Optimizing global health initiatives to strengthen national health systems
Health systems seek to achieve overall health improvement through provision of promotional, preventive, curative and rehabilitative health services. Health systems operate at and across national, district, community and individual levels. Governments have the responsibility to strengthen their health systems. Health system strengthening is defined as building capacity in critical components of health systems to achieve more equitable and sustained improvements across health services and health outcomes. Global Health Initiatives (GHIs) are typically programmes targeted at specific diseases and intended to bring additional resources to the health efforts of countries. The purpose of this article is to highlight the opportunities and challenges that exist in effectively optimizing GHI resources to strengthen national health systems and actions that can take advantage of these opportunities.
Les systèmes de santé ont pour objectif une amélioration générale de la santé par la fourniture de services de santé promotionnels, préventifs, curatifs et de rééducation. Les systèmes de santé fonctionnent au niveau national, des districts, des communautés, et au niveau individuel. Les gouvernements ont la responsabilité de renforcer leurs systèmes de santé. Le renforcement des systèmes de santé se définit comme le renforcement des capacités des composantes essentielles des systèmes de santé, afin d’arriver à une amélioration plus équitable et plus durable des services et des résultats en matière de santé. Les initiatives pour la santé mondiale sont des programmes types qui ciblent des maladies spécifiques et visent à apporter des ressources supplémentaires aux efforts consentis par les pays en matière de santé. Le but de cet article est de mettre en évidence les opportunités qui existent pour une optimisation effective des ressources destinées aux initiatives pour la santé mondiale, en vue du renforcement des systèmes de santé nationaux, et les mesures permettant de tirer profit de ces opportunités.
Os sistemas de saúde procuram conseguir uma melhoria global da saúde, através da prestação de serviços de saúde promocionais, preventivos, curativos e reabilitadores. Os sistemas de saúde operam aos níveis nacional, distrital, comunitário e individual e entre eles. Os governos têm a responsabilidade de reforçar os seus próprios sistemas de saúde. O reforço dos sistemas de saúde é definido como a formação de capacidades em componentes essenciais dos sistemas de saúde, para se obterem melhorias mais equitativas e sustentáveis em todos os serviços e resultados da saúde. As Iniciativas Mundiais de Saúde (IMS) são, tipicamente, programas orientados para doenças específicas e destinam-se a constituir recursos adicionais para os esforços dos países na área da saúde. A finalidade do presente artigo é realçar as oportunidades que existem para optimizar eficazmente os recursos das IMS, de modo a reforçar os sistemas nacionais de saúde e as acções que podem tirar partido destas oportunidades.
Health systems seek to achieve overall health improvement through provision of promotive, preventive, curative and rehabilitative health services.1 They encompass the population they serve and a set of six functions, namely: service delivery including interventions within specific disease control programmes;2 the health workforce; information; medical products, vaccines and technologies; financing; and leadership/governance. Health systems operate at and across national, district, community and individual levels. Governments are responsible for strengthening their health systems.
Health system strengthening is defined as building capacity in critical components of health systems to achieve more equitable and sustained improvements across health services and health outcomes.3 These include defining sector policies and strategies; clarifying roles and managing competing demands; ensuring fair and sustainable financing; creating an adequate and productive workforce; ensuring supply, maintenance and proper use of drugs and equipment; improving organization, management and quality of services; and ensuring availability and effective use of facility- or population-based information and monitoring systems. Building capacities may involve actions at one or more levels, from households to national and global levels.
Global Health Initiatives are usually targeted at specific diseases and are intended to bring additional resources to the health efforts of countries.4 Since 2000, the number of GHIs has grown exponentially,5 reaching over 140. Three of the major GHIs are:
- the Global Alliance for Vaccines and Immunization (GAVI) – a global effort to strengthen childhood immunization programmes and bring a new generation of recently licensed vaccines into use in developing countries;
- the Global Fund to Fight AIDS, Tuberculosis and Malaria, which directly contributes to the achievement of Millennium Development Goals (MDGs) 4, 5, 6 and 8; and
- the United States GHI which seeks to achieve significant health improvements and foster sustainable effective, efficient and country-led public health programmes that deliver essential health care whose first principle is to focus on women, girls and gender equality.
