DRAFT Report Scenarios and Options Concerning Revisions to the Community Systems Strengthening (CSS) Framework

The following draft report is the result of work of working group # 1 of the Inter Organizational Task Team on Community System Strengthening (IOTT on CSS). The report was developed under the guidance and coordination of the IOTT Secretariat, and it is presented for consideration to the Global Fund to Fight AIDS, TB and Malaria as a deliverable of the IOTT Secretariats contractual obligations (hosted by ICASO). The report is authored by Michael OConnor (consultant) on behalf and with support of the working group. The members of the working group are: Mary Ann Torres (co-chair) David Ruiz (co-chair) Ruth Morgan David Traynor Mabel Bianco Sally Smith (UNAIDS) Kanna Dharmarajah George Ayala (MSMGF) Lianna V. Sarkisian (World Vision) Manine Arends (HIVOS) Eliot Ross (INPUD) Jenniffer Dietrich - Stop TB Partnership Ivan Varentsov (EHRN) Sophie Dilmitis (ASAP) Anton Ofield-Kerr (IHAA) Susan Chong (La Trobe University)

Scenarios and Options Concerning Revisions to the Community Systems Strengthening (CSS) Framework 1 Introduction: The Global Fund (GF) has been at the forefront of the movement to provide more systematic support to communities in taking up their role in responding to AIDS, TB, and malaria. Thanks to strong support from the NGO and Communities delegations to the GF board, CSS as a concept to be considered in funding requests was introduced in 2008. Beginning with Round 8, application forms for AIDS, TB, and malaria programming from the GF included a new subsection on CSS where applicants were asked to describe what community strengthening activities they would be including. The Global Fund CSS framework was developed in 2009-10 by a technical working group (TWG) through a consultative process that included governments, multilateral agencies, and NGOs 2. Substantial civil society (CS) input to the framework was obtained through a multilingual, moderated, on-line consultation. A face-to-face meeting that included all major CS stakeholders hosted by the International HIV/AIDS Alliance (IHAA), Civil Society Action Team (CSAT), and the International Consortium of AIDS Service Organizations (ICASO) followed the e-consultation. To make the framework align with the GF processes, the TWG was called upon to help develop a set of service delivery areas (SDA) which were linked to outcome indicators. The resulting matrix would allow the CSS activities included in a grant to be linked to a monitoring and evaluation framework. The framework as developed in 2009-10 provides a definition of CSS, an explanation of what is meant by a systems approach, and a description of what types of things need strengthening in order to ensure robust and comprehensive responses to addressing AIDS, TB and malaria programming. Since As the framework was developed for the GF, it spells out six core components of CSS that the GF will support and suggests ten service delivery areas that link to the core components. The approach was, in part, modeled on the health systems strengthening building blocks to strengthen enhance a health system which was being championed by WHO and others at that time. The CSS framework represents a truly remarkable achievement in terms of furthering understanding of the role of community in addressing health and development issues. For the first time, we have started to focus on the community
This document was presented at the IOTT meeting hosted by ICASO and the Global Fund in Geneva, November 25-26, 2013. The meeting participants agreed that in the short term there was a need to do a light revision to the CSS framework to remove the references to the service delivery areas (SDAs) as they were specific to the Global Fund and are now obsolete under the New Funding Model. The decision on what to do in terms of revising the framework can be taken up by the IOTT at a later date after the urgent work to support the roll out of the NFM is finalized. 2 The technical working group included these agencies and organizations: Joint United Nations Programme on HIV/AIDS (UNAIDS); World Health Organization (WHO); United Nations Childrens Fund (UNICEF); World Bank; MEASURE Evaluation; Coalition of the Asia Pacific Regional Networks on HIV/AIDS (7 Sisters); International HIV/AIDS Alliance; United States Agency for International Development (USAID) Office of HIV/AIDS; U.S. Office of the Global AIDS Coordinator (OGAC); United Nations Development Programme (UNDP) Burkina Faso; Ministry of Health and Social Welfare Tanzania; The Global Fund. The TWG was supported by consultants and technical experts as required.
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system as opposed to just the community and civil society. This new way of thinking requires finding ways to systematize community action. We would be hard pressed to find a minister of health who would not say communities are important, but the health systems measurements and investments dont reflect this. CSS will help to ensure that community systems are central to the analysis of what is needed to address health and development in a comprehensive way. Annex 1 provides a summary of the milestones in the evolution of CSS. Having been developed through a multi-stakeholder process, the intention was that CSS would be owned broadly by the health and development community, would eventually grow in acceptance, and would be used alongside the concept of health systems strengthening (HSS) which is embraced by ministries of health around the world, and is championed by WHO, GAVI, World Bank, and most bilateral development assistance partners. The Inter Organizational Task Team (IOTT) on CSS was formed to represent the multi-stakeholder foundation of CSS. In June 2012, the Global Fund, UNAIDS, ICASO, International HIV/AIDS Alliance, and USAID agreed to set up the IOTT on CSS with the purpose of building a common understanding of CSS among the many partners using this concept and exploring ways to broaden the base of support for CSS beyond the GF. Among other things, the IOTT will help develop an evaluation framework and body of evidence to identify the most effective and efficient ways of investing in this area and to explain how CSS interventions link to better health outcomes. (See Annex 2 for the terms of reference [TORs] for the IOTT on CSS). It is important to note that while many agencies are committing time to participate in discussions about CSS, the funding for the IOTT initiative so far has been provided by the GF. If the IOTT is to be credible, other partners will need to contribute equitably to the joint work plan. Recent changes to CSS Some rationalization of CSS in terms of local concerns was undertaken, including the development of a Southern Africa CSS tool by SAT 3. Both UNAIDS 4 and Roll Back Malaria 5 developed disease-specific guidance on CSS with the focus on understanding how to include CSS in GF funding proposals. In June 2013, UNAIDS held a consultation with community leaders and partners on strengthening community systems for treatment expansion. The consultation led to the formation of a task force (TF) which will provide advice to UNAIDS on design and implementation of actions essential to achieving universal access to treatment for people living with HIV through CSS. The time-bound TF will provide advice on tools,

