During the past decade, global health initiatives (GHIs) started funding health system strengthening (HSS) programs alongside disease-specific programs. For my master program Global Health, I did an internship at Wemos where I studied different approaches to HSS. I focused on that of the Global Alliance for Vaccines and Immunisation (Gavi) in particular, which is one of the biggest GHIs in Kenya, Uganda and Zambia.
The development towards HSS funding has been applauded because health systems in low-income countries really need attention. However, these programs – which are labelled as HSS by GHIs – do not always meet the expected long-term goals, and can sometimes even undermine the health system. So far in research, the content of these programs is hardly challenged. During my internship, I studied written resources and held interviews with experts, and based on these, I came across the following problems.
Gavi is a public-private partnership that wants to equitably increase vaccine use in low-income countries. In its HSS programs, Gavi refers to the well-known health systems ‘building blocks’ of the WHO. Although this framework gives a clear overview of which aspects are relevant for a health system, it does not show how those aspects are related to one another. Health systems are complex and the effects are not always straightforward. This reality is reflected by the systems thinking approach. However, in Gavi’s HSS programs, systems thinking is not incorporated. Their HSS programs are all geared towards increased vaccination coverage.
Focus on vaccines
An example of a vaccine-focused HSS program is the following. Gavi wants to address demand generation for vaccinations with an HSS program. However, when demand is generated when people don’t have access to a clinic or vaccinations are unavailable , this could decrease trust in the system. Thus, demand generation can work counterproductive. Gavi can easily miss out on such negative effects, as HSS programs are usually evaluated based on vaccination coverage.
Moreover, when health facilities cannot offer general care like abscess treatment or management of diabetes, people might not return to have their children vaccinated due to a lack of trust towards these facilities. Trust in health systems will only grow when these respond to the health needs of the population. Gavi’s HSS programs – which focus narrowly on vaccines – are unlikely to improve this situation.
The power balance
The current power distribution between GHIs (such as Gavi) and national governments is also problematic. The Paris Declaration for Aid Effectiveness motivates for more country-led development aid. In practice, Gavi labels their HSS activities as country-led because governments develop their proposals in line with the national health plan. However, the proposals must also be related to Gavi’s vaccination goals. These proposals have to be approved by Gavi’s independent review committee, but if they are rejected, countries have to adjust and resubmit them. This time-consuming process often burdens the health ministry. Moreover, if all GHIs require alignment of HSS programs with their own disease-specific goals, limited space is left for countries to invest in true general responsiveness of the health system.
Change is unlikely as long as countries do not have a proper revenue collection system for health financing. When countries can generate their own funding for health and try to pursue universal health coverage (UHC), they could become more independent from donors and focus on all aspects of the health system. Although revenue collection would be interesting for Gavi – because of co-funding for vaccinations – financing and revenue collection for health receive no attention. WHO does focus on UHC, but its influence and independence might be questioned, as employees in its country offices are sometimes funded by Gavi.
In this study I only focussed on three countries and Gavi, but it is likely that other GHIs cause similar problems with their HSS programs. Therefore, the scope of this problem should not be underestimated. To conclude, I think HSS is highly needed, but it is very important to remain critical of the design of HSS in programs funded by GHIs, to ensure that they truly strengthen health systems.
Renée de Jong wrote her thesis for the master programme Global Health at Maastricht University during an internship at Wemos. The full title of the thesis is: ‘Understanding the translation of the health system strengthening concept into practice by Gavi and its effects; a qualitative analysis according to the Bacchi approach’. She can be contacted for the complete abstract or the full thesis. From September 2016 Renée works as a junior Global Health Advocate at Wemos in the Health Systems Advocacy Partnership.