Strengthening Health Systems

1. Strengthening Health Systems Moving Beyond Supporting the Health System: Entering the Third Dimension Presented by: Ann Lion, DrPH, Abt Associates

2. Background • Increasing interest in health system strengthening (HSS) • Recognition that vertical (silo) interventions are unsustainable • Donor interest in investing more in HSS (WHO, GF, USG, DFID, UNAIDS, etc) • WHO Definition: “improving these six health system building blocks and managing their interactions in ways that achieve more equitable and sustained improvements across health services and health outcomes.”

3. HSS Support “The GFATM Five Year Evaluation recommended that the Secretariat “develop and articulate a strategy [for HSS] that allows for a menu of investment approaches to increase the probability that grants will perform well.” “ We will not be successful in our efforts to end deaths from AIDS, malaria and tuberculosis unless we do more to improve health systems around the world…” –President Obama, May 5, 2009.

4. HSS Vagueness… • Yet no universal understanding of what HSS is • WHO definition is broad and interpretations vary • GFATM Technical Review Panel for Round 5 HSS grants found that “the definition of HSS…was too vague and too broad” • No clear guidance (yet) from the US Global Health Initiative on what HSS entails • PEPFAR struggling with what to include in HSS • Global Fund/GAVI/World Bank/WHO trying to organize the joint platform

5. Goal of this Presentation • Clarify existing HSS definition • Supporting vs. strengthening health systems • Propose criteria to distinguish what activities are HSS interventions (support vs. strengthen) • Scope • Longevity • Approach

6. What is Health System Strengthening? • Strengthening health systems goes beyond supporting the system • Supporting focuses on filling gaps to produce better short term outcomes • Strengthening is about making the system function better in the long term

7. Strengthening vs. Supporting Health Systems

8. What is Not Health System Strengthening • Most common misunderstanding of HSS is that it is any activity that supports a HS building block • Focus tends to be on increasing inputs • Often cover only one HS block or disease area • Tend to be short-term solutions • Misconception of HSS often leads to investment in activities that, in effect, only support the system temporarily but posture as HSS

9. The 3 Dimensions of Health Systems • (1) Health system building blocks • (2) Program/disease areas • (3) Performance drivers • Inputs • Policies & regulations • Organizational Structures • Behaviors of HS actors

10. A “Cube” View of the Health System

11. The 3 Dimensions of Health Systems • But focus on performance driver tends to be on inputs, while the remaining drivers are often overlooked by HSS programs

12. Inputs vs. Other Key HSS Performance Drivers

14. How to Design HSS Interventions? • There is no “menu” of HSS interventions • Design will be affected by a number of factors specific to country context and system constraints • A health system strengthening intervention should • Include all 3 dimensions shown in the cube HS illustration • Affect more than one program/disease area • Address country-specific constraints

15. Criteria for Identifying HSS Interventions Is it Health System Strengthening? • Does the intervention have cross-cutting benefits beyond a single disease? • Does the intervention address policy and organizational constraints or strengthen relationships between the building blocks? • Will the intervention produce long-term systemic impact beyond the term of the project? • Is the interventions tailored to country-specific constraints and opportunities, with clearly defined roles for country institutions?

16. Grace Chee** Nancy Pielemeier Catherine Connor Mark McEuen Sheila O’Dougherty Hong Wang ** lead drafter Slavea Chankova Joe Kutzin Marty Makinen David Evans Tahgreed Adams Abdo Yazbeck Acknowledgements

17. Thank you!