2. o Appropriate and effective service delivery depends
on strong health systems
o Weak health systems are a central obstacle to
scaling-up and sustaining AIDS programs
o Health outcome related targets cannot be achieved
without adequate investment in health systems
o Investment in health needs to be embedded in
broader social and economic development planning
3. Health systems strengthening includes:
o Policy development and implementation
o Effective governance and coordination
o Efficient and reliable financing mechanisms
o Increased information on health expenditures and
costs
o Improved quality of health service delivery
o Surveillance and reporting of disease impact within
communities
o Implementation of sustainable health information
systems
4. Strengthening the health system: For
what? For whom?
o For a particular disease or system-wide to
address a range of health priorities? Vertical
or integrated? Or should it focus on promoting
and enhancing health rather than combating
disease? Either/or or both?
o Are health system strengthening plans based
on equity? Do they ensure that
disenfranchised or particularly at-risk
populations are proactively reached?
5. Response to AIDS has contributed to
strengthening health systems:
o Blood safety
o Laboratory services
o Clinical care and treatment
o Procurement and supply management
o VCT
o Human resources
o Data management
o Policies and coordination mechanisms
o Targeted strategies to reach vulnerable and at-risk populations
o Prevention/care/treatment continuum, demand creation
o Community participation and GO/NGO synergies
o Unprecedented funding levels
6. But there have been some challenges
o National health systems struggling to provide adequate basic
health care while facing additional resource allocation and
system management requirements for AIDS
o AIDS created a greater demand for services while at the same
time caused attrition of the limited health workforce
o The sharp increase of resources for HIV/AIDS has brought about
a need to address new critical components, such as:
n Absorptive capacity
n Planning for rapid scale up and human resource planning
n System capacity for effective and safe delivery of treatment
o Limited understanding of the links between the provision of
AIDS services and the broader health systems required to
ensure a sustainable, effective response in the long-term
7. Health system strengthening needed to
make progress in the response to AIDS
o Pandemic has reached an unprecedented scale and
although the it touches all aspects of society, health
systems are and will remain at the forefront of
the response to AIDS
o Areas that have slow progress can only be
addressed within a health system strengthening
frame (e.g., achievements of health objectives for
AIDS met the decline in African health standards in
the maternal and child health sector – what s the
effect over PMTCT?)
o Movement fatigue – can health system
strengthening revitalize the response to AIDS?
8. A recent example: The Global
Campaign for the Health MDGs
o International Health Partnerships (IHP+) areas for
action:
n Enabling countries to identify, plan and address health
systems constraints to improve health related outcomes in
a sustainable, equitable and effective manner
n Generating and disseminating knowledge, guidance and
tools in specific technical areas
n Enhancing coordination and efficiency in aid delivery and
strengthening health systems
n Accountability and monitoring performance
9. Inputs Outputs Outcomes Impact
Funding
Domestic sources
International sources
Plan
Coherent, prioritised
and funded
Harmonization
Aligned international
efforts with national
plan
Well coordinated and
harmonized support
National plan
implementation
Systems strengthening
Priority interventions
scale -up
Capacity building
Programmes
Institutions
People
Accountability
Performance
monitoring
Results focus and
evaluation
Use for better practices
and results
Healthsystemstrengthened
Governance,HR,medicalproducts,information
Increased service
utilization and
intervention
coverage
Reduced inequity
(e.g. gender,
socio -economic
position)
Responsiveness
No drop -off non -
health sector
interventions (e.g.
water & sanitation)
Improved survival
Child mortality
Maternal mortality
Adult mortality due to
infectious diseases
Improved nutrition
Children
Pregnant women
Reduced morbidity
HIV, TB, malaria, repr .
health
Improved equity
Social and financial
risk protection
Reduced
impoverishment due to
health expenditures
Framework for monitoring performance and evaluation
of the scale-up for better health
Improvedservices
Access,safety,quality,efficiency
Process
Aid process
monitoring
Resource tracking Strengthen country health information systems
Evaluation: process, health systems strengthening, impact
M&Eaction
Health system monitoring Coverage monitoring Impact monitoringImplementation
Monitoring
10. But is it all about numbers, technical
soundness, scaling up, services,
commodities, funding, alignment,
harmonization and coordination?
11. A little bit of history of health systems…
o 1945 – 75: universal, comprehensive public services to meet basic health needs
o 60 s and 70 s: Primary Health Strategy to address unsolved problems of basic health
care, to reinforce health infrastructures especially in rural areas
o 1978: International Conference on Primary Health Care – Alma Ata. Health care
for all; health as wellbeing and a fundamental human right
o 1979: Selective Primary Care: WB challenges Alma Ata ( too expensive 5.4 to 9
billion by year 2000) and proposes few interventions to fight against a limited number
of diseases. UNICEF develops GOBI.
o 1985: Good Health at Low Cost recommends equitable distribution of income, access
to public health care services to all, and primary health care reinforced by secondary and
tertiary services but loses to the vertical approach/sectoral interventions
o 1987: WB s structural adjustment policy (enforce fee payment for health services;
encourage privatization of health services; promote (private) insurance programs.
o WHO crisis; appeals to extra-budgetary funds of vertical interventions.
o 1993: WB becomes a major financial institution in health – essential package and new
indicator Disability Adjusted Life Years (DALYs)
o 1998: Public-Private-Partnerships (Gates, UNAIDS, GAVI, Stop TB….)
o 2001: ARVs, UNGASS… Jan 2002 GFATM… 2003: 3 by 5… PEPFAR
o 2007: Global Campaign for the Health MDGs; Health 8… health system strengthening
12. Preparing for the 4th decade of AIDS
o The first decade of AIDS was about losses
o The second decade of AIDS was about hope:
hope for a cure, a vaccine
o Money dominated the third decade of AIDS
believing that resources would do the trick
o How do we want the fourth decade of AIDS
to be known for?
13. The 4th decade of AIDS: back to basics?
o Health system strengthening starts at securing
primary health care for all (PHC is the litmus test of
HSS)
o We have gone through Primary Health Care and
Selective Primary Care, can we think of a Primary
Health Care – PLUS where access to basic and
comprehensive health care can include specificity?
o The spirit of Alma Ata should be rescued since
Health for All – based on social justice and
human rights – is achievable
o We can start by infusing to the MDG rhetoric the
sense of optimism, moral vision and inspiration that
led to Alma Ata
14. The 4th decade of AIDS: back to basics!
o Like in the past, the response to AIDS
can lead the way since its core has
always been fueled by the principles of
inclusion, rights and personal and
collective self-determination
o The world needs an infusion of optimism and
the response to AIDS is inspirational because
it s essentially about commitment to life and
conviction that change can happen
15. The 4th decade of AIDS: back to the
human element
Hu
Health system strengthening is only possible when you go
back to the basics: putting the human being at the
center of the analysis and the response
