global health initiatives and health systems: a commentary on current debates and future challenges...

7/29/2019 Global health initiatives and health systems: a commentary on current debates and future challenges (WP11)

1/20

KNOWLEDGE HUBS FOR HEALTHStrengthening health systems through evidence in Asia and the Pacic

The Nossal Institute

for Global Health

www.ni.unimelb.edu.au

HEALTH POLICY AND HEALTH FINANCEKNOWLEDGE HUB

WORKING PAPER SERIES NUMBER 11 | SEPTEMBER 2011

Global health initiatives and health systems:a commentary on current debates and

uture challenges

Helen M. Robinson

Nossal Institute or Global Health, University o Melbourne

Krishna Hort


John Grundy



2/20

WORKING PAPER SERIES HEALTH POLICY AND HEALTH FINANCE KNOWLEDGE HUB

Global health initiatives and health systems: a commentary on current debates and uture challenges NUMBER 11 | SEPTEMBER 2011

ABOUT THIS SERIESThis Working Paper is produced by the Nossal Institute or Global Health at the University o Melbourne,Australia.

The Australian Agency or International Development (AusAID) has established our Knowledge Hubs orHealth, each addressing dierent dimensions o the health system: Health Policy and Health Finance; HealthInormation Systems; Human Resources or Health; and Womens and Childrens Health.

Based at the Nossal Institute or Global Health, the Health Policy and Health Finance Knowledge Hub aimsto support regional, national and international partners to develop eective evidence-inormed policy making,particularly in the eld o health nance and health systems.

The Working Paper series is not a peer-reviewed journal; papers in this series are works-in-progress. The aimis to stimulate discussion and comment among policy makers and researchers.

The Nossal Institute invites and encourages eedback. We would like to hear both where correctionsare needed to published papers and where additional work would be useul. We also would like to hear

suggestions or new papers or the investigation o any topics that health planners or policy makers would ndhelpul. To provide comment or obtain urther inormation about the Working Paper series please contact; [email protected] with Working Papers as the subject.

For updated Working Papers, the title page includes the date o the latest revision.

Global health initiatives and health systems: a commentary on current debates and uture

challenges.

First Published September 2011

Corresponding author: Helen M. Robinson

Address: The Nossal Institute or Global Health, University o [email protected]

This Working Paper represents the views o its author/s and does not represent any ocial position o theUniversity o Melbourne, AusAID or the Australian Government.


3/20

HEALTH POLICY AND HEALTH FINANCE KNOWLEDGE HUB WORKING PAPER SERIES

NUMBER 11 | SEPTEMBER 2011 Global health initiatives and health systems: a commentary on current debates and uture challenges 1

SUMMARYThe recent establishment o a range o global health initiatives has transormed the landscape o developmentassistance or health by providing signicant increases in unding through innovative nancing mechanisms.

Most global health initiatives have tended to ocus on specic disease program interventions or outcomes,but some, notably the Global Alliance or Vaccines and Immunisation (GAVI) and the Global Fund to FightAIDS, Tuberculosis and Malaria (GFATM), also support health system strengthening. Given the volume ounds involved and the tendency to ocus on vertical programming, global health initiatives have generatedongoing debate about their impact on the already ragile health systems o low-income countries (LICs) andtheir capacity to support health system strengthening. We provide a summary o the key issues in the debate,ocusing on health nancing and service delivery. We then highlight how an initiative launched within thebroader global development sphere, that o the aid eectiveness agenda, is linked to global health initiativesand their interactions with health systems. We conclude by suggesting that those working in the area o healthsystem strengthening need to understand the debates occurring at the global level, and to be aware o thetensions that relate to them. These tensions can be better managed through closer dialogue between healthpractitioners working at the global level and within countries.

1 See or example the agendas o the World Health Assembly and Executive Board during 2002 to 2008.


4/20


2 Global health initiatives and health systems: a commentary on current debates and uture challenges NUMBER 11 | SEPTEMBER 2011

INTRODUCTIONGlobal health initiatives (GHIs) have emerged in recent years as a new type o organisation engaging inand infuencing development assistance or health. Comprising partnerships between government, non-

government, corporate and philanthropic actors, these initiatives have mobilised signicant additional undsor health programs in middle-income countries (MICs) and LICs through a variety o innovative undingmechanisms (Marchal, Cavalli et al 2009; Institute or Health Metrics and Evaluation 2010). This substantialamount o nancial resources has translated into a considerable scaling up o services in many countries.

Most GHIs have ocused on a single or a discreet range o diseases using vertical disease-control approaches,placing less emphasis on the strengthening o health systems needed to deliver these programs. However,given the scale o unding, there has been considerable debate and discussion about the role o GHIs inrelation to health systems in LICs (Balabanova, Mckee et al 2010; Sridhar 2010, among others1).

In 2009, a large international group under the auspices o the World Health Organisation (WHO), called theWHO Maximising Positive Synergies Collaborative Group (WHO MPSC Group), undertook a review o theinteractions between GHIs and country health systems. The study ound that GHIs and health systems are

inherently linked, and have positive and negative impacts on each other (WHO MPSC Group 2009). Similarly,recent evaluations o GAVI and GFATM the key GHIs having specic health system unding programshighlighted that strengthening o national health systems was necessary to enhance the perormance o thetwo initiatives (HLSP 2009; TERG 2009).

Interestingly, these ndings came to light around the same time that the world experienced a nancial crisisaphenomenon that orced several donors to reconsider their unding commitments to global health. Thishas not only put pressure on the ability o GHIs to attract the unding to sustain current work, but has alsoraised questions on their eectiveness in achieving health goals. The reviews, coupled with the need or wiseinvestments and improved eciency, provide an important opportunity to refect on the debates surroundingGHIs and their impact on eorts to strengthen health systems in LICs. These issues are particularly relevant toaid eectiveness reorms that have occurred since the mid-2000s.

