This week’s readings were particularly challenging for many reasons. As a student of global health and someone who hopes to one day work in the field, the readings described the bloated anatomy of an international health system that grows larger and more fractured every year. They also highlighted the ironic game being played with the concept of accountability. On one hand, Birn and Sridhar show that no one—donor countries and recipient countries alike—is held accountability for the effective provision of health care to the citizens of many of the world’s developing nations. “While many global health actors articulate noble intensions, by no means does this certify that money is well spent or reaches its target. There is currently no framework of accountability for global health, and no mechanisms to ensure that actors do not duplicate some services at the expense of others (Cohen 2006),” Birn writes (125).
Yet in a system, where recipient countries are more beholden to meet the requirements and desires of their development aid providers than their own citizens when it comes to providing health care, the only true line of accountability that seems to be one that actually matters and is shallowly pursued is that between elected officials in donor countries who authorized development aid and their voting base. While democratic representation albeit of a completely different citizen base is not completely a negative, the expectation to measure, demonstrate, and see results (preferably before the next election cycle) severely impact what in global health gets funded and how.
One clear example of this is “health systems” funding. As Sridhar notes, the global health community has “waxed and waned” in its rhetoric about the need for more activities to strengthen health systems in developing countries (464). Doing so means focusing on the primary health care systems, service delivery, and health worker shortages and quality—in other words, taking a counter sector, non-disease specific approach to global health interventions.
While the calls to action make sense and are enthusiastically agreed to, not much materializes after this point for several reasons. One, there is a lack of consensus about whether interventions should target specific health issues that often stand as indicators of the health of a health care system, such as child or maternal mortality, or focus more on the brick and mortar interventions, such as building health care facilities. Second, health systems strengthening faces the same issue any new problem that takes a shape different that the ones usually tackled in that it faces competition for support against more established, more certain problem areas. In global health this is the tension that exists between long-followed “vertical interventions,” where a specific disease is addressed. Third, this tension is further exacerbated by the fact that the global health community—as Sridhar points out—has not yet quantified with any clarity the global burden of non-disease-specific deaths. In other words—despite the rhetoric—the global health system doesn’t know how to measure progress against health systems strengthening, so by default it doesn’t tackle it with any great effort.
Underlying all of this is the concept of uncertainty. This uncertainty for researchers—on how to measure health systems strengthening—translates into uncertainty for donors—on if or where to invest funds—and results in this much needed area of global health to be ignored. The uncertainty of the health systems field combined with the aversion to uncertainty by donors, who want to realize and demonstrate improvement within their elected office term, has a immeasurably negative impact on some health care issues like child and maternal mortality, which are disproportionately affected by health systems.
We must take a different approach than the one we are currently pursuing when it comes to health systems strengthening. When it comes to this issue, the global health community must become more creative and proactive in understanding the true nature of health systems issues in specific contexts. I believe this means that organizations that fund global health research, such as the Gates Foundations, should expand their scope and fund research that collects quantitative and qualitative data on the experience of health workers and the interactions between medical staff and patients. While these are only two small aspects of a large issue, the global health community must start somewhere in truly understanding the weaknesses of health systems in different contexts.
When it comes to this issue, I believe the global health community must take a “basic research” approach to delve beyond the one-size-fits-all weak-health-systems moniker. However, doing so demands that donors—whether governments, foundations, or aid agencies—accept that this type of research is not a short-term endeavor. It will likely not yield results that will be easily bound in progress reports and, in some cases, will be beneficial only because they will highlight errors and failures in thinking about the issue. These types of results are difficult—but not impossible—to defend in an “accountable,” track-and-measure-at-all-costs global health policy world. However, failing to make the case to invest in understanding the issue of health systems strengthening and taking risks to pursue solutions will result in the weakening of both “horizontal” and vertical interventions.”