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Karamagi HC, Njuguna D, Kidane SN, Djossou H, Kipruto HK, Seydi ABW, Nabyonga-Orem J, Muhongerwa DK, Frimpong KA, Nganda BM. Financing health system elements in Africa: A scoping review. PLoS One 2023; 18:e0291371. [PMID: 37703243 PMCID: PMC10499258 DOI: 10.1371/journal.pone.0291371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 08/26/2023] [Indexed: 09/15/2023] Open
Abstract
Countries that are reforming their health systems to progress towards Universal Health Coverage (UHC) need to consider total resource requirements over the long term to plan for the implementation and sustainable financing of UHC. However, there is a lack of detailed conceptualization as to how the current health financing mechanisms interplay across health system elements. Thus, we aimed to generate evidence on how to utilize resources from different sources of funds in Africa. We conducted a scoping review of empirical research following the six-stage methodological framework for Scoping Review by Arksey & O'Malley and Levac, Colquhoun & O'Brien. We searched for published and grey literature in Medline, Cochrane Library, PubMed, WHO database, World bank and Google Scholar search engines databases and summarized data using a narrative approach, involving thematic syntheses and descriptive statistics. We included 156 studies out of 1,168 studies among which 13% were conceptual studies while 87% were empirical studies. These selected studies focused on the financing of the 13 health system elements. About 45% focused on service delivery, 13% on human resources, 5% on medical products, and 3% on infrastructure and governance. Studies reporting multiple health system elements were 8%, while health financing assessment frameworks was 23%. The publication years ranged from 1975 to 2021. While public sources were the most dominant form of financing, global documentation of health expenditure does not track funding on all the health system dimensions that informed the conceptual framework of this scoping review. There is a need to advocate for expenditure tracking for health systems, including intangibles. Further analysis would inform the development of a framework for assessing financing sources for health system elements based on efficiency, feasibility, sustainability, equity, and displacement.
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Affiliation(s)
- Humphrey Cyprian Karamagi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - David Njuguna
- Health Economist, Ministry of Health, Nairobi, Kenya
| | - Solyana Ngusbrhan Kidane
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Herve Djossou
- Economic Planning Manager, Ministry of Health, Benin
| | - Hillary Kipchumba Kipruto
- Universal Health Coverage–Life Course, WHO Regional Office for Africa, Brazzaville, Republic of the Congo
| | - Aminata Binetou-Wahebine Seydi
- Data Analytics and Knowledge Management, World Health Organization (WHO) Regional Office for Africa, Brazzaville, Republic of Congo
| | - Juliet Nabyonga-Orem
- Health Financing, Universal Health Coverage Life Course Cluster, World Health Organization, Regional Office for Africa, Brazzaville, Congo
| | - Diane Karenzi Muhongerwa
- Health Financing, Universal Health Coverage Life Course Cluster, World Health Organization, Regional Office for Africa, Brazzaville, Congo
| | - Kingsley Addai Frimpong
- Health Financing, Universal Health Coverage Life Course Cluster, World Health Organization, Regional Office for Africa, Brazzaville, Congo
| | - Benjamin Musembi Nganda
- Health Financing, Universal Health Coverage Life Course Cluster, World Health Organization, Regional Office for Africa, Brazzaville, Congo
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Agyepong I, Spicer N, Ooms G, Jahn A, Bärnighausen T, Beiersmann C, Brown Amoakoh H, Fink G, Guo Y, Hennig L, Kifle Habtemariam M, Kouyaté BA, Loewenson R, Micah A, Moon S, Moshabela M, Myhre SL, Ottersen T, Patcharanarumol W, Sarker M, Sen G, Shiozaki Y, Songane F, Sridhar D, Ssengooba F, Vega J, Ventura D, Voss M, Heymann D. Lancet Commission on synergies between universal health coverage, health security, and health promotion. Lancet 2023; 401:1964-2012. [PMID: 37224836 DOI: 10.1016/s0140-6736(22)01930-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2021] [Revised: 09/15/2022] [Accepted: 09/27/2022] [Indexed: 05/26/2023]
Affiliation(s)
- Irene Agyepong
- Faculty of Public Health, Ghana College of Physicians and Surgeons, Accra, Ghana.
