Interactions between health systems and Global Health Initiatives: a WHO/Italy collaborative effortCarissa EtienneAssistant Director-GeneralHealth 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 immunizationHIV/UA assessment report Global Plan to stop TBWorld 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 enigmaquoting 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 equityResponsiveness, financial fairness and efficiency

The intermediate goals are:Greater access and coverageQuality 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

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 suburb YEARS But money is not all: Life expectancy in Glasgow, UK WHR, 2006100 5482affluent suburb

The right questionHow 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 ShiftingCommitment to produce 140,000 health care workers in PEPFAR2Importance of broad health systens strenthening in PEPFAR 2

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

TimeTimeTime

The big challenge 1: not to miss the opportunity

The big challenge 2: do it right

The process: a broad multi-stakeholder collaborationAcademiaCivil SocietyImplementers and GHIs

Make the slide nice and add a photo (Francesca)

The products: a broad multi-stakeholder collaborationAn academic in a peer-review journalA case libraryA set of recommendationsA 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

Chart1

17311887

24013120

275717072

Pre-GHI

Post-GHI

Sheet1

LCSt.MarcHinche4th Qtr

Pre-GHI1731240275720.4

Post-GHI1887131201707231.6

North45.946.94543.9

Prenatal visits, Rwanda

Chart1

11881303

13292490

14144065

17073714

Pre-GHI

Post-GHI

Sheet1

KabarondoMulindiRukaraRusumo

Pre-GHI1188132914141707

Post-GHI1303249040653714

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 targetsEnhance leadership Engage communities Improve evidence

Thank you

**55% of people live in urban areas but 75% of doctors, 60% of nurses and 58% of other health workers live in urban areas