Interactions between health systems and Global Health Initiatives: a WHO/Italy collaborative effort

Carissa EtienneAssistant Director-General

Health Systems and ServicesWorld Health Organization

The context: Global progress on MDG 4

The context: Global progress on MDG 5

The context: Global progress on ART

The diagnostic: the challenges to scale up services for HIV, TB, malaria, and immunization

HIV/UA assessment report

Global Plan to stop TB

World Malaria report

GAVI/Norad report

• Inadequate financing• HR crisis • Affordable commodities • Stigma, discrimination…• Accountability

• Partnership alignment • Inadequate financing • Laboratory capacity • HR crisis • Quality drugs

• Drug efficacy • Information system • Inadequate financing

• HRH and Community

services • M&E

• HR crisis • Inadequate financing • Leadership and

management • Inter-agency

coordination

The challenge: How do many consider health systems?

An eminent economist

“a riddle, wrapped in a mystery, inside an enigma”…quoting Churchill

An eminent Health Systems expert

- Black hole- Black box- Shopping list

An initial answer: WHO defines health systems

The main goals are:

– Improving health and health equity– Responsiveness, financial fairness

and efficiency

The intermediate goals are:– Greater access and coverage– Quality and safety

A health system consist of all organisations, people and actions whose primary intent is to promote, restore or maintain health

The inevitable debate…

Disease specific programmes vs.

health systems

…but the wrong question

Government health spending per capita(low, lower middle and upper middle income

countries)

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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

Government health spending per capita(low, lower middle and upper middle income

countries)

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1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

upper middle income lower middle income low income

Low Income

Lower Middle IncomeGovernment health spending per capita

(low, lower middle and upper middle income countries)

0

50

100

150

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250

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

upper middle income lower middle income low income

Government health spending per capita(low, lower middle and upper middle income

countries)

0

50

100

150

200

250

1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006

upper middle income lower middle income low income

Upper Middle Income

What fuels the debate: Government Health spending per capita

What fuels the debate: Total annual resources available for AIDS 1986 - 2005

The reality check: Life Expectancy vs. Spending

The reality check: Health outcomes and health spending

deprived suburbdeprived suburb

YE

AR

S

But money is not all: Life expectancy in Glasgow, UK

WHR, 2006

100

5454

8282

affluent suburbaffluent suburb

The right question

How can global health initiatives and country health systems optimize their interactions to achieve their common goal of improving health outcomes?

In other words: we need to look at the big picture

The good signals: GAVI and Health Systems Strengthening

The good signals: Global Fund and Health Systems Strengthening

The good signals: PEPFAR and Health Systems Strengthening

• Normative work and wide implementation of Task Shifting• Commitment to produce 140,000 health care workers in PEPFAR2• Importance of broad health systens strenthening in PEPFAR 2

Make the slide nicer -- Add here a PEPFAR photo or logo (Francesca)

1. Time2. Time3. Time

The big challenge 1: not to miss the opportunity

The big challenge 2: do it right

The process: a broad multi-stakeholder collaboration

• Academia

• Civil Society

• Implementers and GHIs

Make the slide nice and add a photo (Francesca)

The products: a broad multi-stakeholder collaboration

• An academic in a peer-review journal

• A case library

• A set of recommendations

• A declaration

Findings

Known sources

- 14 new studies

- Over 250 studies and reports

- 22 country case studies

Two emerging points

- GHIs and country health systems are not independent - GHIs and country health systems are dynamic,

complex entities

studying their interactions defies over-simplistic, single variable, linear analysis and

raises caution with respect to generalizations.

Findings: service delivery

– Expanded access and uptake of targeted services (caution: attribution)

– Expanded access and uptake of non targeted services

– Evidence on role of GHIs or health systems on equity and quality of health services is weak and mixed

Polio vaccination, Haiti

Prenatal visits, Rwanda

Findings: finance

– Association of GHIs with overall increases in global resources for health

– No clear correlation between GHI resources and domestic health budgets or reallocation of resources

– GHIs have contributed to some improvements in health aid-effectiveness, particularly in the area of predictability of financing

– Indication that disease-specific funding may not be well enough aligned

Government spending on HIV

Findings: governance

– Evidence of early lack of alignment

– More recent progress

– Enhanced community participation

Findings: health workforce

– Some potentially negative impacts on already overstretched human resources for health

– Measures to strengthen the health workforce ongoing

– Measures more on in-service training for disease-specific services, and task shifting

Findings: health information

– Focus on coverage, and surveillance for specific diseases

– Innovations in generation and use of new information and communication technologies

– Failure to invest in more rational, robust, efficient and independent common data architecture.

Findings: supply management

– Improvements in availability and affordability of a number of commodities

– Growth in the volume of commodities not matched by improvements in the management of supplies

The recommendations

– Be Bold – Set targets– Enhance leadership – Engage communities – Improve evidence

Thank you