1. Interactions between health systems and Global Health Initiatives: a WHO/Italy collaborative effort Carissa Etienne Assistant Director-General Health Systems and Services World Health Organization

2. The context: Global progress on MDG 4

3. The context: Global progress on MDG 5

4. The context: Global progress on ART

5. The diagnostic: the challenges to scale up services for HIV, TB, malaria, and immunization HIV/UA assessment report Global Plan to stop TB World Malaria report GAVI/Norad report Inadequate financing HR crisis Affordable commodities Stigma, discrimination… Accountability Partnership alignment Inadequate financing Laboratory capacity HR crisis Quality drugs Drug efficacy Information system Inadequate financing HRH and Community services M&E HR crisis Inadequate financing Leadership and management Inter-agency coordination

6. The challenge: How do many consider health systems? An eminent economist “a riddle, wrapped in a mystery, inside an enigma”…quoting Churchill An eminent Health Systems expert - Black hole - Black box - Shopping list

7. An initial answer: WHO defines health systems The main goals are: –Improving health and health equity –Responsiveness, financial fairness and efficiency The intermediate goals are: –Greater access and coverage –Quality and safety A health system consist of all organisations, people and actions whose primary intent is to promote, restore or maintain health

8. The inevitable debate… Disease specific programmes vs. health systems …but the wrong question

9. What fuels the debate: Government Health spending per capita

10. What fuels the debate: Total annual resources available for AIDS 1986 - 2005

11. The reality check: Life Expectancy vs. Spending

12. The reality check: Health outcomes and health spending

13. deprived suburb YEARS But money is not all: Life expectancy in Glasgow, UK WHR, 2006 100 54 82 affluent suburb

14. The right question How can global health initiatives and country health systems optimize their interactions to achieve their common goal of improving health outcomes?

15. In other words: we need to look at the big picture

16. The good signals: GAVI and Health Systems Strengthening

17. The good signals: Global Fund and Health Systems Strengthening

18. The good signals: PEPFAR and Health Systems Strengthening Normative work and wide implementation of Task Shifting Commitment to produce 140,000 health care workers in PEPFAR2 Importance of broad health systens strenthening in PEPFAR 2 Make the slide nicer -- Add here a PEPFAR photo or logo (Francesca)

19. 1.Time 2.Time 3.Time The big challenge 1: not to miss the opportunity

20. The big challenge 2: do it right

21. The process: a broad multi-stakeholder collaboration Academia Civil Society Implementers and GHIs Make the slide nice and add a photo (Francesca)

22. The products: a broad multi-stakeholder collaboration An academic in a peer-review journal A case library A set of recommendations A declaration

23. Findings Known sources - 14 new studies - Over 250 studies and reports - 22 country case studies Two emerging points - GHIs and country health systems are not independent - GHIs and country health systems are dynamic, complex entities  studying their interactions defies over-simplistic, single variable, linear analysis and raises caution with respect to generalizations.

24. Findings: service delivery –Expanded access and uptake of targeted services (caution: attribution) –Expanded access and uptake of non targeted services –Evidence on role of GHIs or health systems on equity and quality of health services is weak and mixed

25. Polio vaccination, Haiti

26. Prenatal visits, Rwanda

27. Findings: finance – Association of GHIs with overall increases in global resources for health – No clear correlation between GHI resources and domestic health budgets or reallocation of resources – GHIs have contributed to some improvements in health aid- effectiveness, particularly in the area of predictability of financing – Indication that disease-specific funding may not be well enough aligned

28. Government spending on HIV

29. Findings: governance – Evidence of early lack of alignment – More recent progress – Enhanced community participation

30. Findings: health workforce – Some potentially negative impacts on already overstretched human resources for health – Measures to strengthen the health workforce ongoing – Measures more on in-service training for disease-specific services, and task shifting

31. Findings: health information – Focus on coverage, and surveillance for specific diseases – Innovations in generation and use of new information and communication technologies – Failure to invest in more rational, robust, efficient and independent common data architecture.

32. Findings: supply management – Improvements in availability and affordability of a number of commodities – Growth in the volume of commodities not matched by improvements in the management of supplies

33. The recommendations – Be Bold – Set targets – Enhance leadership – Engage communities – Improve evidence

34. Thank you