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Health System

HERA's mission is to promote accessible, efficient and equitable health services and health systems. Therefore HERA assists its clients in developing health sector policies and strategies in which cost-effectiveness, equity and sustainability are the underlying principles.

HERA has built substantial experience in developing efficient health systems or important aspects of health systems. While HERA has provided its expertise specifically at national and international level, it's main concern is to achieve health systems that are accessible and affordable to all. In doing so HERA provides also expertise at operational and community level. Involving civil society and taking account of their views is an essential step of this process. In assisting national or local authorities, HERA bases its technical advise on evidence gathered through detailed or focused health sector reviews. HERA has supported national authorities in developing health policy and designing efficient but equitable health sector reforms. The latter includes supporting national authorities and development partners in developing sector wide approaches (SWAp); and working with both public and private sectors. Beyond advising how to do better, HERA is also involved in hands-on planning and managing health services; developing health information systems for improved decision making; supporting human resources for health; and assessing health sector performance through regular monitoring and evaluation.

HERA's experience in health system development covers studies on behalf of national governments, local authorities, multilateral development agencies (e.g. the World Bank, the European Commission, the African Development Bank, the Asian Development Bank, the European Investment Bank, World Health Organisation), bilateral development agencies (e.g. DANIDA, DFID, AFD, DGOS, BTC, DGIS), NGOs (e.g. Cordaid, FARES, Memisa) and private or public institutions (e.g. ITM, universities, hospitals).

Specific fields of expertise include the following:


Health Sector Review or Diagnosis

Health sector reviews are often requested by national authorities in order to review sector organisation and performance, and identify areas for improvement (e.g. in terms of efficiency, equity, accessibility, sustainability); or by development agencies prior to deciding on areas for support or to measure sector performance in the framework of sector support or SWAp.

HERA has carried out sector reviews in more than 25 countries worldwide, including in Sub-Saharan Africa, Asia, the Middle East, Mediterranean, Caribbean, Pacific and Eastern Europe. HERA has developed a specific tool for implementing broad health sector reviews but also does focused reviews when requested.

A health sector review can be a one-off exercise or, for example in the framework of SWAp, a regular annual exercise. For example, HERA has participated in the technical annual review of the SWAp in Tanzania in 2000, 2001, 2003, 2004, 2005 and 2006. And guided the expert review team on 5 of those annual reviews.

A health sector review can be broad, covering all important aspects of the sector, or cover sub-sectors (e.g. pharmaceutical sector reviews); or specific cross-sector strategies such as human resources, sector financing or public-private mix; or cross-sector issues such as HIV/AIDS, good governance, gender.

Some examples of broad sector reviews that resulted in concrete proposals for donor support are:

  • Benin: health sector review on behalf of Danida (1992);
  • Burundi: health sector review on behalf of the EC (1992);
  • Ethiopia: health sector review on behalf of WHO-EC (1993);
  • Ghana: health system review on behalf of Danida (1994);
  • Nigeria: health sector review on behalf of the EC (1994-95);
  • Philippines: health sector review in the context of formulating a HSPSP on behalf of the EC (2005);
  • RDC: health sector review in the framework of a feasibility study for the 9th EDF (2004);
  • Zimbabwe: Health sector review on behalf of the EC (1997-98).

Sector reviews that resulted in adjusting national policies, strategies, sector plans or health sector reforms are for example:

  • Benin: diagnosis of the health sector as a preparation of the health sector round table, and national health strategic plan (1993-94);
  • Moldova: health sector review as support to health sector reform, on behalf of TACIS (1995-96);
  • Palestine: health sector review on behalf of development partners (2005);
  • St. Lucia: health sector review as support to the health sector reform;
  • Yemen: health sector review to prepare 8th EDF support programme (2002);
  • Zambia: joint health appraisal of the Zambia National Health Strategic Plan 2001-2005 (2000-2001).

Sector reviews that are part of a sector support programme evaluation or a SWAp:

  • Bhutan: Joint annual sector review, on behalf of Danida in 2004 and in 2005;
  • Bangladesh: joint health sector review in 2008 (HERA provided support to the pharmaceutical sector review);
  • Ghana: Appraisal of the Danida Health Sector Support Phase III (2002);
  • Mali: Joint Review of the PRODESS, on behalf of WB and development partners (2002);
  • Papua New Guinea: health sector review as preparation to initiate SWAp process on behalf of the AsDB (2002);
  • Tanzania: Health sector reviews in 2001, 2003, 2004 and 2006;
  • Zambia: joint health sector review in 2008 (HERA provided support to the pharmaceutical sector review).

