Global Health Initiatives such as GAVI, GFATM and PEPFAR have incurred criticism of being selective and narrowly defined while placing poor emphasis on - and falling short of - health systems strengthening
By Angela Owiti*
Trainee at Wemos foundation
Global Health Initiatives
What Do We Know About Their Impact On Health Systems?
The Global Health Initiatives (GHIs) were created to help meet the Millennium Development Goals (MDGs) (1). They pool funds and expertise and focus their efforts across different countries towards disease specific interventions, such as anti-retroviral therapy (ART), vaccines and insecticide treated bed nets. While these programmes have reached substantial outcomes in many low and middle income countries (LMICs), they also received criticisms in the first decade of their advent for operating through parallel delivery systems and causing unwanted weakening effects on the countries’ health care systems (2). The first comprehensive report on the interaction between GHIs and country health systems by the World Health Organization (WHO) Maximizing Positive Synergies Collaborative Group recommended that GHIs need to place more emphasis on strengthening health systems. In addition, they concluded that with some adjustments in the way they operate, GHIs can offer critical opportunities to improve ‘efficiency, equity, value for money and outcomes in global public health’ (1).
Moving towards strengthening of health systems
Following the criticisms and recommendations, three large GHIs- the Global Alliance for Vaccines and Immunization (GAVI), the Global Fund to Fight Aids, Tuberculosis and Malaria (GFATM), and the United States President’s Emergency plan for AIDS Relief (PEPFAR)- responded and embraced a commitment towards strengthening health systems since around 2010 (3). However, their HSS (health system strengthening) strategies were seen as being selective and narrowly defined by both Marchal et al (4) and Storeng (5). Since then, the GHIs increasingly encourage countries to request for resources targeted at strengthening health systems, albeit with that narrow view of optimizing the delivery of their disease-specific health programmes (2). Hence, this raises questions of whether health systems in LMICs are really benefitting.
I therefore examined whether GAVI, GFATM and PEPFAR are having reported impacts on the health systems. As a follow-up of reviews published in 2009 and to coincide with the time that the three GHIs started to focus explicitly on HSS, I identified and reviewed 19 articles published between 2010 and 2017 on the effects of GHIs on country health systems, with a particular focus on countries in Sub-Saharan Africa (SSA). The articles however mainly described the situation before the new focus on HSS which was introduced around 2010. Below I present the findings of my literature review.
Findings
The literature review showed that the achievements of GHIs yielded both positive and negative effects. Most of the results relating to the impact on the health systems identified in the reviewed articles are on the health service delivery and the health workforce function, while governance is seldom scrutinized.
Key positive effects include: an increase in access to ART (6); increased linkages between HIV and TB programmes and other healthcare programmes such as maternal and child health services and family planning (6) and pre-service training to increase the capacity of health care workers (HCWs) (7). Adverse effects described include: the ‘internal brain drain’ of health care workers from public health facilities (which already struggle with shortages) to private sector or GHI-funded organizations (8)(9);conflict between top-down strategies of disease programmes and local planning activities (10)(11); and parallel systems which create duplicate tasks and an increased workload for HCWs (also for already overburdened staff); over-emphasis on in-service training of HCWs resulting in per-diem hunting and duplicate training (7)(9). Other findings cover the over-reliance on external donor funds which generate concerns over the long-term sustainability of the programmes, and that GHIs limit their efforts towards a few diseases thus many high burden problems such as maternal and child health, non-communicable and neglected tropical diseases are not equally addressed (10).
Paucity of evidence
Two features from the literature review stood out. First, most of its findings were similar to those of the previous reviews published in 2009 (2)(1). This does not come as a total surprise, because most of the data collected in the identified and reviewed articles were collected before 2010. Secondly, the results showed that there seems to be unequal attention to all GHIs. While my focus was on GAVI, GFATM and PEPFAR, my search did not produce any articles on the interaction of GAVI with health systems. To me this is evidence that not enough attention is being given by both the recipient and donor countries, and the global health research community on the interaction of GHIs with country health systems. An issue which has been previously raised and discussed by the WHO’s Maximizing Positive Synergies Collaborative Group (1). More than half a decade after these GHIs’ explicit commitments to strengthen health systems, this attention seems to be long over-due.
Short term versus long term effects
GHIs were initially intended to salvage emergency situations. Their quick response was mainly in the form of supporting health systems with interventions which fill urgent gaps and primarily focused on increasing inputs. These include short-term interventions such as those that improve or upgrade facilities, improve services or provide salary support (12). Though these interventions have helped to ensure the scale up of treatment such as in the case of HIV/AIDS, they do not lead to the processes that bring about sustainable change and performance. I do agree with Chee et al (12), that it may have been easier to think in the short term but with time it became evident that this approach caused fragmentation in the health systems and, as a result, the negative effects which are also reported in the studies I reviewed were observed.
