Where is the “C” in health systems strengthening by Dr Alfonso Rosales, WVUS
1. WHERE IS THE “C” IN HEALTH SYSTEMS STRENGTHENING?
Africa Christian Health Association Conference
Nairobi, Kenya
February 25, 2015
Alfonso Rosales MD, MPH-TM
WorldVision US
arosales@worldvision.org
HEALTH SYSTEMS STRENGTHENING
2. PRESENTATION OVERVIEW AND PURPOSE
Overview Purpose
HSS systems approaches and framework Review
USAID HSS strategy
PAHO/WHO HSS strategy
UNICEF HSS strategy
Inform
WorldVision Project Models Review in light of USAID strategy
Systems Approach and Community-
Systems Strengthening (CSS)
Discuss integration ofWV models
Feedback Get feedback and questions on making this
approach useful
3. 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
4. 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
5. 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?
6. 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
7. 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)
8. 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
9. 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.
10. 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
12. WV PROJECT MODELS (6)
ttC Timed and Targeted Counseling
CCM Community Case Management
CoH Channels of Hope
CMAM Community Management of Acute Malnutrition
CVA CitizenVoice and Action
COMM Community Health Committees
13. 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 HealthTargeted Impact Study (chTIS)-
ongoing five-year study in collaboration with John
Hopkins School of Public Health to measure the
differenceWV programs are having on Maternal
and Child Health
14. 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.
15. 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
16. CitizenVoice 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
17. 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.
18. CONCLUSION
WorldVision 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?
19. FOUR DIFFERENT LEVELSTO MANIPULATETHE SYSTEM
CommunicationFinancing 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
20. 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
21. 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?
