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Global Public Health. 2014; 9(8):865-879.Lauded for getting specific health issues onto national and international agendas and for their potential to improve value for money and outcomes, public-private global health initiatives (GHIs) have come to dominate global health governance. Yet, they have also been criticised for their negative impact on country health systems. In response, disease-specific GHIs have, somewhat paradoxically, appropriated the aim of health system strengthening (HSS). This article critically analyses this development through an ethnographic case study of the GAVI Alliance, which funds vaccines in poor countries. Despite GAVI’s self-proclaimed ‘single-minded’ focus on vaccines, HSS support is fronted as a key principle of GAVI’s mission. Yet, its meaning remains unclear and contested understandings of the health systems agenda abound, reflecting competing public health ideologies and professional pressures within the global health field. Contrary to broader conceptualisations of HSS that emphasise social and political dimensions, GAVI’s HSS support has become emblematic of the so-called ‘Gates approach’ to global health, focused on targeted technical solutions with clear, measurable outcomes. In spite of adopting rhetoric supportive of ‘holistic’ health systems, GHIs like GAVI have come to capture the global debate about HSS in favour of their disease-specific approach and ethos.
Geneva, Switzerland, WHO, 2012.  p.This document has three broad aims. First, it seeks to unify the worlds of research and decision-making and connect the various disciplines of research that generate knowledge to inform and strengthen health systems. Second, the strategy contributes to a broader understanding of this field by clarifying the scope and role of HPSR. It provides insight into the dynamic processes through which HPSR evidence is generated and used in decision-making. Finally, it is hoped that this strategy will serve as an agent for change and calls for a more prominent role for HPSR at a time when the health systems mandate is evolving towards broader goals of universal health coverage and equity. This strategy on health policy and systems research is intended to augment and amplify WHO’s previous affirmations on the importance of health research, by explaining how this evolving field is sensitive and responsive to the needs of those who are responsible for the planning and performance of national health systems -- decision-makers, health practitioners, citizens and civil society.
Geneva, Switzerland, UNAIDS, 2011 Oct.  p. (UNAIDS Issues Brief; UNAIDS Policy Document; UNAIDS/JC2244E)Over the past 30 years there have been tremendous gains in the global HIV response, but until now there has been only limited systematic effort to match needs with investments. The result is often a mismatch of the two, and valuable resources are stretched inefficiently across many objectives. To achieve an optimal HIV response, countries and their international partners must adopt a more strategic approach to investments. In June 2011 a policy paper was published in The Lancet (Schwartländer et al) that laid out a new framework for investment for the global HIV response. The new framework is based on existing evidence of what works in HIV prevention, treatment, care and support. It is intended to facilitate more focused and strategic use of scarce resources. Modelling of the framework’s impact shows that its implementation would avert 12.2 million new infections and 7.4 million AIDS-related deaths between 2011 and 2020. This modelling also indicates that implementation of the investment framework is highly cost-effective, with additional investment largely offset by savings in treatment costs alone, and enabling the HIV response to reach an inflection point in both investments and rates of HIV infection. (Excerpts)
Geneva, Switzerland, UNAIDS, 2011 Jun.  p. (UNAIDS / JC2141E)This publication describes how the Joint United Nations Programme on HIV / AIDS (UNAIDS) partners with country partners and the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) to strengthen the global response to AIDS and to accelerate progress towards universal access to HIV prevention, treatment, care and support, and the achievement of the Millennium Development Goals (MDGs).
Primary health care as a strategy for achieving equitable care: a literature review commissioned by the Health Systems Knowledge Network.
