USAID’s Health Finance and Governance (HFG) project helps to improve health in developing countries by expanding people’s access to health care. The project team works with partner countries to increase their domestic resources for health, manage those precious resources more effectively, and make wise purchasing decisions. HFG’s research portfolio enhances the ability of USAID to assist countries in delivering priority health services while simultaneously contributing to the global pool of knowledge on health systems strengthening (HSS).

Under this research portfolio, the “Understanding the Dynamics of Successful Health System Strengthening Interventions” study seeks to bring into better balance our focus on “what works” in HSS with “how HSS works” to improve the performance of future HSS efforts. Our aim is to examine the dynamics of HSS project implementation, not to examine the cases as models for HSS interventions. We are pursuing this goal by initially conducting a set of six qualitative, retrospective case studies of successful USAID-supported HSS interventions and then producing a cross-case analysis to draw common patterns across cases.

Cross-case AnalysisStudy SummaryStudy Design
The aim of this study to address four key questions:

1.  How were a range of successful HSS interventions implemented in different countries?
2. What factors facilitated and constrained the successful implementation and documented outcomes of the interventions?
3. What were important factors about implementation that emerged across the different cases?
4. What are the implications of this study for future of implementing HSS interventions?

We chose five cases to examine a small sample of successful HSS initiatives in different places under different conditions and with different features in an attempt to tease out some of the policy setting, adoption, and implementation factors and processes that matter.

• Case study: Maternal & Child Centers of Excellence: Improving health systems and quality of services in the Dominican Republic
• Case Study: Improving Care through Patient-Centered Clinical Pharmacy Services (SIAPS/Ethiopia)
• Case Study: The Dialogue on HIV and Tuberculosis Project, Kazakhstan
• Case study: Zambia Integrated Systems Strengthening Program (ZISSP)
• Case Study: Rwanda’s Twubakane Decentralization and Health Program

While we remain attentive to the range of complex factors that affect success, we seek to distinguish those factors that decision-makers and implementers can control or influence. In so doing, we hope to develop and provide recommendations for adapting and sustaining HSS reforms in low-income countries.