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

Area of Science:

• Global Health
• Health Systems Research
• Implementation Science

Background:

• Limited evidence exists on the practical implementation of health systems strengthening (HSS) interventions.
• Donors require robust data to effectively prioritize investments and advocate for sustained financial support for HSS.

Purpose of the Study:

• To gain a deeper understanding of the implementation dynamics of effective HSS interventions.
• To identify factors influencing the success and sustainability of HSS projects.

Main Methods:

• Retrospective comparative analysis of five USAID-supported HSS projects across diverse countries (Dominican Republic, Ethiopia, Kazakhstan, Rwanda, Zambia).
• Utilized a document review and key informant interviews (n=44) analyzed through an integrated implementation framework.
• Framework examined four distinct phases: pre-condition, pre-implementation, implementation, and maintenance/evolution.

Main Results:

• Pre-condition phase: HSS interventions were influenced by political contexts and financial support levels.
• Pre-implementation phase: Diverse teams fostered a data-informed, inclusive, and transparent project environment.
• Implementation phase: Interventions were multi-tiered, catalyzed government initiatives, supported governance, and adapted to contextual changes. Sustainability was a design consideration, though maintenance and evolution showed less evidence.

Conclusions:

• Successful HSS implementation involves strategic positioning within political contexts, inclusive team dynamics, multi-tiered system engagement, and adaptability.
• Donors can enhance support for HSS by understanding these implementation dynamics to better assist countries in achieving universal health coverage.
• Further research into the maintenance and evolution phases of HSS interventions is warranted.