Incorporating equity, resilience, and social and behavioral change concepts into health systems strengthening

Several key cross-cutting concepts — specifically social and behavior change (SBC), social capital, resilience and youth, and equity — significantly influence health systems challenges and could be leveraged for greater health impact. These concepts are not commonly considered part of health systems strengthening work, but they should be. Here we outline what policymakers, program managers, and project implementers should consider when incorporating SBC, social capital, resilience and youth, and equity into health systems strengthening.

Social and behavior change as a cross-cutting concept in health systems strengthening work

SBC approaches can be leveraged to improve and sustain changes in behaviors, norms and the enabling environment within a health system. SBC interventions aim to affect key behaviors and social norms by targeting the factors that shape them, including individual, social and structural determinants. SBC is grounded in several disciplines, including systems thinking, strategic communication, marketing, psychology, anthropology, and behavioral economics.

In early formative research, the Accelerator asserted that applying an SBC lens to health systems strengthening work means considering the behaviors of individual actors in households and communities and government actors, health system actors, and health facility actors. Based on further literature review, dissemination efforts, and identification of programming examples, the project noted that a key step for incorporating SBC is to intentionally establish behavior change goals alongside health system objectives.

For example, in Guinea, the Accelerator developed a tool to help CSOs undertake SBC-informed budget advocacy in relation to new national policies around community health. And in Togo, an SBC workshop was convened and an SBC-oriented action plan was developed to address barriers to civil society engagement in national universal health coverage (UHC) efforts, which was included in national programming around advancing UHC.

Across the health systems strengthening (HSS) field broadly, integrating SBC approaches can yield important insights and inform programming and measurement. Key recommended actions include:

• Be more intentional: System strengthening requires addressing the human component, including strategic intent with use of SBC approaches; too often SBC within HSS is not explicitly framed as such.
• Start with behavior mapping: Behavior mapping includes identifying (i.e., mapping out) the actions and behaviors of key actors and assessing what actors are being targeted for behavior change and why.
• Work to improve equity: Improving representation in health policymaking is an important step toward more equitable outcomes—and that step often requires changing behaviors to adopt more inclusive processes and collaboration between government, health care providers, health care institutions, and citizens.

Social capital as a potential force for health systems strengthening

Social capital refers to the networks, relationships, norms and trust that enable individuals and communities to work together effectively to achieve common goals. A growing body of evidence shows a relationship between social capital and better health outcomes. However, this evidence is largely based on work from high-income countries and has had uneven success in creating actionable recommendations for global health policy for low- and middle-income countries (LMICs).

The Accelerator sought to contribute to this body of knowledge and make recommendations for HSS policy that leveraged the relationship between social capital and health outcomes through a more rigorous examination of the underlying mechanisms. Based on a deep dive in the literature and robust analysis of longitudinal data from South Africa, the Accelerator formulated conclusions and recommendations for HSS policy:

1. Social capital has a positive relationship with health outcomes, suggesting that interventions fostering social capital can improve population health. Improving social capital may be especially beneficial for improving health equity;
2. Theory suggests that targeting social capital interventions where social capital is low will increase the likelihood of a beneficial health effect; and
3. Researchers should prioritize increasing the body of evidence, including assessing the impact of interventions and policies to build social capital.

Resilience and youth: Connected themes in health systems strengthening

Resilience can be understood as the ability to manage through adversity and change without compromising future well-being. In global health, programming for resilience and youth go hand in hand, with much of the focus on youth programming related to ensuring and protecting future well-being. Youth represent large proportions of the population in many LMICs and are expected to make up 62% of the population in LMICs by 2050.

The Accelerator conducted a case study in Nigeria to understand youth and resilience programming during the shock of COVID-19. The Accelerator interviewed USAID Nigeria staff engaged in programming across sectors and staff from implementing partners to understand how they supported youth resilience and sustained program activities during shocks. Links to systems thinking emerged as a key finding from the case study. Notably, youth-focused projects found focusing on youth employment or income generation was crucial to youth engagement. Resilience and youth programming, deeply connected to the functioning of the overall health system, require systems-wide solutions and systems-wide engagement. The barriers to young people utilizing health care services and the shocks and stresses youth face are multi-faceted, and the best ways to address these issues at scale will be multi-level and multi-sectoral.

Enhancing equity in health systems strengthening efforts

Achieving UHC requires a focus on equity to ensure that services are available and accessible to all without financial hardship. Deliberate attention is needed to ensure that underserved populations are seen and understood, and that policies and programs have pro-equity effects, not only aspirations.

Inclusivity in decision-making, bolstered by localization and good governance, enables health systems to better serve their populations. In Guinea, the Accelerator facilitated the co-creation of action plans and included civil society organizations that represented vulnerable populations in that process. This ultimately led to a new law supporting salaries for community health workers and underscored how more inclusive, equitable processes can contribute to more equitable outcomes.

The Accelerator also documented that implementation research, in concert with adaptive management, can enhance health system equity in several ways. First, implementation research can bridge the gap between the design and implementation reality of pro-poor policies and strategies, as seen in the development of Guinea’s community health policy. Explicitly measuring and accounting for equity-related variables, as done in Ghana to inform the scale-up of primary care networks, also enhances equity. Implementation research can also empower disadvantaged groups to influence programs and policies intended for their benefit.

Key Lessons

SBC, social capital, resilience, youth, and equity are inherently complex and multi-dimensional. Incorporating these into HSS efforts adds another layer of complexity, requiring thoughtful integration and synthesis. Research and learning conducted through the Accelerator has highlighted the potential benefits of doing so, with many in-country actors expressing both willingness and interest in exploring these intersections.

Looking to the future, key lessons for donors and implementing partners engaged in HSS work include a continued emphasis on the human element within health systems. Strengthening health systems necessitates addressing behaviors and social norms and deeply considering population demographics and how households and communities build and maintain connections. Recognizing that health systems are composed of people, with all their unique behaviors and interactions, is essential for driving meaningful and sustainable improvements.