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To what extent should global health initiatives work with country health systems in order to improve health? A recent Lancet report by the WHO Maximizing Positive Synergies Collaborative Group assesses the effects of such initiatives and suggests concrete steps for change.

The WHO Synergies group, which includes several FXB Center affiliates, examined the interactions between country health systems and global health initiatives (GHIs), also known as global public-private partnerships or global health partnerships. GHIs have become increasingly prominent players in the field of global health, particularly with respect to disease-specific treatment and eradication projects. Although GHIs have provided billions of dollars of funding for health projects and have led the way in responding to infectious disease epidemics, particularly HIV/AIDS and malaria, these initiatives have also been criticized for placing additional burdens on already weak country health systems and for introducing inefficiencies by duplicating functions already (nominally) provided by country health systems.

To take an in-depth look into the interactions between GHIs and country health systems, the Synergies group examined the results of 99 peer-reviewed reports, 122 non-peer-reviewed reports, and 15 original studies completed specifically for this assessment. Because of their prominence, the Global Fund to Fight AIDS, Tuberculosis and Malaria; the Global Alliance for Vaccines and Immunizations (GAVI); the US President’s Emergency Plan for AIDS Relief (PEPFAR); and the World Bank Multi-Country AIDS Program (MAP) were the focus of this study. The lengthy article covers issues related to health service delivery, financing, governance, health workforce, health information systems, and supply management systems.

Based on their literature review, the WHO Maximizing Positive Synergies Collaborative Group makes five recommendations:

1. Infuse the health systems strengthening agenda with the sense of ambition and speed that has characterized the GHIs.
2. Extend the targets of GHIs and agree upon indicators for health systems strengthening.
3. Improve alignment of planning processes and resource allocations among GHIs and between GHIs and country health systems.
4. Generate more reliable data on the costs and benefits of strengthening health systems and gather evidence to inform additional and complimentary investments to those of GHIs.
5. Ensure a rise in national and global health financing and in more predictable financing to support the sustainable and equitable growth of health systems.

The Synergies group also provides a list of “action points” that, if adopted, have the potential to evaluate and improve the interactions between GHIs and country health systems.

One of the stated limitations of the article is that it focuses on the effects of GHI activities on country health systems and not vice versa. If global health practitioners are to make improvements in health by promoting favorable interactions between GHIs and country health systems, the negative effects of these interactions on GHIs must also be evaluated and addressed.

Once more data are available on the effects of GHIs on country health systems (and vice versa) and on the extent to which health is improved by interactions between GHIs and health systems, the global health community will have to revisit often-debated questions: What responsibilities do GHIs have concerning country health systems given that the mandates of many GHIs are focused on specific diseases? How big do improvements in health systems or general health indicators need to be for GHIs to divert resources from successful disease-specific programs? Or put another way, when are improvements in health systems or general health indicators small enough to justify decisions made by GHIs to NOT invest in strengthening health systems? What should be done when the priorities or policies of GHIs run counter to those of the countries in which they are working? Should the objectives of the GHIs – and indeed all vertical programs – be revised?

In addition to the 27-page report, Lancet devoted their June 20, 2009, podcast to a discussion of the WHO Maximizing Positive Synergies Collaborative Group. The podcast can be downloaded from the Lancet’s audio archive.