1. Applying a health systems research perspective to the synergy question Peter Berman The World Bank Cape Town July 18, 2009

2. Defining Health System  “A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health”.  A number of different health system frameworks: descriptive, analytical, deterministic/predictive

3. One health system framework

4. Another

5. Diagnosis and Policy Development for the Health System Reform

6. Health Systems Research  Not well-developed concept  Does not mean all research on any aspect of a health system  Health systems research tries to predict or explain the causes of health systems performance (outcomes)  Answers to questions like: What can we learn from differences in health systems across countries/areas that can help explain differences in performance? To improve performance, what health system strengthening strategies should I use? What is likely to be their effect?

7. Health systems research methodology  There is no such thing…yet  Health systems thinking primarily is about how we ask questions and what questions we ask, not a methodology for answering them.  Some key elements of health systems thinking: Focus on outcomes Explicit analytical basis for linking health system inputs, functions, strategies (control knobs?) to outcomes – causal framework Multidisciplinary: economics, politics, ethics, management Design and implementation both important Wide range of research methods relevant – need to understand rigor and validity

8. The “synergy” question  How do categorical programs, like HIV/AIDS, affect health systems performance? What can be done to assure (more) beneficial effects?  Some tough questions embedded in the question: What are the desired outcomes of the health system? What would have happened to the performance of these health systems in absence of the categorical programs (the counterfactual). In the absence of the most rigorous standards of evidence (like RCTs), what shall be accepted as sound evidence?

9. What most of the research has done so far  Not measured outcomes or performance for the health system  Lacked an explicit causal framework and systematic analysis of multiple steps of the causal chain  Focused on inputs or lower level processes  Often used weaker methods, e.g. key informant interviews, rather than representative measures of outputs/outcomes

10. Is it feasible to do rigorous health system research on the synergy question?  Yes, but its hard, will take time, and will be opportunistic  Are the questions political, ethical, or operational?  More rigorous research may be useful, but not a substitute for more operational focus on improving practice – using sound causal framework