Southern African community systems strengthening (CSS) framework, SAT Trust: http://www.satregional.org/publications/en/southern_african_community_systems_strengthening_css_framework as viewed November 2013 4 Supporting Community Based Responses to AIDS: A guidance tool for Including Community Systems Strengthening in Global Fund Proposals: http://data.unaids.org/pub/Manual/2009/20090218_jc1667_css_guidance_tool_en.pdf 5 Malaria Control, Community Systems Strengthening And Community-Owned Response: http://www.rollbackmalaria.org/toolbox/tool_CommunitySystemsStrengthening.html
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best practice materials, and a strategy for intensive action on CSS to be piloted in two countries. Over the past few months, GF has developed a CSS module that is integrated into the disease frameworks of the new funding model (NFM). As well as consolidating the previously developed SDAs into the NFM format, the module emphasizes the aspects of CSS that GF prioritizes. There has been ambiguity in the past about the inclusion of civil society-led service provision as a CSS activity. The modules now make it clear that CSS does not include services since nothing in the remaining modules states that they are or are not the preserve of a given implementer type. In other words, any module can be implemented by any type of implementer, and no module predefines that it should be implemented by government or the private sector or an NGO. The CSS component therefore focuses on strengthening communities ability to deliver or advocate for services, but not to deliver them. The delivery of a service i.e. community TB case detection is an activity under the TB module tool, and strengthening the community organizations involved in this work is a CSS activity. It is important to note, however, that GF decisions do not in and of themselves materially change what CSS is: they merely frame how the GF, as a funder, approaches CSS. The GF anticipates that the CSS module (as with the other components of the disease modules) may require periodic revision based on initial learning from the NFM. Research and analysis After each round of funding, the GF prepared a report on CSS funding summarizing spending on CSS activities by region, type of intervention, and disease category. The reports provide valuable insight into the use of CSS in GF programming. In round 10, the total expenditure on CSS was reported to be 3.35% or about $166 million of approved funding. This amount may not necessarily accurately reflect spending on CSS activities because the activities were not categorized consistently. In TB programming, for example, CSS-type activities are often categorized as Advocacy Communications and Social Mobilization (ACSM). While much of ACSM is spent on mass campaigns, there are aspects of ACSM which strengthen communities involved in TB, so this would be counted a TB intervention, not CSS. Likewise, some countries misunderstood CSS and classified all the funding for community health workers as CSS when it should have been classified under disease intervention. The CSS modules and costed interventions will help to ensure a more accurate measure of CSS funding through the GF. Some analysis on how CSS was used in GF programs was produced, but it is somewhat dated. The HIV/AIDS Alliance 6 produced a report on nine examples of CSS

