Our aim was to gather data from studies in which clear and reproducible methods were used to examine the interaction between global health initiatives (GHIs) and health systems. We searched Cochrane Library, OneSource, and PubMed for English language reports, published from January, 1990, to May, 2009, with the keywords “global health initiatives”, “health systems”, “The Global Fund to fight AIDS, Tuberculosis and Malaria” (“Global Fund”), “Global Alliance for Vaccines and Immunization”
Health PolicyAn assessment of interactions between global health initiatives and country health systems
Introduction
In the past decades, a small number of fatal diseases disproportionately burdened the health systems in low-income and middle-income countries, and, in combination with other health challenges, has slowed progress towards the achievement of the Millennium Development Goals. For example, half the world's population is at risk of contracting malaria, and about 1 million of an estimated 250 million people with malaria died in 2006.1 25 million people have died from HIV/AIDS-related causes since the beginning of the epidemic;2 about 1·3 million people who are HIV-negative die every year from tuberculosis;3 and an estimated 9·2 million children younger than 5 years died in 2007, mostly from preventable conditions.4 Since 2000, several large global health initiatives (GHIs) have resulted in a concerted response to these diseases with effective health interventions and technologies (eg, vaccines, antiretroviral drugs for HIV/AIDS, short-course chemotherapy for tuberculosis, and insecticide-treated bednets and artemisinin in combination with other treatments for the prevention and treatment of malaria). GHIs have capitalised on the urgency that has been generated by the adoption of the Millennium Development Goals. The GHIs indicate the increased involvement of the private sector, philanthropic trusts, and civil society in health care. About 100 GHIs (previously known as Global Public-Private Partnerships or Global Health Partnerships; panel 1) now exist. A few of these initiatives—including, the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund); the Global Alliance for Vaccines and Immunization (GAVI); the US President's Emergency Plan for AIDS Relief (PEPFAR); and the World Bank Multi-Country AIDS Program (MAP)—contribute substantially to the funding for health provided by international donors.
The GHIs have rapidly become an established part of the international aid framework, and have been used to leverage substantial additional financial and technical resources for targeted health interventions. In 2007, the Global Fund and GAVI donated US$2·16 billion in funding, and PEPFAR donated $5·4 billion. GHIs specifically for HIV/AIDS and malaria have been effective in generating rapid responses to these epidemics. By 2007, the Global Fund, PEPFAR, and the World Bank MAP were contributing more than two-thirds of all external funding to control HIV/AIDS and malaria in countries with few resources.5, 6
Additional resources on a large scale might have important effects on public health and health systems in countries with insufficient resources. GHIs have also involved new groups of people (notably civil society organisations, leading to an increased focus on social justice); garnered the political will of donors; pioneered new performance-based approaches; provided support for interventions that had been thought to be unsustainable (such as antiretroviral drugs and treatment for multidrug-resistant tuberculosis); and shown the capacity to adapt to an operating environment that is changing. But despite this shift in the ways in which aid is provided, knowledge of the broad effects of GHIs on country health systems is inadequate.
Decades of neglect and insufficient investment have weakened health systems in most developing countries.7 In the 1980s, economic crises, debt repayment, civil and political unrest, poor governance, and environmental pressures exacerbated poverty and inequality, particularly in Africa. Structural adjustment policies that were designed to improve the stability of fragile economies led, in many cases, to cuts in public health spending. Moreover, the globalisation of labour markets, gathering pace during the 1990s, increased emigration of health workers from the countries that had invested in their training. The worldwide HIV/AIDS epidemic damaged health systems that were already overstretched; therefore, when the worldwide community made a commitment to the health-related Millennium Development Goals in September, 2000,8, 9 the health systems in low-income and middle-income countries were already weak. The GHIs emerged in the context of weakened health systems.10
Although new resources, partners, technical capacity, and political commitment were generally welcomed, critics soon began to argue that increased efforts to meet disease-specific targets with selective interventions were exacerbating the burden on health systems that were already fragile.11, 12 At the same time, the delivery capacity of GHIs was limited by the weaknesses that were present in country systems, such as inadequate infrastructure for service delivery, shortages of trained health workers, interruptions in the procurement and supply of health products, insufficient health information, and poor governance.1, 2, 3, 13, 14 The tensions that have been caused have contributed to a longstanding debate about the interplay of disease-specific programmes or selected health interventions with integrated health systems.