The GAVI Alliance and the Global Fund have identified functional health systems as essential to achieving their objectives and established health systems strengthening funding windows to effectively scale up proven, high-impact interventions and help improve the sustainability of results. Since 2007, the GAVI Alliance has made available US$ 500 million for health systems strengthening in 54 countries, most of which are in the African Region. In addition, the Global Fund has dedicated US$ 1.6 billion to health systems strengthening in 27 countries in the Region since 2005.6 In the recent past the GAVI Alliance, the Global Fund and the World Bank have explored the possibility of creating a health systems funding platform to effectively support countries in line with the principles of the Paris Declaration on aid effectiveness.
The investment of GHI resources in health systems in an integrated manner is yielding positive results, as illustrated in the following examples:
- In 2005, the Global Fund joined DFID and other partners in Malawi to strengthen human resources in order to optimize the implementation of interventions related to MDGs 4, 5 and 6. Between 2005 and 2009, the health worker density increased by 66% (0.87 to 1.44) and, using the Lives Saved Tool (LiST), an evaluation of four coverage indicators (antenatal care, skilled birth attendance, administration of nevirapine for preventing mother-to-child transmission and fully immunized children) showed that 13 187 additional lives were saved due to their increased coverage.7
- In Ethiopia, three GHIs and other partners have supported the recruitment and training of 30 000 extension health workers to rapidly roll out four packages of promotive and preventive services and management of diseases at the community level. Final dose diphtheria, pertussis and tetanus (DPT3) coverage increased from 69% in 2005 to 86% in 2010.
- Similarly, the Government of Rwanda has developed an integrated approach to health delivery and built health system strengthening components into GHI grants, thus avoiding the creation of parallel systems and enabling the renovation and construction of at least 100 health facilities8 and salary support for doctors and nurses, to improve their retention even in rural areas. Based on the Rwanda Demographic and Health Survey 2010, under-five mortality declined substantially from 152 to 76 per 1 000 live births between 2005 and 2010.
Despite these efforts, progress towards the health MDGs has been rather slow in many countries in the African Region. Only Equatorial Guinea and Eritrea are on track to achieve MDG5, and only eight out of the 46 countries in the Region are likely to achieve MDG 4 by 2015.9 Failure to increase the pace towards the achievement of the MDGs is largely blamed on weaknesses within national health systems. Optimizing GHI resources to strengthen national health systems in the Region is expected to reduce the main bottlenecks to reaching disease-specific national and international health goals and targets. These bottlenecks are found in all the six building blocks of the health system and in their interactions, necessitating a holistic approach with strong government leadership.
Government stewardship in strengthening health systems is sometimes overwhelmed by multiple and parallel approaches that fragment resources such that holistic implementation of national health strategic plans is hampered. There is inadequate focus on identifying the system-wide bottlenecks and estimating the related resources needed to optimally implement the interventions supported by the GHIs. In addition, there is suboptimal participation of key national and international partners in the development of national health policies and strategic plans to ensure that they adequately reflect major health priorities, clarify the roles and responsibilities of different stakeholders and maximize the extent to which specific technical strategies and plans benefit from and fit into national health strategic plans.
All the GHIs make their resources available to eligible countries, subject to development and approval of proposals. The different calls for proposals cause difficulty in harmonizing interventions to strengthen a health system. In addition, the intensity and consistency of the dialogue on how best to address systemic bottlenecks in order to effectively scale up high impact interventions vary from country to country. As a result, the health system strengthening components of the proposals may not fully reflect the health systems strengthening priorities set out in the national health strategic plans. Therefore, consistency with national health policies and strategic plans is often undermined.
The large increase in the number of GHIs has underscored the need to improve national capacity to oversee and coordinate a wide range of stakeholders in the health sector. Globally, the slow progress towards the realization of the health systems funding platform has highlighted the challenge in achieving coordination among the GHIs without a well-defined mechanism. The 2011 report on the assessment of the five principles of the Paris Declaration10 showed that, as at 2010, only one (strengthen capacity to coordinate support) out of the 13 targets had been met. For example, only 19% of donors’ missions to the field were jointly undertaken, which is far below the required 40%. However, progress has been significant among the remaining indicators where the responsibility for change lies primarily with governments of developing countries.
