Health systems are expected to be responsive to the health needs of people at all times. For systems to be responsive, they should have an effective monitoring and evaluation system with efficient feedback loops. The burden of disease defines the health needs of people. Hence, a robust disease surveillance system that is accurate and real-time becomes essential. It provides timely alerts for public health emergencies and informs policies for the rising burden of chronic diseases.

Time to access needed healthcare services defines the overall adequacy of health systems to respond to the health needs of people. Time to access a helpline, an ambulance, reach an emergency room, and consult an emergency physician defines a responsive emergency medical system. Waiting times for an elective consultation, diagnostic test, or therapeutic procedure define the adequacy of healthcare provider capacity. Bed occupancy defines the adequacy of the supply of hospital beds against the demand.

Traditionally, the number of doctors, nurses, allied health professionals, beds, x-ray, ultrasounds, ECG, CT scans, etc., beds, ventilators, and dialysis machines per defined population are used to monitor the capacity and strength of health systems. The indicators defined above provide a better assessment of the demand-supply gap than the traditional indicators of capacity and should be part of any monitoring system. The ability to monitor the demand-supply gap in real-time and have plans to handle sudden surges in demand or disruptions to supplies prepares a health system to face public health emergencies in the future and is essential for resilience.

The demand for healthcare services and goods may not be as per actual health needs based on disease burden. Many systems do not measure the gap between healthcare needs and actual demand. The demand for services and health goods is dictated by awareness, accessibility, affordability, and acceptability. Monitoring the need versus demand gap becomes important to improve the overall health status of people. Evaluation of the factors behind the gap will inform policies and strategies to reduce the gap.

The health status of the people is also influenced by social, cultural, economic, environmental, and commercial determinants. It is important to monitor these determinants for health systems to coordinate with other non-health sectors in improving the overall health status. In addition, it’s important to monitor potential health threats emanating from various sources to prevent and prepare health systems for future health shocks.

The production and supply of health goods and workforce may be outside the purview of health systems. However, it becomes imperative for health systems to coordinate with these upstream factors to ensure that there is an adequate supply of resources during normal and public health crisis times as per the emerging needs of people. It is also important to build capacity in applying simulation models to test various public health emergency scenarios and the ability of health systems to mount appropriate responses. It will enable health systems to provide guidance on reserve production capacities and stocks.

One of the primary objectives of health systems is to ensure that people do not face financial hardship in accessing needed healthcare services and goods. Out-of-pocket health expenses (OOPE) as a percentage of household income or expense are used as a surrogate indicator of financial hardship. However, it may not be the right indicator in assessing financial hardship. Foregone essential health needs and social needs like food, children’s education, housing, etc., maybe a better indicator of financial hardship than the OOPE. Similarly, the debt burden is a better indicator. In addition, the sale of vital assets becomes an indicator of extreme financial hardship. Hence, there is a need to bring out more useful indicators in assessing financial hardship.

Health system performance is best assessed by the proportion of preventable deaths, diseases, and disabilities. Maternal, infant, under-5 mortality, and premature deaths (less than 65 or 70 years of age) are the best indicators of health systems performance. The incidence of communicable and non-communicable diseases reflects a failure of disease preventive systems. Disabilities like blindness, limb amputations, paralysis, etc., are highly preventable if standard treatment guidelines are followed across systems. Tracking these is a fundamental responsibility of good health governance.

Health expenditures are monitored at national and sub-national levels. Health expenditure as a percentage of GDP is the commonly used measure to evaluate if a given health system is spending enough to improve health status. While it broadly correlates with the health status of people, it is a poor reflection of the efficiency of the system. Hence, total health expenditure (THE) should be indexed to the health status of people. In addition, the proportion of OOPE of THE is used as a measure of the adequacy of health coverage. As mentioned in the previous section, we need better indicators of financial hardships in accessing needed healthcare.

For good governance, robust monitoring & evaluation (M&E) systems become fundamental. M&E system, in turn, depends on a good national health information management system (HIMS) and people with the capacity to use the information appropriately. Digital information and communication systems have become vital for both M&E and Information, Education, and Communication (IEC) functions of the governments. Hence, there is a need to strengthen these areas for strong and resilient health systems.     

Dr. Krishna Reddy Nallamalla

President, InOrder-The Health Systems Institute
President (Asia), ACCESS Health International

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