Social and Behavior Change and Health Systems Strengthening

"High performing health systems enable all stakeholders, from clients to policymakers, to practice behaviors that support health, while the collective practice of these behaviors reinforces and strengthens the health system..."

Health system strengthening (HSS) comprises the strategies, responses, and activities that are designed to sustainably improve country health system performance. Social and behaviour change (SBC) programming applies systematic insights about why people behave the way they do, and how behaviours shift, to empower individual and collective changes and to create enabling social, physical, market, and policy environments. But what is the role of SBC within HSS programmes? This document from the United States Agency for International Development (USAID) Bureau for Global Health, Office of Health Systems, highlights how SBC may be integrated into HSS programmes to strengthen HSS programme implementation and measurement and to improve the system's ability to support the practice of healthy behaviours.

Following an introduction to what SBC and HSS each consist in, the document explores SBC/HSS integration, which can increase chances for social change that transforms the social norms and structures that influence individual decision-making. Namely, "Improved inclusion of SBC approaches within HSS, and more awareness of HSS principles among SBC practitioners, can help make certain health practices more acceptable, link households to resources, services and networks, mobilize communities around uptake and service quality, and advocate for stakeholders to support such collective action."

The document goes on to explore how SBC supports characteristics of a strong health system, where health becomes a shared responsibility between patient and healthcare workers and communities. A population who feels respected by the health system - e.g., thanks to health providers with strong communication and counseling skills - is more likely to feel confident and comfortable in seeking care and practicing healthy behaviours, especially when culturally supported in doing so. In turn, a healthy population lessens the burden of chronic disease and the impact of disease burden on the health care system.

USAID contends that use of SBC theories and methods can also help address the underlying reasons for health system actor performance, thereby improving the overall performance of the health system. For example, SBC may identify normative issues such as corruption as an underlying factor limiting a health system actor's ability to do the expected job and address it through a mixture of traditional SBC approaches and social norm work. This logic model works in the other direction as well. Strengthening the health system to more effectively support and facilitate the health-supporting activities of actors within the system could improve the enabling environment for behaviour change in individuals, communities, and institutions.

As outlined here, SBC contributes to all three USAID health system priority outcomes:

1. Quality - SBC's foundational use of design thinking considers the needs and interests of users in the design of services, ensuring that services respond to those needs. Example: Incorporating social and behavioural insights into how the healthcare worker presents information and choices to the client can have a significant impact on behaviours.
2. Equity - SBC works to ensure active empowerment and participation of clients and providers, with particular emphasis on underserved, socially excluded, and vulnerable populations, in healthcare choice and decision-making. Example: SBC approaches can promote more equitable norms (including gender norms), empower people to improve their own health and access to care, and hold the health system to account. (A text box in the document looks at social accountability efforts, in particular, which are designed to amplify community voices and create collective action that inspires or supports behaviour and norm changes of community members.
3. Resource optimisation - Improving the efficient, equitable, and effective use of resources requires the health workforce and health system leadership to create norms around accountability/good governance, responsiveness to community needs, and shared responsibility and shared power for resource allocation and decision-making with community members. Example: SBC can help countries and partners design insurance schemes with the end user in mind and market insurance to users to drive uptake.

A case study of USAID's work to decrease HIV prevalence and mortality rate in Muheza, Tanzania, illustrates the potential that SBC/HSS integration holds. The Applying Science to Strengthen and Improve Systems (ASSIST) Project sought to increase participation in HIV testing and treatment retention (beneficiary behaviour) and to improve communication and linkages between health facilities and different types of community structures (system provider behaviour). USAID applied the Community Health System Strengthening (CHSS) model, which leveraged existing community resources to extend the reach of community-based health workers and to create efficient information flows between facilities, home-based care (HBC) volunteers, and community groups. The implementing partners brought together representatives from local community groups, facilities, HBC volunteers, and local government officials to create community improvement teams that identified local HIV and health gaps and developed and tested locally feasible strategies to bridge those gaps. Results included an increase in the number of people tested regularly for HIV, a significant increase in the proportion of men being tested, an increase in the number of referrals made by HBC volunteers, and improvements to the referral tracking process.

In the area of measurement and monitoring, USAID notes that support of community health volunteers (CHVs) and quality improvement (QI) techniques are HSS approaches that not only commonly incorporate explicit SBC elements but that provide examples of programme design, monitoring, and research at the HSS/SBC nexus.

Concluding the report are a list of considerations for HSS and SBC investments. Here are a few examples along the lines of measurement and monitoring:

• HSS should incorporate behavioural metrics into HSS programme monitoring, evaluation, research, and learning (MERL), understanding the role of behaviours in the programme's theory of change and including behaviours as key indicators of HSS programme progress and impact.
• SBC should incorporate a systems-oriented and complexity-aware lens to the design, implementation, and evaluation of SBC programmes and activities - including HSS outcome metrics into SBC programme monitoring and measurement where appropriate.