Adequate funding for health system strengthening through domestic resources remains a daunting challenge for many countries in the Region. In general, the opportunities offered by GHIs such as GAVI and the Global Fund for health system strengthening have been inadequately utilized, while most other GHIs do not provide such opportunities. This may require exploring the prospects of making better use of the existing health system funding windows and increasing their numbers among GHI-supported programmes.
Despite these challenges, the support from GHIs provides several opportunities. In addition to committing substantial resources, GHIs play effective roles in advocacy, coordination and technical support. With the support of GHIs, some countries have successfully implemented programme specific interventions that have led to the reduction or elimination of diseases. Most of the countries in the Region have presented documentation showing success in the polio eradication agenda, with only one country still endemic in the African Region. Eritrea, Rwanda and Swaziland took only four years to exclude malaria from the ten leading causes of morbidity, controlling it to a level where the disease has ceased to be of any public health significance. The Measles Partnership Initiative contributed to measles mortality reduction11 by 85% between 2000 and 2010. Furthermore, the introduction of performance-based funding approaches has contributed to increased accountability at country level.
All GHIs support and agree with the five principles of the 2005 Paris Declaration on aid effectiveness. Additionally, in 2011 the Fourth High Level Forum on Aid Effectiveness came up with the Busan Partnership for effective development cooperation. Earlier, in 2006, GAVI and WHO had developed Working Paper No. 4 on “Opportunities for Global Health Initiatives in the Health System Action Agenda”12 that was presented as a background document to the GAVI board. The paper outlined how GHIs could support health systems strengthening and in which specific areas. Given its relevance to all GHIs, that paper provides an opportunity to enhance the ability of GHIs to work together in synergy.
In May 2008, WHO launched a process to generate evidence-informed guidance through the Maximizing Positive Synergies (MPS) project13 and has engaged stakeholders in a collaborative effort to build new knowledge on how GHI-supported programmes are impacting national health systems, and to harness this evidence for policy and implementation. The first draft document in 2009 presented an initial compilation of findings from MPS research partners who have analysed GHI-health systems interactions in more than 20 countries. Furthermore, in the same year, through the Civil Society Consortium, evidence of the interactions between GHIs and the health systems and the role of the civil society was documented for Kenya, Malawi, Uganda and Zambia.
The Grand Challenges in Global Health14 is an initiative by the Bill and Melinda Gates Foundation to address an imbalance in which only a tiny fraction of the resources spent on research is focused on discovering and developing new tools to fight the diseases that cause millions of deaths each year in developing countries. Grand Challenges in Global Health focuses on 16 major global health challenges with the aim of engaging creative minds across scientific disciplines to work on solutions that could lead to health system advances and breakthroughs in developing countries. Grand challenges 1–3 are:
- one vaccination dose at birth;
- no refrigeration needed vaccines; and
- needle-free vaccines.
All the three grand challenges have grant opportunities for research.
GHIs actively support policy directions at national level, especially with regard to the provision of services free of charge at the point of delivery. They thus promote pre-payment mechanisms and contribute to progression towards universal coverage. In addition, they promote accountability among beneficiaries.
There is need to strengthen country stewardship, management capacity and advocacy for estimation of all the resources required for implementation of interventions so that all the expected system-level needs across the six building blocks are taken into account to enhance allocation efficiency. Involvement of partners in the development of national health strategic plans, within government set guidelines, is of paramount importance to ensure common agreement and buy-in on priorities, financing and reporting mechanisms and to ensure also that the specific roles in implementing the strategic plans are clarified, and that GHI interventions fit into the national health strategic plan.
During proposal development, there is need to promote a holistic approach on how best to address systemic bottlenecks in order to effectively scale up high-impact interventions. Integration of the proposed interventions into national health strategic plans should be a prerequisite for successful implementation of the interventions.