This paper provides an overview o the key issues, specically in terms o shortcomings, around the interactionso GHI programs with health systems. This is done by rst looking at the impacts on health nancing andservice delivery, ollowed by a review o GHIs approaches to health systems strengthening. The paper thenhighlights how aid eectiveness is also linked to GHIs programming and health systems strengthening eorts,and suggests that tensions inevitably arise as a result o the aims o the three processes. It concludes byarguing that these tensions need to be actively managed through closer dialogue between global, national andsub-national health practitioners.

This paper is based on a selective review o the literature, so as to identiy a range o viewpoints, rather than acomprehensive survey. It largely draws upon the evaluations o key GHIs, namely those o GAVI (HLSP 2009)and GFATM (TERG 2009), the study conducted by the WHO MPSC Group (2009) on interactions betweenGHI programs and health systems and related documents released around the same time that the reviews

were undertaken. Some o the literature rom these studies was subsequently peer-reviewed and published inscientic and academic journals. As the inormation base on GHIs and health systems is rapidly developing,here the ocus was on literature produced between 2000 and 2010.


5/20



CONCEPTS AND DEFINITIONS

Health Systems and Health System Strengthening

In accordance with WHO, we dene health systems as all organizations, people and actions whose primarypurpose is to promote, restore or maintain health (WHO 2000; WHO 2007). WHO urther describes healthsystems as characterised by six main components: service delivery, a health workorce, inormation systems,medical products, vaccines and technologies, and nancing, as well as leadership and governance (WHO2007). This paper ocuses on nancing and service delivery when discussing the impacts o GHI programs onhealth systems, as these have been the areas that have received the most attention in reviews and debatesabout GHIs. This is not to say that other eorts in capacity building or improving access to drugs are notimportant, but rather to ocus the analysis more clearly.2 Unlike health systems, health systems strengthening(HSS) is not consistently reerred to with a standard denition. In this paper, the term is understood as aprocess, comprising various strategies and initiatives, aimed at enhancing the unctioning o any or all o thecomponents o health systems to achieve more equitable and sustained improvements across health servicesand health outcomes (WHO 2007).

The policies and actions aimed at improving health outcomes or individuals and amilies in LICs can operate atdierent levels o health systems. Drawing on Hanson, Ranson et al (2003) description, we dene the ollowinglevels o action and infuence, which are delineated on the basis o the impact and nature o decision making:

(1) household or individual health consumer level;

(2) community levelnaturally orming clusters o households in a delineated local area;

(3) health service delivery level, comprising networks o clinics, hospitals and other related services;

(4) health sector level, which is responsible or local policy and oversight o service delivery, most otenprovincial or regional governance;

(5) national levelthe sovereign state, and encompassing all the legal and regulatory responsibilities o thestate related to health and well-being;

(6) regional level, where neighbouring countries collectively discuss health policy, priority setting and jointaction; and

(7) global level o international and multilateral policy making and action.

As this is an increasingly complex area, here we adopt a narrower ocus by looking at the infuence o actionsrelated to GHIs globally and nationally.

Global Health InitiativesGlobal Health Initiatives are diverse in nature, ranging rom ormal, legally incorporated entities to moreinormal groups variously called partnerships, alliances, international partnerships, councils and projects.Their members come rom the various arms and agencies o national governments, the corporate sector,not-or-prot sector, academia, civil society and even individuals representing their own interests. GHI roles

include: providing a range o services related to a specic disease or health issue, providing technical advice,advocacy, conducting research and coordinating and delivering prevention and treatment services. Others aresolely nancing mechanisms. There are now thought to be about 100 GHIs providing development assistanceor health (DAH). Among the most prominent GHIs in terms o infuence and nancial resources are GAVI, theBill and Melinda Gates Foundation (Box 1), GFATM, the US Presidents Emergency Plan or AIDs Relie and theWorld Banks Multi-Country AIDS Program. For a more comprehensive list, see the WHO MPSC Groups review(2009).

2 Those seeking a wider review are reerred to the WHO MPSC Groups review (2009), which provides a comprehensive overview o the interactions between GHIsand health systems in relation to all six areas, based on literature published up to 2009.


6/20



While dicult to dene, GHIs do have some common eatures. The WHO MPSC Group (2009) suggests thatthese include: a ocus on specic diseases or on selected interventions, commodities or services; relevance toseveral countries; ability to generate substantial unding; inputs linked to perormance; and direct investmentin countries, including partnerships with non-government organisations and civil society. We would add theimportant eature o operating in this newly expanded policy space at the global level.

For the purposes o this paper, we reer to GHIs as a new institutional layer in the health arena. The termglobal is a contentious one and is not always used consistently. While they exist at a global level, most GHIsaim to make health improvements at the national and sub-national level. Though there have been a rangeo international and multinational organisations operating at this level or more than a century, these newerinstitutions appear to operate in a manner quite dierent rom those that already existed. Over a comparativelyshort time, GHIs have emerged, gained authority and voice and are giving this global level its own identity andcharacter.

Box 1. The Bill and Melinda Gates Foundation and Development Assistance for Health

The Bill and Melinda Gates Foundation was created in early 2000. By 2006, with the addition o a major contribution rom investor WarrenBuet, it has become the biggest philanthropic institution in the world, with a total endowment o an estimated US$60 billion.1 TheFoundation has recently announced that it will increase the amount it will spend to about US$3 billion per year.2

Following a reorientation o the Foundation in 2006, global health has become one o three major areas o activity.

Under its global health program, by ar the largest grants have been made to GAVI, which will receive US$1.5 billion 1999-2015 orboth the purchase o vaccines and general operating support. Other grantees receiving large amounts are: Program or AppropriateTechnology in Health with US$825 million, Global Fund to Fight AIDS, Tuberculosis and Malaria with US$650 million, World HealthOrganization with US$300 million and Medicines or Malaria Venture with US$200 million.

The majority o unding is or research in the areas o HIV/AIDS, malaria, maternal and reproductive health, immunisation o childrenand other inectious diseases. The actual breakdown o unds allocated is very dicult to categorise rom publicly available inormationbecause o the lack o detailed inormation on each grant and the dierences in length o time o each grant.

The Foundation has identied three interrelated programs:

Discovery:closinggapsinknowledgeandscienceandcreatingcriticalplatformtechnologiesinareaswherecurrenttoolsare

lacking.

