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CSU 64/2009: INTERACTIONS BETWEEN GLOBAL HEALTH INITIATIVES AND COUNTRY HEALTH SYSTEMS

Thursday, 22nd of October 2009

CHILD SURVIVAL UPDATE 64/2009: INTERACTIONS BETWEEN GLOBAL HEALTH   INITIATIVES
AND COUNTRY   HEALTH SYSTEMS
 
  1) NOTE TO READERS
 
  Apologies to readers of the PEPFAR evaluation for omitting the URL
  address, which is http://www.annals.org/cgi/content/full/150/10/688
 
 
  2) Global Health Initiatives like GAVI, the Global Fund, and PEPFAR have   proliferated in the last decade.
 
  This recent and well documented (223 references!) article from The    Lancet is sure to generate much discussion. In the article, also    available with tables at
  http://www.thelancet.com/journals/lancet/article/PIIS0140-6736  (09)60919-3/fulltext the authors look at the large and growing number of   Global Health Initiatives in the light of their impact on health systems  at the country level.
 
  To an extent, the GHIs have anticipated many of the critiques by putting   some of their investment funds into building the health systems which   form the groundwork for categorical interventions.
 
  Good reading.
 
  BD
 
  'An assessment of interactions between global health initiatives and country health systems'
 

Original Text
 
  The Lancet, 20 June 2009
 
  World Health Organization Maximizing Positive Synergies Collaborative
  Group‡
  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.
  Panel 1
  Global health initiatives with involvement of several stakeholders
  HIV/AIDS
  Accelerating Access Initiative to HIV Care; African Comprehensive
  HIV/AIDS Partnerships; Global Business Coalition on HIV and AIDS; Global
  Coalition on Women and AIDS; Global Fund to Fight AIDS, Tuberculosis and
  Malaria; Global Media AIDS Initiative; Global Reporting Initiative; HIV
  Vaccine Trials Network; HIV/AIDS Treatment Consortium (Clinton
  Foundation HIV/AIDS Initiative); Hope for African Children Initiative;
  Inter-Company for AIDS Drug Development; International Partnership
  Against AIDS in Africa; International pharmaceutical company initiative
  to support AIDS orphans (Step Forward); Maternal to Child Transmission;
  Multi-Country HIV/AIDS Program; President's Emergency Plan for AIDS
  Relief; Safe Injection Global Network; The Corporate Council of Africa;
  Viramune Donation Program
  Malaria
  African Malaria Partnership; Antimalarial Product Development;
  Artesunate Suppository for Emergency Treatment of Severe Malaria;
  European Malaria Vaccine Initiative; Japanese Pharmaceutical, Ministry
  of Health, WHO Malaria Drug Partnership; Malarone Donation Program;
  Medicines for Malaria Venture; Multilateral Initiative on Malaria;
  NetMark, a Regional Partnership for malaria Prevention; Roll Back
  Malaria; WHO Novartis Coartem
  Tuberculosis
  Action TB Program; Eli Lilly Multi-Drug Resistance Tuberculosis
  Partnership; Partnership Against Resistant Tuberculosis; Sequela Global
  Tuberculosis Foundation; Stop TB partnership (Stop TB); The Global
  Alliance for TB Drug Development; Tuberculosis Diagnosis Initiative
  Onchocerciasis
  African Program for Onchocerciasis Control; Mectizan Donation Program
  Dengue
  Dengue Vaccine Project; Pediatric Dengue Vaccine Initiative
  Trachoma
  WHO Alliance for the Global Elimination of Trachoma (GET 2020); Lassa
  Fever Initiative
  Tetanus
  Campaign to Eliminate Maternal and Neo-natal Tetanus
  Schistosomiasis
  Praziquantel manufacturing project; Schistosomiasis Control Initiative
  Sexually transmitted infections
  Global Microbicide Project; International Partnership for Microbicides
  Blindness
  Global initiative to eliminate unnecessary blindness (Vision 2020);
  International Trachoma Initiative
  Hookworm
  Human Hookworm Vaccine Initiative
  Trypanosomiasis and leishmaniasis
  Gates Foundation/University of North Carolina Partnership for the
  Development of New Drugs; Sleeping Sickness Initiative; WHO Programme to
  Eliminate Sleeping Sickness
  Dracunculiasis
  Guinea Worm Eradication Program; Global Alliance to Eliminate Leprosy
  Lymphatic filariasis
  Global Alliance to Eliminate Lymphatic Filariasis
  Poliomyelitis
  Global Polio Eradication Initiative
  Lassa fever
  Lassa Fever Initiative
  Meningitis
  Meningitis Vaccine Project at WHO/PATH
  Nutrition
  Global Alliance for Improved Nutrition
  Vaccines
  Children's Vaccine Program at PATH; European Malaria Vaccine Initiative;
  Global Alliance for Vaccine Initiative; International AIDS Vaccine
  Initiative; International Vaccine Institute; Malaria Vaccine Initiative;
  Meningitis Vaccine Programme; Pneumococcal Vaccines Accelerated
  Development and Introduction Plan; Pediatric Dengue Vaccine Initiative;
  South African AIDS Vaccine Initiative; Vaccine Fund; Vaccine Vial
  Monitors
  Health policy and systems
  Alliance for Health Policy and Systems Research; Global Outbreak Alert
  and Response Network; Health InterNetwork; International Health
  Partnership
  Drugs for neglected tropical diseases
  African Network for Drugs and Diagnostics Innovation; Alliance for
  Microbicide Development; Diflucan Partnership Program; Drugs for
  Neglected Diseases Initiative; Foundation for Innovative New
  Diagnostics; TROPIVAL (French-based research and development partnership
  for neglected diseases); Global Campaign for Microbicides; Médecins Sans
  Frontières, Drugs Initiative for Neglected Diseases; Microbicides
  Development Programme 2; Strategies for Enhancing Access to Medicines;
  The Institute for OneWorld Health
  Diarrhoea control and hand washing
  Global Public-Private Partnership for Hand Washing with Soap; Partners
  in Global Health Through Hand Washing
  Nutrition
  Global Alliance for Improved Nutrition; Vitamin A Global Initiative;
  Micronutrient Initiative
  Chemical safety
  International Program on Chemical Safety
  Counterfeit
  Pharmaceutical Security Initiative; WHO Pharmaceutical Associations Anti
  Counterfeit Drug Initiative
  Reproductive health
  Consortium for Industrial Collaboration in Contraceptive Research;
  Concept Foundation; UNFPA contraceptives access project
  Pharmaceutical regulation
  International Conference on Harmonization of Technical Requirements for
  Registration of Pharmaceuticals for Human Use
  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—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—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—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.
  Definitions
  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 of common features, including their focus on specific diseases or
  on selected interventions, commodities, or services; relevance to
  several countries; ability to generate substantial funding; inputs
  linked to performance; and their direct investment in countries,
  including partnerships with non-governmental organisations and civil
  society (table 1). Variations also exist within this subset,
  particularly in the area of governance structures (table 1).
  Nevertheless, since these GHIs have important features in common they
  can be discussed as one group for the purpose of this analysis.
 