| | - Neil Spicer
- Global Health and Development, London School of Hygiene & Tropical Medicine, London, UK
| | - Gorik Ooms
- Department of Public Health and Primary Care, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
| | - Albrecht Jahn
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Claudia Beiersmann
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Hannah Brown Amoakoh
- Department of Epidemiology, Noguchi Memorial Institute for Medical Research, University of Ghana, Accra, Ghana; Ghana and Department of Global Health Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, Netherlands
| | - Günter Fink
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Allschwil, Switzerland
| | - Yan Guo
- Department of Global Health School of Public Health, Peking University, Peking, China
| | - Lisa Hennig
- Heidelberg Institute of Global Health, Heidelberg University, Heidelberg, Germany
| | - Mahlet Kifle Habtemariam
- Office of the Director, Africa Centers for Disease Control and Prevention, Addis Ababa, Ethiopia
| | - Bocar A Kouyaté
- National Malaria Research and Training Centre, Nouna, Burkina Faso; Ministry of Health, Koulouba, Ouagadougou, Burkina Faso
| | | | - Angela Micah
- Institute for Health Metrics and Evaluation, Department of Health Metrics Sciences, School of Medicine, University of Washington, Seattle, WA, USA
| | - Suerie Moon
- Department of International Relations and Political Science, Graduate Institute of International and Development Studies, Geneva, Switzerland
| | - Mosa Moshabela
- School of Nursing and Public Health, University of KwaZulu-Natal, Glenwood, Durban, South Africa
| | - Sonja Lynn Myhre
- Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway
| | - Trygve Ottersen
- Division of Infection Control, Norwegian Institute of Public Health, Oslo, Norway
| | | | - Malabika Sarker
- James P Grant School of Public Health, Brac University, Dhaka, Bangladesh
| | - Gita Sen
- Public Health Foundation of India, Bangalore, India
| | | | | | - Devi Sridhar
- Usher Institute, Edinburgh Medical School, University of Edinburgh, Edinburgh, UK
| | - Freddie Ssengooba
- Department of Health Policy, Planning and Management, College of Health Sciences, School of Public Health, Makarere University, Kampala, Uganda
| | | | - Deisy Ventura
- Global Health and Sustainability Graduate Program, School of Public Health, University of São Paulo, São Paulo, Brazil
| | - Maike Voss
- Centre for Planetary Health Policy, Berlin, Germany
| | - David Heymann
- Department of Infectious Disease Epidemiology, Faculty of Epidemiology and Population Health, London School of Hygiene & Tropical Medicine, London, UK
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3
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Buffardi AL. Sector-wide or disease-specific? Implications of trends in development assistance for health for the SDG era. Health Policy Plan 2018; 33:381-391. [PMID: 29351607 DOI: 10.1093/heapol/czx181] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 11/27/2017] [Indexed: 01/03/2023] Open
Abstract
The record of the Millennium Development Goals broadly reflects the trade-offs of disease-specific financing: substantial progress in particular areas, facilitated by time-bound targets that are easy to measure and communicate, which shifted attention and resources away from other areas, masked inequalities and exacerbated fragmentation. In many ways, the Sustainable Development Goals reflect a profound shift towards a more holistic, system-wide approach. To inform responses to this shift, this article builds upon existing work on aggregate trends in donor financing, bringing together what have largely been disparate analyses of sector-wide and disease-specific financing approaches. Looking across the last 26 years, the article examines how international donors have allocated development assistance for health (DAH) between these two approaches and how attempts to bridge them have fared in practice. Since 1990, DAH has overwhelmingly favoured disease-specific earmarks over health sector support, with the latter peaking in 1998. Attempts to integrate system strengthening elements into disease-specific funding mechanisms have varied by disease, and more integrated funding platforms have failed to gain traction. Health sector support largely remains an unfulfilled promise: proportionately low amounts (albeit absolute increases) which have been inconsistently allocated, and the overall approach inconsistently applied in practice. Thus, the expansive orientation of the Sustainable Development Goals runs counter to trends over the last several decades. Financing proposals and efforts to adapt global health institutions must acknowledge and account for the persistent challenges in the financing and implementation of integrated, cross-sector policies. National and subnational experimentation may offer alternatives within and beyond the health sector.
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Affiliation(s)
- Anne L Buffardi
- Research and Policy in Development (RAPID) Programme, Overseas Development Institute, 203 Blackfriars Rd., London SE1 8NJ, UK
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Ooms G, Hammonds R. Global constitutionalism, applied to global health governance: uncovering legitimacy deficits and suggesting remedies. Global Health 2016; 12:84. [PMID: 27914471 PMCID: PMC5135750 DOI: 10.1186/s12992-016-0216-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 11/15/2016] [Indexed: 11/10/2022] Open
Abstract
Background Global constitutionalism is a way of looking at the world, at global rules and how they are made, as if there was a global constitution, empowering global institutions to act as a global government, setting rules which bind all states and people. Analysis This essay employs global constitutionalism to examine how and why global health governance, as currently structured, has struggled to advance the right to health, a fundamental human rights obligation enshrined in the International Covenant on Economic, Social and Cultural Rights. It first examines the core structure of the global health governance architecture, and its evolution since the Second World War. Second, it identifies the main constitutionalist principles that are relevant for a global constitutionalism assessment of the core structure of the global health governance architecture. Finally, it applies these constitutionalist principles to assess the core structure of the global health governance architecture. Discussion Leading global health institutions are structurally skewed to preserve high incomes countries’ disproportionate influence on transnational rule-making authority, and tend to prioritise infectious disease control over the comprehensive realisation of the right to health. Conclusion A Framework Convention on Global Health could create a classic division of powers in global health governance, with WHO as the law-making power in global health governance, a global fund for health as the executive power, and the International Court of Justice as the judiciary power.
