Existing health systems in the developing world are fragile and many are unable to provide effective health services -- and so there is growing consensus that the success of global health initiatives will depend on "health system strengthening" (a recent buzzword in global health). But a new literature review in this week's PLoS Medicine suggests that while many global health initiatives and agencies claim to support health system strengthening, their claims may not always be matched by their actions.
Bruno Marchal and colleagues at the Institute of Tropical Medicine-Antwerp, Belgium, reviewed the key strategic documents published by major global health initiatives and agencies (the authors use the term "global health actors"). Some examples of global health actors included in their review are UNAIDS; WHO; the Global Fund to Fight AIDS, Tuberculosis and Malaria; Roll Back Malaria; the African Programme for Onchocerciasis Control; the Global Alliance for Vaccines and Immunization; and the Global Network for Neglected Tropical Disease Control.
Marchal and colleagues examined the claims that these global health actors made about the importance of health system strengthening and compared these with the actors' actual activities and programmes.
"We found a clear gap between the language used by global health actors and their actual activities," say Marchal and colleagues. "Virtually all global health actors claim to support health systems, but instead they focus on disease-specific interventions or on activities targeting health system functions essential for implementation of their own programmes."
The authors argue that global health actors tend to emphasize, in their strategic documents, the importance of interventions that can achieve a rapid impact and that have measurable short-term outcomes -- rather than the longer-term goal of health system strengthening.
When these global health actors do address weak health systems, they often do so in a way that selectively helps their own programme achieve its goals. "In practice," they say, "micro-level solutions (incentives and support for general health services carrying out programme activities) or support to specific sub-systems essential for effectively implementing the programme (drug delivery, surveillance, etc.) are the norm."
Although global health actors identify weak health systems as the major barrier to the success of their programmes, say Marchal and colleagues, their responses tend to focus on their own specific objectives.
Funding: This literature review was funded by institutional funding of the Institute of Tropical Medicine, Antwerp. The funders had no role in designing, conducting, or analyzing the literature review, the decision to publish, or preparation of the manuscript.
Citation: Marchal B, Cavalli A, Kegels G (2009) Global Health Actors Claim To Support Health System Strengthening--Is This Reality or Rhetoric? PLoS Med 6(4): e1000059. doi:10.1371/journal.pmed.1000059
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Institute of Tropical Medicine, Antwerp
Department of Public Health