[Johannesburg, South Africa], University of the Witwatersrand, Centre for Health Policy, Health Systems Knowledge Network, 2007 Mar.  p.In this paper we want to explore the contribution that primary health care can make to address the social determinants of health in the context of a changing society. The concept of primary health care, endorsed by the World Health Organisation in the Alma Ata Declaration in 1978, has been implemented in very different ways all over the world. We look at the main features of primary health care: what are the conditions that enable the introduction of primary health care, what is the evidence of the primary health care approach to promote health equity and inter-sectoral action and how may the health systems enhance the impact of primary health care on health equity, taking account of contextual factors. The aim is to draw an operational framework that may contribute to further developments in health systems contributing to more equity. Addressing social determinants of health should take into account the actual evolutions in the changing society, in order to assess adequately the changing needs that will be presented to the health care system.. (Excerpt)
[Johannesburg, South Africa], University of the Witwatersrand, Centre for Health Policy, Health Systems Knowledge Network, 2006 Feb.  p. (Health Systems Knowledge Network (KN) Discussion Document No. 1)During July and August 2005 the Health Systems Knowledge Network Hub produced a wide-ranging literature review for discussion at a meeting in India between Hubs and the rest of the Commission on the Social Determinants of Health (Doherty, Gilson and EQUINET 2005). The review was based on literature sourced from within the consortium managing the hub as well as from institutions networked with the consortium members. Some key references from existing materials were also followed up. Given the wide scope of work on health systems, it was not feasible to conduct a general electronic search. Nor was it possible to access substantial quantities of grey literature, given the difficulties associated with identifying and locating copies of this type of literature. Because of time constraints, the review focused on reviews of international experience and articles documenting new lines of investigation. Articles that were, at the time, in press were specifically sought out to ensure as up-todate an evidence base as possible. The review began by presenting data showing that health services tend to be used proportionately more by richer than poorer social groups. It analysed the social factors affecting access to, and uptake of, health services and showed how these interact with inequitable features of the health care system. Overall, the review argued that the interaction between household health-seeking behaviour and experience of the health system generates differential health and economic consequences across social groups. The long-term costs of seeking care often impoverish poorer households, reinforcing preexisting social stratification. The review then examined in some detail the features of the health care system that contribute to inequity (such as certain approaches to priority-setting, resource allocation, financing, organisation, human resources, and management and regulation). (Excerpt)
Challenging inequity through health systems. Final report: Knowledge Network on Health Systems. WHO Commission on the Social Determinants of Health.
[Johannesburg], South Africa, University of the Witwatersrand, Centre for Health Policy, Health Systems Knowledge Network, 2007 Jun.  p.The way that health systems are designed, financed and operated acts as a powerful determinant of health. The Health Systems Knowledge Network reviewed the evidence on different approaches to improving health equity outcomes through health systems. The focus was on innovative approaches that effectively incorporate action on the social determinants of health, and on strategies of policy development and implementation. Key themes were: Using the health sector to leverage inter-sectoral actions that address the social determinants of health; Enabling social empowerment in support of health equity; Identifying key elements of vision and health system architecture necessary to secure social protection and universal coverage; Building and maintaining national policy space for health policies that seek social justice; and Strengthening management and stewardship capacities within the health sector. The Health Systems Knowledge Network was chaired by Lucy Gilson of the Centre for Health Policy, and made up of 14 experienced policy-makers, academics and members of civil society from around the world. The Network engaged with other sections of the Commission and also commissioned a number of systematic reviews and case studies. This is the final report of the network.
Coordination, management and utilization of foreign assistance for HIV / AIDS prevention in Vietnam. Assessment report.
Ha Noi, Vietnam, CCRD, 2006 Oct. 82 p. (CCRD Assesssment Report)International assistance for HIV / AIDS prevention and control in Vietnam has significantly contributed to combating this epidemic. However, while current resources have not yet fully met the needs, the management and utilization of resources still had many limitations which affect the effectiveness of foreign assistance and investments. The independent assessment was prepared for the Conference on “the Coordination of Foreign Assistance for HIV / AIDS Prevention and Control”. Analytical assessment and comments on the management and coordination of foreign aid were made on the basis of Government’s official procedures and regulations on those issues. This research was carried out in October, 2006.