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Affiliation(s)
- Gorik Ooms
- Department of Global Health and Development, London School of Hygiene and Tropical Medicine, Keppel St, London, WC1E 7HT, UK.
| | - Rachel Hammonds
- Law and Development Research Group, Faculty of Law, University of Antwerp, Venusstraat 23, 2000, Antwerpen, Belgium
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Risso-Gill I, McKee M, Coker R, Piot P, Legido-Quigley H. Health system strengthening in Myanmar during political reforms: perspectives from international agencies. Health Policy Plan 2016; 29:466-74. [PMID: 23749651 DOI: 10.1093/heapol/czt037] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Myanmar has undergone a remarkable political transformation in the last 2 years, with its leadership voluntarily transitioning from an isolated military regime to a quasi-civilian government intent on re-engaging with the international community. Decades of underinvestment have left the country underdeveloped with a fragile health system and poor health outcomes. International aid agencies have found engagement with the Myanmar government difficult but this is changing rapidly and it is opportune to consider how Myanmar can engage with the global health system strengthening (HSS) agenda. Nineteen semi-structured, face-to-face interviews were conducted with representatives from international agencies working in Myanmar to capture their perspectives on HSS following political reform. They explored their perceptions of HSS and the opportunities for implementation. Participants reported challenges in engaging with government, reflecting the disharmony between actors, economic sanctions and barriers to service delivery due to health system weaknesses and bureaucracy. Weaknesses included human resources, data and medical products/infrastructure and logistical challenges. Agencies had mixed views of health system finance and governance, identifying problems and also some positive aspects. There is little consensus on how HSS should be approached in Myanmar, but much interest in collaborating to achieve it. Despite myriad challenges and concerns, participants were generally positive about the recent political changes, and remain optimistic as they engage in HSS activities with the government.
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van de Pas R, Mans L, de Ponte G, Dambisya Y. The Code of Practice and its enduring relevance in Europe and Eastern and Southern Africa. HUMAN RESOURCES FOR HEALTH 2016; 14:30. [PMID: 27381472 PMCID: PMC4943475 DOI: 10.1186/s12960-016-0122-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
BACKGROUND The relevance and effectiveness of the WHO Global Code of Practice on the International Recruitment of Personnel will be reviewed by the World Health Assembly in 2015. The origins of the Code of Practice and the global health diplomacy process before and after its adoption are analyzed herein. METHODS AND RESULTS Case studies from the European and eastern and southern African regions describe in detail successes and failures of the policy implementation of the Code. In Europe, the Code is effective and even more relevant than before, but might require some tweaking. In Eastern and Southern Africa, the code is relevant but far from efficient in mitigating the negative effects of health workforce migration. CONCLUSIONS Solutions to strengthen the Code include clarification of some of its definitions and articles, inclusion of a governance structure and asustainable and binding financing system to reimburse countries for health workforce losses due to migration, and featuring of health worker migration on global policy agendas across a range of institutional policy domains.
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Affiliation(s)
- Remco van de Pas
- Health Policy Unit, Department of Public Health, Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerp, Belgium.
| | - Linda Mans
- Wemos Foundation, P.O. Box 1693, 1114 AK, Amsterdam, The Netherlands
| | - Giulia de Ponte
- Amref Health Africa Onlus, via Alberico II, n.4, 00193, Rome, Italy
| | - Yoswa Dambisya
- ECSA Health Community Secretariat, 157 Olorien, Njiro Road, P.O. Box 1009, Arusha, Tanzania
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Barnes A, Brown GW, Harman S. Understanding global health and development partnerships: Perspectives from African and global health system professionals. Soc Sci Med 2016; 159:22-9. [DOI: 10.1016/j.socscimed.2016.04.033] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Revised: 10/27/2015] [Accepted: 04/28/2016] [Indexed: 11/29/2022]
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From Millennium Development Goals to post-2015 sustainable development: sexual and reproductive health and rights in an evolving aid environment. REPRODUCTIVE HEALTH MATTERS 2015; 21:113-24. [PMID: 24315068 DOI: 10.1016/s0968-8080(13)42737-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Using research from country case studies, this paper offers insights into the range of institutional and structural changes in development assistance between 2005 and 2011, and their impact on the inclusion of a sexual and reproductive health and rights agenda in national planning environments. At a global level during this period, donors supported more integrative modalities of aid - sector wide approaches, poverty reduction strategy papers, direct budgetary support - with greater use of economic frameworks in decision-making. The Millennium Development Goals brought heightened attention to maternal mortality, but at the expense of a broader sexual and reproductive health and rights agenda. Advocacy at the national planning level was not well linked to programme implementation; health officials were disadvantaged in economic arguments, and lacked financial and budgetary controls to ensure a connection between advocacy and action. With increasing competency in higher level planning processes, health officials are now refocusing the post-2015 development goals. If sexual and reproductive health and rights is to claim engagement across all its multiple elements, advocates need to link them to the key themes of sustainable development: inequalities in gender, education, growth and population, but also to urbanisation, migration, women in employment and climate change.
