1. Whatisdifferent in differentapproaches to HealthSystemsStrengthening? A briefreview of concepts and semantics George Shakarishvili Senior Advisor, HealthSystemsStrengthening 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 MDGs: HSS is key for reaching the MDG health targets Evidence: Research on GHIs Political support: G8, H8, HLTF, and other high-level forums 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) - Primarycare framework (WHO 2008) - Systems framework (Atun, 2008) “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 “Health system strengthening, the new buzzwordin discussions about international health, is in danger of becoming a container conceptthat is used to label very different interventions.” PLoSMedicine 2009, Vol6, Issue 4 “There is lack of consensus onwhat health-system strengthening means, and consequently on how it should be done and evaluated.” Lancet 2010,377: 1222-23. 6736(10)60679-4

6. Operational research, implementation research

7. Quality of care

9. External factors: epidemiology, demography, polit-economy...

11. Harmonization

12. Alignment Operational HealthSystemsStrengthening

14. Reducing health-related financial risks

16. Access via common proposal form (GF/GAVI) Access via jointly assessed national health strategy (WB/GF/GAVI) “Existing financing” Harmonization of existing HSS support Health systems fundingplatform(GAVI-GFATM-WB-WHO) Harmonized grant/credit management “New financing” Opt 1 Opt 2