Implementing health system strengthening projects at USAID: Findings from five cases using an integrated framework

ABSTRACT

Evidence on the implementation of health systems strengthening (HSS) interventions is scarce. Donors need this information to prioritise investments and lobby for continued financial support. To develop a deeper understanding of the implementation dynamics of robust HSS interventions, we retrospectively compared five USAID-supported projects in the Dominican Republic, Ethiopia, Kazakhstan, Rwanda, and Zambia. A document review and key informant interviews (n = 44) were conducted, coded, and analysed in each of the five cases using an integrated implementation framework. The framework was organised by four phases of implementation. For the pre-condition phase, data-driven HSS interventions were nested in a range of political contexts and with differing levels of financial support. In pre-implementation, cases relied on diverse teams that created a data-informed, inclusive, and transparent project ethos for implementation. Implementation was located at multiple tiers of the health system, used interventions as catalysts for government initiatives, supported governance/accountability initiatives, and responded nimbly to contextual changes in the implementation climate. There was less evidence of maintenance and evolution but all cases were designed with an eye towards sustainability. This research yields important insights about the dynamics of HSS, identifying ways donors can better support countries to achieve universal health coverage.

KEYWORDS:

• Implementation research
• health systems strengthening
• USAID
• development

Acknowledgements

This study was made possible by the United States Agency for International Development’s financial support of the Health Finance and Governance Project. The authors would like to thank the Technical Advisory Group at USAID for overall study guidance and advice on communicating the findings, including Elisa Adelman, Katie Qutub, Rochika Chaudhry, Diana Frymus, Helen Petach, Amy Kay, Claudia Conlon, Jean-Jacques Frere, Aye Aye Thwin, Ishrat Husain, and Bob Emrey. The authors would also like to thank Ted Keane, Cristina Sciuto, Lily Rosenthal, and Hannah Arem for contributing to data collection and analysis. Thanks also to Emily Mendenhall who provided feedback on this manuscript. Finally, the authors express their gratitude to all interview participants who were kind enough to share their experiences about health systems strengthening.

Disclosure statement

No potential conflict of interest was reported by the authors.

Ethics approval

This study was submitted to the Institutional Review Board at Abt Associates and Johns Hopkins Bloomberg School of Public Health where it was determined to be exempt from review. Verbal consent was obtained from all study participants.

ORCID

Adam D. Koon http://orcid.org/0000-0002-9031-9810

Daniela C. Rodriguez http://orcid.org/0000-0003-2523-1123

Notes

1 The full repository of submitted cases can be accessed here: https://hssglobalcall.hsaccess.org/.

Additional information

Funding

This work was supported by the United States Agency for International Development [grant number AID-OAA-A-12-00080]. The funding source was involved in study design and data collection. Through a Technical Advisory Group, the funding source provided regular feedback on the analysis and interpretation of data for this study. Two of the authors, JN and SS, are or were USAID staff during this study’s implementation but did not participate in data collection.