Civil Society Success on the Ground - Community Systems Strengthening and Dual-Track Financing: Nine Illustrative Case Studies: http://www.aidsalliance.org/includes/Publication/Civil_society_success_eng.pdf
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type programming in 2008; UNAIDS 7 included ten case studies on CSS in their 2009 guidance on CSS in HIV programming. There do not appear to be any recent country level case studies. Independent research on CSS is also limited. A poster will be presented at the upcoming ICAAP conference in Bangkok by Susan Chong of La Trobe University on Enablers & Barriers to Community Systems Strengthening. The poster reports on interviews conducted with 15 respondents from four countries Malaysia, Indonesia, Viet Nam, and the Philippines to gain an understanding of the enablers and impediments to countries incorporation of CSS into proposals to the GF. The study reports on: the skepticism and uncertainty on the part of government ministries, donors, and UN agencies on viability and implementation of CSS underlying tension between government and NGO sectors based on past conflicts (e.g. political) added workload for government ministries as administrators of grants for CSS, stretching their already limited resources only a small core group of NGOs has knowledge and comprehension of CSS GF operational and grant implementation processes are unfamiliar to most NGOs

Observations included in Susan Chongs study are consistent with the feedback and complaints received from civil society organizations involved in GF programs. These can be summarized as follows: lack of awareness by beneficiaries of the existence of the CSS opportunity challenges in getting CSS endorsed by CCMs due to lack of an evidence base limited technical assistance and qualified consultants to help develop CSS components into proposals technical assistance often focuses on proposal development and less on implementation need to define the role of CSS in the implementation of the human rights aspect of the new GFs strategy need to build an evidence-base and documentation to assess the impact of CSS

A research agenda to build the evidence for CSS is being developed by one of the IOTT working groups. Some research topics that would be very helpful to the review of the CSS framework include the following: up-to-date country studies on CSS successes; it would be particularly interesting to compare CSS across diseases and regions

Supporting Community Based Responses to AIDS: A Guidance Tool for Including Community Systems Strengthening in Global Fund Proposals http://data.unaids.org/pub/Manual/2009/20090218_jc1667_css_guidance_tool_en.pdf

repeat of the work done by Susan Chong in other regions, to understand the dynamics and what kind of information is needed to get CSS buy-in by governments comparison of CSS across development assistance platforms analysis of perceived gaps, ambiguities, and issues not discussed in the current CSS framework analysis of CSS as expressed in TB and HIV programing analysis of how to ensure a greater focus on systems thinking in CSS programming analysis on how the framework can be made more relevant to health systems strengthening

