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

from Paul Chinnock, TropIKA.net:

It has often been alleged that the increased focus on three major infectious diseases - HIV/AIDS, malaria and tuberculosis - seen in recent years has damaged the health systems of poor countries and made it harder for them to provide care for patients suffering from other conditions. While many people have supported this claim, there has been a lack of data to establish whether, and to what it extent, it is actually true.

A major study, published in the Lancet, has now addressed the issue in depth and, while the findings are of some concern, the researchers have also been able to identify ways in which the big disease-specific programmes and health systems can "interact to mutually reinforce their effects".

To conduct the study, WHO set up a team (the World Health Organization Maximizing Positive Synergies Collaborative Group) involving WHO staff and researchers working for governments, universities, aid organizations and campaign groups across the world. The team conducted a comprehensive search intended 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". They restricted their search to the period 1990-2009. Fifteen new studies were also commissioned by WHO to generate further new data. The resulting 32-page article is, according to the authors, the most detailed compilation of evidence so far available on this important topic.

The researchers found evidence that GHIs had prevented many deaths from the three conditions on which they focus. However, in addition to the benefits, harms were also noted. These include: increased inequalities in health services, reduced quality of services because of pressures to meet targets, decreases in domestic health spending, misalignment between GHIs and country health needs, distraction of government officials from their wider health responsibilities, and the creation of expensive parallel bureaucracies.

There have also been cases where healthcare workers have been lured away from government hospitals by the higher salaries paid by international organizations involved in GHIs. In addition, the rush to win grants from the Global Fund to fight Aids, TB and Malaria may have led to proposals being put forward for programmes that are inappropriate for the countries concerned. The researchers conclude that the GHI sector has weak accountability and that independent evaluation of its programmes is generally lacking.

The published study includes a detailed list of actions that can be taken to improve matters. The four main messages are that:

• health systems strengthening needs to be a higher priority for GHIs
• targets for GHIs need to include indicators for health systems
• GHIs need to work harder to collect more reliable information about their effects
• donors need to increase their financial support of not only GHIs, but also health systems.

The authors say that, if the necessary reforms can be made, it is possible to achieve improved efficiency, equity, value for money, and outcomes in global public health, The study is also discussed in a Lancet editorial.

Reference

1. World Health Organization Maximizing Positive Synergies Collaborative Group (2009). An assessment of interactions between global health initiatives and country health systems. Lancet; 373(9681) 2137-2169.