1.1. Introduction

The Sustainable Development Goals adopted by 193 countries at the 2015 UN General Assembly, as well as the Political Declaration on universal health coverage (UHC) adopted in 2019 (UN, 2019), have affirmed that health system strengthening is the principal means to achieving the shared goal of UHC. The importance of health systems strengthening has been underlined by recent events such as the coronavirus disease 2019 (COVID-19) pandemic (WHO, 2020), which highlighted the role of the health system in protecting the population. For policy-makers to effectively focus their health system strengthening efforts and see them translate into improvements in health system performance, they need to be able to determine which areas to prioritize and direct resources towards. In this context, regular health systems monitoring, appraisal and assessment take on a great significance, especially in view of gaining a solid understanding of key strengths and shortcomings.

Over the years, assessments of health systems and their performance have been given different labels, including “health system profile”, “health sector situation analysis”, “health system monitoring”, “health system analysis”, “health system assessment” and “health systems performance assessment” (European Observatory, 2010; WHO, 2010; Berman & Bitran, 2011; Wendt, 2012; WHO Regional Office, 2012; Rajan, 2016; USAID, 2018). Similarly, the description of individual assessments conducted is wide ranging and includes terms such as tool, approach, exercise and instrument. The diversity of descriptors is both a symptom and a cause of the confusion surrounding the precise purpose, scope and content of these activities.

In part, the vast terminology reflects the different, yet overlapping, objectives of assessment efforts, which include describing the health system’s structures, evaluating distinct health system functions, measuring health system performance and supporting health reform efforts. However, there is also a lack of consistency in the use of terminology. The lack of consistency and comparability can place a huge burden on policy-makers who may be presented with findings from several assessments, conducted by different actors, using different methodologies, and no accompanying explanation of how to interpret them.

Indeed, one of the motivations for the UHC2030 – a coalition of countries, global health organizations, philanthropic foundations and civil society that was launched in 2016 – was to address this diversity and lack of a coordinated approach to activities to strengthen global health systems (UHC2030, 2020). UHC2030’s harmonization and alignment mandate produced the UHC2030 Technical Working Group (TWG) on Health System Assessment (HSA). The TWG’s objectives were to study the different HSA approaches, compare their relative strengths and weaknesses and, ultimately, draw on this experience to propose a Health System Performance Assessment (HSPA) approach for UHC. Acknowledging the confusion in terminology, the TWG, and this volume, employs the term “Health System Assessment”, HSA, in a generic way to mean a system-wide exercise whose aim it is to appraise the health system as a whole.

The aim of this edited volume is to outline a conceptual and practical approach to link existing assessments, such that the information collected across many different HSAs can be used to inform a common understanding of health system performance, or the attainment of the health system’s objectives.

1.2. Health system frameworks and assessments: from labels to content

Over the last couple of decades, several different conceptual health system frameworks have been produced to help promote an understanding of the health system (Murray & Frenk, 2000; Arah et al., 2003; Aday et al., 2004; Roberts et al., 2004; Commonwealth Fund, 2006; Atun, 2012; Kruk et al., 2018), many have also served as the basis of efforts to measure health system performance. In parallel, several HSA tools have been created with the aim of providing a system-wide and comprehensive analysis of relevant health systems areas, such as health financing, governance, human resources for health, health programmes and cross-cutting topics (European Observatory, 2010; WHO, 2010; Berman & Bitran, 2011; Wendt, 2012; Rajan, 2016; USAID, 2018). All of these efforts aim to provide a common starting point – a clear and simple conceptualization of the health system – from which its users can make further progress to achieve their health policy goals.

Although there is a great deal of overlap across these efforts, as detailed in Chapter 2, which affirms a consensus on the basics of health system design, there are important differences in the level of prominence that different assessments to parts of the health system have and the amount of emphasis they place on HSPA. One way to think of the range of HSAs is as rough continuum. At one end, there exist a range of HSA tools that describe the current structure of the health system through the health system functions or building blocks, or evaluate these structures in light of health system reform (WHO, 2007). At the other end, there are tools that focus on evaluating how well the system is performing overall, by examining the extent to which health systems are meeting a set of defined objectives. These approaches usually rely more on quantitative measures and analytic methods, often referred to as HSPA. Ultimately, health system strengthening relies on an understanding of both ends of the continuum, and how they link together. Such an approach can help to clarify the relationship between the performance of the health system functions and the performance of the health system. For example: How does the pooling of resources influence access, quality and financial protection? How does service delivery influence how people-centred and efficient the health system is? And how resilient are health system functions and health system outcomes to external shocks?

1.3. The Health Systems Performance Assessment Framework for Universal Health Coverage

In an effort to bridge the gap between HSA and HSPA approaches, and address the UHC2030 TWG’s mandate to harmonize and align existing assessment approaches we use this volume to showcase the development of a new Health System Performance Assessment framework for Universal Health Coverage. The HSPA Framework for UHC presented in this volume is informed by an analysis of existing health system frameworks, HSA and HSPA tools, guidance and technical contributions from the TWG, the authors’ original research and a wide range of contributions from experts.

