groups, and increased funding to nongovernmental organizations (NGOs) and faith-based bodies (Biesma et al., 2009; Samb et al., 2009; Yu et al., 2008). Negative effects on health systems include the reallocation of or reduction in funding for other health or non-health priorities; attrition in the public health or primary care workforce as a result of increased incentives to work for donor-funded programs; and the “distortion of recipient countries’ national policies, notably through distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoring and evaluation systems” (Biesma et al., 2009, p. 239; Samb et al., 2009; Yu et al., 2008). In general, the evidence is mixed and limited for determining whether effects are positive or negative (Biesma et al., 2009; Samb et al., 2009; Yu et al., 2008). In recent years, there has been more research devoted to the interaction between global health initiatives and health systems, and this research has produced recommendations for ensuring that health systems are strengthened, not weakened by global health initiatives.

The ability of societies generally, as well as public health and clinical care entities in particular, to address the HIV epidemic is contingent upon functioning health systems. The term “health system” is intentionally broad, referring to all of the societal resources mobilized to achieve and preserve health, and thus a health systems approach to constraints offers a different lens from that of a disease-specific response (see Table 9-1) (Mills, 2007). Many scholars have argued that investments in response to scaling up disease-specific services could be more appropriately targeted to interventions that broadly strengthen health care systems (Travis et al., 2004; Yu et al., 2008). In 2009 the WHO Maximizing Positive Synergies Collaborative Group issued five recommendations (paraphrased here) for improving the joint effectiveness of large global health programs and partner country health systems: (1) prioritize health system strengthening, (2) agree on and track health system strengthening indicators, (3) align planning and resource allocation between global health initiatives and country health systems, (4) generate more reliable data for the costs and benefits of strengthening health systems, and (5) commit to increased national and global health financing that is more predictable in order to support sustainable and equitable growth of health systems (Samb et al., 2009). The challenge for global health donors is that health system interventions require long-term investments and the longer time lags between interventions and outcomes make such interventions more difficult to measure and evaluate (Bärnighausen et al., 2012).



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