Delivery:implementingandscalingupprovenapproachesbyidentifyingandproactivelyaddressingtheobstaclesthattypicallyliein

the path o adoption and uptake.

Policyandadvocacy:promotingmoreandbetterresources,effectivepolicies,andgreatervisibilityofglobalhealthsoasto

eectively address the Foundations priority health targets.

See: http://www.gatesoundation.org/global-health/Pages/overview.aspx.

1 By comparison U K Welcome Foundation has endowment o US $19 billion and Ford Foundation has US $ 11 billion.2 Economist January 6, 2009.


7/20



GLOBAL HEALTH INITIATIVES AND HEALTH SYSTEMS

The Impact o GHI Programs on Health Systems

Most GHIs, such as GFATM, GAVI and the World Banks Multi-Country AIDS Program, are primarily nancinginstruments. These initiatives channel unds to countries or specic health programs with a goal, amongothers, o scaling cost-eective interventions to increase coverage and access. The sheer scale o undsprovided, coupled with GHIs vertical program approach and emphasis on scaling up services, have generatedconsiderable interest in the impact o GHI programs on already weak health systems in LICs. As early as2001, when GHIs were starting to become more prominent in health development, it was envisaged that theinitiatives would have important eects on health systems (Biesma, Brugha et al 2009). However, it is onlyover the past ew years that the impacts o GHI programs have been better understood, due to evaluations oGHIs, systematic reviews o evidence and empirical studies conducted within countries. Some o the negativeimpacts on health systems highlighted across the literature include:

(1) The lack o accountability o global donors to country governments (Sridhar 2010).

(2) The emphasis on scaling up disease-specic interventions may increase the burden on an alreadyoverstretched human resource capacity by generating additional demand or health care (WHO MPSCGroup 2009).

(3) The ocus on specic health areas distracts governments rom other national priorities, including eorts tostrengthen health systems (Biesma, Brugha et al 2009).

(4) A variable degree o alignment with country planning processes and priorities: while many GHI programsare linked with country planning processes, they also result in the creation o additional planningstructures within countries.3 The prolieration o unding sources and coordinating mechanisms increasesadministrative burdens and leads to ragmentation, thereby undermining harmonisation (Sridhar 2010; WHOMPSC Group 2009).

In this section, we ocus on how GHIs have impacted on two specic components o health systems: nancing

and service delivery. Reviews such as those carried out by the WHO MPSC Group (2009) and Biesma andcolleagues (2009) provide a detailed overview o how GHI programs interact with health systems.

Health fnancingglobal and national

During the past decade, GHIs have played a signicant part in the major increase in unds made availableglobally or Development Assistance or Health (DAH). While there are diering estimates o the overall increasein unds, it is clear that DAH has increased both as a proportion o overall oreign aid and as a proportion oworld Gross National Income (GNI). The OECD (2009) reports that DAH increased rom US$2.5 billion in 1990(0.16% o GNI) to more than US$13 billion in 2005 (0.41% o GNI); health aid as a proportion o total overseasdevelopment assistance increased rom 4.6% in 1990 to almost 13% in 2005.

Total DAH has continued to increase despite the 2009 global nancial crisis, reaching US$26.9 billion in2010, a 50% increase on the US$17.8 billion in 2006 (IHME 2010). It is estimated that in 2010 GHIs provided

approximately 20% o total DAH (up rom about 15% in 2006); bilateral government assistance provided nearly50% (up rom 35% in 2006); and the proportion contributed by the United Nation (UN) system and othermultilateral agencies (approximately 20% in 2010) and Non Government Organisations (NGOs) (5% in 2010)had both allen. Increased unding rom GHIs was responsible or about 50% o the increase in total DAHbetween 2006 and 2010 (authors estimates based on IHME data). It has also been reported that the GHIs tendto make longer term commitments or project unding than do the more traditional bilateral and multilateral aidagencies. Dodd and Lane (2010) ound that GHIs accounted or ve o the six longest commitment periodsidentied in their review.

Due to the infuence o GHIs, this increased DAH has been targeted at certain specic diseases and hasmarkedly changed the manner in which control o these diseases is unded. For example, the WHO MPSCGroup estimates that, in 2007, GHIs accounted or two-thirds o external unding or HIV/AIDS prevention andcare, 57% or tuberculosis control and 60% or malaria control (2009).

3 Such as the GFATMs country coordinating mechanism and GAVIs interagency coordinating committee.


8/20



Whether or not the increased DAH substitutes or national health spending is a raught issue, both public andprivate donors generally want to see their aid as increasing the total amount available or national spending onhealth. GFATM, or example, includes in its country agreements undertakings that its unds will not be used toreduce the overall level o national spending in the specic areas related to its initiatives.4 However, the WHOMPSC Group noted that there was inconclusive evidence on the impact o increased GHI unding on domesticgovernment expenditure or health. While there was some evidence o reduced government expenditure on HIVin sub-Saharan Arican countries receiving GHI support, there was also evidence that GHIs have contributed toa reduction in user ees and out o pocket expenses, especially or those suering rom the targeted diseases(WHO MPSC Group 2009).

Despite this increased unding, many in the aid sector question whether it is sucient to do the job. In onerecent initiative, a group o donor governments established the High Level Taskorce on Innovative InternationalFinancing or Health Systems, which attempted to estimate the total cost o meeting the targets set in thehealth-related Millennium Development Goals (MDGs), based on the needs o the 49 poorest countries (Fryatt,Mills et al 2010). The task orce investigated both the capital investments required and the ongoing operationalunds needed to sustain the delivery o health services underpinning the MDG targets.

The Taskorce estimated that while US$31 billion was currently spent on the health-related MDGs globally bynational and international partners, a urther US$36-45 billion per year is required. While the value o sucha global estimate is somewhat limited, it does give an indication o the order o magnitude o the undingrequired. Moreover, as many commentators have observed, it is a relatively small amount compared with thecosts o, or example, the bailing out o major banks during the global nancial crisis.

