Health Systems Strengthening in PostConflict Settings: Perfectly logical or totally insane

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Health Systems Strengthening in Post-Conflict
Settings Perfectly logical or totally insane?

• Yogesh Rajkotia
• Senior Health Systems Advisor
• October 5, 2007

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The Challenge Health Status
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The Challenge Health Status
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The Challenge Health Status
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The Challenge Health Status
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The Landscape
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Projected coverage gap Liberia
Source Liberia MoHSW, Presentation to Partners
Forum, Oct 4, 2007
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Are we nuts? HSS in post-conflict states?

• South Sudan is not ready for health systems
  strengthening Geneva
• We believe that focusing on HSS is not
  appropriate at this time for South Sudan
• USAID Cooperating Agency
• Why focus on HSS when there are so many critical
  health needs in S. Sudan? Washington DC

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Key Findings from Southern Sudan
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Structure of the S. Sudan Health System
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In a nutshell

• Limited/no public salaries for health workers
• Limited/no supplies of drugs
• No public budget for recurrent costs
• Inadequately trained health workers
• Poor infrastructure at health facilities
• Limited standardization of services
• Large degree of variation by NGO provider

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Why limited finances supplies?

• Financial disbursements to States slow
• Insufficient funds for salary support and other
  recurrent costs at State County level
• Budget process not based on data
• States and counties unclear about budget process
  at central level

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Why no/limited drugs?

• GoSS/MDTF procurements slow over 1 year process
• Facilities rely on multiple donors/NGOs for drugs
• Donor/NGO distribution systems weak
• Facilities counties have limited forecasting
  capacity
• Weak storage capacity many drugs damaged and/or
  expired

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Why limited management?

• State-level management capacity
• Most states lack dedicated planning staff
• Insufficient funds for salary support
• Poor HMIS flows
• State health management teams not functional
• Lack critical tools processes
• Members unclear on roles/responsibilities
• States lack critical communication coordination
  infrastructure (internet, phone)

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State-level communication infrastructure
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County-level management capacity

• County administrations nascent many non-existent
• Salary support for county staff very limited
• Skills at county level lacking
• County health management teams not highly
  functional
• Role of county vis-à-vis NGOs unclear
• Coordination with State level minimal
• Functional teams have limited interaction with
  village health teams

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Community-level management capacity

• Village health committees exist as historic part
  of Sudanese health system
• Some are more functional than others Depends
  mainly on community involvement and NGO
  willingness to engage
• Where they are working, community teams play
  fundamental role of health promotion management
  of health facilities

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• How does health systems strengthening fit into
  the Transition agenda?

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What does it mean to transition?

• Transition of Resources How to structure donor
  resources when relief agencies leave?
• Transition of Leadership How to move a highly
  fragmented system into one led by the MoH?

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Transition of resources

• Move away from clinic-specific finance to
  county/state/nationally pooled or coordinated
  finance
• Move away from many multiple, disparate
  drug/commodity supply systems to fewer, more
  comprehensive systems
• Develop strategy for moving away from donor
  financing of recurrent costs
• Coordinated plan for new infusion of investment
  in infrastructure

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Transition of leadership

• Develop national policy framework
• Basic package, infrastructure, decentralization,
  systems processes
• Systematize service providers
• Performance-based contracts in Afghanistan
• Establish nuts-and-bolts processes, such as
  payroll, budgeting, HMIS, procurement, etc
• Strengthen decentralized management structures
• Supervision, planning, monitoring, etc
• Facilitate civil society participation
• Village health committees
• Community health workers

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The Musts of the transition process

• Service delivery must NOT be interrupted during
  transition phase
• Early stages of transition may require
  significant external financing of recurrent costs
• Citizens must not lose confidence in the public
  sectors ability to deliver basic services
• Critical to establishing legitimacy of newly
  formed governments
• Development-oriented service delivery must focus
  on capacity development
• Concrete steps include joint supervisory visits
  and joint planning exercises

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The approach in Afghanistan

• Development of policy framework, including
• Basic Package of Health Services
• Defining HR cadres
• 2. Rapid expansion of primary health care
  services
• Effectively allocating donor investments in
  infrastructure
• Contracting NGO and other non-state providers to
  expand services
• Rapid training based on newly defined HR cadres
• 3. Strong government focus on management of the
  health sector
• Establishing priorities, policies, strategies and
  plans
• Delineating roles responsibilities between
  central prov. levels
• Collecting and using information to make
  evidence-based decisions
• Overseeing, monitoring, and coordinating
  activities NGO activities
• 4. Leveraging civil society
• Community management health facilities
• Developing system of community health workers

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The result in Afghanistan
Source Afghanistan Health Sector Balanced
Scorecard National and Provincial Results. MoPH,
JHSPH, IIHM. 2006
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Estimate for 2000 from 2002 State of the
Worlds Children, UNICEF Estimate for 2004/05
from 2006 Afghanistan Household Survey, JHU and
IIHMR
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Conclusions

• Were not nuts HSS is a critical in part of the
  transition from relief to development
• Focusing on policy development early on is
  critical to ensure reconstruction efforts are
  systematic, not ad hoc
• Post-conflict approach cannot be pure relief or
  pure development must be a hybrid formula

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Thank You!