[Editors note: A copy of the article, Marchal B, Cavalli A, Kegels G (2009)
Global Health Actors Claim To Support Health System
Strengthening—Is This Reality or Rhetoric? PLoS Med 6(4)
is availble with the editor AIDS ASIA e FORUM]

Strengthening health systems 'rhetoric, not reality'

Carol Campbell

3 June 2009. Health initiatives aren't improving health systems, say researchers
World Bank/Dominic Sansoni 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.

http://www.plosmedicine.org/article/info%3Adoi%2F10.1371%2Fjournal.pmed.1000059