Cross-sector reviews including several sectors are for example:

  • Malawi: Bi-annual independent multi-disciplinary review of national HIV/AIDS programme, on behalf of the National Aids Council (2005-2007);
  • Uganda: Sector- based assessment of Aids spending (2006).

Examples of sector reviews focused on sub-sectors:

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Health Sector Reform

HERA has supported national authorities worldwide in formulating or monitoring health sector reforms. Formulating health sector reforms requires reviewing and eventually adapting health policy, their translation in health strategies and how those strategies are being implemented (who, what, how and when).

Sector reforms can also focus on a sub-sector such as pharmaceutical sector reforms, which HERA supported and/or reviewed in Kenya, Lesotho and Rwanda.

Examples where HERA has supported national authorities in formulating health sector reforms:

  • Belgium: Blue Print for the Flemish Health System in the 21st Century, on behalf of the Flemish Government (1999);
  • Benin: Preparation of the health sector round table. Proposal for health system reform (1993-1994) and Assistance to the Ministry of Planning in developing the 5 year national development plan and its financing strategy (1994-1997);
  • Djibouti: Study of the national health sector and technical support to the MOH in reorganising the health system, on behalf of the WB (1992-93);
  • Mongolia: Support to the MOH in implementing health sector reform concepts, on behalf of the AsDB (1997, 1999);
  • Palestine: Health sector review in West bank and Ghaza strip with a view to formulate sector reforms, on behalf of several development partners (2003);
  • RDC: Feasibility study for the 9th EDF, resulting in proposals for reforming health financing strategies (2004) and Institutional support to the MOH (2006);
  • St. Lucia: Support to the MOH in formulating health sector reform options (1998); costing of major hospitals in the context of the reform (2000); developing national health strategic plan (2005);
  • Zanzibar: Technical support to the MOH for defining the health sector reform process and content, on behalf of Danida (2003-2005).

HERA monitors ongoing health sector reforms, for example:

  • Egypt: Monitoring the process and the impact of the health sector reform programme, on behalf of the EC (2001-2005);
  • Lesotho: Mid-term review of the support to the health sector reform, on behalf of the EC (2004);
  • Morocco: Monitoring the health sector reform and health insurance reform programme, on behalf of the EC (2002-2006);
  • Namibia: Evaluation of the Namibian Integrated Health programme, supporting the health system reforms, on behalf of the EC (1997) and resulting in a change review in 1998;
  • Zambia: Support to the MOH in costing the transition of the health sector in the context of the health sector reforms, on behalf of Danida (1997); and joint health appraisal of the Zambia national health strategic plan 2001-2005, reviewing the progress of the health sector reforms and making proposals for change, on behalf of several donors (2000-2001).
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Policy Development and Policy Dialogue

HERA has supported national authorities worldwide in developing and reviewing health policy. Supporting development agencies in their policy dialogue with national authorities is another domain where HERA has gained substantial experience.

  • Armenia: Strengthening health legislation and licensing, and reform of the national financing strategies, on behalf of the WB (2005);
  • Belgium: Blue Print for the Flemish Health System in the 21st Century, on behalf of the Flemish Government (1999); ;
  • Papua New Guinea: Support to MOH and donors in preparing procedures, tools and institutional changes for SWAp, on behalf of AsDB (2003); and preparation of an AsDB paper on experiences on health sector reform in PNG, within the context of AsDB's participation in WB's proposed scaling up of poverty reduction;
  • Senegal: Evaluation of the Urban Health Project in Pikine, on behalf of the DGOS (Belgian Cooperation) and policy proposals for the Belgian Medical cooperation (1997);
  • Suriname: Evaluation of the Netherlands's policy on referral of selected diseases, with a view to adapt the existing policy; on behalf of DGIS (2004);
  • Uganda and Tanzania: Harmonisation and MDGs, a perspective from Tanzania and Uganda. Preparation of an issue paper for the High-Level Forum on the Health MDGS, on behalf of WHO (2003);
  • EC: Supporting the EC health network in drafting a manual on EC approaches in the health sector (2002-2003); and supporting the evaluation unit of EuropeAid in developing evaluation tools of health sector support programmes (2004-2005);
  • International: Co-organising with WHO and the University of Antwerp, the international conference on 'Economics of Health Insurance in Low and Middle Income countries', Antwerp 17-18 January 1197;
  • All of the above support to health sector reform has resulted in developing or adjusting policy; and required support to the policy dialogue between development agencies and national authorities.
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Sector Wide Approach (SWAp)

HERA has been involved in sector-wide approach in health as from the early days of its conceptualisation and initial implementation through supporting governments and development agencies in developing innovative financing instruments; through supporting several development agencies in acquiring experience in SWAp and developing institutional mechanisms for supporting SWAp; through supporting governments and development agencies in preparing and initiating sector-wide approach; and through monitoring health sector performance in the context of SWAp.

