1. Health Systems Strengthening
Improving our capacity to
develop capacity in health
Leonardo Cubillos-Turriago
Senior Health Specialist
World Bank Institute
Core Group Spring Meetings 2013
April 23rd, 2013
Baltimore, MD
This presentation is based on WBI’s Capacity Development Results Framework, and on the work of WBI &
WBG health programs

2. Health Systems Strengthening
Cambodia faces a rapid increase in NCD
Sub Saharan Africa has increased health
expenditure and access to ART, but still lacks
adequate access to the other basic medicines
Need for Governance & Transparency are on
top on the agenda in the Egyptian Health
Care System
Increased prevalence of AIDS in prisons in the
Democratic Republic of Congo

3. Health Systems Strengthening
Some facts…
• Financial development assistance for health increased from
US$10.5 billion in 2000 to US$27 billion in 2010.
• Each year donors spend more than $20 billion on products
and activities designed to enhance the capacity of
developing countries. This level of commitment reflects
commitment of donors.
• The Paris Declaration on Aid Effectiveness signed by more
than 100 multilateral and bilateral donors states that the
“capacity to plan, manage, implement, an account for
results… is critical for achieving development objectives”

4. Health Systems Strengthening
Global Health: Where are we?
What have we achieved
• Eradication of smallpox
• Reduction in the burden of
communicable diseases
• Dramatic reductions in
infant and maternal
mortality rates
• Increased life expectancy
• Strengthened health
systems
Our challenges
• Resurgence of pandemics:
multi resistant tuberculosis
• We are suffering from more
NCDs
• Rising health care inequalities
• 2 billion people without access
to basic medicines
• Expenditures are mounting. As
an example, 25% of TGHE go
to medicines (15% only 7 years
back).

5. Health Systems Strengthening
Global Health: Where are we?
Our challenges
• MDG 4, 5 & 6 will not be
met
• MDG 1 will be met partly
due to China’s economic
growth

6. Health Systems Strengthening
CHALLENGES IN CAPACITY
DEVELOPMENT
1. Definition of capacity and capacity development are very broad
– “Capacity” is understood as the ability of people, organizations, and society
as a whole to manage their affairs successfully
– “Capacity development, CD” is understood as the process whereby
people, organizations, and society as a whole
unleash, strengthen, create, adapt, and maintain capacity over time (OECD
2006b)
2. Lack of consensus about operational definition of CD
3. Lack of consensus about the expected results
4. Links between CD outcomes and development goals are poorly
articulated
5. It is hard to identify good practices for replication because there is
inattention to measure results attained
6. Many programs are poorly grounded on theory
7. Many programs lack consistent conceptual frameworks
8. Process by which change occurs is poorly understood
9. Importance of strategy is overlooked

7. Health Systems Strengthening
DEFINITION (1)
• Capacity for development, is the availability of
resources (human, financial, technical) and
the efficiency and effectiveness (these depend
on socio-political, institutional, and
organizational factors) with which societies
deploy those resources to identify and pursue
their development goals on a sustainable
(when results and performance are locally
owned and can be replicated and scaled up by
local actors) basis.

8. Health Systems Strengthening
DEFINITION (2)
Capacity development, is a locally driven process
oflearning by leaders, coalitions and other agents of
change that brings about changes in
sociopolitical, policy-related, and organizational
factors to enhance local ownership for and the
effectiveness and efficiency of efforts
Transformational learning interventions ought to be
designed and implemented aiming at acting on
change agents. They would, in turn, act on socio
political, policy-related, and organizational factors.

9. Health Systems Strengthening
Capacity development is a necessary
condition for the development process.

10. Health Systems Strengthening
THREE INSTITUTIONAL CAPACITY DEVELOPMENT
AREAS where change should occur

11. Health Systems Strengthening
The conduciveness of the
sociopolitical environment to
achievement of the goals
is made up of the political
and social forces that
determine the priority
given to the development
goal by the
government, the private
sector, and the civil
society.

12. Health Systems Strengthening
The efficiency of the policy
instruments and other formal
means by which the society
guides action to achieve the
goals
They are to be used to
guide stakeholder
action. They can take
the form of
administrative
rules, regulations, laws,
and standards.