The case for revising the framework Many actors have pointed to the need for a more fundamental review of CSS in order to provide a framework that can move CSS to the next level, both for the GF and others engaged in strengthening communities role in health and development. The CSS framework could be a source of evidence-based and normative guidance for CSS for health and development planning more generally. At the same time, it is clear that such a revision will need to be based on a comprehensive understanding of how CSS programming has and has not contributed to improvements in health, the critical success factors that have enabled successful CSS (both within and outside the context of the GF), as well as a clearer understanding of the role of CSS in relation to AIDS, tuberculosis, malaria, and other health issues. Scenarios for discussion Scenario one: Revise the framework to fall into line with the new GF module In the process of developing the new funding model, the GF made a decision to revise the way CSS was being described. The changes involved moving the ten CSS SDAs into four interventions and related activities which will be tied to budgets and a monitoring framework. These changes will not alter the essence of CSS but will clarify which aspects of CSS are fundable through the GF. The result is that the GF will need to revise and update the framework or some of its components to take into account the new way of allocating and measuring results as part of the NFM. In particular, the M&E framework and suggested indicators developed for the original CSS framework will need to be aligned with the new modules. CSS indicators will eventually need to be presented to the Monitoring and Evaluation Reference Groups (MERG) for each disease to coordinate and harmonize performance indicators. Possible approaches: Light touch virtual consultation on revisions to the framework

The revision to the framework could be done fairly expeditiously through the same process that was used in developing the CSS modules and four interventions which are now included as part of the NFM. The GF asked an experts committee to provide advice on how CSS should be incorporated in the NFM, and what activities and interventions should be included. The committee was made up of organizations and individuals involved in all three diseases and included representatives from regional CSO networks and key populations. The timing of the process did not lend itself to an in-depth discussion, and the consultation was one-sided in that the consultant asked questions and the experts provided their views on relevant issues. Due to time constraints, and given the nature of what was needed by the GF, this is an acceptable method in the short run. This expert-driven process would probably be the least costly and quickest way to re-write a GF-specific CSS framework. In addition to updating the terminology in the framework to align with the new concepts of modules and interventions, the experts would need to review the suggested activities provided and make an effort to develop examples from all disease areas. In addition the link to HSS will need to be spelled out and justified. More in-depth consultation process to revise the GF CSS framework Assuming there is sufficient time, a more in-depth process could be put in place by the GF to revise the framework to bring it in line with the way CSS is being presented in the NFM. The advantage of an intensive approach would be that the users at the country level will have a much better understanding of what is expected concerning CSS in the NFM. A more in-depth consultation process may allow time to test and revise some of the guidance on CSS being developed for the NFM. The new framework as adapted through such a process would be specifically focused on GF use of CSS for its programming in AIDS, TB, and malaria so it would follow that the consultation be hosted and facilitated by the GF. However, there would be a benefit to engaging the technical partners, and KP and CS networks to host virtual or in-person consultations to solicit detailed feedback on CSS. Broadening the pool of participants in a consultation on the framework would be very useful, particularly if it can be done in such as way as to involve other regions and language groups that have been marginally involved so far. Another side benefit for a more in-depth process is that governments and CCMs can be specifically targeted so that their misunderstanding and concerns about CSS can be solicited and dealt with. With a light touch or a more in-depth consultative process the GF will end up with a revised framework on CSS which aligns with the NFM Scenario 2: CSS continues to evolve and broaden While the GF will need to update the CSS guidance material and parts of the framework to align with the NFM, there may be a case to be made for a parallel stream of work to develop a CSS framework that is not just focused on the three diseases which, by necessity, was the focus of the existing CSS framework. This does not in any way undermine the importance of the GF initiated framework since it