Health service delivery

While the additional unding channelled by GHIs or specic diseases is an important development in globalhealth, it is equally important to consider where the nances are being invested and the returns on theseinvestments.

In a review o the impact o GHIs on health service delivery, the WHO MPSC Group (2009) noted that one

characteristic o GHIs was their ocus on scaling up selected services that have proven to be eective. Theimpact o GHI unding on three areas was examined: access or coverage, equity and quality o services.

The group ound evidence o signicant increases in coverage o key interventions or target diseases (AIDS,malaria, TB) and vaccination, although it was not always clear how much o the increase could be attributedto contributions rom the GHIs. There was also evidence o both positive and negative eects on coverageo non-targeted services and conditions. When the disease-control programs that are unded by GHIs areseen alongside the reports on progress in meeting the health-related MDGs (see, or example, WHO 2010a),expansion in service delivery is apparent in many countries. However, in the case o HIV/AIDS, or example,the numbers o new inections continues to rise, and approximately 55% o those estimated to need treatmentcurrently receive it.

The WHO MPSC Group noted that the introduction o standardised protocols and measurement o adherence

to these protocols have contributed to improved quality o service delivery (World Health Organization,Maximizing Positive Synergies Collaborative Group 2009). However, the emphasis on meeting numericaltargets may have a negative impact both on equity (with eorts directed towards target populations in urbanand easy to reach areas) and on service quality. The group raised questions about the extent to which thediseases or conditions targeted by GHIs aligned with the needs and priorities o recipient countries. Theynoted that while GHIs address issues o global importance based on global epidemiological evidence, preciseassessment o need was not available or most LICs.

Table 1 illustrates the issues discussed in this section within specic country contexts, based on literaturepublished since 2009. From the evidence available, it is clear that GHI programs have both positive andnegative impacts on health systems in LICs. While there has been ragmentation o systems, creation o parallelstructures and distortion in resource allocation, governance and multi-stakeholder participation have also

4 Such as the GFATMs country coordinating mechanism and GAVIs interagency coordinating committee.


9/20



improved in several countries.

The relationship between GHI programs and health systems, however, is not one way. It has also been wellacknowledged that health systems need to be strengthened in order to sustain scaling-up o services. A WHO

report noted: [W]ithout more support to help countries build health system capacity, the resources mobilisedby GHIs are unlikely to reach their ull potential (WHO 2006). Next we turn to reviews o GHI approaches tostrengthening health systems.

Table 1. Interactions between GHI Programs and National Health Systems

Study Area Findings related to health systems

Global Fund in Nepal High disease control outcomes, especially or at-r isk groups, and strengthened civil societypartnerships. However, high levels o system ragmentation with creation o parallel monitoringand evaluation structures (Trgrd and Shrestha 2010).

Global Fund in Thailand Signicant improvements in disease control and improved civil society partnerships. Onbalance, there was not an overall benet or negative impact on health systems development

(Hanvoravongchai, Warakamin et al 2010).

Global Fund in Papua New Guinea(PNG)

GFATM-supported activities were ound to be coordinated with the National HIV and TBprograms. However, parallel and vertical systems were established to meet the demandso program scale-up and the perormance-based nature o GFATM investment (Rudge,Phuanakoonon et al 2010).

Global Fund in Indonesia High integration o GFATM investments into vertical programs, strengthening o stewardship andgovernance and litt le integration o monitoring and evaluation into the national health inormationsystem. Potential distortions in human resource allocation as sta shit into incentive-basedpositions o GHI-unded programs (Desai, Rudge et al 2010).

Global Fund in Laos Improved extension o health acili ties and access to care or high-risk groups or TB and HIV.Good integration with national programs, with the exception o monitoring and evaluation. Apositive impact on health systems development, although the distortion o resource allocation(communicable disease control in contrast to maternal and child health) is raised as a concern(Mounier-Jack, Rudge et al 2010).

GAVI: Governance in ve Asiancountries

Although GAVI governance mechanisms demonstrated high levels o perormance in relationto GAVI application processes, there were signicant gaps in strategic gap analysis. Managingthrough systems, rather than being over-reliant on committees, will broaden participation inimplementation and, in doing so, expand the reach o immunisation and maternal and childhealth care (Grundy 2010).

Impact o GHIs in Mali Positive synergies between disease-specic interventions and non-targeted health servicesare more likely to occur in robust health serv ices and systems. Disease-specic interventionsimplemented as parallel activities in ragile health services may ur ther weaken theirresponsiveness to community needs, especially when several GHIs operate simultaneously(Cavalli, Bamba et al 2010).

Impact o GHIs on services in

Zambia and South Arica

Evidence suggests that while GHIs have contributed signicantly to enabling the rapid scaling

up o anti-retroviral therapy in both countries, they may also have had a negative impact oncoordination, the long-term sustainability o treatment programs and equity o treatment access(Haneeld 2010).

Impact o GHIs on HIV/AIDs servicesin seven countries

Positive eects included the creation o opportunities or multi-sectoral participation, greaterpolitical commitment and increased transparency among most partners. However, the quality oparticipation was oten limited, and some GHIs bypassed coordination mechanisms, especiallysub-national ones, weakening their eectiveness (Spicer, Aleshkina et al 2010).


10/20



The Approach o GHIs to Health System StrengtheningSince the beginning o their operation, many GHIs have recognised the need to strengthen health systemsin order to maximise achieving health goals. The ramework document o GFATM, or example, states that

the organisation will support the substantial scaling up and increased coverage o proven and eectiveinterventions, which strengthen systems or working: within the health sector; across government departments;and with communities (GFATM 2002). The document also says that GFATM will support programs thataddress the three diseases [AIDS, tuberculosis and malaria] in ways that will contribute to strengtheninghealth systems (GFATM 2002). Since 2002 GFATM has been supporting health systems strengtheningeitheras a part o specic disease programs or as a component that supports delivery o programs across AIDS,tuberculosis and malaria (Box 2).

