Abt Associates Inc.  In collaboration with:I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane University’s School of Public Health

better systems, better health

Better Health Systems: Strategies that Work Presentation series at the Global Health Council

Fred RosensweigApril 3, 2012

Lessons Learnedin Organizational Capacity Building for Health Systems Strengthening

Agenda

Definition of capacity building Overview of Health Systems 20/20 capacity-building

activities Our methodology for determining lessons learned Lessons learned Summary

Definition of Capacity Building

System-level capacity building has three levels of intervention Individual level – knowledge and skills Organizational level – single organization System level – multi-organizational in nature

Health Systems 20/20’s Focus

Regional and country-level organizations that enable health system strengthening• National government agencies that have stewardship role• Research institutions that provide evidence for HSS• NGOs and consulting firms that provide TA• Education and training institutions that train health system

leaders Strengthened 24 organizations over six-year period

Three Broad Types of Organizational Capacity-building Activities

Comprehensive capacity building covering core organizational competencies

Strengthening capacity of central government agencies

Targeted organizational capacity building in a specific technical area

Examples of Organizations Health Systems 20/20 Has Strengthened

Government HIV/AIDS Office in MOH (DRC) NAC Secretariat (Liberia) MOH Health Economics and Financing Directorate (Afghanistan) MOH HIS Directorate (Namibia)

NGOs/Consulting Firms AFENET (regional) PROSALUD (Bolivia) Health Systems Action Network (global)

Research Institutions HSPI (Vietnam) ISED (Senegal) ECSA (regional) Regional School of Public Health in Benin (regional) HEARD (South Africa)

Education and Training Institutions Kinshasa School of Public Health (DRC) National TB and Leprosy Training Center in Zaria (Nigeria)

Characterizing Health Systems 20/20 Capacity-building Activities

Almost all multi-year in nature Most led by team leader skilled in organizational

development and change management Wide range of organizational types Both new and well established organizations Covered a wide range of settings including fragile

states Majority in Africa

Methodology to Develop Lessons

Review of documentation Interviews with team leaders (16) Interviews with heads of client organizations (9) Analysis of interview data and determination of

lessons learned Validation with capacity-building and HSS specialists

Lessons Learned

Four Categories of Lessons

1. Role of organizational capacity building in HSS

2. Targeted organizational capacity building3. Design of organizational capacity building

activities4. Practice of organizational capacity building

Role of Organizational Capacity Building in HSS

1. Organizational capacity building should be aimed at those organizations whose role is to strengthen the health system

Organizations to Strengthen in Context of HSS

Role and Functions Illustrative Organizations

Leadership/stewardship Offices in MOH (e.g., HIV/AIDS, NAC)

Research Universities, research institutes

Technical assistance NGO, consulting firms, universities

Training Training institutions

Advocacy NGOs

Standard setting Professional organizations, MOH

Role of Organizational Capacity Building in HSS

2. Success of HSS efforts depends on both overall management and technical capacity of organizations that strengthen the health system

Without management capacity to set direction, plan and implement activities, and manage resources, technical capacity-building will have limited impact

Targeted Organizational Capacity Building

3. Select the right partner for targeted organizational capacity-building activities Functional management and administrative

systems Leadership commitment to use strengthened

capacity Staff buy-in and commitment Willingness to engage as full partners

Targeted Organizational Capacity Building

4. Targeted capacity building in HSS approaches requires a strong learning-by-doing component at each stage and a willingness by partner to engage and learn Qualitative data collection and analysis are more difficult

to master Capacity-building process must be led by senior expert in

methodology Most capable partners are busy and have limited time to

engage

Design of Organizational Capacity Building Activities

5. Take a holistic and comprehensive approach and focus on full range of organizational competencies Starts with needs assessment Reflected in intervention plan Basis for monitoring and mid-course adjustments Interconnectedness of interventions

Core Organizational Competencies

Management Systems

GovernanceTechnical As-sistance and

Training

Resource Mobiliza-tion

Technical Competence

Organizational Development

Focusing on the Whole Organization

“As a result of all of this assistance, one of the greatest things we have achieved is cohesion in the network. Without the governance assistance, as well as the development of some of the fundamentals, it is highly likely that the network would have crumbled in the first year. We have different institutions, different cultures, and different ways of doing things and yet we have maintained cohesion and I attribute a lot of that to the assistance to the Health Systems 20/20 project.”

David Mukanga, AFENET Executive Director

Design of Organizational Capacity-Building Activities

6. When creating a new or nascent organization, ensure it has a viable business model

In other words, does the organization offer programs and services that others are willing to support?

Design of Organizational Capacity-Building Activities

7. Design capacity-building activities so the client organization has the incentives to engage in the capacity-building process Tied to longstanding relationships Tangible incentives Offers potential business opportunities Attractiveness to funders

Design of Organizational Capacity-building Activities

8. Define benchmarks for success and milestones for measuring progress at the beginning and update on an ongoing basis

Illustrative Organizational Capacity-building Indicators

Accepted and understood strategy to guide decision-making Adequate number of qualified staff with clear roles and responsibilities to

carry out key functions Leadership that can provide direction and align actions with strategy Management capacity to plan, budget, and implement activities Key management systems (financial, IT, HR, and procurement) in place

and functioning Effective relationships with other organizations established Governance structure that provides oversight and checks and balances Ability to mobilize resources to carry out mandate and be financially viable

Practice of Organizational Capacity Building

9. Form a partnership with host organization by ensuring trust and collaborative engagement “During the design phase we had a series of discussions with the Health Systems 20/20 team. We explained our problems, provided our recommendations and suggestions. We also had inputs from the Health Systems 20/20 team…we listened to their recommendations and saw flexibility from their team. It was a consensus agreement from both parties that led to successful outcomes.”

Dr. Salehi, Afghanistan HEFD

Practice of Organizational Capacity Building

10. Maximize use of local consultants and organizations and provide appropriate supervision Consistent with spirit of country ownership Local expertise exists in many countries with some

exceptions (e.g., organizational development) Effectiveness depends on providing direction and

necessary supervision

Practice of Organizational Capacity Building

11. Ensure buy-in and commitment from senior leadership by:

Agreement on assessment dimensions Review and approval of all consultants Regular check-ins Communication with others in the organization Responsiveness to client’s priorities

Practice of Organizational Capacity Building

12. Be flexible and adapt the approach and interventions to emerging needs

“While the consultancy had objectives, it wasn’t very rigid. Many times with consultants – they are not flexible. The project is designed before they even get involved and they want to carry it out as it was written. But you encounter rocks in the road; things change. The good thing about this consultancy was that they were flexible. You can’t always do everything that was in the original plan.”

Luis Fernandez, Executive Director, PROSALUD

Practice of Organizational Capacity Building

13. Tailor all interventions to the country context, size and sophistication of client organization, and resources available

Stage of growth State of the country Time required Availability of qualified local consultants

Summary

We have improved our understanding in some key areas: How organizational capacity building contributes to HSS Which organizations to strengthen in the HSS context What organizational capacities to strengthen How to design and implement comprehensive and targeted

capacity-building activities

Measurement remains an Achilles heel

Final Questions

Should donors be investing in organizational capacity building?

What agreement can be reached on the measures we should use?

How can we better document and communicate the value of these investments?

Abt Associates Inc.  In collaboration with:I Aga Khan Foundation I Bitrán y Asociados I BRAC University I Broad Branch Associates I Deloitte Consulting, LLP I Forum One Communications I RTI International I Training Resources Group I Tulane University’s School of Public Health

better systems, better health

www.HealthSystems2020.org

Thank you