1 Strengthening Health Systems: From Global to Local Sara Bennett, Associate Professor Johns Hopkins School of Public Health Global Health Council Satellite Session Health System Strengthening: What is Everyone Doing? June 13, 2011

Key points  There is both conceptual confusion and multiple approaches to HSS  Conceptual confusion is problematic – but it may be premature to fix conceptual frames  Multiplicity of approaches is a good thing, if it reflects responsiveness to differing contexts  Need to embrace more nationally driven HSS agendas and support the development of national-level capacity to drive such agendas 2

Different current approaches to HSS 3

Problems of lack of conceptual clarity  Too much time spent explaining things to each other and to outsiders!  Fragmentation and lack community across a small field  Lack of agreed standards to track commitments and achievements  Cyclical trends in priority for health systems 4 Oh, but how do you accommodate system dynamics and emergent behaviors? I support a diagonal approach to HSS with positive synergies

Intrinsic features of field that promote cyclical policy (source: Rochefort 1988)  Complexity of field and heterogeneous problems  Exaggerated ideologies – over-confidence, disillusionment  Incomplete development of scientific basis  Mismatch of goals and means  Linked to social and economic cycles  Not sexy! 5

From global to local 6 Context specificity of HSS Cycles leave insufficient time for country implementation National commitment to HSS may be more important than global funding Need for local research to build global evidence base

Future health systems – DFID- supported research consortium 7 Philosophy Country-driven research, focus on local capacity development Countries Afghanistan, Bangladesh, China, India, Uganda and neighbours X-cutting themes Unlocking community capabilities, stimulating innovation, understanding intervening in complex adaptive systems Interventions M-health schemes to better link informal providers to formal health care system Vouchers for transport to facilities New approaches to regulation Community scorecards for health

Reflections  Diversity of proposed interventions reflects local contexts and histories  Country leadership motivates and empowers country researchers  Responsiveness to local concerns facilitates links to policymakers and other research users  Planned research processes incorporate learning and adaptation  Relinquishing leadership can be frustrating for northern researchers and challenging for generalizable findings 8