Developing and maintaining innovative financial instruments in preparation of sector support and/or SWAp:

  • Cameroon: Analysis of the financing mechanisms of health districts with a view to develop a joint financing mechanism;
  • Myanmar: Preparation of a Multi-Donor Health Fund;
  • RDC: Proposal for a twin Health Fund approach (both demand and provider financing;
  • Tanzania: Evaluation of the district basket funding mechanism in the context of the ongoing SWAp (2003);
  • Zambia: Proposals for financing the National Health Strategic Plan 2001-2005 in a framework of SWAp;
  • Zimbabwe: Proposals for multi-donor basket financing of capital and recurrent costs of district health services (EC and Danida, 1997-1999).

Supporting development agencies in acquiring experience in SWAp and documenting SWAp experience:

  • Papua New Guinea: Support to AsDB and AusAid in gaining experience in SWAp (2003-2004) and preparation of an AsDB paper on experiences on health sector reform in PNG, within the context of AsDB's participation in WB's proposed scaling up of poverty reduction (2004);
  • EC: Supporting the EC health network in drafting a manual on EC approaches in the health sector, including sector support policy programmes (2002-2003); and supporting the evaluation unit of EuropeAid in developing evaluation tools of health sector support programmes (2004-2005);
  • UNFPA: Thematic Evaluation of UNFPA experience in increasing aid effectiveness through participation in SWAps (2008);
  • DGOS: Evaluation of the Belgian general and sector budget support modality.

Support to government and development agencies in preparing and initiating SWAp:

  • Papua New Guinea: Exposing national authorities and development agencies (AsDB, AusAid, NZ) to international SWAp experiences (2003); Support to MOH and donors in preparing procedures, tools and institutional changes for initiating an innovative SWAp, on behalf of AsDB (2003-2004);

Monitoring health sector performance in the context of SWAp:

  • Bhutan: Joint annual sector review, on behalf of Danida in 2004 and in 2005;
  • Ghana: Appraisal of the Danida Health Sector Support Phase III in the context of the ongoing SWAp (2002);
  • Mali: Joint Review of the PRODESS, on behalf of WB and development partners (2002);
  • Papua New Guinea: Monitoring health sector and SWAp performance on an annual basis on behalf of the government and development agencies (2005, 2006-2008);
  • Tanzania: Annual health sector performance reviews in the context of the ongoing SWAp in 2001, 2003, 2004, 2005 and 2006;
  • Zambia: Joint health appraisal of the Zambia national health strategic plan 2001-2005, reviewing the progress of the health sector reforms and making proposals for change, on behalf of several donors (2000-2001).
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Public Private Partnership

Apart from working with public authorities and developing the public health sector, HERA also provides expertise to private sector initiatives and private providers; and advises both public and private partners on public private partnership.

  • Belgium: Institutional analysis and development of a medium-term operational plan for the Belgian association against Cancer (1995) and institutional analysis of the Organisation for TB prevention (1996);
  • Belgium: Plan for change of public and private hospital configuration and organisation in the province of Luxemburg, on behalf of EIB (2003-2004);
  • Belgium: Financing mechanisms of primary and secondary prevention of Aids, including public and private providers (1994) and developing a medium-term operational plan for Aids prevention (1994);
  • Caribbean: Plan for strengthening public and private medical laboratory services (1999);
  • Europe: Appraisal of investment proposals by the EIB in hospital development in several European countries (Austria, Belgium, France, the Netherlands, Romania) (2003-2006);
  • Mongolia: Strategy for reorganising first line health provision through initiating family group practices in not-for-profit private sector, on behalf of AsDB (1997);
  • Rwanda: Study on the viability and feasibility of BUFMAR (drug store serving the needs of the church-related health facilities), within the context of a newly developed and increasingly performing national drug store, on behalf of Mmeisa (1999). (Pre-) Feasibility study of the possible production of quality ARV combination drugs in Rwanda, on behalf of KfW (2005);
  • Tanzania: Joint review of public private partnership in the context of SWAp (2005) and review of the proposed model for Expansion of the pilot Accredited Drug Dispensing Outlets (ADDO) model implemented in the Ruvuma region of Tanzania to cover the rest of the country, on behalf of Danida (2006).;/li>
  • Globally META: promoting public private partnership in addressing issues related to transparency in medicines.
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Planning, Organisation and Management

HERA performs institutional analysis with a view to propose organisational changes for improved efficiency and organisational performance. HERA also supports institutions in developing institutional change; developing medium to long-term strategic plans; and managing health and development.

