How much does it cost to purchase an insecticide-treated bed net to help combat the spread of mosquito-borne diseases like malaria? According to the Against Malaria Foundation, it can be as little as US$ 2. Based on this and considering other factors – like additional costs for distribution, the average lifespan of the net and its effectiveness at preventing malaria – it is possible to create a model to determine how much it costs to prevent someone from contracting malaria and to estimate how many extra years of a healthy life they will gain by avoiding the disease. Similarly, there are models for the cost-effectiveness of employing an additional nurse in a health facility. These types of models can help policy-makers and funders decide how best to allocate spending. But what if the question is how access to services or quality of care can be improved by investing in better information systems? Or, what are the benefits of financing a new outreach programme for community health care workers? Does it compare with providing another bed net?
While few would argue against investing in health systems strengthening – indeed there has been substantial push back on so-called vertical programmes, or initiatives that focus efforts only on tackling a specific disease – quantifying the impact of these types of investment has remained elusive. This difficulty arises from the complex nature of health systems strengthening interventions. It is difficult to know the costs of different interventions, let alone understand the causal pathways and the intended and unintended consequences of these interventions. This can be compounded by unreliable (not to mention unavailable) data.
Towards addressing this challenge, the Alliance for Health Policy and Systems Research and Health Systems Global are starting a new programme of work to nurture the development of modelling approaches and techniques to measure the impact of health systems strengthening interventions on the provision of essential health services, including in primary health care settings. The programme is supported by the Bill and Melinda Gates Foundation. By establishing a set of country-level learning ecosystems involving policy-makers, researchers and development partners, we aim to facilitate the use of modelling approaches in informing health systems resource allocation decisions in select low- and middle-income countries.
During a kick-off consultation in Geneva, Switzerland, on 12–13 June, policy-makers from Costa Rica, Ghana, Indonesia, Nigeria, South Africa and Thailand, as well as representatives from funding and development agencies, global health organizations and academia gathered to kick off this programme of work. The consultation explored the experiences and challenges of countries in understanding and measuring the impacts of investments and interventions made in their health systems. In countries with limited resources and investments in their health systems, this is even more important. Dr Kelechi Ohiri, Director-General of the Nigeria National Health Insurance Authority, emphasized this: “It is crucial to appreciate the constraints in which we work, and this is where modelling can help us optimize the performance of the health system in light of the constraints.”
Other discussions included the need to generate demand for and ensure uptake of modelling information by policy-makers at national and subnational levels, as well as possible approaches to modelling that ensure the utility of the models. In this context, Dr Walaiporn Patcharanarumol, Director of the Global Health Division at the Ministry of Public Health in Thailand, highlighted how useful modelling can be: “In Thailand, modelling played a role in our move towards universal health coverage, but policy-makers were always interested in the costs involved in the interventions,” she said. “We need models that have robust methodology, that are based on reliable data and that are clear to understand,” she emphasized.
The Alliance recognizes that creating useful models will be a challenge. That is why we are taking a context-specific and iterative approach to their development – responding to health systems questions identified by policy-makers and ensuring that these questions can inform an ongoing health system reform process. Discussions on how best to create learning ecosystems and move this work forward will continue at the Eighth Global Symposium on Health Systems Research in Nagasaki, Japan, in November 2024. After that, with partners, we will work with teams from three low- and middle-income countries to build learning ecosystems over the next three years through which different models and approaches can be tested.