has been very important in deepening the dialogue regarding the role of community in sustainable health programming. As a starting place, it would be helpful for the IOTT to come to a consensus about whether or not CSS is a concept that should be promoted beyond its use as a tool in GF grants. So far, the framework has served to build the case for greater community engagement in sustainable AIDS, TB, and malaria programming. Could the same case be made in programming related to other health or development fields? What would CSS look like if applied to strengthening communities involved in vaccine delivery, child wellness, or water and sanitation programming? Would it be helpful to have other health or development partners involved in shaping CSS and its future uses? If the IOTT sees value in this proposition, it would be helpful to look at the definitions of CSS from the point of view of other programming areas. Does the current definition need to be revised to make it accessible to other health or development initiatives? The CSS definition developed by the GF process is shown in Annex 2. It would be useful to hear views of other development agencies, but on the surface there is nothing in the current definition and goals of CSS that makes it health-specific. Assuming the current definition meets the muster to be acceptable more broadly, there would nevertheless be a need to rewrite the interventions content and programming examples that are included. If the IOTT comes to the conclusion that CSS as a concept, can and should be embraced beyond the three diseases, what steps would be needed to bring on other partners? How do we develop a CSS Framework with broader relevance? How to get there: reach out to the CS focal points from all major development and health organizations and explore their interest in participating in using CSS as a tool in their programming; the list of participants could include: global, regional, and national organizations supporting communities and key populations, as well as bilateral and multilateral funding agencies develop a consensus vision for CSS which each participant can share within their organizations and constituencies test the framework through on-line consultations and revise according to feedback once a generic framework is endorsed, each sector will be able to research and develop guidance material which would be specific to their programming area and region

How to manage the evolution of CSS Once the future vision of CSS can be agreed upon, the question of how CSS is managed and who takes the lead in supporting its evolution will need to be addressed. There are strong arguments to maintain the current multi-stakeholder model of supporting CSS through the IOTT. The downside of the status quo is that the IOTT is a loose structure that is far less influential because of its diversity than an organization such as WHO, which hosts the intellectual leadership of HSS. On the other hand, strong leadership on CSS by WHO or WB would come with drawbacks as well. Neither organization has the quite the same track record with CS as does the GF, but if a UN agency were to back CSS it would have a much broader remit and scope of use. If the exploration of CSS with other partners fails to generate any interest, there is no reason not to disband the IOTT and return the leadership and accountably of the evolution of CSS to the GF. The GF as the main user of CSS will be responsible for developing the concept as a programming tool in the fight against AIDS, TB, and malaria. In doing so, they will continue to call upon the expertise of NG0s and multilateral and bilateral partners to provide guidance, advice, and relevant field research. While the GF is not a normative agency per se, it is sufficiently committed to the role of communities in addressing health that it would be a natural step for the GF to continue as the lead agency for CSS. Other outstanding questions and issues: HSS/CSS link In late 2012, there was a lot of work on the part of the GF and WHO to explore the idea of linking HSS and CSS. The idea was not to merge the two concepts, but to be clearer about the links between them. Many CSS activities are closely aligned to the community aspects of the HSS building blocks, but many others are beyond the focus of a health system. For example, support to increase the capacity of community health workers is a CSS activity that fits into HSS building block 1. However, advocacy for law reform or training for police officers on stigma are CSS activities which are beyond the scope of HSS. Annex 4 shows an early attempt to link HSS and CSS. In the end, the decision was taken that linking CSS and HSS was going to be unproductive, but is this still a question worth exploring? How can the links between HSS and CSS be better articulated without losing the unique nature of both areas? Both HSS and CSS are essential ingredients in health programming. At the moment, both fields work in isolation. Greater understanding of their roles and mutual interdependence would be helpful. Is CSS only about health? As a result of its origins, CSS has focused on health and, in particular, AIDS, TB, and malaria programming. It is important to note that, historically, the bulk of CSSdesignated programming is directed to communities involved in HIV programming.

In the NFM, CSS is articulated as a module under each of the disease areas and it is expected that more CSS activities in TB and malaria programming will result from this change. As discussed previously, it might be appropriate for CSS to be considered in many other programming areas. In all likelihood, some aspects of CSS are incorporated as part of most health and development endeavors, even if not branded as CSS.

