of the health system and its performance, describes health system components and links health system performance to inputs and processes of how the health system functions.

Measures of health system performance

                These are valued outcomes of the health system which are defined and measurable. Point and trend measures of their values must be obtained.

Example: One measure of health system performance might be vaccination coverage. The percentage of vaccinated children would be the ‘indicator’ of health system performance in this case. The vaccination coverage of one or more vaccine may be set as critical and measured. When the data pertains to a single time point it is called ‘point’ data. When the measurements span several months or years, one is often able to observe a general pattern- generally increasing/ decreasing/static. This is called the ‘trend’ of that measure.

Assessment of health system performance

                Performance benchmarks or thresholds (criteria) are used to make a judgment whether the performance achieved by a health system is satisfactory and meet priorities for action to improve health system performance.

Example: If Measles vaccination coverage of 75% or more is considered satisfactory to control measles, health system performance will be judged as satisfactory if measles vaccine coverage exceeds 75%. However, if the priority is elimination of measles and vaccination coverage of at least 95% is required to achieve that goal, measles vaccination coverage of 75% will be unsatisfactory.

Descriptions of health system components

                This includes quantitative and qualitative information on various parts of the health system in terms of their inputs, organization, and processes.

Description of relevant external factors and components affecting the health system and performance

                This includes quantitative and qualitative information on other structures and processes that may affect health system components and health system performance.

Example: Civil unrest or economic depression may affect health system performance. Such factors will be included here.

Theory and hypothesis about the causal linkages between health system components and external components and factors and health system performance

                Many workers have investigated/ suggested mechanisms/factors which influence health system outcomes, describing linkages between health system components and external factors. This body of work forms the theoretical basis in this element of HSA. The previous elements would supply evidence of actual linkages and influences on the health system under study. Taken together, theory and evidence-based propositions may be made about how the inputs, organization, and processes associated with different health system components and external components/ factors affect health system outcomes. Hypotheses about how changes in these components/factors would change health system outcomes may also be proposed. The combined effect would be the creation of a ‘causal chain’ linking the health system and results.

Proposals for health system change or reform to improve performance

                Following a formal, explicit causal analysis, recommendations for policy change and operational change may be proposed. If implemented, the changes should positively affect health system outcomes. Recommendations could include proposals for costing, action, timetables, and phasing.

Assessment of the feasibility of policy and operational change

                Every proposal for change/reform must undergo feasibility assessment that includes

  • Technical feasibility (based on national and international experience)
  • Capacity for implementation and management
  • Stability in the policy environment
  • Costs and their effects on the design and implementation of change strategies

Example: It is recommended that the Health Information System (HIS) be digitized to improve health system performance. Technical feasibility would include consideration of existing IT infrastructure, capacity to handle data, available bandwidth, etc. The change would require several IT professionals for both implementation and management of the new HIS. If there is a shortage of such personnel, the change cannot be implemented (or can be implemented partially). If there is political instability, it will adversely affect policymaking and implementation. Similarly, multiple policy changes introduced at short intervals will create instability in the policy environment. Where spending on health is very low, cost-cutting will ensure that well-thought out recommendations are modified to suit the available resources. Such changes are likely to influence the implementation of change strategies.

Estimates of the effects of change on performance

                Here, predictions/ estimates of how recommended changes in policy and action are likely to affect the health system and health system outcomes are made. Often, such estimates/ predictions determine if the recommended changes will be adopted and implemented. Predictions/estimates may also enable prioritizing between recommendations (based on potential impact on health system outcomes).

It is important to note that all elements mentioned above need not be included in every Health System Analysis.

Useful Links:

Links to previous articles in this series:

Link to USAID Health Systems Assessment Approach:


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