Changing Global Health Systems and Institutional Arrangements Signals the Transition Needed to Meet the Current Global Health Needs. January 2010 PLoS Medicine published a very interesting four-part weekly series on this subject.  I have posted a few excerpts below:

The study had three aims; (1) to advance current understanding of the interplay of actors in the system; (2) to evaluate its performance; and (3) to identify opportunities for improvement.

The traditional actors on the global health stage, which have traditionally been comprised of governmental agencies, are now being joined by an ever-greater variety of civil society and nongovernmental organizations, private firms, and private philanthropists. This rise of multiple new actors in the system creates challenges for coordination such as determining the roles various organizations should play, the rules by which they play, and who sets those rules in order to avoid waste, inefficiency, and turf wars. The lack of a clear set of rules that constrain distortion of priorities by powerful actors can threaten less powerful ones. Proposals to improve the issues facing coordination include setting global health agendas in ways that build upon the enthusiasm of particular actors and to ensure that financing be equitably shared also is a very important issue to consider.

At the same time this transition in actors and relationships among them are taking place, there are also transformations faced by the health system itself.  For example, the success of child survival efforts has meant that noncommunicable diseases, including cardiovascular disease, cancer, diabetes, and neuropsychiatric disease, are growing in prevalence alongside the continuing threats of communicable diseases. Some of the questions asked are (1) what functions must an effective global health system accomplish; (2) what kind of arrangements can better govern the growing and diverse set of actors in the system to ensure that those functions are performed; (3) and how can past experiences be used to address them and the coming wave of new health challenges?

The authors believe that the biggest challenge facing global health today is to reconcile the ongoing global-level transformation with the need to further strengthen and support national-level health systems. These global health agencies should be concerned with not only assessing the level of health, but also at its distribution, giving equity a central place in assessing a health system and bringing insight to diseases previously neglected on the research community. Neglected disease research should involve building capacity of endemic-country scientists which would lead to the involvement of affected communities not only as targets of interventions but as co-producers of results and integrating the Research and Development and Distribution (R&D&D) communities. Investments in human capacity that began in the 1970s are now bearing fruit as scientists from Africa, Asia, and Latin America take a key role in advancing research, as in the case of malaria. Translating knowledge into action is the critical goal that must not be forgotten in the reorganization process. This integration would not only allow for a more central role for endemic-country researchers in an increasingly globalized research system facilitating the connection of local and international researchers, but also direct funding to local researchers and institutions.

One model for enabling some coherence in the resource allocation process for its mandated diseases is the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM). It is a partnership between governments, civil society, and the private sector that supplements existing efforts dealing with the three diseases. The Global Fund has become the main source of finance for programs to fight AIDS, tuberculosis and malaria, and has provided funding of $ 19.3 billion for more than 572 programs in 144 countries. It provides a quarter of all international financing for AIDS globally, two-thirds for tuberculosis and three quarters for malaria. The Global Burden of Disease and Disease Control Priorities Projects have provided country estimates of years of healthy life lost to illness and injury, identified major risks, and estimated the cost-effectiveness of interventions.  However, widely accepted principles on how to translate these figures into resource allocation decisions are lacking.

Coordination is the cornerstone of this integration; however, few organizations wish to be coordinated because of the costs and loss of autonomy entailed. Thus, coordination requires a consensus and to reach this consensus, participants must share a clear set of goals and perceive that they are key participants.

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