Kara Hanson on enhancing the resilience and responsiveness of health systems

In this short video Kara Hanson from London School of Hygiene and Tropical Medicine (LSHTM) explains how universal health coverage (UHC) aims to make services available to everyone, without leading to financial impoverishment. The challenge is to provide the services that are needed while at the same time maintaining quality. To achieve UHC, health financing functions must be considered. Firstly, where the money to fund UHC will come from, but also how finances will be pooled to protect people against the risks of ill health. The purchasing of services must also be considered. Outcomes must be of high quality but also be efficient and equitable.


Kara Hanson is a professor of health system economics and the head of the Department of Global Health and Development at the London School of Hygiene and Tropical Medicine (LSHTM). She is also a member of the Health Economics and Systems Analysis research group. She was trained in development economics and health economics, and she has worked on health systems organisation and financing, mostly in sub-Saharan Africa, since 1988. She has worked at LSHTM since 1997. She completed her doctorate at the Harvard School of Public Health. Kara is a member of the Centre for Evaluation and the Malaria Centre. She is co-Research Director of RESYST.


RESYST is a DFID funded international research consortium that aims to enhance the resilience and responsiveness of health systems to promote health and health equity and reduce poverty. It conducts its research in a variety of low and middle-income countries in Africa and Asia, seeking to identify lessons that are transferable across contexts. RESYST also carries out multi-country and comparative research, enabling lessons to be learned across settings.  RESYST focuses on the following critical health system components:


Financing is concerned with how revenue is raised for health systems, pooled together and used to provide health care services. Research focuses on how best to finance UHC in low and middle-income countries. In recent years, there has been a growing focus on achieving universal access to health services without the risk of financial catastrophe or impoverishment associated with obtaining care. Few lower income countries have financing systems that are capable of providing a universal health system with many relying heavily on out-of-pocket payments (including user fees) for funding services, and have limited and fragmented pre-payment mechanisms.

Debates about how to expand pre-payment funding mechanisms have concentrated on increasing the coverage of health insurance schemes, especially in sub-Saharan Africa; however, many of these schemes have achieved relatively low population coverage and generated little revenue for health care funding. The potential to increase funding from general tax sources and through improved tax collection mechanisms has been less widely considered.

Current research addresses the following questions:

1)     How can progressive financing systems be developed in different contexts, particularly through increasing domestic public funding?

2)     What features of benefit package design and purchasing arrangements within health insurance schemes promote health equity and better financial protection for the poor?

Health workforce

In many low-income countries, severe shortages of health workers has led to poor service delivery, inequalities in health and stalled development. Research will identify effective policy interventions to strengthen the health workforce in underserved areas.

Human resource constraints, including global shortages, skill imbalances, low motivation and poor performance, have been well documented by recent global initiatives. However, there has been much less progress in identifying effective interventions to address these constraints. Research in several key areas is needed to inform human resource policy development.

RESYST research in this area will focus on identifying practical interventions that attract health workers to rural areas where the vast majority of poor and disadvantaged patients live. Consortium researchers will also critically evaluate the role of the private sector (both commercial and not-for-profit) in training health workers in developing countries, and investigate how different payment mechanisms influence the professional behaviour of health workers.

Current research addresses the following questions:

1)     What policy measures are most effective at attracting and retaining health workers to provide essential services in underserved areas?

2)     What role can the private (for profit and not-for-profit) sector play in addressing human resource constraints in lower income countries?

3)     What is the impact of different payment mechanisms on health care providers’ decisions and provider-patient relationships?


Within the Governance theme, research is particularly focused on the relationships among frontline actors and mid-level management, and leadership in health policy implementation processes.

Governance is a central element linking and guiding the other health system building blocks including financing and health workforce. Good governance requires some level of accountability to the beneficiaries and the broader public; a policy process that engages and allows negotiation among stakeholders; sufficient state capacity, power and legitimacy to manage policymaking and implementation processes effectively; and engagement by non-state actors in policy processes, service delivery partnerships and in oversight and accountability.

A key challenge of governance research is the difficulty of disentangling the effects of changes in governance and accountability from those of parallel changes occurring in the health system; there is also potential for opposition to the research. As one strategy to address these challenges, research will be conducted within Learning Sites located at sub-national level to: i) conduct action research to support local managers in taking action on issues prioritised by them and of relevance to RESYST; and ii) to investigate critical governance issues in real time, as health system policies are implemented.

Current research addresses the following questions:

1)     How can health system accountability be strengthened to support improved responsiveness?

2)     What specific strategies can support effective implementation of new (financing and human resources) policies?

3)     How can health system leadership capabilities be strengthened?


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