Research Article: Global Health Actors Claim To Support Health System Strengthening—Is This Reality or Rhetoric?

Date Published: April 28, 2009

Publisher: Public Library of Science

Author(s): Bruno Marchal, Anna Cavalli, Guy Kegels

Abstract: Bruno Marchal and colleagues argue that most current strategies aimed at health systems strengthening remain selectively targeted at specific diseases.

Partial Text: The recent explosion in the number of global health initiatives has dramatically changed the landscape of public health and international aid. During an initial honeymoon period, these initiatives started implementing their disease-specific activities in low-income countries. But the honeymoon is over, and there is now an increasing realisation that such initiatives ignore a wider problem—existing health systems in the developing world are fragile and unable to provide effective health services, especially in sub-Saharan Africa [1],[2]. Simultaneously, there is a growing consensus that effective global initiatives require well-functioning health systems [3]. As a result, health system strengthening (HSS) in low-income settings is now regarded, in the words of Alaka Singh at the World Health Organization (WHO), as “the ‘first-order’, immediate/medium-term goal to create the necessary enabling institutional and systemic environment to achieve and sustain ‘higher order’ MDGs [Millennium Development Goals] in the long(er) run” [4].

The terms “global health initiative” and “global health partnership” are much used but ill defined. They cover very different groups of actors [5]. In this paper, we discuss international initiatives and key agencies working in the domain of HSS. Acknowledging their different nature, we use in this paper the term global health actor (GHA) for reasons of simplicity.

The selective, disease-specific nature of most current HSS strategies should not surprise us. True to their narrow focus, GHAs favour vertical programmes, which they consider the most efficient method to implement their activities. Furthermore, some actors appear to perceive health systems as “bottomless pits” in which external support disappears without a trace [23]. Instead of investing in long-term strengthening of national stewardship capacity, they prefer lifting specific health system constraints that impede progress towards their objectives.

The renewed attention upon health systems is welcome, but many GHAs are doing no more than putting old wine in new bottles. They claim that their selective practices are contributing to strengthening systems, while in reality the opposite might be the case.



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