What is different in different approaches 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

Global Health Council Satellite SessionHealth System Strengthening: What is Everyone Doing?

June 13, 2011

HSS: A high priority on the global health agenda

Evidence:

Research on GHIsPolitical support:

G8, H8, HLTF, and other high-level forums

MDGs: HSS is key for reaching the MDG health targets

Increased demand and supply (2007-2010) World Bank: USD 2.5 billionGFATM: USD 1.7 billionGAVI Alliance: USD 0.8 billion

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

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)

- Primary care framework (WHO 2008)

- Systems framework (Atun, 2008)

“There is lack of consensus on what health-system strengthening means, and consequently on how it should be done and evaluated.” Lancet 2010, 377: 1222-23. 6736(10)60679-4

“Health system strengthening, the new buzzword in discussions about international health, is in danger of becoming a container concept that is used to label very different interventions.” PLoS Medicine 2009, Vol 6, Issue 4

“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• Operational research, implementation research• Quality of care• Performance assessment

Do definitions matter?

HSS: A single definition or multiple dimensions?

• Interventions: inputs, processes, policies, etc. leading to outputs, outcomes, and impact

Health Systems Strengthening

• Overarching principles: equity, efficiency, sustainability…• External factors: epidemiology, demography, polit-economy...• Systems thinking

• Coordination• Harmonization• Alignment

Programmatic

Conceptual

Operational

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

Common weaknesses of HSS funding applications

1. Dissociation of HSS: lack of linkages between proposed HSS interventions and HS goals

2. Fragmented approach to HSS: strengthening specific “building blocks” vs. strengthening the system

3. Verticalization of HSS: HSS is viewed as a separate entity

4. 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

5. Lack of analytical foundation: addressing visible symptoms vs. underlying causes of poor health system performance (how vs. why)

Health systems funding platform(GAVI-GFATM-WB-WHO)

“Existingfinancing”

“New financing”

Harmonization of existing HSS support

Access via common proposal form (GF/GAVI)

Access via jointly assessed national health strategy (WB/GF/GAVI)

Harmonized grant/credit management

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