Examples of institutional analysis performed by HERA, with a view to supporting institutional change:

  • Belgium: Institutional analysis of the Belgian association against Cancer and development of a medium-term operational plan for change (1995); institutional analysis of the Organisation for TB prevention (1996);
  • Belgium: Institutional and organisational analysis of hospital service provision in the province of Luxemburg, with the development in a global health plan, on behalf of EIB (2003-2004);
  • Botswana: Organisational review of the Ministry of Health, which resulted in a plan for change of the organisation (2002);
  • Burkina Faso: Long-term support to the Public Health School at Ouagadougou in the development of a long-term strategic plan for institutional change, on behalf of Danida (1992-93);
  • EC: Institutional analysis of the Aids Task Force in the context of a global evaluation of the EC HIV/AIDS programme (1996). Options for institutional reform for the AIDS Task Force;
  • Lesotho, Madagascar, Rwanda: Institutional and organisational analysis of the central medical stores (in the context of a broad pharmaceutical sector review), with proposals for change that have been or are being implemented;
  • Namibia: Change review of the institutional reforms, on behalf of the EC (1998-99).

Examples of support to managing health and development:

  • Egypt: supporting the MOH and the Swiss Red Cross in strengthening financial sustainability of the National Blood system (2006-2007);
  • Egypt: Designing and testing of a performance based contracting system for the provision of family health services in the context of the Egypt Health Sector Reform Project (2000);
  • Kenya, Mali, Rwanda, Swaziland, Uganda, Tanzania, Zanzibar, Zimbabwe: support to developing strategic development or operational health or pharmaceutical plans, on behalf of different donors (BTC, DRC, EC, WB, ...);
  • Lesotho: Capacity building of the NDSO (central medical stores), on behalf of the WB (2006-2007);
  • Mongolia: training of senior MOH staff in health sector reform concepts (1997);
  • Palestine: supporting MOH to develop planning and management capacity, on behalf of EC (2004-2005);
  • Papua New Guinea: supporting the MOH in developing tools, mechanisms and procedures for initiating SWAp (2003);
  • St. Lucia: support to MOH in developing health sector reform strategies and medium term health strategic plan (2005);
  • Zimbabwe: long-term support to MOH in managing and financing health services (2005-2006).
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Monitoring and Evaluation

Monitoring and evaluation is an important domain where HERA has developed substantial high-level expertise. HERA has implemented more than 50 evaluations worldwide, covering a wide scope from project to sector and global level. HERA did review evaluation methodologies used by many international development agencies, supported development agencies in developing evaluation tools and developed its own tools. HERA, on behalf of different development agencies, monitors health sector reform processes worldwide and has evaluated development aid at a global level for several agencies.

Examples of project evaluations:

  • HERA has carried out more than 50 project evaluations in more than 35 countries world-wide. See the reference list or use the search function.;

Examples of sector-wide evaluations:

  • Benin: health sector review on behalf of Danida (1992);
  • Burundi: health sector review on behalf of the EC (1992);
  • Ethiopia: health sector review on behalf of WHO-EC (1993);
  • Ghana: health system review on behalf of Danida (1994);
  • Nigeria: health sector review on behalf of the EC (1994-95);
  • Papua New Guinea: health sector evaluation on behalf of AusAid (2005);
  • Philippines: health sector review in the context of formulating a HSPSP on behalf of the EC (2005);
  • RDC: health sector review in the framework of a feasibility study for the 9th EDF (2004);
  • Tanzania: annual technical reviews in 2001, 2003, 2004, 2005 and 2006 in the context of the SWAp;
  • Zimbabwe: Health sector review on behalf of the EC (1997-98).