  Table 1Table image
  Information about global health initiatives selected for analysis
 
  What are health systems?
  WHO defines health systems as “all organizations, people and actions
  whose primary intent is to promote, restore or maintain health”.30, 31
  This definition includes efforts to address the determinants of health,
  besides direct activities to improve health. A health system is
  therefore “more than the pyramid of publicly owned facilities that
  deliver personal health services”,30 and includes non-state sectors such
  as non-governmental organisations, civil society organisations, and the
  private sector. For example, 40—70% of health care in sub-Saharan Africa
  is provided by faith-based organisations, indicating the importance of
  inclusion of all health delivery providers in a country's health system.
  32 The purpose of the WHO health-systems framework (consisting of
  service delivery; health workforce; information; medical products;
  vaccines and technologies; financing; and leadership and governance) is
  to “promote common understanding of what a health system is and what
  constitutes health systems strengthening”.30 Although these building
  blocks help to clarify the essential functions of health systems,
  efforts to address health systems should recognise the interdependence
  of each part of the health system.30
  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
  several countries to finance the delivery of specific types of services
  for priority health problems that arise in many low-income countries.
  This effort interacts with country health systems in several ways. We
  have developed a conceptual framework by using information from two
  existing models—one that identifies distinct functions or building
  blocks of health systems30 and the other that describes the interactions
  between GHIs and these functions.33 In our conceptual framework, we
  identified five points of interaction between GHIs and country health
  systems (ie, governance, finance, health workforce, health information
  systems, and supply management systems), and each of these is
  interlinked and contributes towards a sixth point of interaction that is
  the delivery of health services (figure 1). The central role of the
  community is recognised in our model. Also, all aspects of the six
  points of interaction take place within a general context that includes
  many economic, social, political, environmental, and other factors that
  are not included in our analysis.
 
  Figure 1 Full-size image (44K)
  Conceptual framework of the interaction between global health
  initiatives and country health systems
  The conceptual framework is not optimum, and these data and analysis
  have limitations that arise because health systems are complex,
  context-specific, and changing. Any attempt to better understand the
  interactions requires assessment of more than the routinely gathered
  data, which are usually about the effectiveness and cost efficiency of
  isolated biomedical interventions. Such data have little capacity to
  indicate how complex systems function to give results.
  Findings
  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
  availability of health workers, health facilities, diagnostics, drugs,
  and other supplies, and also provisions for financing, and policies or
  programmes that make particular services a priority for delivery.
  Although these dimensions of health systems all affect service delivery,
  we focus on three key factors that represent aggregate issues in the
  assessment of services—ie, service access or coverage, equity in
  services, and service quality.
  Panel 2
  Summary of key findings
  Service delivery
  Access and uptake of the health services targeted by global health
  initiatives (GHIs) has increased in many cases
  Evidence of the effects of GHIs on access and uptake of non-targeted
  health services shows positive and negative effects
  Positive effects (and mitigation of potential negative effects) of GHIs
  on non-targeted health services are likely when they have been
  explicitly planned or when the health system is robust, or both
  GHIs have contributed to improvements in some aspects of health equity.
  GHIs have not directly addressed the causes of health inequity or the
  social determinants of health
  Increase in access to some targeted health services has been faster than
  that to services not targeted by the GHIs, showing a new dimension of
  health service inequity
  Through the promotion of standardised guidelines, GHIs have contributed
  to improving quality of treatment and services for targeted
  interventions
  The promotion of performance-based assessment has been associated with
  improved quality of services in some cases but, in others, pressures to
  meet targets has produced distortions and led to compromises in quality
  Financing
  Resources administered through GHIs have contributed to an aggregate
  increase in overall health financing
  Evidence for the association between GHI funding and changes in overall
  domestic public sector health spending, or reallocation within national
  health budgets, is inconclusive
  GHIs have promoted the principle of free services at the point of
  delivery of targeted interventions but have not invested systematically
  in the development or extension of prepayment health financing
  mechanisms
  The GHIs are associated with several innovative financing mechanisms and
  have contributed to some improvements in health aid effectiveness,
  particularly in the area of predictable financing
  Disease-specific funding might not be sufficiently aligned with country
  priorities or the national burden of disease
  Governance