This edited volume will build upon the seminal existing health system frameworks that are already in place. The contribution will be to outline where the key discrepancies exist across HSA and HSPA approaches, and to suggest a new overarching framework that illustrates the relationship between the performance of the heath system functions and the intermediate objectives and final goals of the health system. In doing this we hope to provide policy-makers with the HSPA Framework for UHC, a practical tool that will allow them to measure the performance health system functions and outcomes, outlining proposed assessment areas linked to routinely collected indicators. This tool will provide policy-makers and analysts with a starting point from which they can conceptually, and practically, link health system functions to key health system outcomes, and hus a common approach to HSPA.

The HSPA Framework for UHC is designed to provide a systems approach to enable the reuse of HSA and HSPA information from existing tools for health system performance. This brings performance assessment to the heart of efforts to strengthen health systems. Placing “for UHC” in the title of the framework supports this logic and affirms health systems strengthening as the principal means of achieving UHC, thereby underlining the need for regular evaluations of health systems performance. As a result, the HSPA Framework for UHC underpins countries’ efforts to strengthen health systems with the overarching vision of UHC in mind.

The HSPA Framework for UHC proposed in this edited volume has five key features, which are outlined throughout the course of the volume:

• it adopts an explicit health system definition and scope with clear boundaries
• it sets out the main health system goals and outcomes
• it identifies and describes the health system’s functions
• it provides a framework for assessing the performance of each function
• it outlines the relationship the performance of each function to the attainment of health system goals and outcomes.

The HSPA Framework for UHC and its key features are set out in detail in Chapter 3. The definition, scope and boundaries of the health system follow Murray & Frenk’s definition: “health actions…whose primary intent is to improve or maintain health” (WHO, 2000). The HSPA Framework for UHC, therefore, aims to assess actions only within the health system performance while acknowledging – but not explicitly assessing – the substantial impact on health of a range of socioeconomic determinants that lie outside the boundaries of the health system. In the same way, the framework shows, but does not aim to assess, the impact of contextual factors on the health system and the health system’s impact on broader societal goals. From a practical policy perspective, focusing on actions that lie within the health system allows this framework to be used as an instrument to identify accountable parties or institutions. These actors can then be linked to the performance of specific components of the health system and, more importantly, to mechanisms for improvement.

Outlining the health system’s goals is essential to any assessment of performance. In line with other health system frameworks, the HSPA Framework for UHC assesses the performance of a health system by the extent to which it achieves its intermediate objectives and final goals. Across international frameworks there is some consensus on the broad objectives of the health system, such as: health improvement, system responsiveness, equity, fair financing and efficiency. However, there are still broad differences around what constitute health system responsibilities. This volume will focus on considering what the key health system outcomes are in light of past work in this area.

Building upon a review of key HSA tools, the HSPA Framework for UHC identifies health system functions as a starting point for HSPA. The rationale for placing functions at the core of performance is that this reflects the dynamic nature of a health system (what health systems do) and its processes. The HSPA Framework for UHC aims to further our understanding of the role that health system functions play in health system performance by focusing on two separate but related questions: First, how can we assess the performance of the functions? And second how can performance of the functions be linked to health system performance? To do so, the volume will lay out the priority areas for assessment for each health system function and outline an initial set of indicative measures corresponding to these assessment areas, drawing from indicators commonly collected in other HSA and HSPA activities. The HSPA Framework for UHC will showcase these assessment areas, and illustrate the links between health system function performance and the attainment of the health system goals.

1.4. Approach and structure of the volume

In this edited volume, we share the process of the development of a joint approach to HSPA. The following two chapters reflect on the key existing HSA tools and propose a common and practical framework that intends to link the descriptive analysis with evaluation, focusing on health system outcomes. More specifically, Chapter 2 provides a review of existing health system frameworks and HSA tools. In doing so, this volume draws and builds upon previous conceptual work and HSA approaches. These insights are then used to inform the development of the HSPA Framework for UHC, which is presented and outlined in Chapter 3.

The second part of the volume consists of four chapters that outline the main health system functions, which serve as the basis of the HSPA Framework for UHC: Governance (Chapter 4), Resource Generation (Chapter 5), Financing (Chapter 6) and Service Delivery (Chapter 7). Each chapter outlines the responsibilities for the corresponding function; a framework to assess the performance of that function; and its links with the health system’s intermediate and overall goals. Moreover, the chapters provide a range of assessment areas and corresponding indicative performance measures for each function, drawn from routinely collected data and existing HSA tools.

Finally, Chapter 8 lays out the HSPA Framework for UHC detailing the connections between the intermediate and final goals and the performance of the health system functions, thus providing policy-makers with actionable tools to assess performance. Chapter 9 brings together the key takeaways from this volume, how this framework should and should not be used, and outlines remaining gaps and next steps.

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