health). Large global health initiatives such as PEPFAR, the Global Fund, and the Global Alliance for Vaccines and Immunization have facilitated the tremendous increase in development assistance for health, but there is concern about the effects, intended and unintended, of these initiatives on partner country health systems (Bärnighausen et al., 2012; Biesma et al., 2009; Grépin, 2012a; Levine and Oomman, 2009; Samb et al., 2009). There is widespread consensus within the global health community on the need to strengthen health systems in order to improve health outcomes and meet global targets such as universal health coverage and the health-related Millennium Development Goals1 (Shakarishvili, 2009; Task Force on Global Action for Health System Strengthening, 2008; WHO, 2009). Many of the largest donors and multilateral organizations involved in global health have faced challenges in scaling up services because of health systems weaknesses and have responded by supporting interventions specifically designed to strengthen components of the health system (Palen et al., 2012; Shakarishvili, 2009).

In 2007, WHO developed a framework for health systems strengthening (HSS) that identifies six building blocks corresponding with the essential functions of health systems:

1. Leadership and governance,

2. Financing,

3. Information,

4. Medical products, vaccines, and technologies (shortened to “medical products and technologies” by the committee),

5. Health workforce, and

6. Service delivery (WHO, 2007a).

These building blocks are interdependent, and the relationships between the building blocks deserve as much attention as the individual components (WHO, 2007a, 2009). The building block framework, illustrated in Figure 9-1, has been adopted by the Office of the U.S. Global AIDS Coordinator (OGAC) and others stakeholders that are emphasizing the prioritization, organization, and execution of activities in the essential area of strengthening health systems (Friedman et al., 2011; OGAC, 2009f).

Large donor-funded global health initiatives interact with each building block within partner country health systems. Despite sharing the same goal as partner country health systems—to improve health outcomes—initiatives such as PEPFAR can have negative as well as positive effects on these sys-

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1 In 2000, world leaders committed to the United Nations Millennium Declaration and adopted eight Millennium Development Goals to reduce the most important determinants and consequences of poverty (United National General Assembly, 2000).



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