This document discusses lessons learned from organizational capacity building efforts to strengthen health systems. It defines capacity building at the individual, organizational, and system levels. It then summarizes Health Systems 20/20's work strengthening over two dozen organizations across multiple countries over six years. Key lessons include: focusing capacity building on organizations that strengthen health systems; taking a comprehensive approach across all organizational competencies; ensuring partner buy-in and flexibility; and maximizing local expertise. Measurement of impact remains a challenge.

1. better systems, better health
Lessons Learned
in Organizational Capacity Building
for Health Systems Strengthening
Better Health Systems: Strategies that Work
Presentation series at the Global Health Council
Fred Rosensweig
April 3, 2012
Abt Associates Inc.
In collaboration with:
I Aga Khan Foundation I Bitrán y Asociados
I BRAC University I Broad Branch Associates
I Deloitte Consulting, LLP I Forum One Communications
I RTI International I Training Resources Group
I Tulane University’s School of Public Health

2. Agenda
 Definition of capacity building
 Overview of Health Systems 20/20 capacity-building
activities
 Our methodology for determining lessons learned
 Lessons learned
 Summary

3. Definition of Capacity Building
System-level capacity building has three levels
of intervention
 Individual level – knowledge and skills
 Organizational level – single organization
 System level – multi-organizational in nature

4. Health Systems 20/20’s Focus
 Regional and country-level organizations that enable
health system strengthening
• National government agencies that have stewardship role
• Research institutions that provide evidence for HSS
• NGOs and consulting firms that provide TA
• Education and training institutions that train health system
leaders
 Strengthened 24 organizations over six-year period

5. Three Broad Types of Organizational
Capacity-building Activities
 Comprehensive capacity building covering core
organizational competencies
 Strengthening capacity of central government
agencies
 Targeted organizational capacity building in a
specific technical area

6. Examples of Organizations Health
Systems 20/20 Has Strengthened
Government Research Institutions
 HIV/AIDS Office in MOH (DRC)  HSPI (Vietnam)
 NAC Secretariat (Liberia)  ISED (Senegal)
 MOH Health Economics and  ECSA (regional)
Financing Directorate  Regional School of Public Health
(Afghanistan) in Benin (regional)
 MOH HIS Directorate (Namibia)  HEARD (South Africa)
NGOs/Consulting Firms Education and Training Institutions
 AFENET (regional)  Kinshasa School of Public Health
 PROSALUD (Bolivia) (DRC)
 Health Systems Action Network  National TB and Leprosy
(global) Training Center in Zaria (Nigeria)

7. Characterizing Health Systems 20/20
Capacity-building Activities
 Almost all multi-year in nature
 Most led by team leader skilled in organizational
development and change management
 Wide range of organizational types
 Both new and well established organizations
 Covered a wide range of settings including fragile
states
 Majority in Africa

8. Methodology to Develop Lessons
 Review of documentation
 Interviews with team leaders (16)
 Interviews with heads of client organizations (9)
 Analysis of interview data and determination of
lessons learned
 Validation with capacity-building and HSS specialists

9. Lessons Learned

10. Four Categories of Lessons
1. Role of organizational capacity building in
HSS
2. Targeted organizational capacity building
3. Design of organizational capacity building
activities
4. Practice of organizational capacity building

11. Role of Organizational Capacity
Building in HSS
1. Organizational capacity building should be
aimed at those organizations whose role is to
strengthen the health system

12. Organizations to Strengthen in
Context of HSS
Role and Functions Illustrative Organizations
Leadership/stewardship Offices in MOH (e.g., HIV/AIDS, NAC)
Research Universities, research institutes
Technical assistance NGO, consulting firms, universities
Training Training institutions
Advocacy NGOs
Standard setting Professional organizations, MOH

13. Role of Organizational Capacity
Building in HSS
2. Success of HSS efforts depends on both overall
management and technical capacity of organizations
that strengthen the health system
Without management capacity to set direction, plan
and implement activities, and manage resources,
technical capacity-building will have limited impact

14. Targeted Organizational Capacity
Building
3. Select the right partner for targeted organizational
capacity-building activities
 Functional management and administrative
systems
 Leadership commitment to use strengthened
capacity
 Staff buy-in and commitment
 Willingness to engage as full partners

15. Targeted Organizational Capacity
Building
4. Targeted capacity building in HSS approaches
requires a strong learning-by-doing component at
each stage and a willingness by partner to engage
and learn
 Qualitative data collection and analysis are more difficult
to master
 Capacity-building process must be led by senior expert in
methodology
 Most capable partners are busy and have limited time to
engage