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Annex 1 Major milestones in the development of CSS DATE January 2007 Activity Communities and NGO delegations hosted a meeting in Amsterdam to increase civil society impact on the Global Fund strategic options and deliberations8 May 2007 The GF board meeting passed a decision to strengthen and scaleup civil-society and private sector involvement in GF processes, and called for routine inclusion in proposals of measures for strengthening of community systems August 2008 The GF commissioned a review exercise in Pretoria where a list of 13 CSS indicators was developed and included in the guidance of Round 8 applications 2009 Launch of International HIV/AIDS Alliance report Civil Society Success on the Ground: Community systems strengthening and dual-track financing November/ December 2009 to March 2010 June 2009 February 2010 Draft CSS framework prepared by independent consultant with support from a multi-stakeholder technical working group (TWG) practices in community level service delivery and systems strengthening UNAIDS CSS guidance developed Community-level HIV service delivery indicators were presented and discussed during UNAIDS MERG, Stop-TB Partnership Indicator Working Group, and Malaria Monitoring and Evaluation Reference Group (MERG) March 2010 Web-based civil society consultation on the CSS framework organized by the International HIV/AIDS Alliance and CSAT, followed by validation meeting held in Brighton 18-19 March June 2010 June to August 2010 January 2011 UNAIDS guidance updated; malaria-focused guidance developed with support from the Red Cross Outreach to prepare partners to understand CSS while writing R10 proposal Service delivery areas (SDAs) reviewed and revised by the TWG

November 2009 GF commissioned nine field research exercises to document best

Increasing Civil Society Impact on the Global Fund to Fight AIDS, Tuberculosis and Malaria: Strategic Options and Deliberations. Brook K Baker. ICASO; 2007. http://www.icaso.org/resources/CS_Report_Policy_Paper_Jan07.pdf

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January 2011 March to July 2011 May to August 2011

Analysis of CSS in Round 10 9 Outreach to prepare partners to understand CSS while developing Round 11 proposals (Nairobi, Chennai, Bangkok) CS networks promote CSS at regional and country levels including regional adaptation of the framework in Southern Africa led by SAT and a training workshop with national HIV networks hosted by EANNASO

August 2011 May 2012

UNAIDS updates guidance tool Meta analysis by Tulane University: selected community system strengthening-type interventions with health delivery services effects and health outcomes

May 14 to 15, 2012 July 2012 November to December 2012 June to July 2013

CSS technical partners meeting, Bethesda, MD Launch of Inter Organizational Task Team CSS at IAC Washington GF hosts discussions concerning health and community systems strengthening alignment Consultation CSS in the new funding model

November 2013 IOTT planning meeting

CP_Analysis_R10_CommunitySystemsStrengthening_18Jan2011.doc

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Annex 2 The Inter Organizational Task Team on Community Systems Strengthening

The aim of the Inter-Organizational Task Team on CSS is to increase the awareness, overall understanding, and profile of Community Systems as a critical component of any effective response to HIV, TB and malaria, by creating more inclusive, equitable, and effective systems leading to improved health outcomes in relation to the three diseases as well as by incorporating interventions that promote human rights; to deepen the understanding and expand the use of Community System Strengthening by key donors, UN agencies, bilateral organizations, national and ministries of health and other relevant government bodies, and other key stakeholders by:

Supporting information sharing between partners engaged in design, and development of CSS concepts, tools, training and research Supporting the alignment of the Community Systems Strengthening framework with guidance from technical agencies and donors Developing tools and indicators that enable an analysis of the role of Community Systems in improving health at country level and gather evidence that provides the basis for planning appropriate support to these systems. Promote the inclusion of interventions that promote human rights, sexual orientation and gender equality, Maternal, Newborn and Child health, Family Planning, Sexual and reproductive health rights, and broader health of communities Gathering evidence on the most effective ways of developing, supporting and strengthening Community Systems Developing and sharing tools to carry out a gap analysis on CSS Mapping the availability of capacity building and training on CSS, particularly for CCMs, and assess gaps related to needs.

