In 2000, the UN Millennium Declaration was signed by 189 countries, and translated into eight Millennium Development Goals (MDGs) for development and poverty eradication. Three of the eight MDGs are directly related to health, reducing child mortality; improving maternal health; combating HIVAIDS, malaria and other diseases. The ambitious nature of these goals - that are supposed to be achieved by 2015 - coupled with concern about the massive health challenges being faced by the world's poorest countries, has led to a growing momentum within the field of global health. This momentum in part takes the form of a series of high profile global health initiatives including The Global Fund to Fight AIDS, TB and Malaria (GFATM);: Stop TB, Roll Back Malaria, The Presidential Emergency Plan for AIDS Relief PEPFAR;: and the Global Alliance for Vaccines and Immunization (GAVI).
Recent evidence, however, suggests that based on current trends many low-income countries are unlikely to achieve the MDG health targets by 2015. Even more worrisome is that those countries furthest away from the targets, i.e. those with the worst health status, are least likely to make significant progress. This is despite the fact that for the health problems that must be tackled to reach the MDGs, there are a growing number of effective and affordable interventions as well as increasing international assistance for specific diseases, characterized by the emergence of billion dollar funds. Rather there is growing consensus that a primary bottleneck to achieving the MDGs in low income countries is health systems that are too fragile and fragmented to deliver the volume and quality of services to those in need. For example, Chen describes the \"double crisis\" of devastating disease and overwhelmingly failing health systems in many low-income countries. The High Level Forum on achieving the Health Millennium Development Goals identified major shortfalls in the health workforce, lack of donor coordination and weak information systems as critical challenges to achieving Millennium Health Goals. The Lancet series on child survival noted the critical need for strengthened health systems to achieve child health gains and this year's World Health Report argued that \"The 3 by 5 initiative [to provide 3 million people with access to antiretrovirals by 2005] cannot be implemented in isolation from a regeneration of health systems.\"
While stronger health systems appear to be a pre-requisite to achieving the health MDGs, there is currently little direct focus on systems strengthening. The drive to produce results for the MDGs has led many stakeholders to focus on their disease priority first, with an implicit assumption that through the implementation of specific interventions the system will be strengthened more generally. Experience to date however, suggests that if health systems are lacking capabilities in key areas such as the health workforce, drug supply, health financing, and information systems they may not be able to respond adequately to such opportunities. Furthermore, there is concern that already weak systems may be further compromised by over-concentrating resources in specific programmes, leaving many other areas further under-resourced.
This paper aims to assist the development of a greater and more widely shared understanding of approaches to health system strengthening. It uses the MDGs as a starting point, and reviews the advantages and limitations of pursuing health systems strengthening through the lens of individual service or disease specific initiatives. It argues that part of the challenge is to get more existing knowledge into practice, but that a stronger body of knowledge about which system strengthening strategies are effective, and which are not, is also urgently needed. If these challenges do not receive serious and sustained attention, there is a risk that many current praiseworthy efforts will be not achieve their goals. This is the first of a number of Lancet papers prior to the Ministerial Summit on Health Research, which will focus particularly on developing health policy and systems research, on knowledge dissemination, and on promoting the use of findings by decision makers.
Travis, P.; Bennett, S.; Haines, A.; Pang, T.; Bhutta, Z.; Hyder, A.A.; Pielemeier, N.; Mills, A.; Evans, T. Overcoming health systems constraints to achieve the Millennium Development Goals. Lancet (2004) 364 (9437) 900-906. [DOI: 10.1016/S0140-6736(04)16987-0]