Strengthening health systems on the other hand is not just about filling gaps but ensuring that the six health system building blocks – leadership and governance; financing; service delivery; health workforce; health information systems and medicines and other commodities – function better (13). It also involves “managing these building blocks in a manner that strives to achieve more equitable and sustained improvements across health services and health outcomes” (12). The 2004-2009 Malawian Emergency Human Resources Programme (EHRP) that was co-funded by the GFATM was a promising example. It involved the recruitment and pre-training of HCWs, but more importantly policies and activities that are related to financial and non-financial incentives, such as employment conditions and staff placements, were implemented to address issues such as inadequate staffing and low motivation. The EHRP was also done with the collaboration of different international initiatives, the health sector-wide approach (SWAp) and the Malawian government. All of which is intricately related to the system building block of service delivery. There was a reported significant increase in the HCW density. However, the longer term effects of the EHRP on Malawi’s health workforce and its sustainability are not reported in literature.
Research on health systems is needed
The Sustainable Development Goals (SDG) demonstrates a renewed global commitment to health, underpinned by SDG3 including its ambitious target on Universal Health Coverage (UHC). For that we need to build strong and responsive health systems to ensure that all people and communities have access to essential and affordable health services. Achieving UHC for all countries requires global commitment. GAVI, GFATM and PEPFAR claim to be part of the solution. But both the donor and recipient countries need to hold them accountable and ensure that they are not just talking the talk but also walking the walk. Positive benefits will only happen if we explicitly set out to achieve them. For this we need research on health systems! Good measuring frameworks and knowledge sharing to highlight both the best practices and lessons learnt. This will help countries build their systems and meet the needs of the people and the communities.
*About the author
Angela Owiti is pursuing an Advanced Master degree in International Development (AMID) at the Radboud University in the Netherlands and is a trainee at Wemos foundation. This literature review was conducted for the foundation’s activities in the Health Systems Advocacy Partnership (HSAP), which is active in five countries in SSA: Kenya, Uganda, Zambia, Tanzania and Malawi.
References
- Samb B, Evans T, Dybul M, Atun R, Moatti JP, Nishtar S, et al. An assessment of interactions between global health initiatives and country health systems. Lancet [Internet]. 2009;373(9681):2137–69. Available from: http://dx.doi.org/10.1016/S0140-6736(09)60919-3
- Biesma RG, Brugha R, Harmer A, Walsh A, Spicer N, Walt G. The effects of global health initiatives on country health systems: A review of the evidence from HIV/AIDS control. Health Policy Plan. 2009;24(4):239–52.
- Warren AE, Wyss K, Shakarishvili G, Atun R, de Savigny D. Global health initiative investments and health systems strengthening: a content analysis of global fund investments. Global Health [Internet]. 2013;9(1):30. Available from: http://globalizationandhealth.biomedcentral.com/articles/10.1186/1744-8603-9-30
- Marchal B, Cavalli A, Kegels G. Global health actors claim to support health system strengthening – Is this reality or rhetoric? PLoS Med. 2009;6(4):1–5.
- Storeng KT. The GAVI Alliance and the “Gates approach” to health system strengthening. Glob Public Health [Internet]. 2014;9(8):865–79. Available from: http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=4166931&tool=pmcentrez&rendertype=abstract
- Rasschaert F, Pirard M, Philips MP, Atun R, Wouters E, Assefa Y, et al. Positive spill-over effects of ART scale up on wider health systems development: Evidence from Ethiopia and Malawi. J Int AIDS Soc. 2011;14(SUPPL. 1):1–10.
- Bowser D, Sparkes SP, Mitchell A, Bossert TJ, Bärnighausen T, Gedik G, et al. Global Fund investments in human resources for health: Innovation and missed opportunities for health systems strengthening. Health Policy Plan. 2014;29(8):986–97.
- Mussa AH, Pfeiffer J, Gloyd SS, Sherr K. Vertical funding, non-governmental organizations, and health system strengthening: perspectives of public sector health workers in Mozambique. Hum Resour Health [Internet]. 2013;11(1):26. Available from: http://human-resources-health.biomedcentral.com/articles/10.1186/1478-4491-11-26
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- Chee G, Pielemeier N, Lion A, Connor C. Why differentiating between health system support and health system strengthening is needed. Int. J. Health Plann. Manage. [Internet] 2013 Jan; 28(1):85–94. Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3617455/
- World Health Organization. Everybody’s business: strengthening health systems to improve health outcomes: WHO’s framework for action. [Internet]. 2007 p. 1–56. Available from: http://www.who.int/healthsystems/strategy/everybodys_business.pdf
