Lancet Articles Fire Up Fresh Debate Over Global Health Programs

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The long-simmering debate over the impact of disease-specific programs on health-system strengthening may have just reached a boil.

Today’s Lancet features an in-depth exploration of the impact of global health programs, particularly those aimed at tackling HIV/AIDS, tuberculosis and malaria. The debate has gained steam in recent weeks, since the White House announced its new global health initiative that appears to step back from programs like PEPFAR in favor of broader health-system strengthening.

The crux of the issue is summed up this way in one of the Lancet articles: “Some critics have claimed that these initiatives burden health systems that are already fragile in countries with few resources, whereas others have asserted that weak health systems prevent progress in meeting disease-specific targets.”

That statement is from the summary of a piece, authored by World Health Organization Maximizing Positive Synergies Collaborative Group, that assesses the interaction between health systems and health initiatives. That article, along with several other accompanying pieces in the Lancet, frames the impact of disease-specific initiatives as a mixed bag.

The issue is complex, as the WHO authors acknowledge readily. “Two points have become clear from our assessment,” they write. “First, GHIs and country health systems are not independent but are inextricably linked. Second, the two are dynamic, complex entities such that examination of their interaction cannot be a simplistic, single variable, linear analysis, therefore raising caution about generalisations.”

There’s no question that AIDS and malaria programs have saved lives, and there’s some evidence of other “positive benefits” in things like health equity, training, community participation, and the like, as the Lancet says it an editorial. But that same editorial also says there are some “several adverse effects” of global health programs on broader health systems, such as “misalignments” between health initiatives and countries’ needs and the “creation of expensive parallel bureaucracies” to manage those initiatives.

In an article on the global health funding, authors Normala Ravishankar and others write that development assistance for health (DAH) has quadrupled in recent years–climbing from $5.6 billion in 1990 to $21.8 billion in 2007. They also report that non-governmental organizations, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, “became the conduit for an increasing share of DAH,” with the proportion of funds going through UN agencies and developing banks declining.

“The influx of funds has been accompanied by major changes in the institutional landscape of global health, with global health initiatives such as the Global Fund and GAVI (the Global Alliance for Vaccines and Immunization) having a central role in mobilizing and channeling global health funds,” the authors write.

What seems to be lost in the current debate is that when Congress reauthorized PEPFAR last year, lawmakers seemed to have some of these issues in mind. The new law includes broad new mandates that address health-system strengthening, such as a requirement that the Office of the US Global AIDS Coordinator recruit and train 140,000 new health care workers and launch new nutrition and food security initiatives.

If we pull back from PEPFAR now, we will miss on an opportunity to build on the strong infrastructure it has put in place. And we will fail to provide the resources needed to broaden the program’s impact, from AIDS to other health needs.

0 thoughts on “Lancet Articles Fire Up Fresh Debate Over Global Health Programs

  1. Health GAP

    The World Health Organization (WHO) is releasing data in the coming days that demonstrate the impact of “global health initiatives” such as the Global Fund to fight AIDS, Tuberculosis, and Malaria, the U.S. PEPFAR program, and GAVI on health systems in developing countries.

    Preliminary data was included in a 36-page article will be published in the June 20 issue of The Lancet; more detailed and up-to-date, multi-country studies are being presented in Venice at a WHO meeting 22-23 June. Many health experts, however, are baffled by the misinterpretation of that data by the very journal in which some of these preliminary data were published.

    Overall, the results of the “Maximizing Positive Synergies Project,”-a project bridging people accessing healthcare in the poorest parts of the world, frontline implementers, academics and policy makers-reveal ambitious scale-up of interventions that have likely saved millions of lives, from increased coverage of malaria prevention efforts to immunization interventions, to aggressive scale up of AIDS treatment. There are also promising signs of positive benefits to broader health systems. The project will make policy recommendations about how GHI funded programs can maximize the positive benefits to health systems overall and reduce the occurrence of unintended negative effects.

    The Lancet editorial accompanying the piece, which will also be published June 20, however, seems to conflate lack of conclusive data with some negative results. The editorial suggests that the failure of the GHIs to solve every development problem that exists, including poverty-related disease burden, pre-existing weak health systems, and governments’ weak capacity means that GHIs are not effective. In other areas, experts were confused as the Lancet editorial has simply made statements at odds with the data presented.

    “The Lancet editorial misrepresents basic data—if policy makers simply read this editorial it would suggest a course of action not borne out by evidence,” said Dr. Jen Cohn, Director of the University of Pennsylvania’s Global Health Equities Program, who worked with grassroots civil society organizations in Kenya, interviewing hundreds of patients, health care workers and civil society implementers as part of the project. “This editorial seems out of touch with people on the ground who have benefitted from the resources of GHIs and who are advocating to improve the positive health systems effects of these programs.” Dr. Cohn continued.

    For example, the editorial states that GHIs are causing “steepening inequalities in health services,” when the article states: “Data show an overall trend of improved equity in access and outcomes for GHI-targeted interventions” and goes on to explore the causes for this positive effect on equity. “Editorial perspective is by definition somewhat subjective,” said Dr. Cohn. “But editorial perspective that contradicts much of the assembled evidence–that’s concerning.”

    Health experts are calling for a retraction or correction of The Lancet’s editorial to ensure that readers are not misguided. They also urge a close reading of the wealth of underlying data that supports smarter and expanded programming to fight priority diseases while simultaneously strengthening underlying health systems.

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