Strengthening health systems ‘rhetoric, not reality’

Health initiatives aren't improving health systems, say researchers Copyright: World Bank/Dominic Sansoni

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Researchers claim to have found a "clear gap" between what most international health organisations say they are doing to strengthen health systems, and the reality on the ground.

Writing in PLoS Medicine, they say that although ‘global health actors’ (GHAs) may claim to be strengthening health systems, they actually engage almost exclusively with activities that match their own specific aims.

Global health initiatives such as the US President’s Emergency Plan for AIDS Relief (PEPFAR) and Roll Back Malaria tend to concentrate on single diseases. This ignores the wider problem of fragile health systems in developing countries, say the researchers.

The team, from the public health department at the Institute of Tropical Medicine in Antwerp, Belgium, reviewed GHAs’ strategic documents. They found that "virtually all GHAs claim to support health systems, but instead focus on disease-specific interventions or on activities targeting system functions essential for implementing their own programmes".

For example, the Global Alliance for Vaccines and Immunisation focuses on strengthening elements of health systems essential to immunisation programmes.

Part of the problem, say the researchers, is that GHAs use the term ‘health system strengthening’ for any capacity building. "We need a definition that is both shared and consistently applied," they write.

They also suggest GHAs’ "enormous financial leverage" may be undermining individual countries’ health systems.

In 2005, the Ugandan government health budget of US$112 million was overshadowed by US$167 million spent by three GHAs.

Such well-resourced programmes can attract local health workers, drawing them away from the general health system into disease-specific programmes.

Badara Samb, a senior advisor on health systems and services for the WHO, told SciDev.Net that shifting GHA policy is "fraught with challenges" because there is little research-based evidence showing how to improve interactions between national health systems and GHAs.

"Aligning the efforts of [GHAs] with the need to strengthen health systems has become a new imperative," he says.

Samb says the WHO led studies last year to identify ways for GHAs to achieve their objectives and strengthen countries’ health systems. The results should be available this month (June).

Meanwhile the Belgian research team’s findings are reflected in another new PLoS Medicine paper analysing whether the rollout of antiretroviral medication in Ethiopia was effective.

The study suggests the programme, led by GHAs including PEPFAR, may have caused an ‘internal brain drain’ of doctors. Numbers in the public sector dropped during the rollout, while numbers of non-profit staff increased.

Link to full paper analysing GHAs

Link to full paper on Ethiopian antiretroviral rollout