On Thursday, 8 November, colleagues in the Ministry of Health and I published a brief Comment in Journal of the Royal Society of Medicine: Short Reports responding to a review of interactions between global health initiatives (like the Global Fund and PEPFAR) and country health systems. We shared Rwanda's perspective on the importance of true country ownership in promoting integration and maximizing synergies.
Country Ownership to Strengthen Synergies Between Global Health Initiatives and Health Systems
Agnes Binagwaho, Sabin Nsanzimana, Corine Karema, Michel Gasana, Claire M. Wagner, and Cameron T. Nutt
As policymakers and researchers in Rwanda's health sector, we applaud Josip Car and colleagues' review of interactions between Global Fund investment and country health systems.1 Their trenchant analysis may not close the door on confidently advanced claims about the dangers of global health initiatives that are not based upon rigorous evidence, but it has helped to raise the bar for the debate.Several recent studies focused on Rwanda (that either did not fall within Car et al.'s timeframe or did not specifically investigate Global Fund programs and were thus not included in the review) together provide robust support for the argument that interventions explicitly designed to combat HIV/AIDS, tuberculosis, and malaria can be implemented in such a way as to strengthen the overall health system.2-4
In fact, Rwanda's reductions of greater than 75% in mortality due to AIDS and tuberculosis between 2000 and 2010 were accompanied by a 70% decline in child mortality and a 60% decline in maternal mortality over the same timeframe.5 This was not a fortunate accident, but due to collaborative planning with civil society and development partners, and true country ownership of program implementation and evaluation.
From the beginning of Rwanda's AIDS response, the public sector has been committed to constructing platforms of care able to address multiple chronic and acute conditions. When a clinic is built and staffed to offer HIV services to women, the same woman trying to prevent vertical HIV transmission to her unborn child will also require a safe place to deliver as well as a trained birth attendant. So will her neighbors, whether HIV- positive or not.
As is often said in the Ministry of Health, "if you give Rwanda money to help the youngest child born today, we will ensure that it also helps the oldest person by tomorrow." When implemented according to principles of authentic partnership and when investing in public infrastructure and human resources, disease-specific global health initiatives can not only achieve positive spillover effects, but can also catalyze the development of comprehensive and equitable primary care systems in the poorest countries.
The time has come for scholars and policymakers to move past unfounded worries about whether to invest in the pandemics of AIDS, tuberculosis, and malaria; what we must now devote our full attention to is the question of how best to harness synergies and maximize impact in the pursuit of health as a human right.
1 Car J, Paljarvi T, Car M, Kazeem A, Majeed A, Atun R. Negative health system effects of Global Fund's investments in AIDS, tuberculosis and malaria from 2002 to 2009: systematic review. J R Soc Med Sh Rep 2012;3:70.
2 Price J, Leslie JA, Welsh M, Binagwaho A. Integrating HIV clinical services into primary health care in Rwanda: a measure of quantitative effects. AIDS Care 2009;21:608-614.
3 Kalk A, Groos N, Karasi JC, Girrbach E. Health systems strengthening through insurance subsidies: the GFATM experience in Rwanda. Trop Med Int Health 2010;15:94-97.
4 Shephard D, Zeng W, Amico P, Rwiyereka AK, Avila-Figueroa. A controlled study of funding for Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome as resource capacity building in the health system in Rwanda. Am J Trop Med Hyg 2012;86:902-907.
5 WHO: World Health Statistics 2012. World Health Organization, Geneva 2012.