13. Health Systems Strengthening
The effectiveness of the
organizational arrangements
that stakeholders inside and
outside of government adopt
to achieve the goals.
Systems, rules of
action, processes, perso
nnel, and other
resources with which
actors work together.

14. Health Systems Strengthening
Open
Knowledge
connect to
global knowledge
Collaborative
Governance
coalesce stakeholders to
make change happen
Innovative
Solutions
scan & incubate
innovations
Growth &
Competitiveness
Fragile States Governance Climate Change
Health Systems Urban PPP Others
Catalyze change for development results
Structured
learning
e-Institute
Knowledge
Exchange
SSKE
Open Government &
Open Aid
Participation &
Oversight by Non-
Government Actors
Citizen Feedback
using ICTs
Multi-stakeholder
Collaborative Action
Competitions & Grand
Challenges
Development
Marketplace DM 2.0
Innovation Lab
By strengthening the capacity of government and non-governmental actors
to collectively tackle development challenges
Results Areas

15. Health Systems Strengthening
Learning, joint learning, and joint action as the
basis for Capacity Development

16. Health Systems Strengthening
Learning outcomes exemplified

17. Health Systems Strengthening
CRITICAL QUESTIONS IN THE
DESIGN, IMPLEMENTATION, AND MONITORING
OF CAPACITY DEVELOPMENT EFFORTS
• What is the program’s development
objective?
• What are the prevailing capacity factors?
• Who are the appropriate agents of change?
• What is the change process?
• What are the learning outcomes?
• What are the activities and instruments?
• What is our implementation strategy?
• How are we measuring progress & results?
Are we co-
creating this with
local leaders /
communities? Are
we encouraging
an open analysis
and an open
discussion among
stakeholders
through out the
program cycle?

18. Health Systems Strengthening
SOME EXAMPLES…
1. Cambodia – Developing the capacity of the
community & the health system to monitor &
control HTA & DM: The experience of MoPoTsyo
2. DRC – Developing the capacity of the prisoners
and the prison system to take sustainable action
on HIV-AIDS: The experience of RDCompétence
3. East Africa – Improving the capacity of
transparent and accountable procurement &
supply management of basic medicines: The
experience of e-nepp (WBI)
4. Latin America – Improving the capacity to set
fair, accountable, and actionable priorities in
health (WBI)

19. Health Systems Strengthening
“Pooled funds will
never be able to
cover 100% of the
population for
100% of the costs
and 100% of
needed services…
Each country fills
the box in its own
way, trading off the
proportion of
services and the
proportion of the
costs to be met
from pooled
funds”, (WHO, 201
0).
LITIGATION IS BEING USED TO ENFORCE ACCESS
TO PRIORITIZED AND NON PRIORITIZED
SERVICES
Source: WHO, Global Health Report 2010

20. Health Systems Strengthening
DO PEOPLE ACCESS
THEM WITHOUT
GOING TO COURTS?
BASIC
SERVICES
No
No
YESi
YES
IV I
IIIII
TYPES OF LITIGATION
Fuente: Cubillos et al (2012),"Universal health coverage
and litigation in Latin America", JHOM

21. Health Systems Strengthening
COSTA RICA: TREND ON INDIVIDUAL RIGHTS LITIGATIONS
RULED BY THE CONSTITUTIONAL CHAMBER (SALA IV) OF THE
SUPREME COURT OF JUSTICE
Source: Bruce M. Wilson. Enforcing Rights and Employing an Accountability Function.
University Central Florida – CHR Michelsen Institute, March 2009

