Global health programs improve specific health outcomes but can constrain health systems of poor countries

The emergence of global health initiatives (GHIs), eg, The Global Fund and PEPFAR, has resulted in a striking expansion of key health interventions in recent years, from which millions have benefited. There is also evidence, however, that such initiatives can constrain the health systems of poor countries and that many opportunities to improve efficiency, equity, value for money and outcomes in global public health are still being missed. The health systems strengthening agenda needs more investment, and to be infused with the same sense of ambition and speed that has characterised GHIs. This is one of five key recommendations in a new multi-partner report published in a Health Policy paper in this week's edition of The Lancet.

In the report—the most comprehensive evidence published to date—the WHO Maximizing Positive Synergies Collaborative Group focuses on the activities of four leading GHIs—The Global Fund to Fight AIDS, Tuberculosis and Malaria, The US President's Emergency Plan for AIDS Relief (PEPFAR), the Global Alliance for Vaccines and Immunization (GAVI), and the World Bank's Multi-country AIDS Programme. The project incorporated 15 new studies submitted at the invitation of WHO for the preparation of this report. While acknowledging that each GHI is different from the others, the authors saw important common themes emerge. The Group looked at how these GHIs (which emerged during or after 2000) and health systems interact both positively and negatively across several areas: service delivery, financing, governance, the health workforce, information systems, and supply management.

The authors stress the significant gains in service delivery that have been achieved in poorer countries targeted by GHI investments. Such investments have often strengthened primary care and local community involvement. However, uptake of services not targeted by GHIs has not always expanded in line with targeted services, and major challenges remain in many countries to deliver quality health services to all who need them.

Financing of global health has seen a net increase since the advent of these GHIs, with health ODA more than doubling between 2001 and 2006, growing from US$ 5.6 to 13.8 billion annually. One consequence of the increase in external funding, however, is that countries may decrease their own spending on specific diseases and sometimes health in general. Sustained funding for health over the longer term remains a major concern in many countries.

The authors say that GHIs have both exposed, and on occasion contributed to, weaknesses in overall arrangements for good governance of health systems in many poorer countries. There is also a need for GHIs to harmonize their activities with country priorities and planning processes further. GHI involvement has led to some innovations in governance, but there are further opportunities to strengthen collaborative partnerships and ensure greater accountability at all levels.

The scale-up of priority interventions supported by GHIs has not been matched by the required extension in the health workforce. In some cases, GHIs have been linked to increased urban-rural health imbalances, and with loss of healthcare workers from the public sector to GHI projects. In other cases, GHIs have provided incentives such as housing and salary top-ups, which may help countries retain health workers in rural areas. More ambitious action is now needed to address long-term human resources shortages.

The authors report a void in information related to the state of health systems in many countries. GHIs have improved health information related to their specific interventions and diseases, but information related to non-GHI targeted outcomes has, in general, not been enhanced. While GHIs have contributed to innovations in health information and associated technologies, there is an urgent need to improve the collection and use of data at primary facility level.

GHI contributions to improving the supply chain are recognized. However, when these improvements result from the creation of parallel systems by GHIs, they may compromise opportunities for a country to develop its own supply management system. For optimisation of drug supply, countries may require complex advice to navigate international trade rules intellectual property rights. GHIs could have an increasingly important role here.

The authors conclude with five recommendations to accelerate the joint effectiveness of GHIs and country health systems to improve health.

• Infuse the health systems strengthening agenda with the sense of ambition and speed that has characterized the GHIs;
• Extend the targets of GHIs and agree indicators for health systems strengthening;
• Improve alignment of planning processes and resource allocations among GHIs and between GHIs and country health systems;
• Generate more reliable data on the costs and benefits of strengthening health systems, and evidence to inform additional investments to those of GHIs;
• Ensure a rise in national and global health financing and in more predictable financing to support the sustainable and equitable growth of health systems.

"The financial crisis poses some fundamental questions about the way the international community uses its resources", says Dr Carissa Etienne, Assistant Director-General of WHO. "And the response is that while we clearly need more funds for health, we also need to identify opportunities to deliver better results and value for money. Building stronger health systems and promoting greater synergies between health systems and individual health programmes are key to making this happen."

Dr Richard Horton, Editor of The Lancet, comments that: "This report is the result of an unprecedented collaboration between those leading global health initiatives (GHIs) and independent scientists. Their collective goal has been to measure the effects of major disease-specific financing policies on health systems. The conclusions are complex, but the clear message seems to be that there have been both advantages and disadvantages to health systems—and so broader population health—following the introduction of GHIs.

"Health systems have been chronically neglected by GHIs. There are welcome signs that this situation is changing. But a great deal more needs to be done to strengthen and measure the contribution of GHIs to a country's overall health sector. The prize is large and the opportunity substantial. This report has the potential to trigger the necessary changes within GHIs to transform their contributions to vital public health objectives."

To hear an interview with Lancet Editor Dr Richard Horton, see: http://press.thelancet.com/synergies.mp3
For key messages, see: http://press.thelancet.com/pskm.doc
For key quotes, see: http://press.thelancet.com/pskq.doc
For examples, see: http://press.thelancet.com/psexamples.doc
For extended contact list, see: http://press.thelancet.com/psc.doc
For press release en francais, see: http://press.thelancet.com/psf.doc
For the full Positive Synergies Health Policy report, see: http://press.thelancet.com/psfinal.pdf

A Lancet Editorial related to the report will be available later in the week but is not finalised at this time.

The Maximizing Positive Synergies between Health Systems and Global Health Initiatives effort (MPS) was launched in 2008 by the World Health Organization (WHO) with the collaboration and financial support of the Government of Italy. This report is the first output of an ongoing collaborative effort between WHO and a consortium of academic and civil society groups to produce original evidence on GHI-health system interactions in more than 20 countries. The project incorporated 15 new studies that were submitted at the invitation of WHO for the preparation of this report.

A symposium to mark the release of this report will be held at the London School of Hygiene & Tropical Medicine on 18 June. The research findings and recommendations will then be presented to a meeting convening Ministers of Health and high-level representatives of UN agencies, GHIs, non-governmental organizations and world-renowned academics in Venice on 22-23 June in advance of the upcoming G-8 Summit meeting in Italy (8-10 July).

The Lancet Press Office T) +44 (0) 20 7424 4949 E) pressoffice@lancet.com

Sarah Russell, WHO, Geneva, Switzerland T) +41 22 791 5412 /+41 79 598 6823 E) russellsa@who.int

Lindsay Wright, London School of Hygiene and Tropical Medicine: email: T) +44 20 7927 2073 E) Lindsay.Wright@lshtm.ac.uk

Felicity Porritt, Media Consultant, WHO, London T) +44 1 732 459559 / +44 7739 419219 E) felicity.porritt@mac.com

(Paris) Marie-Christine Simon, ANRS, Paris T) +33153946030 / +33 6 8507 1023 marie-christine.simon@anrs.fr