Viviana Mangiaterra, Head of Resilient and Sustainable Systems for Health at the Global Fund since 2014, spent most of her career working in the field of maternal and child health services at the WHO and later at the World Bank. Hired to conceptualize the Global Fund’s commitment to health system strengthening, she designed the tools and framework that underpin the RSSH pillar of the 2017–2020 strategy. Having accepted a position as Associate Professor at Università Bocconi in Milan, Mangiaterra will write a report on progress made with respect to health system strengthening before leaving the Global Fund in September.
What were the main challenges when you joined the Global Fund team in 2014?
In 2014, the funding for activities aimed at strengthening health systems and including it in programs was already comprised in the grants, but the reflection process and paradigm shift really began in 2016 as part of preparations for the 2017–2020 strategy.
There was already consensus on the importance of investing in health systems, which is needed to achieve the GF’s expected outcomes, so we refined the strategy and started fine-tuning the work. The Ebola experience proved to be crucial: the crisis resulted in progress being erased in three countries by considerably weakening their health systems. As a result, activities targeting pandemics came to a halt, and patients stopped visiting the health centers for testing and treatment. As ties with the community system were quite weak, for months there was no strategy for reaching patients.
The reflection process is also placed within the perspective of the Sustainable Development Goals, which aim to be more inclusive and systematic than the Millennium Development Goals, and require responses that are cross-cutting, systemic and sustainable.
The entire team, together with Mark Dybul, worked hard to put in place baseline studies in the different countries, and for the first time, investing in RSSH became a strategic goal in and of itself and, more generally, an action point. The concepts of resilience and sustainability contained in the name RSSH bear witness to this shift, does not indicate a significant change in terms of the investment figures (about 27% is earmarked for health systems), but we worked on identifying the priorities.
What organizational changes did this shift involve?
First, we developed a methodology to track and measure investments in RSSH because we didn’t have a sense of the big picture; the information was scattered among different sources and nobody had a clear idea of the nature or volume of the Global Fund investment in this area. Using the tool we developed, which consisted of a dashboard, enabled us to better understand what was being funded and done in the field. It also allowed us to develop a culture of how to better optimize the investments. In addition, we engaged in a reflection process with the Secretariat and the operations group to look at the priorities for funding, given the global momentum created by all the donors working on health systems.
In operational terms, this paradigm shift also translated into moving towards a patient-centered approach. The success of such an approach will depend on strengthening ties with the patient environment and the community system. The latter, when operating, is crucial to reaching patients and is also a resilience factor in the event of a system crisis.
The discussions also addressed how we can better track health system indicators. Previously, the teams had made significant investments in health information systems and the supply chain; the data was provided by supply chain audits. But it was necessary to complement that analysis with data on health human resources, a crucial topic, and on the organization and performance of the community system. Activities such as strengthening national strategies, developing community health strategies and defining good governance and the role of community health workers have become very important. Together with the operations teams, we worked on the concept of integrating patient-centered services. Sustainability is based on interventions that are well aligned with and included in comprehensive service packages provided at the local level by community actors.
Which beneficiary countries were early adopters in this area?
Some countries have demonstrated the value added of integrating GF investments into national health system strengthening plans. Some evaluations have been very positive and have shown that political leadership was an essential element in early adopter countries in terms of primary and community health. The GF did not lead the way in these processes, rather, it aligned itself with the will of the presidents of the countries in question. The Global Fund placed its trust in them, and the positive outcomes are encouraging.
There is now growing scientific proof that investing in primary and community health is key to offering accessible and quality health services. The more global momentum that has coalesced around achieving the SDGs and universal health coverage has made it possible to establish partnerships supported by the World Health Organization. The Global Fund is a stakeholder in this process through the funding it allocates, and through its participation in primary health platforms and in the G7, guided by France. So, the time is right.
Some interesting examples have not yet been documented, such as Benin, and Afghanistan, which provides integrated services via “family health houses”, in which community health workers provide integrated packages of services, and to which patients are referred by midwives and community health workers who send them for HIV and TB tests as well as pre- and post-natal consultations.
How is the Secretariat preparing for the upcoming cycle by integrating RSSH?
We are in the process of fine-tuning the tools designed to assist with drafting concept notes and technical guides to help countries reflect on their investment priorities for RSSH in their national strategies. The needs are many, and so it may be useful to set priorities that consider financial constraints and the relatively short term of grants (three years). We are now in a better position than we were three years ago; efforts have been made to strengthen the process of developing national strategies, which specify those priorities. If this strategy is sufficiently robust, integrated and supported by a budget, it will help guide the choice of priorities for those three years. In addition, the joint work being done with the governments of beneficiary countries to define their capacity to mobilize domestic resources is crucial. These investments in health will have a positive impact on the economy and development of these countries and their leaders are conscious of that.
It is important to acknowledge that our investments are still limited and have a "catalyzing" effect. They do not, in any way, cover all the needs, a situation that calls on us to also engage in dialogue with the other technical and financial partners.
What are you discussing with the other health system partners?
I’ve seen big changes; we have many more partners than we did five years ago. Donors have a real desire to align their efforts and provide support to the governments of recipient countries. The Global Fund no longer makes investments that are not aligned with the national health development plans of recipient countries, we avoid spreading ourselves thin and support national strategies. We are working hard to align ourselves with Gavi, the Vaccine Alliance, and others. We hold quarterly meetings to analyze the DHMIS results and we plan to integrate immunization indicators into our HSS dashboard to align our country dialogue activities. Integrating our data will help better identify investment priorities.
The Global Financing Facility (GFF) and the World Bank have shown interest in the dashboard, which will also be used in the GFF’s next wave. This would enable us to use the same analysis of the health system situation and develop a global financial plan to reflect the needs of all partners. Partnerships are also being established with bilateral partners like the French, Germans and Scandinavians. These countries also sit on the CCM, which could help bring these topics to the discussion table. Our discussions with France center on the community system and health system strengthening through integrated health centers as a first-line investment. As for Great Britain, it would like to focus on universal health coverage.
The next three years will be crucial in terms of investing in sustainable and resilient health systems. The climate is conducive to this, especially with regards to the universal health coverage conceptual framework, which is becoming an umbrella for all activities in this field. The next deadlines (G7, G20 and UHC) and the restructuring of the WHO are all converging on health system strengthening. The planets are now aligned for positive results.