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Patel P, Cummings R, Roberts B. Exploring the influence of the Global Fund and the GAVI Alliance on health systems in conflict-affected countries. Confl Health 2015; 9:7. [PMID: 25709711 PMCID: PMC4337057 DOI: 10.1186/s13031-015-0031-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2014] [Accepted: 01/05/2015] [Indexed: 01/12/2023] Open
Abstract
Background Global Health Initiatives (GHIs) respond to high-impact communicable diseases in resource-poor countries, including health systems support, and are major actors in global health. GHIs could play an important role in countries affected by armed conflict given these countries commonly have weak health systems and a high burden of communicable disease. The aim of this study is to explore the influence of two leading GHIs, the Global Fund and the GAVI Alliance, on the health systems of conflict-affected countries. Methods This study used an analytical review approach to identify evidence on the role of the Global Fund and the GAVI Alliance with regards to health systems support to 19 conflict-affected countries. Primary and secondary published and grey literature were used, including country evaluations from the Global Fund and the GAVI Alliance. The WHO heath systems building blocks framework was used for the analysis. Results There is a limited evidence-base on the influence of GHIs on health systems of conflict-affected countries. The findings suggest that GHIs are increasingly investing in conflict-affected countries which has helped to rapidly scale up health services, strengthen human resources, improve procurement, and develop guidelines and protocols. Negative influences include distorting priorities within the health system, inequitable financing of disease-specific services over other health services, diverting staff away from more essential health care services, inadequate attention to capacity building, burdensome reporting requirements, and limited flexibility and responsiveness to the contextual challenges of conflict-affected countries. Conclusions There is some evidence of increasing engagement of the Global Fund and the GAVI Alliance with health systems in conflict-affected countries, but this engagement should be supported by more context-specific policies and approaches.
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Affiliation(s)
- Preeti Patel
- Global Health and Security, Department of War Studies, King's College London, London, UK
| | | | - Bayard Roberts
- Health Systems & Policy, London School of Hygiene & Tropical Medicine, London, UK
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Bruen C, Brugha R, Kageni A, Wafula F. A concept in flux: questioning accountability in the context of global health cooperation. Global Health 2014; 10:73. [PMID: 25487705 PMCID: PMC4258948 DOI: 10.1186/s12992-014-0073-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2014] [Accepted: 09/28/2014] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Accountability in global health is a commonly invoked though less commonly questioned concept. Critically reflecting on the concept and how it is put into practice, this paper focuses on the who, what, how, and where of accountability, mapping its defining features and considering them with respect to real-world circumstances. Changing dynamics in global health cooperation - such as the emergence of new health public-private partnerships and the formal inclusion of non-state actors in policy making processes - provides the backdrop to this discussion. DISCUSSION Accountability is frequently reduced to one set of actors holding another to account. Changes in the global health landscape and in relations between actors have however made the practice of accountability more complex and contested. Currently undergoing a reframing process, participation and transparency have become core elements of a new accountability agenda alongside evaluation and redress or enforcement mechanisms. However, while accountability is about holding actors responsible for their actions, the mechanisms through which this might be done vary substantially and are far from politically neutral.Accountability in global health cooperation involves multipolar relationships between a large number of stakeholders with varying degrees of power and influence, where not all interests are realised in that relationship. Moreover, accountability differs across finance, programme and governance subfields, where each has its own set of policy processes, institutional structures, accountability relations and power asymmetries to contend with. With reference to the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, this paper contributes to discussions on accountability by mapping out key elements of the concept and how it is put into practice, where different types of accountability battle for recognition and legitimacy. SUMMARY In mapping some defining features, accountability in global health cooperation is shown to be a complex problem not necessarily reducible to one set of actors holding another to account. Clear tensions are observed between multi-stakeholder participatory models and more traditional vertical models that prioritise accountability upwards to donors, both of which are embodied in initiatives like the Global Fund. For multi-constituency organisations, this poses challenges not only for future financing but also for future legitimacy.
