Question & problem
Health system strengthening refers to initiatives that improve one or more functions of health systems, leading to better health. There is a large body of evidence on what works to strengthen health systems in low- and middle-income countries (LMICs), much of which is aligned to the World Health Organization (WHO) health system building blocks (service delivery; health workforce; information; medical products, vaccines and technologies; financing; and leadership/governance). Despite the fact that some people with disabilities have additional health needs, and many face additional barriers to accessing healthcare, inclusion of people with disabilities is largely missing from this evidence base.5 Separately, a smaller evidence base exists on increasing the effectiveness of specific health-related services targeting people with disabilities, such as health-related Community Based Rehabilitation (CBR), rehabilitation services more broadly, and mental health services. This second evidence base is less closely aligned to the building blocks. Reviewing these outputs in parallel goes some way towards identifying effective strategies for strengthening health systems for disability inclusive development.
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Recommendations
Key recommendation
Action
Outcome measures used to evaluate effectiveness of health system strengthening interventions should be disaggregated by disability status. This requires including standard tools for reported functional limitation, such as the Washington Group tools, in primary studies evaluating what works in health system strengthening. In addition to health status, outcomes such as impact on functioning or quality of life should also be measured and reported.
Key recommendation
Action
Conduct more rigorous primary research on the effectiveness of health and rehabilitation related CBR, and rehabilitation services, that takes into account context and effectiveness across different groups (e.g. different types of disability, age, sex). Use available toolkits by the UN and ICED to address known barriers to health services and quantify the impact of interventions to improve disability inclusion across health services, particularly at a systems level. Invest in high quality research studies such as Randomised Controlled Trials to identify optimal interventions
Key recommendation
Action
Develop National Action Plans or coordination mechanisms (e.g. a national disability board) to integrate disability-related health and rehabilitation services in health system strengthening activities and policies. Align coordination activities to the health-system building blocks, and consider disability inclusion across these.
Key recommendation
Action
Ensure representation of people with disabilities in all efforts to involve service users in governance of health systems (including integration activities described above), for example on advisory panels, in review of policies or through “Disability Desks” in key ministries. Support people with different impairment types, genders and ages to contribute their perspectives and ensure all are respected and included.
Challenges
Challenge #1: There is a large body of evidence on what works for health system strengthening, but disability is not on this agenda
- High quality evidence, including randomised controlled trials (RCTs), robust meta-analyses and recent overviews of systematic reviews exist to identify what works in health system strengthening globally, including in LMICs
- Much of this literature is formulated around the World Health Organisation health system building blocks, supporting activities to strengthen each component and the interlinkages between them
- Most frequently, the effectiveness of heath-system strengthening interventions is evaluated in terms of health outcomes, and does not include disaggregated data on whether it is as effective for people with disabilities as people without
- Considering additional barriers to health care people with disabilities may face, and additional healthcare needs they may have, there is a need for health system strengthening intervention evaluations both to disaggregate evidence by disability status, and to consider broader measures of success – such as impact on functioning or quality of life
Challenge #2: There is limited evidence on what works to strengthen health-related services targeting people with disabilities
- Community Based Rehabilitation (CBR) is a strategy for community-based inclusive development that includes (but is not limited to) facilitating access to health and rehabilitation for people with disabilities.
- CBR exists in over 90 countries, but coverage is variable. The effectiveness of CBR interventions has not been rigorously evaluated, but there is some evidence from a small number of small-scale studies that CBR does improve clinical outcomes, functioning and quality of life among clients
- Efforts have been made to identify appropriate indicators for evaluating CBR (such as impact on quality of life), however these have not been used in further evaluations.
- Rehabilitation services are broadly defined by WHO as a set of interventions to optimise functioning and reduce disability in individuals with health conditions in interaction with their environment.
- There is evidence that multidisciplinary rehabilitation service models with mixed inpatient and outpatient care can reduce mortality for people who experience onset of a condition that can lead to disability.
- More primary studies are needed on what works to overcome known barriers to accessing health services, and how these can be scaled up to health system level.
Challenge #3: CBR and Rehabilitation are siloed from broader health system strengthening activities
- Health- and rehabilitation-related CBR, and rehabilitation services, are generally perceived as separate to broader health system strengthening activities, in part due to their historic donor-based funding models.
- Fragmentation of services and vertical service delivery can increase barriers to access, allow poor quality services to endure, lead to inefficient resource allocation and decreased user satisfaction and ultimately limit health outcomes for people with disabilities.
