Making decisions about the future of health systems

Introduction: Sustainability of health interventions in developing countries has been limited by the capacities of their health systems. As a result, efforts have been invested by the international community to make health systems thinking coherent. Aim: To examine the sustainability of a health system during and after cessation of international support from the Swiss Red Cross (SRC) in eye care services in the Brong Ahafo region, Ghana. Methods: Between July 2008 and January 2010, multiple case study approaches were applied to measure the sustainability of activities, identify the main shocks affecting health systems, and analyse the structure of social networks and their impact on the governance of health systems. This involved one-to-one in-depth interviews, dkect observations, document review, and social network analysis Findings: The district health systems were affected by shocks from different origins (local, regional and national). District hospital managers were able to respond to negative shocks of local origin but had limited capacity to find solutions to shocks originating from outside their district. Within the health system studied, it was apparent that health interventions that had the greatest observable effects, that were the least complex and the most compatible with the mandate of the hospital were more likely to be continued by hospital managers than the other activities Further, after the departure of SRC in 2006, the social network shifted from a dense network in which all the districts were connected with each other to a centralised network composed of five isolated districts. This led to a negative impact on the capacity of hospital mangers to respond to regional shocks and find appropriate solutions in a timely manner. Conclusion: International organisations need to transition from the management of health projects towards health systems approaches taking into account the governance of health systems