16. Design of Organizational Capacity
Building Activities
5. Take a holistic and comprehensive approach and
focus on full range of organizational competencies
 Starts with needs assessment
 Reflected in intervention plan
 Basis for monitoring and mid-course adjustments
 Interconnectedness of interventions

17. Core Organizational Competencies
Technical
Organizational Competence
Resource
Management Mobilization
Technical
Governance Assistance and
Training

18. Focusing on the Whole Organization
“As a result of all of this assistance, one of the greatest things
we have achieved is cohesion in the network. Without the
governance assistance, as well as the development of some of
the fundamentals, it is highly likely that the network would have
crumbled in the first year. We have different institutions, different
cultures, and different ways of doing things and yet we have
maintained cohesion and I attribute a lot of that to the assistance
to the Health Systems 20/20 project.”
David Mukanga, AFENET Executive Director

19. Design of Organizational Capacity-
Building Activities
6. When creating a new or nascent organization,
ensure it has a viable business model
In other words, does the organization offer programs
and services that others are willing to support?

20. Design of Organizational Capacity-
Building Activities
7. Design capacity-building activities so the client
organization has the incentives to engage in the
capacity-building process
 Tied to longstanding relationships
 Tangible incentives
 Offers potential business opportunities
 Attractiveness to funders

21. Design of Organizational Capacity-
building Activities
8. Define benchmarks for success and
milestones for measuring progress at the
beginning and update on an ongoing basis

22. Illustrative Organizational Capacity-
building Indicators
 Accepted and understood strategy to guide decision-making
 Adequate number of qualified staff with clear roles and responsibilities to
carry out key functions
 Leadership that can provide direction and align actions with strategy
 Management capacity to plan, budget, and implement activities
 Key management systems (financial, IT, HR, and procurement) in place
and functioning
 Effective relationships with other organizations established
 Governance structure that provides oversight and checks and balances
 Ability to mobilize resources to carry out mandate and be financially viable

23. Practice of Organizational Capacity
Building
9. Form a partnership with host organization by
ensuring trust and collaborative engagement
“During the design phase we had a series of discussions with
the Health Systems 20/20 team. We explained our
problems, provided our recommendations and suggestions.
We also had inputs from the Health Systems 20/20
team…we listened to their recommendations and saw
flexibility from their team. It was a consensus agreement
from both parties that led to successful outcomes.”
Dr. Salehi, Afghanistan HEFD

24. Practice of Organizational Capacity
Building
10. Maximize use of local consultants and
organizations and provide appropriate supervision
 Consistent with spirit of country ownership
 Local expertise exists in many countries with some
exceptions (e.g., organizational development)
 Effectiveness depends on providing direction and
necessary supervision

25. Practice of Organizational Capacity
Building
11. Ensure buy-in and commitment from senior
leadership by:
 Agreement on assessment dimensions
 Review and approval of all consultants
 Regular check-ins
 Communication with others in the organization
 Responsiveness to client’s priorities

26. Practice of Organizational Capacity
Building
12. Be flexible and adapt the approach and
interventions to emerging needs
“While the consultancy had objectives, it wasn’t very rigid.
Many times with consultants – they are not flexible. The
project is designed before they even get involved and they
want to carry it out as it was written. But you encounter
rocks in the road; things change. The good thing about this
consultancy was that they were flexible. You can’t always do
everything that was in the original plan.”
Luis Fernandez, Executive Director, PROSALUD

27. Practice of Organizational Capacity
Building
13. Tailor all interventions to the country context, size
and sophistication of client organization, and
resources available
 Stage of growth
 State of the country
 Time required
 Availability of qualified local consultants

28. Summary
We have improved our understanding in some key
areas:
 How organizational capacity building contributes to HSS
 Which organizations to strengthen in the HSS context
 What organizational capacities to strengthen
 How to design and implement comprehensive and targeted
capacity-building activities
Measurement remains an Achilles heel

29. Final Questions
 Should donors be investing in organizational
capacity building?
 What agreement can be reached on the measures
we should use?
 How can we better document and communicate the
value of these investments?

30. better systems, better health
Thank you
www.HealthSystems2020.org
Abt Associates Inc.
In collaboration with:
I Aga Khan Foundation I Bitrán y Asociados
I BRAC University I Broad Branch Associates
I Deloitte Consulting, LLP I Forum One Communications
I RTI International I Training Resources Group
I Tulane University’s School of Public Health