22. Health Systems Strengthening
22
COLOMBIA: GROWING RESOURCE ALLOCATION AS A RESULT
OF LITIGATIONS FOR NON PRIORITIZED MEDICATIONS (45%
ANNUAL INCREASE)
0
20.000.000
40.000.000
60.000.000
80.000.000
100.000.000
120.000.000
140.000.000
160.000.000
1998-07
2000-05
2000-08
2000-10
2000-12
2001-03
2001-05
2001-07
2001-09
2001-11
2002-01
2002-03
2002-05
2002-07
2002-09
2002-11
2003-01
2003-03
2003-05
2003-07
2003-09
2003-11
2004-01
2004-03
2004-05
2004-07
2004-09
2004-11
2005-01
2005-03
2005-05
2005-07
2005-09
2005-11
2006-01
2006-03
2006-05
2006-07
2006-09
2006-11
2007-01
2007-03
2007-05
2007-07
2007-09
2007-11
2008-01
2008-03
2008-05
2008-07
2008-09
2008-11
2009-01
2009-03
2009-05
2009-07
2009-09
2009-11
2010-01
ValorMensual Recobros(USD/08)
Valor Presentado Valor Aprobado
Source : Eduardo Alfonso, Estudio de Caso de Colombia, en Proceso de Elaboración por WBIHS, Agosto2010

23. Health Systems Strengthening
LITIGATION HAS AN IMPORTANT
IMPACT ON EQUITY
Fuente: Cubillos, Escobar, et al (2012),"Universal health coverage
and litigation in Latin America", JHOM
Fuente: Capítulo 4 Ferraz. Yamin, Gloppen Litigating health rights:
Can courts bring more justice Health?. 2011

24. Health Systems Strengthening
DEVELOPMENT OBJECTIVE
To contribute to improve the level and
distribution of key health outcomes, as well as
the governance, accountability, transparency
and financial sustainability of the health
sector of participating countries. As such, it is
expected that the Initiative, would
ultimately, contribute to the realization of
health as a human right.

25. Health Systems Strengthening
INSTRUMENTS OF CHANGE
Support participating countries create and/or strengthen regional and
national multi-stakeholder coalitions that contribute to the following set of
objectives:
• Strengthen the capacity of countries to exchange knowledge and share
experiences;
• Enhance the effectiveness of policy instruments;
• Implement fair, transparent, and technically sound priority setting
processes that progressively realize the right to health;
• Improve key stakeholder ownership of the health and judiciary systems;
• Empower citizens to contribute to the ultimate improvement of health
systems;
• Ensure that access to health services is non-discriminatory; and
• Improve the quality and access to health services by citizens (right
holders)

26. Health Systems Strengthening
Knowledge
Exchange
Analytical Work
Online
community
Country Multi
Stakeholder activities
Latin American Multi
Stakeholder activities
Global Multi
Stakeholder activities
06/
11
06/
10
06/
13
06/
12

27. Health Systems Strengthening
The conduciveness of the
sociopolitical environment to
achievement of the goals
Political & social leaders
have expressed
commitment to embark
in a multi stakeholder
process of change.

28. Health Systems Strengthening
The efficiency of the policy
instruments and other formal
means by which the society
guides action to achieve the
goals
Rulings are changing
New laws & regulations are
being discussed & approved

29. Health Systems Strengthening
The effectiveness of the
organizational arrangements
that stakeholders inside and
outside of government adopt
to achieve the goals.
Actor regularly meet
together. New & different
channels of communication
are appearing.
Actors work together.

30. Health Systems Strengthening
Open
Knowledge
connect to
global knowledge
Innovative
Solutions
scan & incubate
innovations
Collaborative
Governance
coalesce stakeholders to
make change happen
Knowledge Exchange
Multi-level
Multi-stakeholder
coalition building
ICT Platform
An Example of WBI’s Approach in
Constitutional Mandates and Priority Settings in Health

31. Health Systems Strengthening
“A post-2015 world should have more engagement of
people, inclusivity, transparency, and accountability.
Emerging governance models also provide opportunities for
far greater citizen participation, influence and intersectoral
action.
Civil society and community dimensions of “country
ownership” are vital for both strong policy development
and for holding all stakeholders accountable for progress.”
High Level Dialogue on Health in the Post-2015 Development Agenda,
Gaborone, 4-5 March 2013

32. Health Systems Strengthening

33. Health Systems Strengthening
Thank you!
lcubillosturriag@worldbank.org
For more information
• The World Bank Institute
• saluderecho@worldbank.org
• www.worldbank.org
• www.saluderecho.net