in this lecture, we'll be introducing the concept of health system strengthening and discussing some of the ways in which it differs from traditional programming efforts. Health system strengthening is built on the principle of universal health coverage, that is, that all people can access health services needed one and where they need them without financial hardship. It includes essential health services ranging from health promotion and prevention to treatment, rehabilitation, and palliative care. The declaration of Alma Ata, adopted in 1978, was the first of its kind to underscore the importance of primary health care as an approach to achieve universal healthcare for all. The declaration also stressed the need to invest in health systems and build primary health care from the bottom up. In practice however, emphasis on cost effectiveness, created competing programs but acted independently on selective primary health care. Over the past few decades, international community has affirmed the crucial role that health system strengthening plays in achieving improved health. Most recently, it was upheld by the international community as a key strategy to achieving universal health care. In the 2018 Astana Declaration. Specifically the Astana Declaration stated that primary health care is the most inclusive effective and efficient approach to enhancing people's physical and mental health as well as social well being. In short, a health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. So, how do health system strengthening approaches compared to traditional approaches? As you can see in this two by two, table, there are two key aspects of health system strengthening approaches that stand out. The first is whether the intervention messed with an existing infrastructure and build on local structures such as public sector hospitals. This might be in comparison to those interventions where a private hospital or NGO facility is used developing a parallel system. The second key aspect of a health system strengthening approach is the type of intervention is typically cross cutting across multiple disease areas as supposed to focus on one specific disease. For instance, an intervention that seeks to train public sector nurses to develop quality antenatal care is taking the health system strengthening approach in that it is focused on improving the quality of existing care and focused on training nurses which would have met benefits across multiple disease areas. In comparison and intervention that invests in an NGO led TB screening that requires the recruitment and training of a new hire capture of health workers would not be seen as a health system strengthening approach. In this scenario, the NGO may create a distortion to the existing coverage. Additionally, creating a tighter focused on one disease does not result in benefits across multiple disease areas. It is important to note, however, that there may be traditional approaches that have health system strengthening elements and also health system strengthening approaches that are more traditional in their mechanism as depicted by these two question marks here. Non health system strengthening approaches can cause duplications, distortions, disruptions and distractions. For instance, efforts that are made to develop new cater's solely for a specific disease may have higher pay attracting health workers. However, with staffing shortages, this may deplete public sector staffing. Additionally those interventions that do leverage health systems infrastructure but that are disease focused might have specialized training that could result in absenteeism and also increased reporting requirements that might reduce time to provide quality care. In comparison, health systems strengthening approaches aim to leverage existing health systems structures with interventions that are systems focused. For instance, approaches to strengthen health systems can be cross cutting and address root issues such as preventive care as compared to disease specific issues. This cross cutting approach in turn, can be more efficient allocation of funds, such that benefits are enjoyed across multiple health challenges. Furthermore integration into existing health systems infrastructure, ensure greater long term sustainability. And finally, health systems interventions typically also seek to reach scale across the state or a nation. Realistically, most countries operate through a patchwork combination of both health systems and non health systems approaches. In the next lecture, we will touch on the concept of systems thinking.