Similarly, GAVI has a specic unding stream or HSS. In 2004, the organisation commissioned a study onthe barriers to increasing immunisation coverage. The study ound that health system constraints outside oimmunisation programs were limiting expansion in coverage or hindering sustainability o high immunisationrates (GAVI 2004). Health system barriers identied included insucient resources going to health care, limitedfexibility in use o resources, management ineciencies and shortages in human resources or health (GAVI2004). Under-investment over a number o years and a lack o will to address human resources issues seriouslyhad caused a ailure to establish eective systems or workorce planning, production and management,resulting in shortages, poor distribution and an inadequate skill mix (GAVI 2004). Thus, in December 2005,GAVIs Board approved the creation o a unding window or HSS related to delivery o immunisation (Box 2).

Despite the eorts by GHIs to support weak health systems in LICs, it has been suggested that undedactivities are alling short o producing wide positive impacts. This is largely attributed to the act that, asBalabanova, Mckee et al (2010) point out, the HSS activities supported by GHIs involve support or a limitedset o unctions necessary or the delivery o their own activities or integration o their activities into the existingsystem. For example, as already mentioned, both GFATM and GAVI und only those HSS activities related totheir own areas o ocus. For these reasons, Marchal, Cavalli et al (2009) argue that while many GHIs claimto und HSS activities, these can actually be considered selective disease-specic interventions. Thus, the

criticisms around the impacts o GHI programs on health systems continue to hold true.

Box 2. The Global Fund to Fight AIDS, Tuberculosis and Malaria and Health System Strengthening

The GFATM has long recognised the key role health systems play in supporting progress towards its goals.

The Global Funds major objectives in providing unding or HSS are to:

(1) improve grant perormance and

(2) increase the overall impact o responses to the three diseases.

GFATM recognises that supporting the development o equitable, ecient, sustainable, transparent and accountable health systemsurthers achievement o these objectives.

Currently, GFATM allows applicants to apply or unding to respond to health system weaknesses either through a program (by disease)approach, or by a cross-disease approach, recognising that the response may dier substantially in dierent settings. The organisationalso accepts national health strategy applications provided that they have been properly validated and that civil society and the privatesector have participated in the development o these strategies.

See: Pearson 2008


11/20



AID EFFECTIVENESS AND HEALTH SYSTEMS STRENGTHENINGApart rom the unique mechanisms adopted to mobilise and disburse unds, GHIs have also been recognisedor their eorts in engaging various stakeholders (including people living with disease and or-prot actors) in

decision making, raising the position o health on the development agenda and adapting to the new agendasthat emerge as the global health architecture evolves. The latter characteristic is particularly pertinent to theissues raised in this paper. O relevance to GHIs and health systems, particularly, is the aid eectivenessagenda o development partners.

What about Aid Eectiveness?Over the past decade, health development has been characterised not only by the advent o GHIs but alsoby a reorm movement regarding aid eectiveness. Donors have always been mindul o the need to sellthe achievements o their aid programs domestically, but the increases in DAH have led to a rethinking. Thisis not surprising because increased unding usually goes hand in hand with greater scrutiny and oversight,but it is important to recognise that this agenda also builds on the growing evidence base o what works indevelopment programming.

The aid eectiveness agenda, captured in the Paris Declaration on Aid Eectiveness (OECD 2005), and later inthe Accra Agenda or Action (OECD 2008), aims to improve the delivery, management and use o developmentassistance (which includes DAH) in order to maximise the impact on development. In order to meet this goal,the agenda, which was agreed to by more than 100 development partners, centres on a number o principlesthat endeavour to change the nature o the relationships between donors and recipients and reorm the waybilateral and multilateral aid is delivered and managed (Box 3).

Box 3. The Paris Declaration and the Accra Agenda

The ve key principles o the 2005 Paris Declaration, which aims to strengthen aid governance and improve aid per ormance, are:

Ownership:Developingcountriessettheirownstrategiesforpovertyreduction,improvetheirinstitutionsandtacklecorruption. Alignment:Donorcountriesaligntheiraidprogramswiththeseobjectivesanduselocalsystems.

Harmonisation:Donorcountriescoordinatewitheachother,simplifyproceduresandshareinformationtoavoidduplication.

Results:Developingcountriesanddonorsshiftfocustodevelopmentresults,andresultsaremeasured.

MutualAccountability:Donorsandpartnersareaccountablefordevelopmentresults.

The 2008 Accra Agenda introduced new elements to aid eectiveness:

Predictability:Donorswillprovidethree-to-ve-yearforwardinformationontheirplannedaidtopartnercountries.

Countrysystems:Partnercountrysystemswillbeusedtodeliveraidastherstoption,ratherthandonorsystems.

Conditionality:Donorswillswitchfromrelianceonprescriptiveconditionsabouthowandwhenaidmoneyisspenttoconditions

based on the developing countrys own development objectives.

Untyingaid:Donorswillrelaxrestrictionsthatpreventdevelopingcountriesfrombuyingthegoodsandservicestheyneedfrom

whomever and wherever they can get the best quality at the lowest price.

See: OECD 2005; OECD 2008

As a consequence, several recommendations have been put to GHIs to address the issues raised in the ParisDeclaration and the Accra Agenda. These have ocused on the engagement o GHIs with country systems andon the operation o GHIs themselves. The recommendations include:

(1) Funding mechanisms:

Adapttousingamixoflongertermandprogrammaticfundingtosupportscalingup.

Adoptamoretargeted,results-focusedorchallenge-basedfundingapproachwhereinnovationandpiloting

are required.

Seektoprovidecountryallocationestimatesbasedonagreedcriteriaofneed,toimprovepredictabilityandequity o distribution (Isenman, Wathne et al 2010).


12/20



(2) Aid alignment:

GHIprogramsshouldbebetteralignedwithnationalcountrystrategiesandplans(Biesma,Brughaetal

2009; WHO MPSC Group 2009).

RecipientcountriesshoulddevelopcoherentnationalstrategieswithwhichGHIscanalign(Balabanova,Mckee et al 2010).

Improvecoordinationofdonorinvestmentstosupportnationalstrategicplans(Biesma,Brughaetal2009)

(3) Donor harmonisation and coordination:

RecipientcountriesshouldbeallowedmoreexibilityinusingGHIresources(Biesma,Brughaetal2009).