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Annex 3 What is community systems strengthening? The goal of CSS is to achieve improved health outcomes by developing the role of key affected populations and communities and of community-based organizations in the design, delivery, monitoring and evaluation of services and activities related to the prevention of HIV, tuberculosis, malaria and other major health challenges and the treatment, care and support of people affected by these diseases. Community systems strengthening (CSS) is therefore an approach that promotes the development of informed, capable, and coordinated communities and communitybased organizations, groups, and structures. It involves a broad range of community actors and enables them to contribute to the long-term sustainability of health and other interventions at the community level, including an enabling and responsive environment in which these contributions can be effective. Key underlying principles of community systems strengthening include: a significant and equitable role in all aspects of program planning, design, implementation and monitoring for community-based organizations and key affected populations and communities, in collaboration with other actors; programming based on human rights, including the right to health and to freedom from discrimination; programming informed by evidence and responsive to community experience and knowledge; commitment to increasing accessibility, uptake and effective use of services to improve the health and well-being of communities; accountability to communities for example, accountability of networks to their members, governments to their citizens, and donors to the communities they aim to serve.

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Annex 4 Comparison of HSS and CSS

HSS SDAs HSS-1: Building Health Workers Capacity Illustrative examples of activities: Training of service provider and nonservice provider health workers (e.g. nurses, doctors, health planners, policymakers, facility managers) Study tours Hiring service provider and non-service provider health workers Providing financial and non-financial benefits to health workers HSS-2: Developing Organizational and Facility Management Systems Illustrative examples of activities: Executing policies, norms and regulations at the institutional level (e.g. setting up hospital accounting system, improving hospital waste management system) HSS-3: Increasing Demand for Service Utilization Illustrative examples of activities: Conducting information/education/communication campaigns Preparing communication materials HSS-4: Developing Procurement and Supply Chain Management System Illustrative examples of activities: Supporting transportation system development Hiring procurement agents Packaging Shipping Logistics

HS Building Blocks Human Resources

CSS SDAs CSS-4 Human Resources: skills building for service delivery advocacy and leadership.

Service Delivery

CSS-7: Community based activities, and servicesdelivery, use and quality

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HSS-5: Strengthening Information and M&E Health Systems Information Illustrative examples of activities: System Developing indicators Developing reporting system Developing disease surveillance system Hiring and deploying M&E officers Collection of program M&E data HSS-6: Developing Research and Analytical Capacity Illustrative examples of activities: Hiring policy researchers and analysts Conducting policy analysis Undertaking operations & implementation research Health system research Epidemiologic studies HSS-7: Developing, Executing and Stewardship Monitoring Legislation, Policies, Norms and and Regulations at the System Level Governance Illustrative examples of activities: Developing social health insurance regulations Revising providers reimbursement system Revising clinical protocols of care Revising composition of benefits package Supporting inter-sectoral coordination Undertaking policy supervision visits HSS-8: Enhancing Capacity of the Health Financing System Illustrative examples of activities: Providing cash support to scale-up health insurance enrolment Developing revolving funds Providing financial and non-financial incentives to increase service utilization Health Financing

CSS-9: Monitoring and evaluation, evidence building. CSS-1: Monitoring and documenting community and government interventions CSS-10: Strategic and operational planning.

CSS-2: Advocacy communications and social mobilization CSS-3: Building community linkages, collaboration and coordination CSS 8 Management accountability and leadership. CSS-5: financial resources

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HSS-9: Infrastructure development Illustrative examples of activities: Construction, rehabilitation and maintenance of clinical and non-clinical facilities (e.g. hospitals, primary care clinics, Ministry of Health facilities, local government facilities etc.) Provision of equipment, furniture, hardware, software, vehicles and other assets that contribute to health systems strengthening

Infrastructure

CSS-6: Material Resourcesinfrastructure, information and essential commodities (including medical and other products and technology)

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