IN THE FIELD SPOTLIGHT – ABT GLOBAL

Beyond Borders and Building Blocks: The Future of Health Systems Strengthening

Kelly Saldana, VP of Global Health, Abt Global

Conflict, Climate, the Next COVID…

Today, the health sector is on the frontlines of multiple crises. More people and pathogens are on the move than at any time in history. Migration, climate change, and conflict are creating complex health challenges and vulnerabilities worldwide, including increased illness, malnutrition, changes in vectors and disease patterns, and disruptions in health service delivery.

The future of public health is at a crossroads. Now more than ever, countries’ commitments to health equity and access depend on resilient health systems capable of absorbing shocks and responding to evolving demographics, environmental conditions, and population needs. Donors, leaders, and domestic health financing and solutions must embrace ambiguity and complexity in pursuit of resilience. There are many new ideas on how to improve health systems, but it would be a misuse of the potential if we focus on the shiny new ideas without grounding them in a deep understanding of both the history of how and why health systems have evolved the way they have.

Health for All and Health System Strengthening in a Changing World

The Health for All movement began in 1978 with the Alma Ata conference and declaration on primary healthcare (PHC). However, it lacked clear definitions for specific outcomes, leading to a shift toward selective primary healthcare, which prioritized specific interventions. Over the decades, national and geopolitical health reforms emerged in regions like the former Soviet Union, Central America, and Africa, yet none achieved sustained progress and results for the people.

As health goals became increasingly verticalized in the 2000s—focusing on individual diseases—and governments recognized that many health reforms were ineffective, the World Health Organization articulated a framework for improving the performance of health systems to achieve better health outcomes. This framework, known as the health systems building blocks, includes governance, finance, information systems, human resources for health, service delivery, and access to medical products and technologies, offering crucial insights into health system functions.

Intended to align various health programs, the building blocks became fragmented across initiatives. The President’s Emergency Fund for AIDS Relief (PEPFAR) prioritized essential components—the health workforce, data, supply chains, and leadership countries desperately needed to deliver HIV/AIDS services—and over time these interventions generated rich evidence for what works when programs invest in systems strengthening to improve health service delivery and outcomes. 

Still, programs that have a primary focus on strengthening health systems and health security are going to be more effective than a program primarily focused on reducing HIV/AIDS—even if funding for the latter vastly outweighs funding for the former.

Central to health equity and resilience are two key issues: Most global health assistance has concentrated on specific diseases, services, and health outcomes, rather than “health for all,” the principal of universal health coverage. Inevitably, many populations fall through the cracks of vertical programs, with inequitable outcomes. Additionally, most health initiatives were not designed to prepare countries for near- or long-term shocks, such as conflict, migration, and climate change. Aside from a small stream dedicated to health system strengthening, expenditures in low- and middle-income countries (LMICs) have focused on short-term health care—areas that are easily tracked but do not foster resilient systems.

The global aid community tends to favor linear solutions—vaccines prevent disease, better seeds grow better crops—but systems change is not so straightforward. Investing in systems and resilience requires society and the overall political economy to value health security, disease prevention, and resilience.

COVID highlighted the critical importance of health systems. Siloed interventions are insufficient for improving healthcare. This situation underscores the need for integration across health system building blocks and a focus on foundational health aspects.

Solutions, Beyond Building Blocks: How Primary Care Can Advance Equity, Resilience, and Localization in Rapidly Changing Contexts

As nations contend with the pandemic's multifaceted impacts, there is a renewed urgency to enhance PHC capacities, improve health system resilience, and prioritize equity in healthcare delivery. According to a recent USAID report, “Primary Impact,”[i] primary healthcare is viewed as the most inclusive, equitable, and cost-effective pathway to achieving universal health coverage. It is also essential for bolstering health system resilience to prepare for, respond to, and recover from crises. And it can be the bridge between vertical programing that struggles to reach more than two billion people and the aspiration of universal health coverage.

PHC emphasizes accessibility, continuity, and comprehensiveness of essential health services, addressing individuals’ health needs throughout their lives with preventive, curative, promotive, and rehabilitative care. As a decentralized model, PHC also aligns with localization goals, focusing on the local networks[ii] and resources necessary to provide contextually relevant services. This approach fosters health systems that are responsive and resilient to the unique challenges faced by local populations through decentralized decision-making and power-sharing.

This moment presents a significant opportunity for health systems. We must capitalize on the progress made over the last two decades. Though health systems were a relatively new field in 2007, the advancements achieved since have cultivated practitioners worldwide.

Countries have gained valuable insights that can advance PHC, drawing on evidence from six generations of health systems strengthening programs[iii] across numerous nations.

With a focus on understanding data and evidence, we can maintain momentum toward progress without repeating past mistakes

Kelly Saldana has 25 years of experience in international development and health. She worked in many regions of the world while serving in senior roles at the U.S. Agency for International Development (USAID).

For over 30 years, Abt has helped countries revolutionize quality and regulatory systems, inclusive healthcare policies and delivery models, innovative financing and financial protections, and sustained access to essential health services and products. With 1000+ staff working in health systems worldwide, we co-develop and lead interventions with a deep understanding of the interplay between governance, system processes, cultural nuances, social norms, and stakeholder power dynamics.

This article originally appeared in the Fall 2024 edition of Service Contractor magazine.