Supporttheongoingengagementofnon-stateandcivilsocietystakeholders(Biesma,Brughaetal2009).

Radicallysimplifytheglobalhealtharchitectureandreducetransactioncosts(Balabanova,Mckeeetal2010).

(4) Health system weaknesses:

GHIsshouldmorecomprehensivelyaddresshealthsystemweaknessesandassistcountriestoaddress

public sector health worker shortages through long-term unding (Biesma, Brugha et al 2009).

CountriesandGHIsshouldidentifyandaddresscomplex,morefundamentalhealthsystemneeds(WHOMPSC Group 2009).

Ensureintegrationofprogramsinservicedelivery(Balabanova,Mckeeetal2010).

(5) Improved evidence or health system interventions, and indicators or measuring

health system changes:

Identifyindicatorsandtargetsforhealthsystemchangestoenableperformancemeasurementandprovide

more evidence on health system investments and their costs and benets (WHO MPSC Group 2009;Balabanova, Mckee et al 2010).

(6) Capacity building:

Supportrecipientcountriestodevelopacoherentnationalstrategyforprioritisingexternalsupportand

managing it together with local resources in a coordinated way (Balabanova, Mckee et al 2010). Givemoreattentiontocapacitydevelopmentofcountrypartners,particularlyintermsoflongertermand

sector-wide assessment and planning (Isenman et al 2010).

GHIs and the global health community have attempted to address many o the problems. Looking at theHIV/AIDS-ocused GHIs over 2002-07, Biesma, Brugha et al (2009) documented improvements, particularlyin alignment with national joint strategies, support or national monitoring and evaluation systems andincreased training and improved working conditions or health workers. However, they noted less progress inharmonisation at country level, as illustrated by the creation o multiple country coordination mechanisms inaddition to parallel GHI-specic administration and reporting structures.

Globally, a range o coordinating structures and mechanisms has been developed, including agreementssuch as the Best Practice Principles or country engagement o global health partnerships, as well as new

mechanisms like the International Health Partnership (IHP+, see Box 4) and the proposed common nancialplatorm or World Bank, GAVI and GFATM (Balabanova, Mckee et al 2010; WHO 2006).


13/20



Box 4. What is the International Health Partnership?

The International Health Partnership, or IHP+, was launched in 2007 to promote the principles o the Paris Declaration and theAccra Agenda. It is open to all developing and developed country governments, agencies and civil society organisations involved in

improving health who are willing to sign up to the commitments o the IHP+ Global Compact. It currently has 47 members.

In addition to the Global Compact, development partners also made a number o agency-specic commitments, as outlined below.

Partner Commitments:

Improvehowtheyworktoimplementtheagreementsincountrycompactsandtoexpandthepartnershiptoothercountriesand

partners.

Establishajointprocessforin-countryassessmentofnationalhealthandHIV/AIDSplansandstrategies.

Accelerateprogressbydevelopmentpartnersonrealisingthebehaviourchangessetoutinglobalandcountrycompactsandin

accordance with commitments made in the Paris Declaration and the Accra Agenda.

Establisharobustframeworkformutualaccountability.

Supportcivilsocietyengagementatalllevels.

Harmoniseprocurementpolicies.

GHI commitments:

TheGAVIBoardcommittedtosupportIHP+inOctober2008.

TheGFTAMcommittedtodesigninganewnancingarchitecturebasedondisease-specicnationalplanstosimplifygrant

management and processes and align with countries or implementation in 2010; it will monitor all grants or consistency with ParisPrinciples.

GAVIandGFATMwilljointlyexploreopportunitiesforcommonprogrammingandfundingsupportforHSS.

United Nations commitments:

TheUnitedNationsInternationalChildrensEmergencyFund,UnitedNationsFamilyPlanningAssociation,UnitedNations

Development Program, World Health Organization and the Joint United Nations Program on HIV/AIDS each agree to work closelythrough the UN resident coordinator to align their process in IHP+ countries.

TheWorldBankwillcontinuetoprovidetechnicalsupportthroughexistingprograms.

See Ministerial Review Communiqu, 5 February 2009 at: http://www.internationalhealthpartnership.net/CMS_les/documents/ministerial_review_meeting_commu_EN.pd (accessed 15 December 2010).


14/20



Is the HSS Platorm Better Aligned with Aid Eectiveness?A practical response by the GHIs and international agencies to the challenges o implementation presentedby the Paris Declaration and the Accra Agenda has been the HSS Platorm. This was established in 2009 as

a joint arrangement between the World Bank, GAVI, GFATM and WHO. It was introduced as a mechanism tocoordinate, mobilise, streamline and channel the fow o existing and new international resources to supportnational health strategies (World Bank 2010).

The ocus o the HSS Platorm is to increase investment in national health system strengthening strategiesin accordance with the principles o aid eectiveness. The platorm will also undertake joint assessment onational health plans and increase investments in national health planning (World Bank 2010). The rationale orintroducing a health systems platorm is based also on the need to devise a more rational distribution o healthcare resources. The plan to mobilise more resources or health systems development is a response to the actthat more than hal o all DAH goes to control o communicable diseases, with little by comparison or basichealth service delivery (England 2009).

The aid eectiveness agenda and health system platorm approaches have also been catalysts or moves

towards development o a Global Strategy or Maternal and Child Health, with likely priority areas includingresults-based nancing, new technologies and public-private partnerships (Ban 2010). The emergence o theHSS Platorm and the Global Strategy or Maternal and Child Health indicates that the current trend towardsdevelopment o GHIs is being accelerated by the need or more eective aid management and delivery overmore predictable and longer time rames.

5 It is interesting that multilateral eorts in maternal and child health arising rom the review o the MDGs in 2010 include the development o the OneHealth Model;see www.internationalhealthpartnership.net/en/working_groups/working_group_on_costing.


