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What is d ifferent in d ifferent a pproaches to Health Systems Strengthening ?

What is d ifferent in d ifferent a pproaches to Health Systems Strengthening ? A brief review of concepts and semantics. George Shakarishvili Senior Advisor , Health Systems Strengthening The Global Fund to Fight AIDS, Tuberculosis and Malaria.

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What is d ifferent in d ifferent a pproaches to Health Systems Strengthening ?

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  1. Whatisdifferent in differentapproaches to HealthSystemsStrengthening? A briefreview of concepts and semantics George Shakarishvili Senior Advisor, HealthSystemsStrengthening The Global Fund to Fight AIDS, Tuberculosis and Malaria Global Health Council Satellite Session Health System Strengthening: What is Everyone Doing? June 13, 2011

  2. HSS: A high priority on the global health agenda MDGs: HSS is key for reaching the MDG health targets Evidence: Research on GHIs Political support: G8, H8, HLTF, and other high-level forums Increased demand and supply (2007-2010) World Bank: USD 2.5 billion GFATM: USD 1.7 billion GAVI Alliance: USD 0.8 billion

  3. A (false) vertical vs. horizontal dichotomy • 1940s-1950s: Disease eradication campaigns: cholera, smallpox, malaria • 1960s: Paradigm shift: system strengthening approach • (1969): “the most serious health needs can not be met by teams with spraying guns and vaccination syringes.” John Bryant, “Health and the Developing World” • 1970s -1980s: Primary health care • (1978): Alma-Ata Declaration • 1990s: Health financing reforms • (1993): “World Development Report: Investing in Health” • Early 2000s: Disease outbreak and GHIs • Global Fund, GAVI Alliance, Stop TB, UNAIDS, RBM, PEPFAR, PMI… • 2010s: Integration • (2009): Maximizing Positive Synergies between Health Systems and Global Health Initiatives

  4. HSS: overly explored, but vaguely defined? • An Illustrative List • of Health System Frameworks • - Actors framework (Evans, 1981) • - Fund flows framework (Hurst, 1991) • - Demand-supply framework (Cassels, 1995) • - Performance framework (WHO, 2000) • - Control knobs framework (Hsiao, 2003) • - Building blocks framework (WHO, 2007) • - Primarycare framework (WHO 2008) • - Systems framework (Atun, 2008) • “With the growth of interest in strengthening of health systems, the world now confronts a proliferation of models, strategies, and approaches.” • Lancet 2009, 373: 508–15 • “Health system strengthening, the new buzzwordin discussions about international health, is in danger of becoming a container conceptthat is used to label very different interventions.” • PLoSMedicine 2009, Vol6, Issue 4 • “There is lack of consensus onwhat health-system strengthening means, and consequently on how it should be done and evaluated.” • Lancet 2010,377: 1222-23. 6736(10)60679-4

  5. Do definitionsmatter? Health system strengthening Operational research, implementation research Quality of care Performance assessment

  6. HSS: A single definition or multiple dimensions? Programmatic • Interventions: inputs, processes, policies, etc. leading to • outputs, outcomes, and impact • Overarching principles: equity, efficiency, sustainability… • External factors: epidemiology, demography, polit-economy... • Systems thinking Conceptual Operational • Coordination • Harmonization • Alignment HealthSystemsStrengthening

  7. The Global Fund’s HSS portfolio: a means to an end • Health system goals: • Improving health outcomes (HIV, TB, malaria and also MNCH) • Reducing health-related financial risks • Increasing customer satisfaction

  8. Common weaknesses of HSS funding applications • Dissociation of HSS: lack of linkages between proposed HSS interventions and HS goals • Fragmented approach to HSS: strengthening specific “building blocks” vs. strengthening the system • Verticalization of HSS: HSS is viewed as a separate entity • Dis-balanced request for HSS support: over 75% of cross-cutting HSS support was requested for strengthening the service delivery function of the health system vs. 1% for strengthening health financing system • Lack of analytical foundation: addressing visible symptoms vs. underlying causes of poor health system performance (how vs. why)

  9. Access via common proposal form (GF/GAVI) Access via jointly assessed national health strategy (WB/GF/GAVI) Health systems fundingplatform(GAVI-GFATM-WB-WHO) “Existing financing” Harmonization of existing HSS support Harmonized grant/credit management “New financing” Opt 1 Opt 2

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