Reflections
Global health
Volume 199 - Issue 10

Are global health leaders effectively strengthening local public health systems?

Author:  Mary C Boyle

Med J Aust 2013; 199 (10): 702-703. || doi: 10.5694/mja13.10818
Published online: 18 November 2013
Are global health leaders and funding bodies doing enough to ensure that the rhetoric surrounding health system strengthening becomes reality, or has the concept been relegated to that of a buzzword?
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Winner: Medical practioner category

Global health leadership is, presently and historically, inextricably linked with the provision of billions of dollars of aid (by bilateral aid programs such as the President’s Emergency Plan for AIDS Relief, multilateral agencies such as the Global Fund, and private donors like the Bill and Melinda Gates Foundation), through the work of large-scale global health non-government organisations (NGOs). This association became particularly evident to me while studying for the London School of Hygiene and Tropical Medicine’s locally taught East African Diploma in Tropical Medicine and Hygiene last year. Throughout the campuses of the school’s urban and rural public health care facilities, the proliferation of signposts declaring multiple partnerships and familiar logos denotes the heavy presence and involvement of these NGOs.

In general terms, most of this global health aid is distributed into “vertical programs”, which tend to focus on specific diseases (HIV and malaria being the most common), by a specialised health service using dedicated health workers, having cost-effective interventions with measurable results. These programs have, among their many laudable achievements, successfully enabled the rollout of a variety of treatments as well as effective prevention and education initiatives to target specific issues on a large scale, and have undoubtedly alleviated suffering and saved millions of lives. Highly educated and motivated regional professionals have undertaken world-class research locally in their fields of interest, exemplifying the principle of ownership so imperative in the practice of quality global health.

As well as their program-specific goals, most of the medically focused NGOs and funding bodies explicitly incorporate health system strengthening into their objectives. While the concept of a health system itself is somewhat all-encompassing, for the most part, health system strengthening refers to the government-run public health system, which includes the primary care clinics and hospitals where most of the population can access medical care. It stands to reason that the ultimate “health for all” primary health care-focused goal declared at Alma Ata can only be realised through true health system strengthening, irrespective of the success of vertical programs.

The World Health Organization has identified six “building blocks” of a health system, which can be used to evaluate its essential domains or functions. These are service delivery, health workforce, health information systems, access to essential medicines, financing and leadership or governance. Health system strengthening can be defined as any intervention targeting one or more of these building blocks.

But are global health leaders and funding bodies giving adequate consideration to these building blocks and doing enough to ensure that the rhetoric surrounding health system strengthening becomes reality? Or has the concept been relegated to that of a buzzword, an afterthought that can be disregarded when the primary aims of the program have been achieved or the research question answered? It is difficult to be convinced of the contrary, when one observes the obvious disparities between the high-quality level of care provided to patients enrolled in NGO-funded vertical programs and the care that members of the same community, suffering from conditions not being targeted by NGOs, receive in the general public health system despite the best efforts of health care workers in this setting.

These speculative observations prompted a debate among my diploma classmates (comprising about 60 medical practitioners from 16 nations, of whom one-third were local to the East African region) about potential explanations why the positive outcomes from health-based NGO involvement do not appear to be conferring a benefit of the magnitude one might expect on the local public health system. While this was by no means an exhaustive or definitive debate, it suggested that a twofold situation may exist: NGOs may not be effectively strengthening local public health systems, and there may be some potentially adverse (while inadvertent) consequences of vertical programs on public health systems.

The idea was reiterated that allocation and recipients of aid can be disproportionate, possibly due to a concurrent distortion of health sector priorities. The presence and involvement of multiple NGOs with similar goals but inadequate communication and coordination between them may result in a fragmentation of services with ensuing inequities. Unfortunately, in some cases, the sustainability and accountability of programs subject to external, non-government funding is difficult to monitor and impossible to guarantee absolutely. The comparatively attractive career prospects offered by NGOs to both medical and non-medical staff can lead to an “internal brain drain” from the public sector. The local ministries of health (MOH) incur an additional administrative burden from the allocation and distribution of the aid received, which they may not be fully equipped to manage. Lastly, the possibility of corruption and misappropriation of aid, sadly, cannot be disremembered.

Clearly, strategies to ensure health system strengthening must be a collaborative effort between donor and recipient. The Paris Declaration (2005) and Accra Agenda for Action (2008) outlined the principles, targets and focus for advancement in making aid more effective. More specifically, the 2008 NGO Code of Conduct for Health Systems Strengthening was created to serve as a guide for international NGOs working to limit their harmful effects and maximise their contributions to strengthening public health systems. Key components of this code include sustainable hiring practices, public sector human resource compensation, improving human resource training, minimising the management burden for MOH, supporting the MOH agenda and advocating for public sector strengthening. There are currently about 50 signatories to the code although, to date, there has been no large-scale evaluation of its implementation or effectiveness.

While applauding the undeniable progress made by vertical programs funded by today’s global health leaders, in the future, we must strive to build on these efforts while ensuring true health system strengthening and health for all.

Author

  • Mary C Boyle MB BCh, DTM1,2
  • 1. Department of General Medicine, Royal Children’s Hospital, Melbourne, VIC.
  • 2. London School of Hygiene and Tropical Medicine, London, UK.

Correspondence: Mary.Boyle@rch.org.au

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