15/20



CONCLUSIONSSince the turn o the new millennium, GHIs have quickly emerged as an important player, altering the healthdevelopment landscape in a variety o ways. GHIs have established new orms o governance, pioneered

new mechanisms by which to raise and disburse unds and brought new energy and enthusiasm to achievingdevelopment goals. In countries, the initiatives have sought to promote accountability, transparency andmulti-stakeholder participation, in addition to supporting dramatic scaling up o cost-eective interventionsor particular health programs. The nancial resources available and vertical programming approach o GHIshas generated considerable debates around the eects o GHI programs on national health systems. Thesediscussions are particularly relevant now, a time characterised by calls or more health or money.

This paper sought to highlight the key issues surrounding GHIs and health systems, in terms o impact andapproaches to HSS. Evidence rom around the world suggests that GHI programs and health systems interactin several waysboth positive and negative. We ound that GHIs have been criticised or largely promoting aocus on downstream service delivery and quick solutions in tackling certain prominent disease areas withoutadequately addressing underlying constraints in health service delivery. The concern most oten raised is theragmentation and complexity the GHIs have added to aid unding. At the same time, the global initiatives havealso acknowledged, since the early days o their operation, the need to address their grantees weak healthsystems, but have taken some time to do soor example through specic HSS unding channels. Theirpersistent use o vertical disease-control interventions and approaches continues to be the cause o much othe criticism o GHIs, particularly or those trying to strengthen health systems in LICs.

Many o the criticisms around the impact o GHI programs on health systems are at the heart o the aideectiveness agenda, namely those related to country ownership, alignment with country systems andharmonisation between donors. Isenman and colleagues (2010), as well as WHO (2010b) cite this as aparticular problem or highly aid-dependent countries, though less o an issue or countries where aid is arelatively small proportion o total health nancing. In light o this, most commentators have emphasisedthe need or greater alignment between GHI operations and the principles o aid eectiveness. A varietyo recommendations are currently being implemented by GHIs and development partners in the orm o a

common HSS unding platorm. At the end o 2010, preparatory work to implement the platorm in a selectnumber o countries was being undertaken.5

It is thus apparent that while GHIs programming approaches, HSS and aid eectiveness largely overlap,there is a gap between policy and practice. The gap between what is said and what is done creates a tensionbetween what is occurring at the global level and in countries. We argue that these are tensions which need tobe recognised and managed by those working in health and development globally, nationally or sub-nationally.GHIs ability to mobilise unds and stimulate rapid scaling up o services or particular diseases has proven tobe important to particular health goals. However, this phenomenon still needs to be balanced with HSS, whichis required in order to promote, maintain and restore health equitably and sustainably. Greater attention to thecomplex task o making the aid eectiveness agenda more o a reality requires changes in the way variousactors work, both globally and in countries.

Managing the tension will require close cooperation between health system practitioners working globallyand nationally. At the global level, there is a temptation to see similarities across countries and look or one-size-ts-all solutions. There is also a tendency to introduce additional global coordination mechanisms andstructures, though what may be needed is more attention to country coordination. Country planners seem otento highlight dierences and nd diculty in identiying economies o scale. The truth may well be somewherein between, but it will not be ound unless there is dialogue and exchange o inormation. The tendency o theGHIs to hold themselves up or regular review and evaluation is a welcome advance. Without this, we would nothave the basis o this discussion. However, we would argue that strengthening health systems in LICs providesa better ocus or driving the continued investment in health development. It should be put more at the centreo the dialogue and knowledge exchange between global and national actors. This can only contribute tostrengthening the health systems o LICs.


16/20



REFERENCESBalabanova, D., M. Mckee, A. Mills, G. Walt and A. Haines. 2010. What can global health institutions do to helpstrengthen health systems in low income countries? Health Research Policy and Systems 8, 22.

Ban Ki-moon. 2010. Global Strategy or Womens and Childrens Health. http://www.un.org/sg/h/Global_StategyEN.pd, accessed 12 May 2011.

Biesma, R.G., R. Brugha, A. Harmer, A. Walsh, N. Spicer and G. Walt. 2009. The eects o global healthinitiatives on country health systems: a review o the evidence rom HIV/AIDS control. Health Policy and Planning24, 4: 239-252.

Cavalli, A., S.I. Bamba, M.N. Traore, M. Boelaert, Y. Coulibaly, K. Polman, M. Pirard and M. Van Dormael. 2010.Interactions between global health initiatives and country health systems: the case o a neglected tropicaldiseases control program in Mali. PLoS Neglected Tropical Disease 4, 8: e798.

Desai, M., J.W. Rudge, W. Adisasmito, S. Mounier-Jack and R. Coker. 2010. Critical interactions between GlobalFund-supported programmes and health systems: a case study in Indonesia. Health Policy and Planning 25,Supplement 1: i43-47.

Dodd, R. and C. Lane. 2010. Improving the long term sustainability o health aid: are Global Health Partnershipsleading the way? Health Policy and Planning 25, 5: 363-371.

England, R. 2009. The GAVI, Global Fund, and World Bank joint unding platorm. Lancet374, 9701: 1595-6.

Fryatt, R., A. Mills and A. Nordsrom. 2010. Financing o health systems to achieve the health MillenniumDevelopment Goals in low income countries. Lancet375, 9712: 419-26.

Global Alliance or Vaccines and Immunisation (GAVI). 2004.Alleviating System Wide Barriers to Immunization:Issues and Conclusions rom the Second GAVI Consultation with Country Representatives and Global Partners.

http://www.gavialliance.org/resources/system_wide_barriers_NORAD_study.pd, accessed 5 May 2011.

Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). 2002. The ramework document o the GlobalFund to Fight AIDS, Tuberculosis and Malaria. http://www.theglobalund.org/documents/TGF_ramework.pd,accessed 10 May 2011.

Grundy, J. 2010. Country-level governance o global health initiatives: an evaluation o immunizationcoordination mechanisms in ve countries o Asia. Health Policy and Planning 25(3):186-196; doi:10.1093/heapol/czp047.

Haneeld, J. 2010. The impact o Global Health Initiatives at national and sub-national levela policy analysis o

their role in implementation processes o antiretroviral treatment (ART) roll-out in Zambia and South Arica.AIDSCare 22, Supplement 1: 93-102.