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Affiliation(s)
- Carlos Bruen
- Royal College of Surgeons in Ireland, 123 St Stephens Green, Dublin 2, Ireland.
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11
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Buffardi AL. From polarisation to practice: puzzles and insights on integrated approaches from public health professionals. Glob Public Health 2014; 9:741-51. [PMID: 24992263 DOI: 10.1080/17441692.2014.929724] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
Much of the debate in the global health literature about vertical and horizontal programmatic approaches, between narrowly targeted interventions and those providing broader system-wide support, has taken place at the global level. Based on a comparative case study of international donors in the health sector in Peru that varied in their vertical-horizontal orientation, this article examines the extent to which health care practitioners and national policy-makers perceive and attempt to reconcile the tension between these approaches. Informants readily identified advantages and disadvantages of both approaches, but did not perceive a marked vertical-horizontal division, suggesting that tensions appear to be less pronounced in practice than academic debates suggest. A clear consensus did not emerge, and although more people spoke of a mixed approached, they too puzzled over how best to balance trade-offs. In practice, there were examples of more integrated approaches, targeted aspects of horizontal programmes and system-strengthening elements of vertical programmes; however, they were not explicitly identified as such. Practitioner perspectives reinforced the diverse and dynamic nature of disease, both epidemics and country profiles, and suggest that focusing on periods of transition and points of integration may be a fruitful path forward.
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Affiliation(s)
- Anne L Buffardi
- a Evans School of Public Affairs, University of Washington , Seattle , WA , USA
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Hill PS, Buse K, Brolan CE, Ooms G. How can health remain central post-2015 in a sustainable development paradigm? Global Health 2014; 10:18. [PMID: 24708779 PMCID: PMC3978199 DOI: 10.1186/1744-8603-10-18] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Accepted: 03/17/2014] [Indexed: 12/27/2022] Open
Abstract
In two years, the uncompleted tasks of the Millennium Development Goals will be merged with the agenda articulated in the 2012 United Nations Conference on Sustainable Development. This process will seek to integrate economic development (including the elimination of extreme poverty), social inclusion, environmental sustainability, and good governance into a combined sustainable development agenda. The first phase of consultation for the post-2015 Sustainable Development Goals reached completion in the May 2013 report to the Secretary-General of the High-Level Panel of Eminent Persons on the Post-2015 Development Agenda. Health did well out of the Millennium Development Goal (MDG) process, but the global context and framing of the new agenda is substantially different, and health advocates cannot automatically assume the same prominence. This paper argues that to remain central to continuing negotiations and the future implementation, four strategic shifts are urgently required. Advocates need to reframe health from the poverty reduction focus of the MDGs to embrace the social sustainability paradigm that underpins the new goals. Second, health advocates need to speak--and listen--to the whole sustainable development agenda, and assert health in every theme and every relevant policy, something that is not yet happening in current thematic debates. Third, we need to construct goals that will be truly "universal", that will engage every nation--a significant re-orientation from the focus on low-income countries of the MDGs. And finally, health advocates need to overtly explore what global governance structures will be needed to finance and implement these universal Sustainable Development Goals.
