A Paradigm Shift for Global Health: Within our Reach?

In a previous post, I highlighted some of the pitfalls of relying on disease-specific “vertical” programs, and argued that the approach of global health and development must shift toward one of health systems strengthening. Events within the last few years make me think that we are on the edge of a great opportunity to push health systems strengthening to the forefront of the global health agenda. Here’s why:

• Two international agreements have been made in the last two decades, the Paris Declaration (2005) and the Accra Agenda for Action (2008), which affirmed a commitment to principles of development that include country ownership, alignment of donor support with recipient country goals, and harmonization of aid efforts.
• In 2007, the International Health Partnership was founded to devote resources to furthering the principles outlined in Paris and Accra, with a focus on “country-driven, results-oriented” development work.
• The Global Alliance for Vaccines and Immunization (GAVI), one of the largest global health partnerships, began to commit a portion of its funds to health system strengthening in 2005, and has committed US$ 568 million to health system strengthening as of 2010. More recently, it has dedicated the 2^nd of its four goals for 2010-2015 to “contribute to strengthening the capacity of integrated health systems to deliver immunization”, and has committed 15-25% of its funding to achieving this goal.
• Perhaps most promisingly, a mere five days ago at the Busan forum on aid effectiveness, member countries of the OECD pulled through at the 11^th hour to agree on a set of principles for future development aid. As Jonathan Glennie at the Guardian writes, the agreement “has stronger language on systems-approaches than ever before, insisting that the ‘default’ option should be to use country systems…” Even more significantly, China, India, and Brazil came on board at the last minute, marking the first time these emerging market economies were included into the development fold.

Nevertheless, agreeing to a systems-approach is not the same as instituting one. “What difference will all this hullaballoo mean for the world’s poorest and most vulnerable people?” asks Glennie. Good question. More than 30 years ago, there was a lot of hullaballo going on at Alma-Ata, where 134 countries committed to using primary health care as a vehicle to achieve health for all by 2000. Thirty years later, all of the rhetoric hasn’t even managed to place primary health care at the center of the global health agenda, let alone achieve health for all.

There is a huge difference between rhetoric and action. Despite all of the promising documents, principles, and even monetary commitments to health systems strengthening (which still only make up 2% of development assistance for health), critical answers remain unanswered. What reverberating changes do isolated interventions cause in the greater health care system? How can we limit escalating health care expenditures without compromising quality of care? How do we define and measure quality in the first place? Only with a crucial understanding of the answers to these questions, as well as the leadership and political will to see these efforts through, can we capitalize on this second opportunity we’ve been offered to truly achieve health for all.