Why embedded technical assistance builds stronger health systems: Lessons from Senegal
Technical assistance (TA) in low- and middle-income countries has traditionally prioritized producing strategies, frameworks, and policy documents. While these outputs remain necessary, this model is increasingly misaligned with health system reforms, which are now constrained less by design and more by the institutional capacity required to implement decisions across budgets, programs, and political processes. Drawing on experience in Senegal, this perspective article examines how “embedded” technical advisors working within the Ministry of Health over two years supported coordination, continuity, and access to decision-making processes during reform implementation. We argue that conventional TA is limited by discontinuity, fragmentation, and insufficient proximity to government systems, which may reduce its ability to support implementation. Embedded TA offers a stronger alternative by enabling sustained engagement within government processes, improving cross-actor coordination, and allowing real-time adaptation to implementation constraints, though isolating its specific contribution from other enabling conditions, such as prior institutional strength or favorable funding priorities, remains a limitation of single-case evidence. Embedded TA also introduces risks, including substitution of government functions, accountability drift, political exposure, and conflict between government priorities and advisor judgment, which require deliberate mitigation through strong government ownership, clear role definition, and structured transition planning. This perspective article argues that TA models should shift toward longer-term, flexible engagements that prioritize implementation support and institutional problem-solving, with progress tracked through diagnostic indicators tied to these specific risks rather than deliverable counts alone.
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