Public dissatisfaction with the way health services are run or financed is common due to failing to achieve the health system goals. This is commonly occurring among health systems of low and middle-income countries, even though much improvement in the performance of health systems could be achieved with little or no cost. Therefore, there is a growing interest in health system performance research and many frameworks have been developed in order to assess and improve the quality of healthcare.
The world health organisation (2000) referred to the performance as ‘the extent to which the resources used by a given health sector to achieve their objectives’ (Murray, 2003). Assessing the health system performance and how it reacts towards external shocks as well as how systems carry out certain functions, is a complex procedure; accordingly needs a complex and multifaceted methodology that may vary based on the paradigm utilised in the health system.
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One of the early initiatives in assessing the health system performance was a new national framework that was first used to assess the National Health Systems of the UK in 1998. Using the NHS data, the model proposed six areas to be assessed: health improvement, fair access, effective delivery of appropriate healthcare, efficiency, patient/carer experience, and health outcomes of NHS care (NHS Executive, 1998).
Among various initiatives that have been proposed after the UK one, the WHO introduced the framework of Health System Performance Assessment (HSPA) in 2000, which provides a comprehensive assessment of the performance of a health system by identifying three intrinsic goals that cannot be achieved without fulfilling four key functions. The association between the health system goals and the key functions is presented in figure 3.3.
Figure (3.3): The WHO framework for health system performance assessment
Source: WHO, 2000
Furthermore, one of the major factors that influence the performance of the health system and should be considered in the health system assessment is the political nature of health. Indeed, population health and health care is a highly politicized area worldwide to the extent that political decisions are predominant in certain aspects such as designing the health sector and policies that determine the broader social determinants of health; even policy
development such as health sector reform is driven by economic and financial factors, which may be politically framed. Therefore, considering the political economy of the health system is a core factor in the analysis (Smith et al., 2012).
Stewardship (Oversight) Creating resources (Investment and training) Financing (Collecting, pooling, and purchasing) Developing services (Provision)
Functions the system performs Objectives of the system
Responsiveness
(to people’s o -medical expectations)
Fair (financial) contribution
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This research will assess the three objectives and the four functions of the health system described above in Sudan.
a) Assessing the health system objectives
A good health system is a system that can attain the three main goals of the system: improving health, improving responsiveness to the expectations of the population, and
ensuring fairness in financial contributions and access. That indeed includes two sub-goals: 1) goodness which refers to the best attainable average level; 2) fairness involves minimising the differences among individuals and population groups by preferentially improving the health conditions of the worse-off. In general, achieving good health is not satisfactory if the inequality remains high because the improvement accrues disproportionately to those already enjoying better health whereas the disadvantaged groups may not benefit from these
achievements.
The level of maternal mortality (MMR) will be used as an indicator in the study to assess the health status of mothers in Sudan in order to judge goodness: how well the objective of a good maternal health system is being achieved. The maternal mortality ratio across the states of Sudan will be used to identify the fairness of the system. However, it is important to mention that disparity in MMR levels among states may not be only due to a defect in health system but also other factors such as inequalities in socioeconomic classes, which is
significantly associated with it. Therefore, the assessment of maternal health system is an integrated and complemented set of procedures rather than simple measurement.
Assessing the responsiveness of the system involves more than the assessment of people’s satisfaction with the medical care they obtain. For example, health providers’ rudeness and arrogance in relations with patients (disrespect and abuse) as well as waiting time for non- emergency surgery are very common complaints in unresponsive health systems (WHO, 2014). Population expectations of how they should be treated by health providers also form a key dimension of responsiveness.
Therefore, responsiveness can be defined in two key dimensions; subjective factors that largely rely on patients’ perceptions such as respecting dignity of patients (e.g., locking up infected patients with communicable disease, and refusing to deliver HIV-infected mothers who need caesarean section, confidentiality (e.g., protecting medical records of the patients), and autonomy (e.g., giving the right to the patients to participate in choices about their health); and objective factors which are related to how the health systems meet the patients’ and their families’ concerns, some of which can be directly observed at health facilities. This may include prompt attention (e.g., reasonable waiting time for non-emergencies and
immediate attention in emergencies), amenities of adequate quality (e.g., cleanliness, privacy and space), access to social support networks for people receiving care, and the people’s right to choose the health provider and health organisation from which they want to receive
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healthcare. Furthermore, the responsiveness is varied in practice according to population characteristics, such as that as poor or/and less educated women may expect less thus be more satisfied comparing to rich or/and higher educated women. A similar case may be applied to low and middle-income countries compared with high-income countries with respect to comparing the responsiveness of health system performance on the international level. Goodness and fairness are applied also in the responsiveness, where the health system is expected to perform well on the average for responding to all non-health aspects as well as equally respond to all population groups.
Assessing the fair financing means ensuring fair distribution of the costs of the health system according to household’s or individual’s ability to pay in order to protect them from the cost of illness. Goodness related to financing is not applicable; alternatively, there are good and bad ways to raise the resources for the health systems but they are more or less good
primarily as they affect how fairly the financial burden is shared. Fair financing is concerned only with distribution. It is not related to the total resource bill, nor to how the funds are used. Furthermore, the WHO identified two areas where paying for health services can be unfair: large unexpected expenses that family should pay immediately out of pocket to receive the health services rather than being covered by some kind of pre-payment and imposing
regressive payments, in which those least able to contribute pay proportionately more than the better-off (WHO, 2000).
