Global Health Initiatives for HSS: Experiences of GAVI and the Global Fund
Responses from Featured Experts
Question 1: (Pakistan)
GAVI Alliance, I am sure, is working very effectively to extend the reach and quality of immunization. Is Pakistan part of HSS funds? If yes, what measures have been taken up to now and in which part of the country? What are the future plans for this country?
Frank Nyonator Response:
The GAVI HSS window is working well so far and has generated a lot of interest from the GAVI eligible countries. The GAVI Alliance provides support to national governments through the GAVI Fund. Eligibility is determined by national income and only countries with a Gross National Income (GNI) per capita below US$1,000 in 2003 qualify – currently there are 72 eligible countries. Support is provided in response to country proposals, reviewed by an independent group of experts – mostly health officials from developing countries. The ultimate aim of the support as you correctly indicated ‘to extend the reach and quality of immunization’ Pakistan is a GAVI eligible country and applied last year and their proposal is being reviewed. In addition, the Alliance has introduced a pilot project enabling civil society organizations in 10 countries to apply for support. Pakistan is one of the pilot countries but has not yet submitted an application.
Question 2:
I know of many medical students, public health students, and early career professionals that entered the health profession to focus on global health. Besides Harvard School of Medicine, I have not heard of any programs being developed to incorporate health system development training into their medical training curriculum. It seems to me that an organization such as HSAN would be ideal to lead the development of such programs.
Has there been any thought of creating a standardized curriculum to teach soon-to-be-doctors the most salient skills needed to strengthen health systems from the beginning of their careers?
Such a curriculum would provide a direct path for highly motivated and competent doctors to become qualified in health systems development; this would be a better alternative to the current roundabout nature of gaining the necessary skills through indirect channels.
FN Response:
I will agree with you that issues on how health systems work and how health systems can be strengthened as the backbone to carry existing interventions should be part of undergrad curriculum of medical schools. And like you I have not heard of any programs being developed to incorporate health system development training into their medical training curriculum.
I totally agree with you that an organization such as HSAN would be ideal to lead the development of such programs. I will recommend that HSAN consider working with schools in the various Regions to develop such curricula, which I believe will be beneficial.
Question 3: (Afganistan)
We have just started implementing the GAVI- HSS proposal. However, we are facing many challenges with the procurement procedures according to our procurement law, which is delaying our implementation progress. I am wondering if you could share your experiences and also provide some guidance on how implement our proposal as we planned.
FN Response:
GAVI HSS funds are indeed aligned with country procedures and systems as outlined in the 10 key principles that guide the HSS support. If you are facing a lot of challenges with your procurement procedures according to your procurement law, your Health Sector Coordinating Committee (that oversees the implementation of your HSS support, according the details of your proposal), could discuss the difficulties with your Ministry of Finance and the Procurement Department for resolution.
From our experience, some countries facing similar difficulties had requested partners like UNICEF to do the procurement. This is acceptable to most Ministries of Finance and country Departments of Procurements. Detailed Guidelines for developing and implementation of GAVI HSS support are available at the GAVI Alliance website.
Question 4: (Afganistan)
Afghanistan is one of those countries which have the opportunity of using HSS fund for improvement of its health outcomes. Unfortunately, we have been facing some challenges regarding implementation of this project in terms of weak capacity of health sector along with lengthy procedure of government in terms of financial management.
Then the question is:
How to tackle the issues of low capacity and bureaucracy which is common in developing countries against absorption and utilization of this fund?
FN Response:
The 10 key principles of this funding are designed to overcome the ‘issues of low capacity and bureaucracy which is common in developing countries against absorption and utilization of this fund’. These are:
1. Country-driven: GAVI HSS should address problems identified by countries themselves. Countries are encouraged to use recent immunization program and health sector analyses, the National Health Sector Plan3 and similar documents to identify critical areas for GAVI HSS support and to target gaps in current funding.
2. Country-aligned: GAVI HSS should be consistent with the objectives, strategies and planning cycles of existing government health sector policies and frameworks. GAVI HSS support should be in line with government management systems and financial management procedures and reflected in the national budget wherever possible.
3. Harmonized: GAVI HSS should add value to or complement (but not compete with) current or planned efforts to strengthen the health system by government, civil society and health sector partners.
4. Predictable: GAVI HSS support is, in principle, available for the life of the National Health Sector Plan (or country equivalent).
5. Additional: GAVI HSS funds must be additional to the government’s existing budget and the funds should not displace resources previously allocated to the health sector.
6. Inclusive and collaborative: All key stakeholders in health system strengthening (beyond the immunization program) should be involved in GAVI HSS. Government entities, partners, civil society, and the private sector should all be informed and involved, as appropriate, in the planning, implementation and evaluation stages.
