2024 Webinar on Health Systems Strengthening by the SDC Health Network: Summary and Key Takeaways

The COVID-19 pandemic showed the importance of building health systems’ resilience to prevent and efficiently respond to health shocks. Yet health systems in a large number of low- and middle-income countries (LMICs) suffer from a lack of investment and poor management of available resources, with services relying too heavily on external funding. As a result, infrastructure, technologies and equipment are lacking, and there is an acute shortage of qualified health workers. Furthermore, the absence of financial protection mechanisms forces patients to cover a large part of the costs themselves, thereby exacerbating inequities in access to care and hindering the achievement of Universal Health Coverage (UHC) as part of the 2030 Agenda.

Supporting health systems strengthening (HSS) allows qualitative, affordable, available and integrated care to be provided to patients. It also includes the capacity of health systems to respond adequately to immediate and potential health emergencies. To improve health for all at all ages, a coordinated approach to social, economic, cultural and environmental determinants of health is needed.

The SDC takes a comprehensive approach (Federal Department of Foreign Affairs, Swiss Agency for Development and Cooperation, Global Programme Health Framework 2021-24, 2020.) and supports HSS interventions in LMICs, as follows:

1. Innovative quality health products for poverty-related diseases developed through research and development. This includes product-development partnerships (PDPs), e.g. DNDi.

2. Access to affordable quality health services – with a focus on primary healthcare services, products, and technologies.

3. Inclusive governance and participation by supporting a culture of accountability, anti-corruption and transparency in the allocation and use of resources. At the community level, the SDC supports health promotion initiatives for disadvantaged and marginalised population groups. This includes increasing the health literacy of the population and reinforcing the capacity of communities to advocate for the right to health and health equity.

4. Innovative and sustainable health financing: the SDC supports reforming global and country health financing architecture by:

• making the case for increasing the national budget allocation to the health sector,
• advocating for the cost-effective use of existing resources based on needs,
• advocating for a fairer distribution of health costs and the use of financial protection mechanisms to protect people from out-of-pocket expenses.

5. Addressing factors that determine health: investing in reducing risk factors (environmental pollution, climate change, malnutrition, poverty, water, migration, etc.) is crucial to public health and the return on that investment benefits societies by ensuring a healthy population. The SDC therefore invests in these key determinants of health beyond core health interventions.

6. Gender-sensitive and gender-responsive HSS: health systems are not gender neutral. «Gender is a critical social determinant of health and intersecting gender inequalities reduce people's access to health services and in turn put their health and wellbeing at risk.» (A. Achrekar, S. Akselrod, H. Clark, G. Cuevas Barron, M. Charles, K. Dain, R. Dhatt, M.Khan, J. Koonin, I. Orankoy, S. Thapaliya, C. Umuhoza, Delivering health for all: the critical role of gender-responsive health systems, The Lancet Global Health, March 2024, https://doi.org/10.1016/S2214-109X(24)00120-7).

The SDC supports the integration of women's, adolescents', and girls' sexual and reproductive health and rights (SRHR) into essential benefits packages at the primary healthcare level. Interventions are informed by sex-disaggregated and gender-disaggregated data, and address gender inequality in the healthcare workforce.

The SDC has been present in Zimbabwe and Zambia since 2005, with various interventions addressing HIV/AIDS and strengthening SRHR. The Swiss Cooperation Programme Zimbabwe and Zambia 2023–26 plans a shift towards a broader approach to health, by emphasising quality system delivery and shock-responsive systems to improve health and resilience, especially for women, young people and marginalised populations.

In light of this shift, the learning event aimed to provide conceptual clarity on HSS and an overview of the SDC’s approach, and the comparative advantages and interventions in this regard. An additional objective was to facilitate the sharing of best practices and experiences by selected SDC embassies and country offices in HSS.

Participants were expected to:

• Gain a common understanding of HSS, primary healthcare, integrated services, and multisectoral action in health in a post-pandemic era.
• Learn about the SDC’s approach, engagement and added value in HSS.
• Share knowledge, experience and lessons learned in designing and implementing HSS programmes, advocacy and policy dialogue.
• Identify preliminary HHS intervention packages for the Zambia and Zimbabwe Cooperation Programme 2023–26, acknowledging that this would require further support beyond the webinar and that the event was intended as a first step.

The objective of module I was to provide an opportunity for dialogue with the SDC Cooperation Office (BuCo) in Harare, which is planning to adopt a broader and more holistic approach to its health interventions. This included discussing the BuCo's activities in Dar es Salaam related to health financing and its work on SRHR in Burundi. The module also aimed to offer an overview of the multilateral HSS landscape and the global activities supported by the SDC, such as the P4H Network and the Global Fund. SDC colleagues from both the field and head office shared their insights and lessons learned from HSS interventions.

Part 1: Focus: Buco Harare – Tarnutzer Liliane (25’)

This presentation focused on the SDC’s previous and current approach to addressing health issues in Zambia and Zimbabwe, highlighting a shift from a disease-specific to an integrated, HSS approach. It discussed opportunities, strengths and bottlenecks, and identified needs in terms of developing an HSS approach within the SDC’s health programming.

Part 2: Peer exchange – Matoro Jacqueline and Sibomana Seleus (45’)

Health financing (BuCo Dar es Salaam) - Jacqueline Matoro

The presentation began with an overview of key milestones in health financing in Tanzania. It then addressed the current state of health insurance in Tanzania, highlighting the very low universal coverage rate, with only 15% of the population insured.

