'We thought supporting was strengthening': re-examining the role of external assistance for health systems strengthening in Zimbabwe post-COVID-19.

Zimbabwe has received substantial external assistance for health since the early 2000s, including funding earmarked for, or framed as, health systems strengthening (HSS). This study sought to examine whether external assistance has strengthened the health system (i.e. enabled comprehensive changes to health system performance drivers) or has just supported the health system (by increasing inputs and improving service coverage in the short term). Between August and October 2022, we conducted in-depth key informant interviews with 18 individuals and reviewed documents to understand: (1) whether external funding has supported or strengthened Zimbabwe's health system since the 2000s; (2) whether the experience of COVID-19 fosters a re-examination of what had been considered as HSS during the pre-pandemic era; and (3) areas to be reconsidered for HSS post COVID-19. Our findings suggest that external funders have supported Zimbabwe to control major epidemics and avert health system collapse. However, the COVID-19 pandemic showed that supporting the health system is not the same as strengthening it, as it became apparent at that time that the health sector is plagued with several system-wide bottlenecks. External funding is fragile and highly unsustainable, which reinforces the oft-ignored reality that HSS is a sovereign mandate of country-level authorities, and one that falls outside the core interests of external funders. The key positive lesson from the pandemic is that Zimbabwe is capable of raising domestic resources to fund HSS. However, there is no guarantee that such funding will be maintained. There is a need, then, to reconsider government's stewardship for HSS. External funders need to re-examine whether their funding really strengthens the national health system or just supports the country to provide basic services in their areas of interest.

HIV programme sustainability in Southern and Eastern Africa and the changing role of external assistance for health.

High human immunodeficiency virus (HIV)-prevalence countries in Southern and Eastern Africa continue to receive substantial external assistance (EA) for HIV programming, yet countries are at risk of transitioning out of HIV aid without achieving epidemic control. We sought to address two questions: (1) to what extent has HIV EA in the region been programmed and delivered in a way that supports long-term sustainability and (2) how should development agencies change operational approaches to support long-term, sustainable HIV control? We conducted 20 semi-structured key informant interviews with global and country-level respondents coupled with an analysis of Global Fund budget data for Malawi, Uganda, and Zambia (from 2017 until the present). We assessed EA practice along six dimensions of sustainability, namely financial, epidemiological, programmatic, rights-based, structural and political sustainability. Our respondents described HIV systems' vulnerability to donor departure, as well as how development partner priorities and practices have created challenges to promoting long-term HIV control. The challenges exacerbated by EA patterns include an emphasis on treatment over prevention, limiting effects on new infection rates; resistance to service integration driven in part by 'winners' under current EA patterns and challenges in ensuring coverage for marginalized populations; persistent structural barriers to effectively serving key populations and limited capacity among organizations best positioned to respond to community needs; and the need for advocacy given the erosion of political commitment by the long-term and substantive nature of HIV EA. Our recommendations include developing a robust investment case for primary prevention, providing operational support for integration processes, investing in local organizations and addressing issues of political will. While strategies must be locally crafted, our paper provides initial suggestions for how EA partners could change operational approaches to support long-term HIV control and the achievement of universal health coverage.

Coordinating external assistance for UHC: Pakistan's early experience of the SDG3 GAP.

Pakistan is a lower middle-income setting. External assistance for health and development partners play an important role in health sector development. The federal system and health care delivery as a devolved provincial subject warrant regular and effective coordination among federating units and partners. Pakistan was selected as a priority country in 2019 for the implementation of the Global Action Plan for Healthy Lives and Well-being for All (SDG3 GAP). Given the ongoing universal health coverage (UHC) reforms, the country prioritized two SDG3 GAP accelerators, related to primary health care (PHC) and sustainable financing for health (SFH). Eight partner agencies representing PHC and SFH accelerators jointly planned and conducted a 'PHC for UHC mission' to Pakistan in 2021. This mission paved the way for setting up an SDG3 GAP Coordination Committee and a 'PHC Service Delivery and Financing working group', which have been regularly coming together through in-person and virtual meetings; the latter was relatively uncommon previously and this new way of working provided a chance to build rapport, share workplans, identify duplications in technical assistance and jointly gauge governments' priorities. This has shifted the focus of reforms deliberations from 'what' to 'how', enabling joint strategic planning and implementation. The joint work by SDG3 GAP partners with the Ministry of National Health Services Regulation & Coordination linked discussions on health financing and service delivery reforms for the first time, and has contributed to advocacy, analysis, strategic policy dialogue, institutional strengthening and implementation of UHC reforms, with a focus on PHC. Even though joint work by SDG3 GAP partners undoubtedly shows the potential for better alignment and collaboration, translation of the commitment to better collaboration into concrete impact has been the result of committed and engaged staff members, rather than institutionalized change, which will require strong incentives for collaboration.