Integrated Systems Strengthening (ISS)

Minal Rahimtoola, MPH

Joseph Petraglia, Ph.D

WHY INTEGRATED SYSTEMS STRENGTHENING?

• Pathfinder International recognizes that health services cannot be strengthened in isolation of the community needs.

• The Integrated Systems Strengthening (ISS) approach focuses on influencing how public and private sector health systems and communities work together to improve sexual and reproductive health outcomes.

• The ISS puts community and health systems interaction – which happens within what we call the “zone of interaction” - at the nexus of systems strengthening

ISS APPROACH

Formal Health System

Formal and Informal

Community System

Zone of Interaction

OUR APPROACH

The integrated systems strengthening (ISS) approach supports the development of an informed, competent and engaged group

of stakeholders within the “zone of interaction”, where health systems and community intersect. This interaction is grounded on principles of rights based programming, quality of service

delivery and treatment of health users, and meaningful engagement of communities in decisions about their health.

WHO DO WE WORK WITH IN THE ZONE?

• Community actors – Hard to reach populations – Population subgroups

• Adolescents, men and women, boys and girls • People with disabilities

– Community leaders – Religious leaders – Community based organizations – Non governmental organizations – Advocacy groups

• Health systems actors

– Public health sector stakeholders at the national, regional and district levels – Private health sector stakeholders – NGOs delivering health services – Private practitioners – Community health workers

PATHFINDER’S CLINICAL AND COMMUNITY ACTION TO ADDRESS MATERNAL AND NEWBORN HEALTH (CCA-MNH) MODEL

• Pathfinder’s CCA-MNH model involves working closely with the health system and community to ensure that a whole package of interventions that address post partum hemorrhage (PPH) are ready for action when the need arises.

• The model creates strong community-facility linkages along the continuum of care that are the result of an integrated approach to systems strengthening.

PATHFINDER’S CLINICAL AND COMMUNITY ACTION TO ADDRESS MATERNAL AND NEWBORN HEALTH (CCA-MNH) MODEL

COMMUNITY SCORECARDS ARE ONE WAY OF ENSURING THAT COMMUNITY MEMBERS ARE

OFFERED THE CHANCE TO ENGAGE MEANINGFULLY IN ASSESSMENT OF CLINIC

PERFORMANCE.

NHSDP IN BANGLADESH

• From Pathfinder’s implementation science perspective our ISS frequently faces significant real-world barriers which are important to acknowledge.

• A project in Bangladesh (The NGO Health Service Delivery Program– or NHSDP) : Supports the delivery--through a network of NGOs--of an essential service

package of primary health care

Serves over 22.2 million people, (14%) of total population.

Complements GOB’s efforts to reaching poor and underserved with quality services at an affordable or no fees.

• NHSDP is one in which nicely illustrates the kinds of

challenges we and other implementers face in bringing the C into HSS.

COMPLEX COMMUNITY BENEFICIARIES

NHSDP Beneficiary

Poor Community

Indigenous Population

Elderly peoples

Youth

High risk population

Eligible Couple

Adult Male

Adolescent boys & Girls

Under 5 Child

Physically Challenged

COMPLEX STAKEHOLDERS

NHSDP Stakeholders

Development Partners: USAID,

DFID, Chevron USAID Funded NGOs

GOB:

MOHFW, MOHT, MOLGRD, MOWCA,

Public Reps

Local NGOs

Local Influential

CSR Organizations

Private Organizations

Civil Society Organizations

Partner Consortium Members

Community People

Non-USAID payable

Customers

Right Based Organizations

NHSDP & NGOs, NMC Staffs,

CSPs

CHALLENGES TO COMMUNITY ENGAGEMENT IN SYSTEMS STRENGTHENING

• Heterogeneity of the community. Urban/rural, “poorest of the poor” vs. low income, etc. Competing agendas and, of course, huge power differentials within communities.

• Government-supported “Community agents” often illiterate and uneducated in comparison to NGO Service Promoters. Creates an impression that NGOs are marketing to the community instead of the community organizing to articulate their own needs.

• Very developed and stratified stakeholder landscape creates a very confusing Zone of Interaction from the perspective of the community member.

• Scale of the project makes dealing with informal community structures especially difficult, leading to an over-emphasis on formal structures which are frequently less impactful or able to contribute to normative change.

• Cultural barriers to community members collaborating with providers as equals.

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Thank you

mrahimtoola@pathfinder.org

jpetraglia@pathfinder.org