Some critical points should be taken into consideration in the assessment procedure; firstly, the attainment of the goals is related to the actual resources allocated to the health system in a sense that high level of overall population health is usually associated with countries whose resources are higher. However, as discussed, this does not mean at all the performance is better but may reflect other factors. Therefore, assessment of the performance should be done in relation `with resources; i.e., the worst and the best boundaries that can be accomplished for given circumstances. For example, two countries with different level of goal attainment associated with different levels of resources may have similar health performance
(Donabedian, 1982; Murray, 2000). Secondly, as discussed in the first part of this chapter, it is argued that there are other factors that are not controlled, or partially controlled, by the health system but affect population health such as nutrition level, availability level of essential imported medications, availability of a network of roads and transportation. The counter argument suggests that good systems should pay attention to such factors and intervene or interact with other systems to alleviate the negative impact of these factors on population health. However, it is important to determine the boundaries that the health system is considered responsible for before starting the assessment (Murray, 2000). Lastly, it is argued that under scarce resources, societies regularly prioritise the three goals and make their own policy choices and this affects the extent to which each of the three goals including the
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goodness and fairness are attained ultimately; thus, the relative importance of the objectives are varied across health systems, particularly objectives related to equity which reflect political choice made by individual countries. Eventually, it is only one fixed health budget and trade-offs are made in attaining the three intrinsic goals at least cost, although Murray (2000) believed that there will not be great variance in the importance attached to different goals for most societies in the world. Accordingly, I assess the objectives of the maternal health system in Sudan as indicated in table 3.1 (see chapters 6, 7, and 10).
Table (3.1): the framework for assessing the performance of maternal health systems: the system objectives
objective Indicator Assessment level Data used
The Goodness (Average level)
Fairness (Distribution)
Good health Maternal mortality The overall maternal mortality ratio
The distribution of maternal mortality ratios across the states
Quantitative data: SHHS 2006 and 2010
Responsiveness Women’s satisfaction
on Khartoum level Quantitative data
SARH 2008: Exit interviews with
women who received antenatal care services
- Qualitative data MHSS 2012 : FGDs with users of maternal health services and non-users Financing
fairness
- Rules and criteria of health resources (government- donors) allocation - Health insurance - Procurement System
On the national level Identify gaps among states
- Qualitative data MHSS2012: - in-depth interviews with decision maker group and stakeholder group
b) Assessing the functions of the health System
A well-functioning health system involves aspects related to equitable access to essential medical products, vaccines and technologies of assured quality, safety, efficacy and cost- effectiveness, and their scientifically sound and cost-effective use (WHO, 2007)
“Good health service delivery” is defined as those which deliver effective, safe, quality, personal and non-personal health interventions to those that need them, when and where needed, with minimum waste of resources (WHO, 2007, p. vi); while a well-performing health workforce is defined as ‘one that works in ways that are responsive, fair and efficient
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to achieve the best health outcomes possible, given available resources and circumstances (i.e. there are sufficient staff, skill mix of the health workforce, fairly distributed; they are competent, responsive and productive)’ (WHO, 2007, p.vi). Also, a good health financing function is determined as raising adequate funds for health, in ways that ensure people can use needed services, and are protected from financial catastrophe or impoverishment associated with having to pay for them. It provides incentives for providers and users to be efficient. Lastly, a good stewardship function is identified as ensuring strategic policy frameworks exist, effective oversight, coalition building, regulation, attention to system- design, and accountability. In addition, a good stewardship function is associated with a well- functioning health information system, which involves reliable and timely information on health determinants, health system performance and health status (WHO, 2007).
It is important to clarify that having better health and higher level of responsiveness is not necessarily associated with spending more on health in a sense that at high levels of
expenditure, there may be little additional health gain from more resources; the WHO (2000) mentioned in this regard that ‘The objectives of the health system do not include any
particular level of total spending, either absolutely or relative to income. This is because, at all levels of spending, the resources devoted to health have competing uses, and it is a social choice – with no correct answer – how much to allocate to the health system. Nonetheless there is probably a minimum level of expenditure required to provide a whole population with a handful of the most cost-effective services, and many poor countries are currently spending too little even to assure that.’ (WHO, 2000, p.26). Only high income countries, where the public expenditure has significant contribution to health, spending and allocating budget is determined by policies and budgets of public entities as well as insurance funds whereas in low-income countries, most of the health financing is private and largely out of pocket, thus there is no obvious public policy that can determine completely the allocating of health expenditure.
Fair financing is, however, associated with a good performance of the health systems. Fair financing refers to health systems where ‘the risks each household faced due to the cost of the health system are distributed according to the ability to pay rather than to the risk of illness’ (WHO, 2000, p.35). In other words, the contribution to the health system should reflect the income differences among households. However, most low- and middle-income countries do not protect a large number of people from financial risk and vulnerability that may deter poorer people from buying these services. Consequently, financial fairness depends on progressive prepayment in place of out of pocket expenditure, which should represent a small percentage of the overall immediate health expenditure on the aggregate level as well as a manageable percentage of a household’s income (WHO, 2000). A wide range of indicators have been used to measure financial fairness on the macro- or micro-level.
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In the study described in this thesis, I assess the performance of the four functions of the maternal health system in Sudan using qualitative data (see chapters 8 to 10). In addition, maternal health service utilisation (antenatal and delivery care services) is studied using both qualitative and quantitative data in order to understand the impact of the overall health system performance on utilisation ultimately the overall maternal health (see chapter 7).