To effectively finance national health strategic plans, revenues collected from different sources (income tax, foreign aid including from GHIs, health insurance and some of the innovative means promoted) should be pooled into an integrated health financing mechanism that allows transparent, rational and efficient allocation and use of the resources.15 This will reinforce country efforts to move towards universal coverage with the entire population having access to good quality health services without the financial hardships resulting from out-of-pocket payment for access to these services.
Countries should maximize the use of the existing health system funding windows by ensuring achievement of results in a timely, accountable and transparent manner. In order to sustain results, there is need for long-term investment in health systems strengthening.
It is most important to enhance coordination and communication among GHIs and other key players and to work collaboratively to improve efficiency and harmonization between themselves and with other partners, and alignment to country priorities. This may require the formation of a “collaborative mechanism” or a “platform” for coordination of the contributions of each partner to meet country-specific needs including for health systems strengthening. In addition, there is need to explore how best to expand the number of health system strengthening windows among the other GHI-supported programmes.
WHO and other UN agencies should encourage health systems research, taking advantage of the Grand Challenges in Global Health initiative and the MPS project. Using its convening role, WHO should facilitate the discussion of the proposed actions among GHIs and remain an active player in the process of harmonization through the already established Harmonization for Health in Africa (HHA) and International Health Partnership plus (IHP+).
Strengthening health systems is fundamental to improving health outcomes and accelerating progress toward the health MDGs.16 The ability of GHIs to raise and disburse additional funds to support disease control and strengthen health systems provides a unique opportunity for many countries to fill critical funding gaps in addressing their health development priorities. By addressing the challenges and making good use of the opportunities stated above countries can make tangible progress towards achieving not only disease-specific targets but also long-term and sustainable health outcomes. .
- Gilson L, ed. Health Policy and Systems Research: A Methodology Reader, Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland, 2012.
- Van Damme W et al. (2010). How can disease control programmes contribute to health systems strengthening in sub-Saharan Africa? Studies in Health Services Organization and Policy, Working Paper Series, Working Paper No. 1, Antwerp, Institute of Tropical Medicine, 2010.
- WHO. Working Paper No. 4, Opportunities for Global Health Initiatives in the Health System Action Agenda, World Health Organization, Geneva, Switzerland, 2006.
- WHO. Trade, foreign policy, diplomacy and health; Glossary of globalization, trade and health terms (http://www.who.int/trade/glossary/story040/en/).
- UN. The Millennium Development Goals Report 2009, United Nations, New York, 2009.
- Global Fund. Making a difference sub-Saharan Africa regional results report 2011, the Global Fund, Geneva, Switzerland, 2011.
- Management Sciences for Health. Evaluation of Malawi’s Emergency Human Resources Programme, EHRP Final Report, July 2, 2010.
- Mukherjee JS et al. Rwanda: the Impact of Global Health Initiatives on the Health System: A mix methods analysis, WHO, June 2009.
- MDG 4 (Algeria, Cape Verde, Eritrea, Liberia, Madagascar, Malawi, Mauritius and Seychelles); MDG 5 (Equatorial Guinea and Eritrea).
- OECD. Aid Effectiveness 2005–10: Progress in implementing the Paris Declaration, OECD Publishing (http://www.oecd.org/dataoecd/25/30/48742718.pdf).
- Simons E et al. Assessment of the 2010 global measles mortality reduction goal: results from a model of surveillance data, The Lancet, published online, 24 April 2012.
- WHO. Working Paper No.4, Opportunities for Global Health Initiatives in the Health System Action Agenda, World Health Organization, Geneva, Switzerland, 2006.
- WHO. Interactions between Global Health Initiatives and Health Systems: Evidence from Countries, The Maximizing Positive Synergies Academic Consortium, June 2009 (http://www.who.int/healthsystems/publications/MPS_academic_case_studies_Book_01.pdf).
- Grand Challenges in Health. Grand Challenges Initiative (http://www.grandchallenges.org/about/Pages/Overview.aspx).
- WHO. The World Health Report. Health Systems Financing: the path to universal coverage, WHO, Geneva, Switzerland, 2010.
- de Savigny D & Adam T, eds. Systems thinking for health systems strengthening, Alliance for Health Policy and Systems Research, World Health Organization, Geneva, Switzerland, 2009.