HEALTH SYSTEMS STRENGTHENING

1. HEALTH SYSTEMS STRENGTHENING Planning framework for GFATM 6th round proposal – TB perspective

2. Health system • Stewardship • Financing • Human resources • Technologies and infrastructure • Information and knowledge • Service delivery Malaria control programme HIV/AIDS control programme • Stewardship • Financing • Human resources • Technologies and infrastructure • Information and knowledge • Service delivery • Stewardship • Financing • Human resources • Technologies and infrastructure • Information and knowledge • Service delivery TB control programme • Stewardship • Financing • Human resources • Technologies and infrastructure • Information and knowledge • Service delivery

3. Overview of the steps 1. Identify health systems barriers 1a. Barriers within TB programmes 1b. General systems barriers 2. Address relevant systems barriers 2a. Address barriers within TB programmes (each TB SDA, summarise and highlight general HSS potential in section 4.6.6.) 2b.Address general barriers jointly with HIV and malaria, develop for section 4.6.6. 3. Budget general HSS activities as separate SDA(s) in disease component(s) 3. Budget for each TB SDA

4. Step 1. Identify health systems barriers Section 4.4. ("National programme context for the component"): • 4.4.1: National Monitoring and Evaluation Plan • 4.4.2: Review of broader development frameworks, • "Poverty Reduction Strategy Papers" • "Highly-Indebted Pour Country Initiatives" • 4.4.3: Analysis of the ability of the current health system to achieve and sustain scaled-up interventions as well as existing national health systems strengthening plans. Guiding questions: • What are the main health systems barriers for effective TB control? • Are these barriers unique to TB or part of a wider problem shared by other programmes?

5. 1a. Barriers within TB programme • Stewardship: Insufficient central management capacity for TB control • HR: Insufficient human resources for improved TB control • Technologies and infrastructure: • Weak infrastructure and management of laboratories for smear microscopy, culture and DST • Weak TB drug management system, • Information and knowledge: • Poor recording/reporting and monitoring/evaluation capacity for TB, MDR-TB, TB/HIV • Limited information about the available public and private providers that could become formally involved in TB control • Service delivery: Poor mechanisms for collaboration across different service levels and across all health care providers

6. 1b. General systems barriers Six health systems elements as defined in WHO's draft HSS Strategy: • Stewardship • Health financing • Human resources • Technology and infrastructure • Information and knowledge • Provision of services

7. Example: HR barriers within TB programmes • Lack of human resources (number, competence, motivation) for TB on central and service levels • Lack of HR development plan for TB • Lack of task analysis and clear job-descriptions for TB staff • Poor supervision structure for TB • Inappropriate incentives for TB staff/tasks • Lack of trainers for TB • Non-existing or poor quality training curricula on TB • Private sector staff not involved in HR development strategy for TB See HR framework

8. Examples of general HR barriers • Lack of basic information about the health work force density, distribution and skill mix • Insufficient size and competence of the general health workforce. • Weak structure and poor quality of educational system. • Brain-drain • Weak structure and quality for continued medical education • Poor general supervision and quality control mechanisms • Perverse incentives linked to employment policies, salary structure and payment mechanisms for health staff • Weak regulation concerning private health care provision by staff employed in the public sector

9. 2. Address relevant health systems barriers Guiding questions: • Which responses are most appropriate on a programme-specific basis? • What are their likely implications for other programmes and services? • Can they be designed in a way that benefit both TB and other services? • Which of the planned responses are more appropriately organised as general, system-wide interventions?

10. 2a. Address barriers within TB programmes • =The "conventional" TB programmatic issues • Identify general HSS potential • Relevant in all SDAs (see respective framework): • Lab strengthening • Drug management • PPM • PAL • TB/HIV • MDR TB management • Community TB care • ACSM • Operational Research • HR separate framework, which cuts across all above

11. Plan their implementation with an aim to have positive impact on general HSS • Consider "Dos and don'ts" to ensure alignment and harmonization • Consider "non-negotiable" TB specific elements • Example: HR • Do: Coordinate with other disease programmes, with other departments and services in the MOH as well as other units and services in the provincial/district health services to ensure synergy and consistency with overall local health sector plans and capacity-building frameworks • Don't: Develop programme specific solutions to speed up implementation of TB interventions without considering implications for other programmes, e.g. program specific staff on service level and/or specific incentives without considering the risk of diverting attention away from other important health interventions • Non-negotiable: Full time TB specific staff for planning, supervision and quality control on central, provincial (and district ?) level.

12. Summarize HSS actions within TB programmes under section 4.6.6. • Details should be given under each respective sub-component/SDA (HR cuts across). • Activities, indicators, etc in each respective SDA • Summarize the key HSS actions specific to TB under section 4.6.6. • Need not be comprehensive • Should highlight the intention to maximize general HSS effects of TB specific activities, especially their relevance for HIV and malaria

13. 2b. Address general health systems barriers across all components of the proposal • Among thegeneral health systems barriers across all subcomponent identified in step 1), focus on those that: • Have not been addressed under respective sub-components/SDAs of the TB component; • Could not be tackled by TB programme and partners alone; and • Could be addressed through GFATM support (section 4.6.6. in the guidelines and table 15 on page 54 in the M&E toolkit). • "large scale investments, such as building hospitals and clinics" cannot be included • Apart from this, the field seem open… • Country specific health systems barriers (identified in step 1) should guide

14. Cross-check the relevance and possible overlap with HIV and malaria components • For cross-cutting general HSS actions. agree on which of the three possible components (TB, HIV and/or malaria) should incorporate the general HSS actions. • Objective, detailed activities etc in section 4.6.6.: • Cross-references between components. • Clearly link with the health systems barriers identified in section 4.4 • Provide measurable indicators for each activity • CAUTION: A poorly written general HSS component that lack clear justification and clear indicators can make the whole component fail!

15. 3. Budgeting • Budgets should be developed separately for: • Drugs, commodities and health products (section 5.3.1.) • Human resource costs (5.3.2.). • Procurement and supply management (5.6) • This means that some HSS elements will by default be aggregated across SDAs. • Budget breakdown by SDAs (section 5.4.). • Budget for HSS activities specific to TB should be included each respective SDA • For general HSS actions, which may cut across TB, HIV and malaria components, • Budget HSS SDA in the component that includes these actions (section 5.4.) • Cross-cutting items in either one component, or distributed in several, but no duplication! • Enter required information in the "HSS budget information sheet", to ensure that cross-cutting HSS actions written in a HIV or malaria component can be "saved" if that component fails • How large proportion can be for general HSS? Not defined.

16. Key points • Most efforts to improve TB control can potentially have a positive effect on general HSS • But, it depends on how they are planned and implemented • The general systems barriers need to be addressed jointly by TB, HIV, malaria, MoH and relevant partners involved in HSS • The field is open - the key is to link the proposed actions to identified HSS barriers and funding gaps (No big buildings projects though) • Coordination is needed across TB, HIV and malaria components in order to build strong HSS element

17. Tools and supporting documents • Guidelines and form, section 4.4. – 4.6. • M&E toolkit, Chapter X • HMN tool for M&E, and HIS gaps • HSS budget information sheet • FAQ on HSS, on GFATM homepage • Provisional framework for contribution to health systems strengthening by NTPs and partners. Discussion paper draft. Stop TB Department, 2006

18. how to promote collaboration with HIV, malaria? • No magic / single answer • Can happen at multiple levels • Can happen through different channels • Independent of round 6 • As part of round 6 • Through informal contacts • Through CCM • Through MOH units eg HR department • Need to think in which circumstances it is appropriate / necessary • Ideas?