The challenge … is fundamentally organizational

Jeffrey Sachs has again called on the world to get serious about malaria. In Scientific American he explains why, “The challenge of controlling the disease in Africa by 2010 is fundamentally organizational, not technical.” While partners seem to be in agreement on the basic strategies and interventions, health systems needs remain, including these mentioned by Sachs:

  • harmonization among partners in all sectors
  • transparency, efficiency and accountability of implementing country governments
  • unprecedented coordination of financing, training, monitoring and logistics
  • raised production levels of basic commodities to hundreds of millions of units
  • training for tens or hundreds of thousands of community health workers on malaria control

community-volunteers.jpgThese challenges appear daunting, but Sachs implores partners that, “The consequences of organizational failure, on the other hand, would be almost too painful to behold.”

The Global Fund has been encouraging countries to include health systems strengthening (HSS) components in their proposals for quite some time. This has sometimes been framed as separate grant sections and at others as integrated into disease-specific sections. After six rounds only 1% of funds were distinguished as HSS.

Past Global Fund e-forum discussions have addressed HSS and noted the low priority given to this element, the challenge of weak systems in recipient countries and the inability of health systems to reach communities and households where intervention is most needed.  A current forum contribution, for example, looks at how Nigeria was in the process of laying “foundations of what could have been one of the best public health infrastructures…in Africa” with primary health care in the 1980s and 1990s, but “these infrastructures and gains are almost totally lost.”  Is HSS fighting an uphill battle?

The GFATM directs the Technical review Panel (TRP), “in reviewing a disease component which contains a cross-cutting HSS section, the TRP may recommend for funding either: a. The entire disease component, including the cross-cutting HSS section; b. The disease component excluding the cross-cutting HSS section; or c. Only the cross-cutting HSS section if the interventions in that section materially contribute to overcoming health systems constraints to improved HIV, tuberculosis and malaria outcomes.” The reality is that some countries such as Ghana never benefit from HSS in their malaria grants.

People have often looked to the World Bank to address systems and infrastructural issues. This has not always happened in such a way as to impact on specific health programs. Now the Bank says its “new strategy is about strengthening health systems in developing countries while complementing the efforts of other organizations contributing billions of dollars to combat diseases such as HIV/AIDS and malaria.” In order to avoid the pitfalls of a single disease focus approach, “the Bank is shifting its focus to not only funding vaccines and medicine but doing so in a way that ensures a health system is capable of delivering vaccines, medicine, and general health care to more people.”

According to its second annual report, PMI is also paying attention to health systems as follows” “The PMI is organized around four operational principles based on lessons learned from more than 50 yearsof U.S. Government efforts in fighting malaria, together with experience gained from implementation of PEPFAR, which began in 2003. The PMI approach involves: •Use of a comprehensive, integrated package of proven prevention and treatment interventions; •Strengthening of health systems and integrated maternal and child health services; •Commitment to strengthen national malaria control programs and to build capacity for country ownership of malaria control efforts; and •Close coordination with international and in-country partners.”

Just as partners are in agreement about the major malaria control interventions for scale up to 2010 and beyond, we also hope they agree and coordinate their efforts to strengthen the health systems that not only will deliver these interventions, but also will hopefully sustain them.

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