7. Catalytic: GAVI HSS is not intended to stimulate the creation of stand-alone independently managed projects. It is expected however, that GAVI HSS will be an agent for catalytic change where possible, for example to support small-scale approaches or strategies in a geo-graphically discrete area that could subsequently be scaled up by government.
8. Innovative: GAVI encourages the development of innovative models or approaches. GAVI HSS can therefore be used to try something completely new, to pursue a different approach to that tried in the past, or to adapt approaches found to be useful in other countries.
9. Results-oriented: Countries must link their strategies for tackling “bottlenecks” or barriers in the health system with specific indicators that can show how the GAVI HSS funds will ultimately result in improved immunization coverage and other child and maternal health outcomes. The ultimate impact and results of the proposal should be evidenced at the peripheral level (i.e. district and service delivery levels).
10. Sustainability-conscious: Countries should consider the financial and technical sustainability of GAVI HSS support and describe how they expect to sustain the recurrent costs and impact of GAVI HSS support beyond the life of GAVI funding where relevant.
If these principles are followed, I believe some of your difficulties might be overcome. Your Health Sector Coordinating Committee is expected to provide leadership to ensure that these principles are adhered to. On the issue of low capacity, other countries are using the HSS funds, as part of the flexibility of the fund to build in-country capacity and Afghanistan may want to consider that.
Question 5: (Canada)
We have been working with a number of countries in the South to explore and
strengthen the place of health research in health systems. What has been
your experience with evidence-based system, program and/or policy
development? From your own experience, how do you feel health research can best be fostered, and how can it be effectively linked into health systems?
LeeNah Hsu Response:
Linking health research to health system requires that the researcher is working with the system. More specifically, the health researchers, be it clinical or system, are working as part of public health system and conducting research requested by the government. The chances are very likely the results will be and have been utilized in the policy and programmes of the system. We have witnessed it in Asia. In cases where researchers were contracted by external entities to conduct some interesting studies about the health system but were not part of the government's own process or request, the results are often debated, contested and not always implemented. The challenge is not only the quality of the research or the soundness of methodology, but also the process of how the research was initiated, by whom, for what purpose, and which intended use would it be. These need to be clear prior to initiating the research, then the likelihood of the findings be utilized by the health system, from the public sector side, would increase. Of course, one should not forget the important role of private sector health research; they have often been utilized to achieve certain private sector objectives.
Questions 6:
How does a country undergoing SWAp (Sector-Wide Approach) integrate GFIs
into its national health priorities to ensure more efficient and effective financing of its health programmes and avoid overlaps in the health sector?
LeeNah Hsu Response:
The question is an excellent one and a complex one. There is no single ready answer. Rather, it is country specific and situation specific. As there is no standard one size fits all SWAp mechanism, there is also not one formular to address the question. How does a country integrate GHI to its SWAp process? The reality has to take into account the political, financial, historical systems context as well as the constraints in a country in its implementation of both SWAp and GHI, where relevant.
Ideally, a rational approach is to be taken and GHI will facilitate the overall sector plan and support it. However, issues relevant ot health and health related indicators are influenced by factors and sectors beyond health. Thus truly effective GHI would require incorporation and collaboration with non-health sectors which health sector SWAp would only address the health sector portion of the issue. This underline the importance of multisectoral collaboration to achieve even the health indicators and MDGs.
Question 7:
What do you suggest should be the core competencies advocated for students interested in Health Systems Development from a global perspective?
In addition, would it not be appropriate to incorporate in the training sessions on health systems entrepreneurship from a development perspective, as well as, health systems analysis, health systems assessment, and policy development?
LeeNah Hsu Response:
Health systems strengthening competency is not a medical professional issue. Rather, it is a systems approach to managing health sector functions and responses to diverse diseases, illness and health promotion. There are several levels from communities to global. The relevant disciplinary aspects include but are not limited to health care financing, health economics, health work force management including projection, compensation, quality assurance and worker migration in addition to health technology and logistics aspect including procurement, warehousing, and transport to ensure timely and appropriate supply of essential medical commodities as well as pricing of medications which would involve trade issues. It also includes the health sector infrastructures and health data (biostatistics and epidemiologic surveillance structure) and health management information systems. It is also critical for the health system to have enabling policies and regulations to facilitate the function of the system.
A strong health system needs certain level of flexibility in order to adjust to the changing dynamics of disease patterns (emerging and re emerging diseases) as well as demographic shifts. Above all, a much less discussed aspect of strengthening health system is the preparedness of the system which is critical in the rapidly evolving world under threats of climate change induced diseases outbreaks.