1. 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

2. HSS: A high priority on the global health agenda Evidence: Research on GHIs Political 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 billion GFATM: USD 1.7 billion GAVI Alliance: USD 0.8 billion

3. 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

4. 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

5. Health system strengthening Operational research, implementation research Quality of care Performance assessment Do definitions matter?

6. 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

7. 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

8. 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)

9. Health systems funding platform (GAVI-GFATM-WB-WHO) “Existing financing” “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 Opt 1 Opt 2