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Affiliation(s)
- Peter S Hill
- School of Population Health, The University of Queensland, Herston Road Herston, 4006 Brisbane, Australia
| | - Kent Buse
- Joint United Nations Programme on HIV/AIDS, (UNAIDS), 20 Avenue Appia CH-1211, Geneva 27, Switzerland
| | - Claire E Brolan
- School of Population Health, The University of Queensland, Herston Road Herston, 4006 Brisbane, Australia
| | - Gorik Ooms
- Institute of Tropical Medicine, Nationalestraat 155, 2000 Antwerpen, Belgium
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Cailhol J, Craveiro I, Madede T, Makoa E, Mathole T, Parsons AN, Van Leemput L, Biesma R, Brugha R, Chilundo B, Lehmann U, Dussault G, Van Damme W, Sanders D. Analysis of human resources for health strategies and policies in 5 countries in Sub-Saharan Africa, in response to GFATM and PEPFAR-funded HIV-activities. Global Health 2013; 9:52. [PMID: 24160182 PMCID: PMC4016264 DOI: 10.1186/1744-8603-9-52] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2013] [Accepted: 09/25/2013] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Global Health Initiatives (GHIs), aiming at reducing the impact of specific diseases such as Human Immunodeficiency Virus (HIV), have flourished since 2000. Amongst these, PEPFAR and GFATM have provided a substantial amount of funding to countries affected by HIV, predominantly for delivery of antiretroviral therapy (ARV) and prevention strategies. Since the need for additional human resources for health (HRH) was not initially considered by GHIs, countries, to allow ARV scale-up, implemented short-term HRH strategies, adapted to GHI-funding conditionality. Such strategies differed from one country to another and slowly evolved to long-term HRH policies. The processes and content of HRH policy shifts in 5 countries in Sub-Saharan Africa were examined. METHODS A multi-country study was conducted from 2007 to 2011 in 5 countries (Angola, Burundi, Lesotho, Mozambique and South Africa), to assess the impact of GHIs on the health system, using a mixed methods design. This paper focuses on the impact of GFATM and PEPFAR on HRH policies. Qualitative data consisted of semi-structured interviews undertaken at national and sub-national levels and analysis of secondary data from national reports. Data were analysed in order to extract countries' responses to HRH challenges posed by implementation of HIV-related activities. Common themes across the 5 countries were selected and compared in light of each country context. RESULTS In all countries successful ARV roll-out was observed, despite HRH shortages. This was a result of mostly short-term emergency response by GHI-funded Non-Governmental Organizations (NGOs) and to a lesser extent by governments, consisting of using and increasing available HRH for HIV tasks. As challenges and limits of short-term HRH strategies were revealed and HIV became a chronic disease, the 5 countries slowly implemented mid to long-term HRH strategies, such as formalisation of pilot initiatives, increase in HRH production and mitigation of internal migration of HRH, sometimes in collaboration with GHIs. CONCLUSION Sustainable HRH strengthening is a complex process, depending mostly on HRH production and retention factors, these factors being country-specific. GHIs could assist in these strategies, provided that they are flexible enough to incorporate country-specific needs in terms of funding, that they coordinate at global-level and minimise conditionality for countries.
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Affiliation(s)
- Johann Cailhol
- School of Public Health, Faculty of Community Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Isabel Craveiro
- Unit of International Public Health and Biostatistics, Instituto de Higiene e Medicina Tropical, CMDT, WHO Collaborating Centre for Health Workforce Policy and Planning, Universidade Nova de Lisboa, Lisbon, Portugal
| | | | - Elsie Makoa
- Faculty of Health Sciences, National University of Lesotho, Maseru, Lesotho
| | - Thubelihle Mathole
- School of Public Health, Faculty of Community Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Ann Neo Parsons
- School of Public Health, Faculty of Community Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Luc Van Leemput
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - Regien Biesma
- Department of Epidemiology and Public Health Medicine, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | - Ruairi Brugha
- Department of Epidemiology and Public Health Medicine, Division of Population Health Sciences, Royal College of Surgeons in Ireland, Dublin 2, Ireland
| | | | - Uta Lehmann
- School of Public Health, Faculty of Community Health Sciences, University of the Western Cape, Cape Town, South Africa
| | - Gilles Dussault
- Unit of International Public Health and Biostatistics, Instituto de Higiene e Medicina Tropical, CMDT, WHO Collaborating Centre for Health Workforce Policy and Planning, Universidade Nova de Lisboa, Lisbon, Portugal
| | - Wim Van Damme
- Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium
| | - David Sanders
- School of Public Health, Faculty of Community Health Sciences, University of the Western Cape, Cape Town, South Africa
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14
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Warren AE, Wyss K, Shakarishvili G, Atun R, de Savigny D. Global health initiative investments and health systems strengthening: a content analysis of global fund investments. Global Health 2013; 9:30. [PMID: 23889824 PMCID: PMC3750586 DOI: 10.1186/1744-8603-9-30] [Citation(s) in RCA: 63] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2012] [Accepted: 07/03/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Millions of dollars are invested annually under the umbrella of national health systems strengthening. Global health initiatives provide funding for low- and middle-income countries through disease-oriented programmes while maintaining that the interventions simultaneously strengthen systems. However, it is as yet unclear which, and to what extent, system-level interventions are being funded by these initiatives, nor is it clear how much funding they allocate to disease-specific activities - through conventional 'vertical-programming' approach. Such funding can be channelled to one or more of the health system building blocks while targeting disease(s) or explicitly to system-wide activities. METHODS We operationalized the World Health Organization health system framework of the six building blocks to conduct a detailed assessment of Global Fund health system investments. Our application of this framework framework provides a comprehensive quantification of system-level interventions. We applied this systematically to a random subset of 52 of the 139 grants funded in Round 8 of the Global Fund to Fight AIDS, Tuberculosis and Malaria (totalling approximately US$1 billion). RESULTS According to the analysis, 37% (US$ 362 million) of the Global Fund Round 8 funding was allocated to health systems strengthening. Of that, 38% (US$ 139 million) was for generic system-level interventions, rather than disease-specific system support. Around 82% of health systems strengthening funding (US$ 296 million) was allocated to service delivery, human resources, and medicines & technology, and within each of these to two to three interventions. Governance, financing, and information building blocks received relatively low funding. CONCLUSIONS This study shows that a substantial portion of Global Fund's Round 8 funds was devoted to health systems strengthening. Dramatic skewing among the health system building blocks suggests opportunities for more balanced investments with regard to governance, financing, and information system related interventions. There is also a need for agreement, by researchers, recipients, and donors, on keystone interventions that have the greatest system-level impacts for the cost-effective use of funds. Effective health system strengthening depends on inter-agency collaboration and country commitment along with concerted partnership among all the stakeholders working in the health system.
