Health Systems Strengthening

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 Session
Health System Strengthening: What is Everyone Doing?
June 13, 2011
HSS: A high priority on the global health agenda
MDGs: HSS is key for reaching the MDG health targets
Political support:
Research on GHIs
G8, H8, HLTF, and other
high-level forums
Increased demand and supply (2007-2010)
World Bank:
USD 2.5 billion
USD 1.7 billion
GAVI 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
“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
- Actors framework (Evans, 1981)
- Fund flows framework (Hurst, 1991)
- Demand-supply framework (Cassels, 1995)
- Performance framework (WHO, 2000)
“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
- 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
Do definitions matter?
Health system strengthening
Operational research, implementation research
Quality of care
Performance assessment
HSS: A single definition or multiple dimensions?
Interventions: inputs, processes, policies, etc. leading to
outputs, outcomes, and impact
• Overarching principles: equity, efficiency, sustainability…
• External factors: epidemiology, demography, polit-economy...
• Systems thinking
Health Systems Strengthening
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
Opt 1
Access via common
proposal form (GF/GAVI)
Opt 2
Harmonization of existing HSS support
Access via jointly assessed
national health strategy (WB/GF/GAVI)
Harmonized grant/credit