Lancet. 2007 Jul 7; 370(9581):15-16.A new spirit of cooperation and coordination between the key global players in the fight against HIV/AIDS was cemented at a meeting for programme implementers in Kigali, Rwanda, in mid-June. The partnership comes amidst concerns about rising infection rates in some countries where infections had slowed, as well as worries about the unpredictability of funding for HIV/AIDS activities. The collaboration is expected to curb duplication of efforts and wastage of resources, and to ultimately scale-up AIDS prevention and treatment. The meeting-usually an annual gathering for the US President's Emergency Plan for AIDS Relief (PEPFAR) and its grantees-opened up for the first time to include the Global Fund to Fight AIDS, Tuberculosis and Malaria, UNAIDS, the World Bank, UNICEF, WHO, and the Global Network of People Living with HIV/AIDS (GNP+), who were all co-sponsors of the conference. (excerpt)
Bulletin of the World Health Organization. 2007 Mar; 85(3):192-199.International health policy-makers now have a variety of institutional instruments with which to pursue their global and national health goals. These instruments range from the established formal multilateral organizations of the United Nations to the newer restricted-membership institutions of the Group of Eight (G8). To decide where best to deploy scarce resources, we must systematically examine the G8's contributions to global health governance. This assessment explores the contributions made by multilateral institutions such as the World Health Organization, and whether Member States comply with their commitments. We assessed whether G8 health governance assists its member governments in managing domestic politics and policy, in defining dominant normative directions, in developing and complying with collective commitments and in developing new G8-centred institutions. We found that the G8's performance improved substantially during the past decade. The G8 Member States function equally well, and each is able to combat diseases. Compliance varied among G8 Member States with respect to their health commitments, and there is scope for improvement. G8 leaders should better define their health commitments and set a one-year deadline for their delivery. In addition, Member States must seek WHO's support and set up an institution for G8 health ministers. (author's)
Lancet. 2006 Dec 9; 368(9552):2095-2100.At the United Nations International Conference on Population and Development in Cairo in 1994, the international community agreed to make reproductive health care universally available no later than 2015. After a 5-year review of progress towards implementation of the Cairo programme of action, that commitment was extended to include sexual, as well as reproductive, health and rights. Although progress has been made towards this commitment, it has fallen a long way short of the original goal. We argue that sexual and reproductive health for all is an achievable goal--if cost-effective interventions are properly scaled up; political commitment is revitalised; and financial resources are mobilised, rationally allocated, and more effectively used. National action will need to be backed up by international action. Sustained effort is needed by governments in developing countries and in the donor community, by inter-governmental organisations, non-governmental organisations, civil society groups, the women's health movement, philanthropic foundations, the private for-profit sector, the health profession, and the research community. (author's)
American Journal of Public Health. 2005 Jul; 95(7):1173-1180.The availability of limited funds from international agencies for the purchase of antiretroviral (ARV) treatment in developing countries presents challenges, especially in prioritizing who should receive therapy. Public input and the protection of human rights are crucial in making treatment programs equitable and accountable. By examining historical precedents of resource allocation, we aim to provoke and inform debate about current ARV programs. Through a critical review of the published literature, we evaluate 4 precedents for key lessons: the discovery of insulin for diabetes in 1922, the release of penicillin for civilian use in 1943, the development of chronic hemodialysis programs in 1961, and current allocation of liver transplants. We then describe current rationing mechanisms for ARVs. (author's)
In: State of the art: AIDS and economics, edited by Steven Forsythe. Washington, D.C., Futures Group International, POLICY Project, 2002 Jul. 58-63.The Declaration of Commitment of the United Nations General Assembly Special Session on HIV/AIDS (UNGASS) calls for spending on HIV/AIDS programs to increase to US$7-10 billion annually by 2005. The Declaration specifies a number of goals at the global and national level and calls for specific actions to reach those goals, but it does not specify how the funding should be allocated. The Report of the Commission on Macroeconomics and Health estimates that spending on HIV/AIDS in low- and middle-income countries should increase by US$14 billion by 2007 and suggests that US$6 billion is needed for prevention, US$3 billion for care, and US$5 billion for antiretroviral (ARV) treatment. A detailed estimate of spending requirements prepared for UNGASS calls for minimum spending of US$9.2 billion annually by 2005 in low- and middle-income countries to provide coverage of essential prevention, care, and mitigation services in an effort to reach the UNGASS goals. Details of spending needs by category of intervention are shown in Figure 1. A recent analysis shows that these coverage levels are sufficient to achieve the UNGASS goals. However no analysis has been done to show whether this is the most cost-effective approach to achieving these goals or whether the same goals could be reached with less funding and a more strategic allocation of resources. (excerpt)