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Affiliation(s)
- Ashley E Warren
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002, Basel, Switzerland
- University of Basel, Petersplatz 1, 4003, Basel, Switzerland
| | - Kaspar Wyss
- University of Basel, Petersplatz 1, 4003, Basel, Switzerland
- Swiss Centre for International Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002, Basel, Switzerland
| | | | - Rifat Atun
- Imperial College London, South Kensington Campus, London SW7 2AZ, UK
- Department of Global Health and Population, Harvard School of Public Health, Harvard University, Cambridge, USA
| | - Don de Savigny
- Department of Epidemiology and Public Health, Swiss Tropical and Public Health Institute, Socinstrasse 57, 4002, Basel, Switzerland
- University of Basel, Petersplatz 1, 4003, Basel, Switzerland
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15
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Brown SS, Sen K, Decoster K. The health systems funding platform and World Bank legacy: the gap between rhetoric and reality. Global Health 2013; 9:9. [PMID: 23497327 PMCID: PMC3607847 DOI: 10.1186/1744-8603-9-9] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Accepted: 02/28/2013] [Indexed: 11/24/2022] Open
Abstract
Global health partnerships created to encourage funding efficiencies need to be approached with some caution, with claims for innovation and responsiveness to development needs based on untested assumptions around the potential of some partners to adapt their application, funding and evaluation procedures within these new structures. We examine this in the case of the Health Systems Funding Platform, which despite being set up some three years earlier, has stalled at the point of implementation of its key elements of collaboration. While much of the attention has been centred on the suspension of the Global Fund's Round 11, and what this might mean for health systems strengthening and the Platform more broadly, we argue that inadequate scrutiny has been made of the World Bank's contribution to this partnership, which might have been reasonably anticipated based on an historical analysis of development perspectives. Given the tensions being created by the apparent vulnerability of the health systems strengthening agenda, and the increasing rhetoric around the need for greater harmonization in development assistance, an examination of the positioning of the World Bank in this context is vital.
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Affiliation(s)
- Scott S Brown
- School of Population Health, University of Queensland, Herston Rd, Herston, QLD 4006
| | - Kasturi Sen
- Wolfson College, University of Oxford, Oxford OX2 6EU, England
| | - Kristof Decoster
- Institute of Tropical Medicine, Nationalestraat 155, 2000, Antwerpen, Belgium
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16
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van Olmen J, Marchal B, Van Damme W, Kegels G, Hill PS. Health systems frameworks in their political context: framing divergent agendas. BMC Public Health 2012; 12:774. [PMID: 22971107 PMCID: PMC3549286 DOI: 10.1186/1471-2458-12-774] [Citation(s) in RCA: 75] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2012] [Accepted: 08/28/2012] [Indexed: 11/28/2022] Open
Abstract
BACKGROUND Despite the mounting attention for health systems and health systems theories, there is a persisting lack of consensus on their conceptualisation and strengthening. This paper contributes to structuring the debate, presenting landmarks in the development of health systems thinking against the backdrop of the policy context and its dominant actors. We argue that frameworks on health systems are products of their time, emerging from specific discourses. They are purposive, not neutrally descriptive, and are shaped by the agendas of their authors. DISCUSSION The evolution of thinking over time does not reflect a progressive accumulation of insights. Instead, theories and frameworks seem to develop in reaction to one another, partly in line with prevailing paradigms and partly as a response to the very different needs of their developers. The reform perspective considering health systems as projects to be engineered is fundamentally different from the organic view that considers a health system as a mirror of society. The co-existence of health systems and disease-focused approaches indicates that different frameworks are complementary but not synthetic. The contestation of theories and methods for health systems relates almost exclusively to low income countries. At the global level, health system strengthening is largely narrowed down to its instrumental dimension, whereby well-targeted and specific interventions are supposed to strengthen health services and systems or, more selectively, specific core functions essential to programmes. This is in contrast to a broader conceptualization of health systems as social institutions. SUMMARY Health systems theories and frameworks frame health, health systems and policies in particular political and public health paradigms. While there is a clear trend to try to understand the complexity of and dynamic relationships between elements of health systems, there is also a demand to provide frameworks that distinguish between health system interventions, and that allow mapping with a view of analysing their returns. The choice for a particular health system model to guide discussions and work should fit the purpose. The understanding of the underlying rationale of a chosen model facilitates an open dialogue about purpose and strategy.