- CBR activities related to health and rehabilitation, and general rehabilitation services, should be acknowledged and integrated within broader health-system activities, so as to gain from evidence-based improvements across the health-system building blocks and ensure equal opportunities for people with disabilities compared with people without.
Challenge #4: Health System Governance is not inclusive
- There is high quality evidence that involving service users in health system governance in LMICs (for example participatory development of polices, or involvement in advisory boards or steering groups for facilities and programmes) is effective.
- There is some evidence that this is also effective in mental health system strengthening, but more primary research is required.
- However, there is no evidence that people with disabilities are routinely involved in participatory approaches to health system governance, despite priority activities to achieve this existing.
Finding the answers
We conducted a review of reviews, examining systematic reviews on health system strengthening and disability in LMICs. No reviews on disability-inclusive health system strengthening were identified, so we reviewed a) the literature on what works for health system strengthening and b) the literature on what works for disability-targeted health and rehabilitation services. This evidence note is based on the findings of 4 overviews of systematic reviews based on global evidence, three systematic reviews including global evidence but focused on LMICs, and four systematic reviews including evidence from LMICs only.
Recommendations & actions
Key recommendation
Action
Outcome measures used to evaluate effectiveness of health system strengthening interventions should be disaggregated by disability status. This requires including standard tools for reported functional limitation, such as the Washington Group tools, in primary studies evaluating what works in health system strengthening. In addition to health status, outcomes such as impact on functioning or quality of life should also be measured and reported.
Key recommendation
Action
Conduct more rigorous primary research on the effectiveness of health and rehabilitation related CBR, and rehabilitation services, that takes into account context and effectiveness across different groups (e.g. different types of disability, age, sex). Use available toolkits by the UN and ICED to address known barriers to health services and quantify the impact of interventions to improve disability inclusion across health services, particularly at a systems level. Invest in high quality research studies such as Randomised Controlled Trials to identify optimal interventions
Key recommendation
Action
Develop National Action Plans or coordination mechanisms (e.g. a national disability board) to integrate disability-related health and rehabilitation services in health system strengthening activities and policies. Align coordination activities to the health-system building blocks, and consider disability inclusion across these.
Key recommendation
Action
Ensure representation of people with disabilities in all efforts to involve service users in governance of health systems (including integration activities described above), for example on advisory panels, in review of policies or through “Disability Desks” in key ministries. Support people with different impairment types, genders and ages to contribute their perspectives and ensure all are respected and included.
Policy priorities
Inclusive health system strengthening requires better integration of health and rehabilitation services targeted at supporting people with disabilities (including health and rehabilitation-related CBR) into general health system strengthening activities. It also requires routine disaggregation of outcomes by disability status, to ensure that people with disabilities are equally as likely to benefit from improvements across health system strengthening. To support this, policies to support health system strengthening should undergo participatory co-creation with, and review by, people with disabilities, to ensure their requirements are included.
Conclusion
Evidence on what works to strengthen health systems does not consider whether outcomes are equally as effective for people with disabilities as people without. Disability-targeted health and rehabilitation services are frequently fragmented, and evidence on what works is sparce. There is a need for a better articulated research agenda around inclusive health system strengthening, bringing together separate dialogues on disability inclusion, rehabilitation and CBR and addressing the integration of these services.
Gaps & research needs
The large body of high-quality evidence on health system strengthening identified does not reference disability. In contrast, a smaller body of evidence on the effectiveness of disability-targeted health and rehabilitation services is of lower quality. There is a need for a better articulated research agenda on inclusive health system strengthening that brings together these concepts, and for high quality and rigorous primary research to be completed to determine what works for inclusive health system strengthening. Moreover, more primary studies are required to test what works in overcoming known barriers to accessing health services frequently experienced by people with disabilities, and of these, what can be scaled up to a health-system level.
Acknowledgements
Peer Review: This brief was reviewed by Onaiza Qureshi and Lambert Felix.
Publication details: © Disability, Evidence Portal, London School of Hygiene & Tropical Medicine, February 2021.
Suggested citation: Islay Mactaggart. Evidence Brief: What are the most effective strategies for strengthening health systems for disability inclusive development? Disability Evidence Portal, 2021.
Disclaimer: The views expressed in this publication are those of the author/s and should not be attributed to Disability Evidence Portal and/or its funders.