Geneva, Switzerland, WHO, 1998.  p. (WHO/FRH/WHD/98.16)The aim of this technical paper is to explore some of the implications of the shift from the 'women in development' (WID) to the 'gender and development' (GAD) approach for the analysis of health and health care issues in general and for the work of WHO in particular. Health policies and programmes have focused on biological aspects of diagnosis, treatment and prevention. Likewise, when considering the differences between women and men, there is a tendency to emphasise biological or sex differences as explanatory factors of well-being and illness. A gender approach in health, while not excluding biological factors, considers the critical roles that social and cultural factors and power relations between women and men play in promoting and protecting or impeding health. While gender interacts with other kinds of inequalities in health, such as social class, race and ethnicity, the focus of the paper is on gender and health. (excerpt)
Geneva, Switzerland, UNAIDS, 2004 Jul.  p.In monitoring resource flows for HIV and AIDS, it has proven easier to collect information on donor governments, multilateral agencies, foundations and nongovernmental organizations (NGOs) than to obtain reliable budget information on domestic outlays for HIV and AIDS in affected countries. As a result, UNAIDS has focused significant efforts on strengthening the capacity of countries to monitor and track expenditures for HIV and AIDS. This report summarizes the latest information available on HIV-related spending in 26 countries. Seventeen of the countries are from the Latin America and Caribbean (LAC) region. Resource tracking in the LAC region, as well as in Thailand, Burkina Faso and Ghana has benefited from the leadership of the Regional AIDS Initiative for Latin America and the Caribbean (SIDALAC), which helped implement the National AIDS Account (NAA) approach. Beginning with pilot projects in three countries in 1997–1998, NAA has now been extended throughout the region, in large part due to the provision of extensive technical assistance by countries involved in the early pilot projects. NAA uses a matrix system that describes the level and flow of health expenditures on AIDS. The NAA model: a) identifies key actors in HIV and AIDS activities; b) uses existing data or makes estimates for specific services or goods purchased; c) analyses domestic (public and private) and international budgets; d) determines out-of-pocket expenditures; and e) assesses the financial dimensions of the country’s response to AIDS. (excerpt)
Ethics and equity in access to HIV treatment. Issue paper: 3rd Meeting, UNAIDS Global Reference Group on HIV / AIDS and Human Rights, 28-30 January 2004.
Geneva, Switzerland, Joint United Nations Programme on HIV / AIDS [UNAIDS], 2004. 6 p.The WHO/UNAIDS 3x5 initiative aims to reach those in need of treatment and to identify those who are hard to reach, especially in populations that have not had access to services. There is a global responsibility to support resource-limited countries to scale up ART in the face of a global public health emergency. In addition, a country-level responsibility exists to ensure treatment is made available as enunciated in human rights guidelines for HIV/AIDS. It will not be possible to reach everyone in need as the 3x5 initiative begins, so it is necessary to work progressively towards universal access. Most countries will use a phased approach and this will necessitate making decisions about priorities in allocating resources. Although adherence to human rights provisions is essential, none of the various human rights treaties or declarations provides criteria for setting priorities or choosing among potentially relevant principles of equity. When not all persons in need of HIV treatment can be served, distribution of HIV treatment services should be guided by principles of equity or fair distribution, and considerations of human rights, including the right to freedom from discrimination and the right to the highest attainable state of health. Policy makers will need to make decisions and various ethical principles will guide these decisions in very different ways. (excerpt)
Hopkins HIV Report. 2002 Jul;  p..The WHO guidelines are based on rigorous evaluation of data collected almost exclusively in developed countries. Of concern is whether guidelines created for HIV-infected populations of developed nations are adaptable to HIV-infected populations worldwide. Specifics regarding the presence of different HIV subtypes, endemic infections such as tuberculosis, genetic determinants, and other health measures such as nutritional status may introduce factors that alter response to treatment. Developing nations that have successfully implemented HAART include Brazil, Thailand, Senegal, and Uganda. Studies are needed to examine responses to HAART and whether changes to the guidelines would better serve populations in different regions around the world. For example, initiation of HAART earlier in the course of HIV disease may have an impact on disease outcomes due to endemic mycobacterial infections such as tuberculosis. With initiation of HAART on a population-wide scale, continuous surveillance of drug-resistant HIV will be needed to update treatment guidelines. A recent study conducted in Gabon demonstrated resistance to antiretroviral therapy. Of great concern is that antiviral drug resistance due to suboptimal therapies could limit the potency of available treatments. (excerpt)
BMJ. British Medical Journal. 2003 Nov 8; 327:1101-1103.Over the past 20 years, the public health community has learnt a tremendous amount about the HIV/AIDS epidemic. Yet, despite widespread discussion about the epidemic and some measurable progress, the overall response has been insufficient: globally 42 million people are already infected with HIV, prevalence continues to rise, and less than 5% of those affected have access to lifesaving medicines. In the face of this growing crisis, the World Health Organization has made scaling up treatment a key priority of the new administration. We argue that not only is the HIV/AIDS epidemic an emergency, but its devastating effects on societies may qualify it as one of the most serious disasters to have affected humankind. As such, this crisis warrants a full disaster management response. (excerpt)