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Affiliation(s)
- Josefien van Olmen
- Institute of Tropical Medicine, Antwerp Belgium, Nationalestraat 155, Antwerp B-2000, Belgium
| | - Bruno Marchal
- Institute of Tropical Medicine, Antwerp Belgium, Nationalestraat 155, Antwerp B-2000, Belgium
| | - Wim Van Damme
- Institute of Tropical Medicine, Antwerp Belgium, Nationalestraat 155, Antwerp B-2000, Belgium
| | - Guy Kegels
- Institute of Tropical Medicine, Antwerp Belgium, Nationalestraat 155, Antwerp B-2000, Belgium
| | - Peter S Hill
- School of Population Health, The University of Queensland, Queensland, Australia
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17
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Hill PS, Dodd R, Brown S, Haffeld J. Development cooperation for health: reviewing a dynamic concept in a complex global aid environment. Global Health 2012; 8:5. [PMID: 22420459 PMCID: PMC3338403 DOI: 10.1186/1744-8603-8-5] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2011] [Accepted: 03/15/2012] [Indexed: 12/03/2022] Open
Abstract
The 4th High Level Forum on Aid Effectiveness, held in Busan, South Korea in November 2011 again promised an opportunity for a "new consensus on development cooperation" to emerge. This paper reviews the recent evolution of the concept of coordination for development assistance in health as the basis from which to understand current discourses. The paper reviews peer-reviewed scientific literature and relevant 'grey' literature, revisiting landmark publications and influential authors, examining the transitions in the conceptualisation of coordination, and the related changes in development assistance. Four distinct transitions in the understanding, orientation and application of coordination have been identified: coordination within the sector, involving geographical zoning, sub-sector specialisation, donor consortia, project co-financing, sector aid, harmonisation of procedures, ear-marked budgetary support, donor agency reform and inter-agency intelligence gathering; sector-wide coordination, expressed particularly through the Sector-Wide Approach; coordination across sectors at national level, expressed in the evolution of Poverty Strategy Reduction Papers and the national monitoring of the Millennium Development Goals; and, most recently, global-level coordination, embodied in the Paris Principles, and the emergence of agencies such as the International Health Partnerships Plus. The transitions are largely but not strictly chronological, and each draws on earlier elements, in ways that are redefined in the new context. With the increasing complexity of both the territory of global health and its governance, and increasing stakeholders and networks, current imaginings of coordination are again being challenged. The High Level Forum in Busan may have been successful in recognising a much more complex landscape for development than previously conceived, but the challenges to coordination remain.
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Affiliation(s)
- Peter S Hill
- Australian Centre for International and Tropical Health, The University Of Queensland, Herston Road Herston, 4006 Queensland, Australia.
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18
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Hafner T, Shiffman J. The emergence of global attention to health systems strengthening. Health Policy Plan 2012; 28:41-50. [PMID: 22407017 DOI: 10.1093/heapol/czs023] [Citation(s) in RCA: 143] [Impact Index Per Article: 11.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
After a period of proliferation of disease-specific initiatives, over the past decade and especially since 2005 many organizations involved in global health have come to direct attention and resources to the issue of health systems strengthening. We explore how and why such attention emerged. A qualitative methodology, process-tracing, was used to construct a case history and analyse the factors shaping and inhibiting global political attention for health systems strengthening. We find that the critical factors behind the recent burst of attention include fears among global health actors that health systems problems threaten the achievement of the health-related Millennium Development Goals, concern about the adverse effects of global health initiatives on national health systems, and the realization among global health initiatives that weak health systems present bottlenecks to the achievement of their organizational objectives. While a variety of actors now embrace health systems strengthening, they do not constitute a cohesive policy community. Moreover, the concept of health systems strengthening remains vague and there is a weak evidence base for informing policies and programmes for strengthening health systems. There are several reasons to question the sustainability of the agenda. Among these are the global financial crisis, the history of pendulum swings in global health and the instrumental embrace of the issue by some actors.
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Affiliation(s)
- Tamara Hafner
- Department of Public Administration and Policy, American University, Washington, DC 20016, USA.
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Sub-Saharan Africa and the health MDGs: the need to move beyond the “quick impact” model. REPRODUCTIVE HEALTH MATTERS 2011; 19:42-55. [DOI: 10.1016/s0968-8080(11)38579-5] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
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