Health Systems Strengthening (HSS) involves improving the performance and impact of a health system through an integrated, multisectoral approach that is flexible, collaborative, practical, and focused on action. Systems Thinking, on the other hand, helps to make sense of complex challenges by recognising how different parts of a system are interconnected. To strengthen the performance and resilience of healthcare systems for improving access, equity, quality, efficiency, and value in SCI services, there must be strong coordination and collaboration among stakeholders at all levels. This requires addressing multiple health system components across the entire continuum of care but adapted to the specific needs, contextual realities, and organisational capacities of countries.

The ISCoS Standards Toolkit offers both an organisational and clinical framework, along with practical guidance for implementation. It supports a comprehensive process of assessment, planning, operationalising and monitoring of SCI Services, whether at a national, subnational, facility or individual patient level. The Toolkit is designed to be flexible and can be used in a range of contexts requiring rapid response or long-term strategic planning. To ensure its effective use, it is essential to consider the broader healthcare system structure that shapes how services are planned, delivered, and managed within a given country or region. 

Health System pillars

The six key health system pillars incorporated into the design of the Toolkit are the following:

• Service Delivery: Healthcare services should be accessible to the population and are delivered in an effective and efficient, timely and transparent manner.
• Governance: The provision of clear direction, accountability and oversight within the health system through policies, regulations, legal frameworks, and the appropriate allocation of resources is vital.
  • Corporate governance involves setting the overall strategy and policies, delegating responsibilities, overseeing management, and establishing effective risk management and accountability systems across the organisation.
  • Clinical governance is an integral part of corporate governance in health service organisations. It ensures that everyone—from frontline clinicians and managers to governing bodies—are accountable to patients and the broader community for delivering health services that are safe, effective, high-quality and continuously improving.
  • Financing: The specification of how resources are generated, pooled, allocated and used to fund healthcare services, covering all sources such as public funding, health insurance, and out-of-pocket payments.
  • Workforce: The availability, retention and equitable distribution of a skilled, motivated and adequately supported healthcare workforce is crucial.
  • Infrastructure: The availability of safe and adequate physical facilities, equipment, assistive technologies, medical supplies, consumables is necessary to support effective healthcare delivery.
  • Data and intelligence: A structured and systematic approach to data collection, analysis and use is essential for monitoring outcomes, evaluating health system performance, guiding improvements, informing policy decisions, and and ensuring transparency and accountability.

Health System Structure

For the purposes of these standards for the organisation and delivery of SCI Services, the healthcare system is viewed across three interconnected levels – macro, meso and micro. Care is provided along a continuum, starting from pre-hospital management through emergency and acute care, inpatient rehabilitation, community reintegration, ongoing health maintenance and potential readmissions. Throughout this continuum, a variety of service providers may be involved, operating at different levels of care (such as primary, secondary, or tertiary) and using different modes of delivery, including inpatient, outpatient, outreach, or telemedicine services.

• Macro-level: This level represents broader external factors that influence healthcare systems and impact on healthcare access, delivery and affordability, such as National/sub-national health policies, insurance systems, funding structures and incentives, laws, regulatory mechanisms, geographical factors, including urban-rural distribution, population demographics and socio-economic factors. 

• Meso Level: This level focuses on the intermediary structures and organisations within a healthcare system, including clear hospital policies, roles and functions, different services/programmes, networking and relationships between different healthcare and community providers along pathways of care. It includes factors like leadership, cultures, resource allocation, financial and clinical performance, quality improvement, and education and training within these organisations.

The macro and meso levels of a health system interact dynamically, with macro-level policies and structures influencing meso-level practices and decision-making, and vice versa. Macro-level factors, such as national health policies and funding frameworks (e.g., for healthcare coverage or reimbursement rates) establish the basis for meso-level actions, such as hospital governance and resource allocation within organisations for delivering services. Regulations and oversight bodies at the macro level (e.g., government, industry or professional associations) often set standards for quality of care, staffing levels, and other aspects of service delivery, which significantly impact meso-level practices (e.g., within organisations and teams). Meso-level organisations can provide data on service delivery, patient-reported outcomes, and resource utilisation that informs macro-level decision-making and policy development. Meso-level organisations are responsible for implementing and adapting macro-level policies to their local contexts, influencing how those policies are perceived and implemented into practice at the ground level. Meso-level actors, like hospital administrators and community health workers, can advocate for changes in macro-level policies and funding to address specific needs or challenges, such as those experienced by patients with SCI. 

• Micro Level: The micro level relates to interactions with person with SCI at an individual level within a specific setting and comprises the interactions between the health professionals, peer mentors, patients, and family. A shared decision-making framework, incorporating best available evidence, professional expertise, patient experiences and preferences, along with use of patient-reported outcome measures supports goal setting, treatment and care planning processes. Micro factors at the level of the team or individual professional include leadership, cultures, relationships, environment, team working, communications, knowledge and training, and continuous quality improvement.