WHERE IS THE “C” IN HEALTH SYSTEMS STRENGTHENING?

Africa Christian Health Association Conference

Nairobi, Kenya

February 25, 2015

Alfonso Rosales MD, MPH-TM

World Vision US

arosales@worldvision.org

HEALTH SYSTEMS STRENGTHENING

PRESENTATION OVERVIEW AND PURPOSE

Overview Purpose

HSS systems approaches and framework Review

USAID HSS strategy

PAHO/WHO HSS strategy

UNICEF HSS strategy

Inform

World Vision Project Models Review in light of USAID strategy

Systems Approach and Community-

Systems Strengthening (CSS)

Discuss integration of WV models

Feedback Get feedback and questions on making this

approach useful

WHY HAVE A SYSTEMS APPROACH?

Health System

Support

Strengthen

Health System

Support Any activity that

improves services

Increasing inputs

Strengthen Changes to

performance drivers

Policies and regulations

Organizational structures

Relationships across the health

systems

HEALTH SYSTEMS OR

HEALTH SYSTEMS STRENGTHENING

Health Systems

Governance, Institutional, Social, and Human systems and sub-systems,

Contributing to the full production of health

“Health is not only…”

Social systems produce health

Mothers, care-givers produce health

Service providers even occasionally do

Health Systems Strengthening

Can be a discrete agency strategy,

based on a set of manageable interests

to contribute specific capacity building and

support to parts of the greater Health

System (i.e. specific ‘building blocks’)

Disease control,

Preventive

services

+ Health promotion,

Social determinants

QUESTIONS

1. What is the role of communities and civil society in Health Systems Strengthening

(HSS)?

Role of communities in Health Systems or Health Systems Strengthening?

What is said and not said about the place of the people (“communities”) in

common health systems framework?

2. Is there a role for PVOs?

3. How should PVOs operate within a HSS strategy?

How should a health systems framework properly integrate the role and value

of communities?

Where is the “C” in Health Systems?

• Let’s start with the basics of the health system building blocks • Before addressing elements that might be missing – let’s see how

we can make this framework be more dynamic and looking more actually like a system

The Basics of the Health System building blocks

• Humans within structures and systems provide the leadership and governance function

• Leadership guides the allocation of all resources, work culture, and vision. • Leadership guides financing, but financing also determines the structure of

leadership. Finally financing is required for nearly all inputs. • Products and technology require financing and are managed by the workforce. • Information is necessary for appropriate governance; it requires financing and

human resources; and it is essential to delivering quality and rational services. • Finally service is delivered by using workforce, products and technology, and

information. As well as infrastructure. • All these things can be represented as relationships (next page)

Leadership/

Governance

Financing

Workforce

Products and

Technology

Information and Research

Service Delivery

We now start to see a health system as a network, which adds some connections or cement between the “building blocks”. As a network, we start seeing the centrality of the workforce and financing, not surprisingly. But some feel that we also have missing pieces in terms of the production of health which is expected from a health system.

Unmodified Network View of the Health System Building Blocks

Limitations of the Model

• No pathways for health production through other sectors, which are not negligible quantities: – Social determinants – Nutrition – WASH – Literacy and education – Female empowerment – Environmental health

• The implied nature of community health mechanisms leads to neglect and insufficient valuation of its contribution

• ‘All models are wrong, but some are useful’ goes the saying, but in this case it would be useful to make this more explicit.

A health system that is not responsive to the

community that it serves can never be really strong

• Community-based systems are still

poorly represented in health system and

health system strengthening frameworks

• There is a tendency to view

communities as clients of clinical

services, and not active participants in

the health system

• New approaches and ways of thinking

are needed to connect as a whole

rather than as discrete elements

WORLD VISION PROJECT MODELS WHAT DO WE HAVE GOING ON?

WV PROJECT MODELS (6)

ttC Timed and Targeted Counseling

CCM Community Case Management

CoH Channels of Hope

CMAM Community Management of Acute Malnutrition

CVA Citizen Voice and Action

COMM Community Health Committees

TIMED AND TARGETED COUNSELING

Timed & Targeted Counseling (ttC)

Target

Population

Mothers, children 0-24 months

Package of

Services

7 interventions for mothers; 11interventions for

children

Delivery

Mechanism

Household-level behavior change counseling

Tools training resource, job aids, and data collection

system

Evidence Child Health Targeted Impact Study (chTIS)-

ongoing five-year study in collaboration with John

Hopkins School of Public Health to measure the

difference WV programs are having on Maternal

and Child Health

TIMED AND TARGETED COUNSELING

Community Case Management (CCM)

Target

Population

Children 0-5 years

Package of

Services

oral rehydration therapy (ORT), zinc for diarrhea,

antibiotics for pneumonia, anti-malarials

Delivery

Mechanism

Community level- building the capacity of CHWs

& National level- typically depends on national

policy

Tools

Evidence Final evaluation for CCM projects is ongoing.

Channels of Hope (CoH)

Target

Population

Faith leaders and spouses

Package of

Services

Education including curricula on HIV, MNCH,

gender and child protection

Delivery

Mechanism

Community level- community counseling &

National level- partnerships with FBOs

Tools training resources, sermon guides

Evidence Uganda/Zambia 2005

Lesotho/Ethiopia/Kenya, 2009

Citizen Voice and Action (CVA)

Target

Population

Community members

Package of

Services

Community gatherings, citizen engagement,

improvement of and influence of policy.

Delivery

Mechanism

Citizen education, community gatherings. Actions

carried out by individuals.

Tools Program guidelines for process development.

Evidence Uganda, 2011: A RCT of community monitoring in

health clinics of 50 Ugandan communities.

Zambia, 2012: Health outcomes from 5 target

location health facilities

Community Health Committees (COMM)

Target

Population

Community System

Package of

Services

Advocacy; leading community action in response

to health barriers/root cause and barrier

analysis/monitoring of community health status;

oversight and promotion of CHW programs;

linkages between COMM, CHWs and households

Delivery

Mechanism

Community-level, through committees

Tools

Evidence COMM itself is not linked to any evaluation

studies that were found.

CONCLUSION

World Vision has many project models that are highly inclusive of the community

Promotes community ownership of programs

Combats attrition

Some WV programs require more robust evaluation to link provided services to

health outcomes.

WV models are commonly used for individual-level interventions, not systems-wide

interventions.

How can we use these models within a systems approach?

FOUR DIFFERENT LEVELS TO MANIPULATE THE SYSTEM

Communication Financing Organization Regulation

• Enabling Environment and Governance

• Service Delivery

• CVA, CCM

Formal Health System

Level

• Social Environment

• Physical Environment

• CoH, COMM Community

• HH Characteristics

• Individual Factors

• ttC Household Level

Leadership /

Governance

Financing

Workforce

Products and

Technology

Information and Research Preventive and curative

facility-based service

delivery

Environmental and

socio-ecological conditions

Preventive and Curative

Community-Based Services

Societal Partnership (civil society

engagement, other sectors

partnership: education, water, food

security, local government)

Community organizing and

mobilization for health

promotion

Community and Household

Health Production

Improved Health

Sarriot Eric, 2015

QUESTIONS AND NEXT STEPS

How can this help WV program planning and proposal development?

How can models be prioritized for implementation when resources are limited?