Next, the presentation reviewed Switzerland's commitments to HSS, focusing on three SDC projects, their approaches, and various entry points. Examples of interventions conducted under these projects were also provided.

Finally, the main lessons learned from these projects were presented:

• Every HSS project should be long-term, starting with a pilot phase, followed by a consolidation phase, and finally scaling up.
• Political and technical dialogue is crucial.
• Operational research should be a central element to inform political dialogue.
• It is important to encourage the use of existing systems and structures rather than creating parallel systems.
• Donor coordination is essential to avoid resource duplication.
• When well implemented, health insurance can be a very powerful mechanism for financing the health sector with national resources.

Integrating SRHR into the PHC package (BuCo Bujumbura) – Sibomana Seleus

The presentation first outlined the main characteristics of the healthcare system in Burundi and its various levels. It provided an overview of SRHR services and their providers in Burundi.

Next, it discussed the strategic priorities of the Swiss Agency for Development and Cooperation (SDC) in Burundi, highlighting various examples of interventions related to sexual and reproductive rights. The presentation explained how the SDC’s interventions aim to integrate SRHR into the primary healthcare system based on WHO's six-pillar HSS model.

Finally, it provided an overview of the key challenges and positive factors regarding SRHR in Burundi, such as social taboos, religious practices, rumours, high living costs, access to quality services, lack of qualified staff, education, and communication.

Part 3: Overview of the global HSS policy dialogue dynamic and trends: multilateral focus – Selena Lopreno, HQ (10’)

The presentation provided an overview of the multilateral HSS landscape. It first provided a general context, discussing the multiple crises and current geopolitical context, the fragmentation of efforts, as well as the paradigm shift among international health organisations, resulting in new funding mechanisms. In this context, the pursuit of public health promotion, the integrated care model, and a broader approach to transforming healthcare systems play a crucial role.

The presentation then reviewed the main global efforts supported by the SDC, such as WHO, the Global Fund, GAVI, UNAIDS, as well as various programmes such as FIND, P4H, SUN, IPPF, PDP, GARDP, MMV and IVCC. The added values brought and challenges faced by each of these organisations were discussed in detail.

Finally, there was a focus on the Global Fund approach, which Switzerland has supported since 2002. This fund focuses on the treatment and prevention of HIV, tuberculosis and malaria, while aiming to improve global health systems by strengthening quality of care, data monitoring, accountability and governance.

The objective of the module was to continue exchange and discussion between the BuCos and head office on HSS interventions, as well as to present key global trends in HSS policy dialogue. SDC colleagues in the field shared their insights and lessons learned from HSS interventions.

Part 1 : Global HSS policy dialogue – Erika Placella, HQ (20’)

Erika Placella gave an overview of the dynamics and trends in global HSS policy dialogue as well as complementarities and leverage for bilateral programmes.

Part 2: Peer exchange – Alma Zukorlic, BuCo Sarajevo & Milton Saranga, BuCo Maputo (20’)

Mental health in action (Buco Sarajevo) – Alma Zukorlic

The presentation focused on the SDC's mental health activities in Bosnia and Herzegovina. It began with an overview of the context, noting a significantly increased number of people with mental health problems and post-traumatic stress, depression, suicide and domestic violence due to the whole legacy of war and the challenges posed by transition processes and economic and political stagnation. The presentation then detailed the mental health project supported by the SDC, which aimed to contribute to the reform of the mental health system with a strong emphasis on engagement with the health authorities. It described the past and current state of the mental health system, including improvements made.

The discussion focused on how to establish and support community mental health centres. It also addressed the success factors for these interventions, in particular the importance of integrating mental health services into existing primary healthcare systems.

Provision of health services in emergency contexts (Buco Maputo) – Milton Saranga

The presentation covered health and WASH services in humanitarian contexts in Mozambique. It began with an overview of the various crises affecting Mozambique, including armed conflicts, natural disasters, and recurring cholera outbreaks.

Next, it reviewed the available health services in Mozambique, highlighting numerous deficiencies in quality and coverage. The presentation also introduced the different SDC partners involved in health and WASH interventions in these contexts.

Finally, the main lessons learned from these interventions were shared:

To address the challenges of emergencies in Mozambique, a comprehensive and adaptable approach is essential, as most emergencies are prolonged. While interventions focused on livelihoods and humanitarian resources are important, they cannot replace broader development efforts— a ‹nexus approach› is needed. Humanitarian aid in emergency contexts can reduce government commitment to providing basic services, leading to a substitution rather than a complementarity of services.

• To address the challenges of emergencies in Mozambique, a comprehensive and adaptable approach is essential, as most emergencies are prolonged.
• While interventions focused on livelihoods and humanitarian resources are important, they cannot replace broader development efforts— a ‹nexus approach› is needed.
• Humanitarian aid in emergency contexts can reduce government commitment to providing basic services, leading to a substitution rather than a complementarity of services.

• Peer experience and exchange, including sharing successful strategies and obstacles, are highly valuable and while specific issues might vary according to context, the core HSS principles, such as the need for sustainable financing and effective governance, remain universally relevant. This reaffirms the value of ongoing dialogue and knowledge sharing within the SDC.
• To strengthen health systems, adopting a comprehensive and inclusive approach is fundamental.
• Continuity of care by health facilities and other care providers is of the utmost importance and SDC activities should be complementary to the basic services provided by the government (and not a substitute for these services). Long-term planning is needed in HSS, using existing structures and avoiding creating parallel structures, where possible. This is why advocacy as well as political and technical policy dialogue is very important.
• Given the issues noted above, coordination between donors and stakeholders is necessary to avoid duplication.