Hanson, K., K. Ranson, V. Oliveira-Cruz and A. Mills. 2003. Expanding access to health interventions: aramework or understanding the constraints o scaling-up.Journal o International Development15, 1-14.

Hanvoravongchai, P., B. Warakamin and R. Coker. 2010. Critical interactions between Global Fund-supportedprogrammes and health systems: a case study in Thailand. Health Policy and Planning 25, Supplement 1: i53-57.


17/20



HLSP, Global Alliance or Vaccines and Immunisation. 2009. Health System Strengthening Support Evaluation2009 Volume 1: Key Findings and Recommendations. London: HLSP. http://www.gavialliance.org/resources/Volume_1_Key_FindingsRecs_GAVI_HSS_Evaluation_FINAL_Report_8th_October_2009.pd , accessed 5 May2011.

Institute or Health Metrics and Evaluation (IHME). 2010. Financing Global Health 2010: Development Assistanceand Countr y Spending in Economic Uncertainty. Seattle: IHME. http://www.healthmetricsandevaluation.org/sites/deault/les/policy_report/2010/nancing_global_health_report_FullReport_IHME_1110.pd, accessed 5May 2011.

Isenman P, Wathne C and Baudienville G. (2010) Global Funds: Allocation Strategies and Aid Eectiveness.Final Report (July 2010). Overseas Development Institute. http://www.odi.org.uk/resources/download/4947.pdaccessed 4 August 2010

Marchal, B., A. Cavalli and G. Kegels. 2009. Global Health Actors Claim To Support Health SystemStrengtheningIs This Reality or Rhetoric? PLoS Med 6, 4: e1000059.

Mounier-Jack, S., J.W. Rudge, R. Phetsouvanh, C. Chanthapadith and R. Coker. 2010. Critical interactionsbetween Global Fund-supported programmes and health systems: a case study in Lao Peoples DemocraticRepublic. Health Policy and Planning 25, Supplement 1: i37-42.

Organisation or Economic Cooperation and Development (OECD). 2005. Paris Declaration on AidEectiveness. http://www.oecd.org/dataoecd/30/63/43911948.pd, accessed 5 May 2011.

Organisation or Economic Cooperation and Development (OECD). 2008. Accra Agenda or Action. http://www.oecd.org/dataoecd/30/63/43911948.pd, accessed 5 May 2011.

Organisation or Economic Cooperation and Development (OECD). 2009. Development Co-

operation Report 2009. Paris: OECD Publishing. http://www.oecd.org/document/44/0,3746,en_21571361_44315115_42202348_1_1_1_1,00.html, accessed 5 May 2011.

Pearson, M. 2008. IHP+: Expanding predictable fnance or health systems strengthening and delivering results.Background paper. HLSP and IHP+. http://www.internationalhealthpartnership.net/pd/TF_Final%20Report%20Background%20Paper%20Oct%2023.pd, accessed 5 May 2011.

Rudge, J.W., S. Phuanakoonon, K.H. Nema, S. Mounier-Jack and R. Coker. 2010. Critical interactions betweenGlobal Fund-supported programmes and health systems: a case study in Papua New Guinea. Health Policyand Planning 25, Supplement 1: i48-52.

Spicer, N., J. Aleshkina, R. Biesma et al. 2010. National and sub national HIV/AIDS coordination: are global

health initiatives closing the gap between intent and practice? Globalization and Health 6, 3.

Sridhar, D. 2010. Seven challenges in international development assistance or health and ways orward.Journal o Law, Medicine and Ethics 38, 3: 459-469.

Technical Evaluation Reerence Group (TERG). 2009. Synthesis Report o the Five year evaluation o the GlobalFund. Geneva: Global Fund to Fight AIDs, Tuberculosis and Malaria. http://www.theglobalund.org/documents/terg/TERG_Summary_Paper_on_Synthesis_Report.pd, accessed 28 November 2010.

Trgrd, A. and I.B. Shrestha. 2010. System-wide eects o Global Fund investments in Nepal. Health Policyand Planning 25, Supplement 1: i58-62.


18/20



World Bank. 2010. Health Systems Funding Platorm. http://go.worldbank.org/0D4C6GPQU0, accessed 5 May2011)

World Health Organization (WHO). 2000. The world health report 2000: health systems: improving perormance.

Geneva: WHO. http://www.who.int/whr/2000/en/whr00_en.pd, accessed 9 May 2011.

World Health Organization (WHO). 2006. Opportunities or global health initiatives in the health systemagenda. Making health systems work: Working paper No. 4. Geneva: WHO. http://www.who.int/management/Making%20HSWork%204.pd, accessed 5 May 2011.

World Health Organization (WHO). 2007. Everybodys business: Strengthening health systems to improve healthoutcomes. WHOs ramework or action. Geneva: WHO. http://www.who.int/healthsystems/strategy/everybodys_business.pd, accessed 5 May 2011.

World Health Organization (WHO). 2010a. Monitoring o the achievement o the health-related MillenniumDevelopment Goals. Report to the Sixty-third World Health Assembly 2010. Geneva: WHO. http://apps.who.int/

gb/ebwha/pd_les/WHA63/A63_7-en.pd, accessed 5 May 2011.

World Health Organization (WHO). 2010b. The World Health Report 2010. Health systems fnancing: the path touniversal coverage. Geneva: WHO. http://www.who.int/whr/2010/en/index.html, accessed 5 May 2011.

World Health Organization, Maximizing Positive Synergies Collaborative Group. 2009. An assessment ointeractions between global health initiatives and country health systems. Lancet373, 9681: 2137-2169.


19/20


NUMBER 11 | SEPTEMBER 2011 Global health initiatives and health systems: a commentary on current debates and uture challenges


20/20

KNOWLEDGE HUBS FOR HEALTHStrengthening health systems through evidence in Asia and the Pacic

A strateg ic partnerships ini tiative funded by the Aust ralian Agency for Inte rnational Development

The Nossal Institutefor Global Health

global health initiatives and health systems: a commentary on current debates and future challenges...

Documents