Cahiers du Médecin. 2002 Dec; 6(58):45-46.This article presents a report from the macroeconomic and health committee to determine the place of health in economic and social development created by the WHO in the year 2000. The main conclusions for all aspects were presented when the report was submitted to the WHO general assembly in 2002. The observations thus raised indicated that economic losses linked to poor health have been underestimated, especially in developing countries and that the role of health in economic growth has been strongly undervalued. Because of this several pathologies are still responsible for a high percentage of avoidable deaths, particularly maternal and perinatal pathologies and infectious diseases in children. It is also noted that the level of health expenses is insufficient and that the recommended financing strategy is based on growth in budgetary credits consecrated to health and to an increase in donor subsidies. The report emphasizes the different essential actions capable of reaching disadvantaged populations and on the correct steering by the public authorities of contributions from donors in the public and private sectors. Other remarks were collected about the various financing mechanisms on the global scale to combat certain endemic infections, specifically AIDS, tuberculosis, and malaria. Efforts to improve access by the populations to essential and indispensable drugs are also being made. The report underlines the need for the signing of a health pact between governments and development agencies in order to increase resources allocated to health. For the development of health in Morocco, the author emphasizes all aspects raised in this report and suggests the creation of a "Health and development" commission as advised by the WHO.
Social Science and Medicine. 2003 Nov; 57(9):1547-1557.Spurred on by donors, a number of developing countries are in the midst of fundamental health and population sector reform. Focused on the performance-oriented norms of efficiency and effectiveness, reformers have paid insufficient attention to the process-oriented norms of sovereignty and democracy. As a result, citizens of sovereign states have been largely excluded from the deliberative process. This paper draws on political science and public administration theory to evaluate the Bangladeshi reform experience. It does so with reference to the norms of efficiency, effectiveness, sovereignty and democracy as a means of making explicit the values that need to be considered in order to make health and population sector reform a fair process. (author's)
[Unpublished] .  p.The South-East Asia region is one of the most diverse and populous in the world. At midyear 1990, the total population of the world was estimated to be 5.3 billion people, of which 1.3 billion (24.6%) lived in the eleven countries of the South- East Asia region. During the next ten years it is expected to grow by 256.6 million, thus making up 25.3% of the world total (Health situation in south-east Asia 1991). The World Health Organization, WHO which is a pioneer organization working in the field of health. In May 1997 in the Thirtieth World Health Assembly adopted resolution WHA 30.43 in which it decided that the main social target of government and of WHO in the coming decades should be the attainment by all the people of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life. This is popularly known as ‘health for all by the year 2000 ‘. What does ‘health for all’ mean? It means simply the realization of WHO’s objective of the ‘the attainment by all peoples of the highest possible level of health” and that as a minimum all people in all countries should have at least such a level of health that they are capable of working productively and of participating actively in the social life of the community in which they live. To attain such a level of health every individual should have access to primary health care and through it to all levels of a comprehensive health system. While the communities might be expected to have a similar general understanding of the meaning of health for all as outlined above, each country will interpret this meaning in the light of its social and economic characteristics, health status and morbidity patterns of its population, and state of development of its health system. In 1978 an International conference on Primary Health Care was held in Alma-Ata, USSR. This conference, which declared that primary health care is the key to attaining health for all, it emphasized that health development is essential for social and economic development, that the means for attaining them are intimately linked, and the action to improve the health and socioeconomic situation should be regarded as mutually supportive rather than competitive. The Declaration of Alma-Ata urged all government to formulate national policies, stategies and plans of action to launch and sustain primary health care as part of a comprehensive national health system and in coordination with other sectors. In the 1979, the Thirty-second World Health Assembly launched the Global Strategy for health for all when it adopted resolution WHA32.30.The Global Strategy indicates the broad lines of action to be taken I the health sector and in related social and economic sectors. It provided global targets to be considered by member states, taking into account their own socioeconomic and health situation and bearing in mind that all countries are aiming at the same targets for the year 2000. (excerpt)