Critical barriers to sustainable capacity strengthening in global health: a systems perspective on development assistance.

Background: Development assistance for health (DAH) is an important mechanism for funding and technical support to low-income countries. Despite increased DAH spending, intractable health challenges remain. Recent decades have seen numerous efforts to reform DAH models, yet pernicious challenges persist amidst structural complexities and a growing number of actors. Systems-based approaches are promising for understanding these types of complex adaptive systems. This paper presents a systems-based understanding of DAH, including barriers to achieving sustainable and effective country-driven models for technical assistance and capacity strengthening to achieve better outcomes Methods: We applied an innovative systems-based approach to explore and map how donor structures, processes, and norms pose challenges to improving development assistance models. The system mapping was carried out through an iterative co-creation process including a series of discussions and workshops with diverse stakeholders across 13 countries. Results: Nine systemic challenges emerged: 1) reliance on external implementing partners undermines national capacity; 2) prioritizing global initiatives undercuts local programming; 3) inadequate contextualization hampers program sustainability; 4) decision-maker blind spots inhibit capacity to address inequities; 5) power asymmetries undermine local decision making; 6) donor funding structures pose limitations downstream; 7) program fragmentation impedes long-term country planning; 8) reliance on incomplete data perpetuates inequities; and 9) overemphasis on donor-prioritized data perpetuates fragmentation. Conclusions: These interconnected challenges illustrate interdependencies and feedback loops manifesting throughout the system. A particular driving force across these system barriers is the influence of power asymmetries between actors. The articulation of these challenges can help stakeholders overcome biases about the efficacy of the system and their role in perpetuating the issues. These findings indicate that change is needed not only in how we design and implement global health programs, but in how system actors interact. This requires co-creating solutions that shift the structures, norms, and mindsets governing DAH models.

Better Board Education for Better Leadership and Management in the Health Sectors of Low and Middle Income Countries.

Board member education must be elevated within the curricula of leadership development programming in Low and Middle Income Countries (LMICs) across the globe. When properly trained and supported, the community, business, and health sector leaders serving on these boards can create the conditions within which those who deliver and manage health services are more likely to successfully achieve the mission of their organizations. The importance of incorporating education for governing body members into health sector leadership development programming, and three strategies for board development, are defined in in this article.