The difficulties that might be inherent in targeted approaches to improvement of health were recognised as early as 1951.15 Since then, much has been written about the vertical and horizontal divide in global public health.16, 17, 18, 19, 20, 21, 22 Despite this legacy, our understanding of the interactions between health systems and the large GHIs that are emerging is incomplete. No robust prospective studies of the effects of GHIs on country health systems have been done. Targeted programmes were compared with interventions that were integrated into mainstream health systems in a systematic review23 but conclusions about the different ways in which disease-specific initiatives can affect health systems could not be drawn because of insufficient robust data. Biesma and colleagues24 have assessed the evidence of the effects of GHIs on health systems in relation to HIV/AIDS. National-level processes have been investigated in a few studies, and the effects of GHIs on health systems with time have been tracked in only a few studies.25, 26 The effects of GHIs with time have been tracked in only a few studies.12, 27, 28, 29 Determination of the extent of the potential for synergism between health systems and GHIs at the subnational and service delivery levels, and the means by which to mutually benefit from such a beneficial interaction have not been attempted in any systematic manner.
The evidence to help understand the interactions between GHIs and health systems is insufficient for several reasons. First, the largest GHIs were launched less than 10 years ago and need some time to show effects on the health systems within countries. Second, when GHIs began, arrangements for prospective assessment of their effect on country health systems were not established. Third, the scientific community has been slow to develop research methods that help in the elucidation of the complex nature of the interactions between GHIs and health systems. Nevertheless, considerable insights have been gained about the opportunities and challenges associated with implementation of GHIs for nearly a decade. This knowledge should now be harnessed and complemented with evidence from rigorously designed studies to take us from a situation in which the broad positive effects of disease-specific work are largely serendipitous to a new framework for global public health that is characterised by a proactive and systematic approach to obtain the maximum synergies.
Section snippets
What are GHIs?
GHIs, Global Public-Private Partnerships, and Global Health Partnerships have not been clearly defined.24 We focus mainly on the four large GHIs (Global Fund, GAVI, PEPFAR, and World Bank MAP) that have invested substantial resources for health since 2000; other disease-specific programmes, such as the African Programme for Onchocerciasis Control, and campaigns for the treatment of neglected tropical diseases are also referred to. The four large GHIs (and many others) are characterised by a set
Framework and methods
A preliminary assessment to understand the interactions between GHIs and country health systems is difficult because of the absence of a commonly used or agreed conceptual or analytic framework, and the absence of rigorous empirical evidence. Nevertheless, we have endeavoured to assess the interactions through a review of the available evidence using a conceptual framework that we have adapted specifically for the purpose of this analysis. Essentially, GHIs represent a concerted effort by
Health service delivery
Delivery of health services that are accessible, equitable, safe, and responsive to the needs of the users represents the main output of any health system (panel 2). Indeed, a characteristic of GHIs is their focus on scaling up selected services that have proven to be effective. Therefore, an analysis of the association of GHIs and health systems should start by examination of the evidence related to service delivery performance. Importantly, however, delivery of services depends on the
What we know and what we do not know
Despite the amounts invested and the important part played by health systems and GHIs, investigators do not have appropriate methods, or sufficient incentives (largely as a result of insufficient investment and political will), to assess the quality and effectiveness of the complex and context-specific interactions between health systems and GHIs. The paucity of robust evidence is testament to these methodological and other shortcomings.
The most robust data relate to indicators for the
Synthesis and recommendations
The goal of the GHIs is to improve health outcomes through targeted interventions for specific diseases or through use of specific technologies. The goal of country health systems is also to improve health outcomes. Our understanding of the interactions between GHIs and country health systems could lead to improved returns on investments. Two points have become clear from our assessment. First, GHIs and country health systems are not independent but are inextricably linked. Second, the two are
Proposal for an action plan
On the basis of our findings, we urge that these recommendations should be swiftly converted into policy and put into action, necessitating concomitant implementation of actions and country-specific adaptation of actions at different levels—ie, international partners; policy makers; programme managers; and researchers (panel 3).
Search strategy and selection criteria
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