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Move from pruning trees in global health to forest management

By guest contributor Dave Algoso

Forest Garden

Global health efforts in the past decade or so have taken an aggressive and largely successful targeted approach to some of the world’s most harmful diseases such as HIV-AIDS, TB and malaria.

With an unprecedented increase in funding for such efforts in this new millennium, the global health sector has made major gains against particular diseases and other health threats. But funding is limited, and has plateaued of late, focusing attention on getting more ‘value for money.’ Many leaders in this field say they are now seeking to identify the “best buys” in global health.

This was the stated purpose of a recent event hosted by the Center for Global Development (CGD) along with Population Services International (PSI), PATH, Devex, and Merck for Mothers which featured experts from those organizations and others. The event was linked to the release of PSI’s Impact magazine issue on “best buys” in global health, which included findings from a survey of global development professionals.

As Humanosphere pointed out, the conversation at the event itself was unfocused. Participants tried to shoe-horn points about systems strengthening into the “best buys” rhetoric, and no one seemed interested in talking about the survey that was ostensibly the basis for the event. Nevertheless, the event served to emphasize the attention that sector experts are paying to health systems.

Global Health Best Buy survey
PSI Impact

Despite the fuzzy rhetoric, it is time to move past targeting the big, diseased trees on the global health landscape to something more akin to comprehensive forest management. Rather than pruning back each threat that arises, we need to cultivate a stronger ecosystem for health.

Groups like Innovations for Poverty Action and GiveWell have done great work to create evidence bases for specific high-impact interventions, and to advocate for funding those interventions. Some of these, like bednets and deworming, have made their way into the popular understanding of global health. There’s also a lot of press around the gadgets and apps of global health tech, from mHealth and tele-medicine to low-cost diagnostic kits. These are all likely candidates for health funding “best buys.”

But experts in the field contend we need to move away from our focus on the trees and better manage the entire forest. That means health systems, service delivery, and community ownership are the most important places to invest in global health.

An Indian doctor examines a tuberculosis patient.  India has the highest incidence of TB in the world. Lack of comprehensive health  systems is one reason TB, including drug-resistant TB, remains one of the world's biggest killers.
An Indian doctor examines a tuberculosis patient. India has the highest incidence of TB in the world. Lack of comprehensive health systems is one reason TB, including drug-resistant TB, remains one of the world’s biggest killers.

A country’s health system includes several interrelated parts: physical infrastructure, regulatory frameworks, supply chains, public and private sector care providers, educational and workforce development systems, patient education efforts, community involvement mechanisms, and more. These parts all work together in order to deliver healthcare effectively and efficiently. Improving the system means tackling any number of these elements, depending on the needs of the country in question. It might require better training for community health workers, a new human resource management system for the national government, an SMS-based feedback system for patients, or something else entirely.

The importance of these systems elements isn’t a new idea. Wonks often talk about the distinction between “vertical” interventions (targeting a specific disease) and “horizontal” interventions (building health systems). Similarly, institutions have received attention in development thinking for years.

What seems significant now is the recognition that investment in health systems is more critical than any specific health intervention. We’ve spent the past decade raising awareness and targeting funds at specific diseases, such as the US government’s focus on AIDS through PEPFAR, or the Gates Foundation’s efforts against malaria. Now the pendulum is swinging a bit toward health systems.

Even if there is broad support for this swing among experts, it may be challenged by our current approaches to funding. The problem with the “best buy” and value-for-money mindset is that it encourages you to look for a clear link between money spent and lives saved. Systems and institutions don’t provide that clear link: such attribution is complicated and easily disputed.

Directing aid dollars toward systems strengthening might be even harder in global health than in other sectors. As Karen Cavanaugh of USAID pointed out at the CGD event, we have been successful in convincing the public that global health challenges are not as intractable as they seem, and are therefore worth tackling. That’s left an impression of simplicity about the interventions needed: delivering vaccines, developing new products, or sending doctors on medical missions are all more straightforward than systems strengthening. We need to encourage a more nuanced understanding.

Part of this nuanced understanding requires seeing how systems strengthening and specific interventions are two sides of the same coin. In any sector, investment in platforms and capacities can make delivery of other products and services possible. Campaigns targeting specific diseases could build on and develop existing system capacity, or could undermine and displace that capacity. Similarly, systems strengthening will have the most success if it produces tangible outcomes on the most critical health issues a system faces. These two approaches should work in tandem.

As health systems receive more attention, we should be able to better understand these nuances. Funding mindsets and mechanisms will be slower to adjust, but shifts there will allow us to ultimately strike the balance between interventions and systems.

Dave Algoso Dave Algoso is the Director of Programs at Reboot, an advisor and implementer for institutions dedicated to social progress. For more from Dave, follow him on twitter, and find his writing on Reboot’s site or his Find What Works blog.


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