An assessment of interactions between global health initiatives and country health systems

Summary

Since 2000, the emergence of several large disease-specific global health initiatives (GHIs) has changed the way in which international donors provide assistance for public health. Some critics have claimed that these initiatives burden health systems that are already fragile in countries with few resources, whereas others have asserted that weak health systems prevent progress in meeting disease-specific targets. So far, most of the evidence for this debate has been provided by speculation and anecdotes. We use a review and analysis of existing data, and 15 new studies that were submitted to WHO for the purpose of writing this Report to describe the complex nature of the interplay between country health systems and GHIs. We suggest that this Report provides the most detailed compilation of published and emerging evidence so far, and provides a basis for identification of the ways in which GHIs and health systems can interact to mutually reinforce their effects. On the basis of the findings, we make some general recommendations and identify a series of action points for international partners, governments, and other stakeholders that will help ensure that investments in GHIs and country health systems can fulfil their potential to produce comprehensive and lasting results in disease-specific work, and advance the general public health agenda. The target date for achievement of the health-related Millennium Development Goals is drawing close, and the economic downturn threatens to undermine the improvements in health outcomes that have been achieved in the past few years. If adjustments to the interactions between GHIs and country health systems will improve efficiency, equity, value for money, and outcomes in global public health, then these opportunities should not be missed.

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.