The rapid response from the Civil Society Consortium of the Maximizing Positive Synergies Initiative to the Lancet Editorial
18 June 2009

The June 20 editorial in The Lancet, Who runs global health? has seriously misinterpreted much of the key evidence on positive synergies between global health initiatives and health systems strengthening in the article that accompanies the editorial. The Lancet has further neglected to analyze a much broader base of evidence collected by academic and civil society researchers as part of the WHO’s Maximizing Positive Synergies project, which will be presented in Venice to global health leaders and the G-8 June 22-33. As members of the civil society team that conducted research in four African countries involving hundreds of research participants on this issue, and as health activists long involved in the fight for global health justice, we take exception to such a biased commentary on the life-saving impacts of the major global health initiatives inc1uding the Global Fund, PEPFAR, and GAVI.

The editorial pays passing lip service to “emerging signs of some positive benefits in health equity, quality of services, innovative financing for health, task shifting, training, community participation, monitoring and education, and the price of medical products.” It then proceeds to claim that “a team of scientists across 30 nations … now reveal several adverse effects of GHIs on health systems. Some of the most troubling harms include steepening inequalities in health services, reduced quality of services because of pressures to meet targets, decreases in domestic spending on health, misalignment between GHIs and country health needs, distraction of government officials from their overall responsibilities for health, the creation of expensive parallel bureaucracies to manage GHIs in countries, the weak accountability of rapidly expanding GHI¬ funded non-governmental sector, and the increased burdens on already fragile health workforces.” According to The Lancet, there of not mere “signs” of negative effects – these negative effects are “revealed” and reified, even though some of them are directly contradictory to the parsimonious citing of positive effects.

Civil society has long been critical of domestic, donor, UN, and GHI health programming that has failed to deliver adequately on the right to health. We have fought for inclusion at the policy table, for dramatically increased resources, for cheaper medicines, for a role in implementation, and for improvements at the coal¬face of delivery. But the more than 3 million people receiving antiretroviral therapy in developing countries, thousands of them health workers themselves, are not “distractions” and “burdens” and they are receiving affordable and cost-efficient life-saving treatment because of strengthened health systems, trained health workers, reliable drug procurement and supply, and improved and extended interface between communities and health services made possible because of unfairly maligned GHls.

It is particularly galling that The Lancet editorial cites decreases in domestic spending on health as a consequence of GHIs. In fact, domestic spending has actually increased in many countries and where instances of substitution exist, those are better laid at the door of the International Monetary Fund and Ministries of Finance that continue to pursue macroeconomic policies that restrict expanded investments in health and education. Likewise, the allegation of misalignment is particularly malign. In a world where the glass for HIV 1 AIDS, TB, and malaria programming is still one-third full at best, how is there misalignment in trying to meet universal access commitments? What is misaligned is that donors and governments themselves have been perversely reluctant to make needed investments in other “country-owned” priorities including child and maternal health, sexual and reproductive health, human resources for health, and now the growing burden of chronic diseases. The misalignment is not because HIV 1 AlDS, TB and malaria have gotten too much, but because other critical health needs have gotten too little.

The Maximizing Positive Synergies project has been a serious but preliminary, evidence-based attempt to glean insights into the ways to make the interactions between GHIs, health systems, and other health service delivery smarter, more complementary, more efficient, more equitable, and most importantly more effective. The early research shows a relatively short and mixed history of positive and negative interactions, but also adaptability. We support the role of the WHO as a normative institution and the importance of evaluation, but we reject The Lancet unfairly and selectively overemphasizing negative effects in the research to date.

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