Lessons Learned in Organizational Capacity Building for Health Systems Strengthening

1. Lessons Learnedin Organizational Capacity Building for Health Systems Strengthening Better Health Systems: Strategies that Work Presentation series at the Global Health Council Fred Rosensweig April 3, 2012

2. Agenda • Definition of capacity building • Overview of Health Systems 20/20 capacity-building activities • Our methodology for determining lessons learned • Lessons learned • Summary

3. Definition of Capacity Building System-level capacity building has three levels of intervention • Individual level – knowledge and skills • Organizational level – single organization • System level – multi-organizational in nature

4. Health Systems 20/20’s Focus • Regional and country-level organizations that enable health system strengthening • National government agencies that have stewardship role • Research institutions that provide evidence for HSS • NGOs and consulting firms that provide TA • Education and training institutions that train health system leaders • Strengthened 24 organizations over six-year period

5. Three Broad Types of Organizational Capacity-building Activities • Comprehensive capacity building covering core organizational competencies • Strengthening capacity of central government agencies • Targeted organizational capacity building in a specific technical area

6. Government HIV/AIDS Office in MOH (DRC) NAC Secretariat (Liberia) MOH Health Economics and Financing Directorate (Afghanistan) MOH HIS Directorate (Namibia) NGOs/Consulting Firms AFENET (regional) PROSALUD (Bolivia) Health Systems Action Network (global) Research Institutions HSPI (Vietnam) ISED (Senegal) ECSA (regional) Regional School of Public Health in Benin (regional) HEARD (South Africa) Education and Training Institutions Kinshasa School of Public Health (DRC) National TB and Leprosy Training Center in Zaria (Nigeria) Examples of Organizations Health Systems 20/20 Has Strengthened

7. Characterizing Health Systems 20/20 Capacity-building Activities • Almost all multi-year in nature • Most led by team leader skilled in organizational development and change management • Wide range of organizational types • Both new and well established organizations • Covered a wide range of settings including fragile states • Majority in Africa

8. Methodology to Develop Lessons • Review of documentation • Interviews with team leaders (16) • Interviews with heads of client organizations (9) • Analysis of interview data and determination of lessons learned • Validation with capacity-building and HSS specialists

9. Lessons Learned

10. Four Categories of Lessons • Role of organizational capacity building in HSS • Targeted organizational capacity building • Design of organizational capacity building activities • Practice of organizational capacity building

11. Role of Organizational Capacity Building in HSS 1. Organizational capacity building should be aimed at those organizations whose role is to strengthen the health system

12. Organizations to Strengthen in Context of HSS

13. Role of Organizational Capacity Building in HSS 2. Success of HSS efforts depends on both overall management and technical capacity of organizations that strengthen the health system Without management capacity to set direction, plan and implement activities, and manage resources, technical capacity-building will have limited impact

14. Targeted Organizational Capacity Building 3. Select the right partner for targeted organizational capacity-building activities • Functional management and administrative systems • Leadership commitment to use strengthened capacity • Staff buy-in and commitment • Willingness to engage as full partners

15. Targeted Organizational Capacity Building 4. Targeted capacity building in HSS approaches requires a strong learning-by-doing component at each stage and a willingness by partner to engage and learn • Qualitative data collection and analysis are more difficult to master • Capacity-building process must be led by senior expert in methodology • Most capable partners are busy and have limited time to engage

16. Design of Organizational Capacity Building Activities 5. Take a holistic and comprehensive approach and focus on full range of organizational competencies • Starts with needs assessment • Reflected in intervention plan • Basis for monitoring and mid-course adjustments • Interconnectedness of interventions

17. Core Organizational Competencies

18. Focusing on the Whole Organization “As a result of all of this assistance, one of the greatest things we have achieved is cohesion in the network. Without the governance assistance, as well as the development of some of the fundamentals, it is highly likely that the network would have crumbled in the first year. We have different institutions, different cultures, and different ways of doing things and yet we have maintained cohesion and I attribute a lot of that to the assistance to the Health Systems 20/20 project.” David Mukanga, AFENET Executive Director

19. Design of Organizational Capacity-Building Activities 6. When creating a new or nascent organization, ensure it has a viable business model In other words, does the organization offer programs and services that others are willing to support?

20. Design of Organizational Capacity-Building Activities • Design capacity-building activities so the client organization has the incentives to engage in the capacity-building process • Tied to longstanding relationships • Tangible incentives • Offers potential business opportunities • Attractiveness to funders

21. Design of Organizational Capacity-building Activities 8. Define benchmarks for success and milestones for measuring progress at the beginning and update on an ongoing basis

22. Illustrative Organizational Capacity-building Indicators • Accepted and understood strategy to guide decision-making • Adequate number of qualified staff with clear roles and responsibilities to carry out key functions • Leadership that can provide direction and align actions with strategy • Management capacity to plan, budget, and implement activities • Key management systems (financial, IT, HR, and procurement) in place and functioning  • Effective relationships with other organizations established • Governance structure that provides oversight and checks and balances • Ability to mobilize resources to carry out mandate and be financially viable

23. Practice of Organizational Capacity Building 9. Form a partnership with host organization by ensuring trust and collaborative engagement “During the design phase we had a series of discussions with the Health Systems 20/20 team. We explained our problems, provided our recommendations and suggestions. We also had inputs from the Health Systems 20/20 team…we listened to their recommendations and saw flexibility from their team. It was a consensus agreement from both parties that led to successful outcomes.” Dr. Salehi,Afghanistan HEFD

24. Practice of Organizational Capacity Building 10. Maximize use of local consultants and organizations and provide appropriate supervision • Consistent with spirit of country ownership • Local expertise exists in many countries with some exceptions (e.g., organizational development) • Effectiveness depends on providing direction and necessary supervision

25. Practice of Organizational Capacity Building 11. Ensure buy-in and commitment from senior leadership by: • Agreement on assessment dimensions • Review and approval of all consultants • Regular check-ins • Communication with others in the organization • Responsiveness to client’s priorities

26. Practice of Organizational Capacity Building 12. Be flexible and adapt the approach and interventions to emerging needs “While the consultancy had objectives, it wasn’t very rigid. Many times with consultants – they are not flexible. The project is designed before they even get involved and they want to carry it out as it was written. But you encounter rocks in the road; things change. The good thing about this consultancy was that they were flexible. You can’t always do everything that was in the original plan.” Luis Fernandez, Executive Director, PROSALUD

27. Practice of Organizational Capacity Building 13. Tailor all interventions to the country context, size and sophistication of client organization, and resources available • Stage of growth • State of the country • Time required • Availability of qualified local consultants

28. Summary We have improved our understanding in some key areas: • How organizational capacity building contributes to HSS • Which organizations to strengthen in the HSS context • What organizational capacities to strengthen • How to design and implement comprehensive and targeted capacity-building activities Measurement remains an Achilles heel

29. Final Questions • Should donors be investing in organizational capacity building? • What agreement can be reached on the measures we should use? • How can we better document and communicate the value of these investments?

30. Thank you www.HealthSystems2020.org