Examples of global or thematic evaluations:

  • Danida: Global and historic review of Danish support to health research (2006);
  • DGOS: Thematic global evaluation of the Belgian development aid in health (bilateral, multilateral, NGOs, universities, etc.) and of the relevance of the Belgian strategic note on health (2005);
  • EC: Evaluation of the EC AIDS/HIV Programme in Developing Countries (1987 to 1996; 350 projects; 82 countries; budget of 200 million USD). Evaluation of the AIDS Task Force in EC, Brussels (1996);
  • EC-ACP-UNFPA-IPPF Joint Programme: Mid Term Review of Sexual and Reproductive Health in 5 countries: Rwanda, Ghana, Burkina Faso, Sudan and Mauritania;
  • EC-ACP-WHO: Mid-term review of the EC-ACP-WHO partnership on Pharmaceutical Policies (2006);
  • ITM: Global evaluation of the framework contract between the Belgian government and ITM (including 44 training and research initiatives) (2006).

Examples of evaluation tools and methodologies:

  • Evaluation methodologies: study of evaluation methodologies used by international agencies in health care programmes, on behalf of LSHTM (1991-93; see publications);
  • Evaluation methodologies: support to the MOH of Turkey in developing health evaluation tools for measuring sector performance at PHC level, on behalf of UNOPS (1997);
  • Health sector evaluation tool: support to the evaluation unit of EuropeAid (EC) in developing health sector evaluation tools in the context of sector support programmes and budget aid (2004-2005);
  • Change review: review of institutional, organisational changes and outputs of the health sector reform process, on behalf of the EC (1998);
  • System audit: support to the system audit of the health services fund in Egypt, on behalf of the EC (2004).

Examples of long-term monitoring of change processes:

  • Egypt: monitoring of the health sector reform process and of the EC support to the health sector reform (2001-2006);
  • Malawi: bi-annual multi-disciplinary assessment of progress of implementation of the NAC strategic HIV/AIDS plan, on behalf of the WB and development agencies (2005-2007);
  • Morocco: monitoring of the health sector reform and health insurance reform process, on behalf of the EC (2002-2006);
  • Papua New Guinea: monitoring of the health sector reform and sector-wide approach (SWAp), on behalf of AusAid and the development agencies (2006-2008).
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Health Information System / Epidemiology / Operational Research

HERA has reviewed and supported development of health information systems; evaluated and supported health and operational research; and implemented epidemiological studies.

Examples of support to developing health information systems, statistical data collection systems:

  • Belgium: review of existing cancer registration mechanisms and proposal for blueprint of a cost-effective Flemish cancer registry network (2001-2002);
  • Mozambique: proposal for developing the national health information system, on behalf of Danida (1990);
  • Rwanda: statistical and geographical data collection and analysis for developing an health development plan for the city of Kigali, on behalf of BTC (2006);
  • Tanzania: review of the health management information system; proposals for future HMIS and support to developing operational implementation plan for change (2000-2001);
  • Tunisia: technical support for the establishment of the development plan of statistical data collection mechanisms and structures for the health sector, on behalf of EC (2006).

Examples of epidemiological studies, spatial epidemiology and operational research:

  • Kenya: Review and appraisal of the Kenyan-Danish Health Research project (KEDAHR);
  • Morocco: epidemiological study of the morbidity and mortality patterns in 5 major hospitals, as part of the health sector reform preparatory work, on behalf of the WB (2000); second epidemiological survey on the morbidity and mortality patterns and cost analysis in 9 major hospitals (2002-2003); data were collected through costing studies, client surveys, hospital data and spatial epidemiological surveys;
  • Rwanda: development of a health plan for the city of Kigali, based on geographic data, spatial epidemiology, output and access data;
  • Multi-country: review of all ongoing 22 health research projects implemented by ITM (Antwerp) within the framework of the framework contract with the Belgian government;
  • Global: review of Danish supported health research and institutional set-up (2006-2007).
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Training and Human Resource Development

HERA has some experience in human resources for health and development. Several HERA partners are teaching health, economics, pharmacy and development at several public health schools worldwide.

  • Burkina Faso: evaluation of basic training curricula of paramedical personnel; support to long-term health manpower planning at national level; development of a master plan for the national public health school; curriculum development for health staff; on behalf of Danida (1992-93 and 1994-97);
  • Rwanda: support to nurse sciences, on behalf of BTC (2002);
  • South-Africa: support to health capacity building, on behalf of BTC (2004);
  • Involvement in training courses: HERA partners are involved in teaching at the Institute of Tropical Medicine (ITM, Antwerp), the Brussels Public Health School (Free University of Brussels), the Public Health School of Louvain; and are guest professor or teacher at a number of south institutions including Algeria, Benin, DRC, Morocco, Rwanda.
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