Health GAP, working with the World Health Organization, Global AIDS Alliance, GROOTS Kenya, UCOBAC in Uganda and a network of global advisors representing civil society are attempting to strengthen health systems in the global south by increasing our knowledge of successful models and by building grassroots campaigns that will lead to stronger health systems.

Background

Thirty years after the Alma Ata declaration calling for “Health for All by 2000,” national governments, civil society advocates, and health care providers have made some progress toward achieving that promise. In some cases, major development initiatives have helped increase access to basic health services, achieving improvements in child survival and reductions in maternal mortality, for example At the same time, there have been serious setbacks in efforts to scale up access to health care services, through developments such as donor support for “selective primary health care,” excluding key interventions that were considered “unsustainable” or not “cost-effective.” More recently, significant new global health initiatives (GHIs) have emerged that harness the expertise and resources of public, private, and civil society stakeholders to address priority diseases and global public health threats.

GHIs have generated unprecedented funding and focus on priority health challenges in the developing world, especially HIV/AIDS, tuberculosis, malaria, and vaccine-preventable illnesses. These initiatives have also led to impressive results, such as reaching three million people in developing countries with antiretroviral treatment. They have also challenged fundamental paradigms regarding stainability and cost-effectiveness in disease prevention and management in poor countries. Nonetheless, global health inequities, fueled by insufficient political will and inadequate financial resources continue to undermine efforts to eradicate poverty and to promote the full enjoyment of the human right to health for all. The implementation of programs funded by GHIs has exposed the crisis of weak health systems suffering from decades of neglect and underinvestment. It is unlikely that the ambitious goals of the GHIs will be achieved without expanded investments in strengthening health systems and increasing the number of health workers.

Unfortunately, some stakeholders perceive an artificial dichotomy between investments in health systems and addressing priority diseases, in part because of the attention and focus generated by major new investments in GHIs. In addition, competition for resources among different targeted health interventions, such as HIV/AIDS and sexual and reproductive health programs have contributed to fragmentation within the global health community despite obvious linkages between among targeted interventions.

At the mid-point in efforts to reach the Millennium Development Goals (MDGs), clearly massive increases in resources are needed to achieve the goal of comprehensive primary health care for all, in a manger consistent with basic principles of human rights and social justice.

Civil society has proven itself an indispensable partner in not only mobilizing resources and implementing services, but also in mobilizing the public and political will to ensure donor and implementing countries sustain their investments. At the same time, new technologies have become available at increasingly lower costs, making comprehensive primary health care including universal access to HIV/AIDS prevention, treatment, and care an achievable target.

What is missing, however, is a common understanding and framework for stakeholders to avoid zero-sum approaches that pit GHIs against investments in health systems, and move all stakeholders toward support for greater investments in effective, results-based health service delivery for all. as

There is a growing consensus that GHIs should fund interventions that are explicitly designed to enhance overall health service delivery at the same time that they improve disease-specific outcomes. Project partners reflect the recognition that integrated delivery of comprehensive primary health services, using priority diseases as a starting point, can lead to healthier communities. This approach, which purposefully maximizes synergies between priority disease initiatives and efforts to scale up access to comprehensive primary health services, holds tremendous promise as a model for effective health development financing. Publicizing and enhancing the synergy between GHIs and comprehensive primary health care is critical to achieving the Millennium Development Goals by 2010. 

However, there are limited data about best practices for successful implementation of such approaches, and there is not a shared and coherent understanding of the policy shifts that priority disease and health systems strengthening (HSS) initiatives should undergo in order to maximize synergies between GHIs and HSS. Moreover, most countries to date have been either unwilling or unable to use the existing flexibility that permit funding for HSS that are already incorporated in some of the GHIs. For example:

• PEPFAR’s Country Operations Planning (COP) processes have not been systematically used by countries wishing to scale-up investments in HSS priorities, such as substantial health worker retention strategies or overall procurement and supply chain management (PSCM) capacity building;
• According to the Technical Review Panel of the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), countries have not used the Global Fund to address substantial ‘upstream’ health systems bottlenecks, despite the clear role of these bottlenecks in hindering the response to the three diseases, and the eligibility of such interventions for funding requests;

However, data do not yet exist about countries’ experiences in attempting to use existing flexibilities of GHIs or HSS planning efforts to maximize positive synergies. Real-time learning collaboratives of civil society partners and other stakeholders are needed in order to support countries in using existing opportunities to maximize synergies between HSS and GHIs. These learning collaboratives would facilitate efforts to inform ongoing policy debates regarding the governance and architecture of GHIs, and would contribute to leveraging upcoming opportunities to shape the GHIs while scaling up implementation of priority programs.

Civil society organizations working on a range of priority issues in health service delivery, and representing a range of communities—not limited to HIV/AIDS, tuberculosis, and malaria—have a critical role to play in generating best practices for maximizing the health systems strengthening impact of GHIs. Civil society has played substantial governance and advocacy roles in scaling up the response to priority diseases; in many countries civil-society groups have also played important roles as implementers of GHIs and HSS efforts. Civil society—particularly communities living with HIV/AIDS and affected by tuberculosis and malaria and other priority diseases—has experienced and can report firsthand the benefit of well-planned GHIs designed to strengthen health systems, as well as the negative impact of broad health sector reforms that have restricted or eliminated highly effective projects because they were considered “too vertical” by donors and/or national governments, or distorting effects of overly narrowly-planned priority disease programs. In addition, civil society will continue to play a predominant role in securing increased funding for GHIs, and will work to secure increased additional funding for comprehensive primary health care for all.

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