How can we evaluate the cost-effectiveness of health system strengthening? A typology and illustrations

Health interventions often depend on a complex system of human
and capital infrastructure that is shared with other interventions, in
the form of service delivery platforms, such as healthcare facilities,
hospitals, or community services. Most forms of health system
strengthening seek to improve the efficiency or effectiveness of such
delivery platforms.This paper presents a typology of ways in which health
system strengthening can improve the economic efficiency of health
services. Three types of health system strengthening are identified and
modelled: (1) investment in the efficiency of an existing shared platform
that generates positive benefits across a range of existing
interventions; (2) relaxing a capacity constraint of an existing shared
platform that inhibits the optimization of existing interventions; (3)
providing an entirely new shared platform that supports a number of
existing or new interventions. Theoretical models are illustrated with
examples, and illustrate the importance of considering the portfolio of
interventions using a platform, and not just piecemeal individual
analysis of those interventions. They show how it is possible to extend
principles of conventional cost-effectiveness analysis to identify an
optimal balance between investing in health system strengthening and
expenditure on specific interventions. The models developed in this paper
provide a conceptual framework for evaluating the cost-effectiveness of
investments in strengthening healthcare systems and, more broadly, shed
light on the role that platforms play in promoting the cost-effectiveness
of different interventions.