Andrew Harmer

Good Health at Low Cost 25 years on: lessons for the future of health systems strengthening

In 1985, the Rockefeller Foundation published Good health at low cost to discuss why some countries or regions achieve better health and social outcomes than do others at a similar level of income and to show the role of political will and socially progressive policies. 25 years on, the Good Health at Low Cost project revisited these places but looked anew at Bangladesh, Ethiopia, Kyrgyzstan, Thailand, and the Indian state of Tamil Nadu, which have all either achieved substantial improvements in health or access to services or implemented innovative health policies relative to their neighbours. A series of comparative case studies (2009-11) looked at how and why each region accomplished these changes. Attributes of success included good governance and political commitment, effective bureaucracies that preserve institutional memory and can learn from experience, and the ability to innovate and adapt to resource limitations. Furthermore, the capacity to respond to population needs and build resilience into health systems in the face of political unrest, economic crises, and natural disasters was important. Transport infrastructure, female empowerment, and education also played a part. Health systems are complex and no simple recipe exists for success. Yet in the countries and regions studied, progress has been assisted by institutional stability, with continuity of reforms despite political and economic turmoil, learning lessons from experience, seizing windows of opportunity, and ensuring sensitivity to context. These experiences show that improvements in health can still be achieved in countries with relatively few resources, though strategic investment is necessary to address new challenges such as complex chronic diseases and growing population expectations.

'It's risky to walk in the city with syringes': understanding access to HIV/AIDS services for injecting drug users in the former Soviet Union countries of Ukraine and Kyrgyzstan

BackgroundDespite massive scale up of funds from global health initiatives including the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund) and other donors, the ambitious target agreed by G8 leaders in 2005 in Gleneagles to achieve universal access to HIV/AIDS treatment by 2010 has not been reached. Significant barriers to access remain in former Soviet Union (FSU) countries, a region now recognised as a priority area by policymakers. There have been few empirical studies of access to HIV/AIDS services in FSU countries, resulting in limited understanding and implementation of accessible HIV/AIDS interventions. This paper explores the multiple access barriers to HIV/AIDS services experienced by a key risk group-injecting drug users (IDUs).MethodsSemi-structured interviews were conducted in two FSU countries-Ukraine and Kyrgyzstan-with clients receiving Global Fund-supported services (Ukraine n = 118, Kyrgyzstan n = 84), service providers (Ukraine n = 138, Kyrgyzstan n = 58) and a purposive sample of national and subnational stakeholders (Ukraine n = 135, Kyrgyzstan n = 86). Systematic thematic analysis of these qualitative data was conducted by country teams, and a comparative synthesis of findings undertaken by the authors.ResultsStigmatisation of HIV/AIDS and drug use was an important barrier to IDUs accessing HIV/AIDS services in both countries. Other connected barriers included:criminalisation of drug use; discriminatory practices among government service providers; limited knowledge of HIV/AIDS, services and entitlements; shortages of commodities and human resources; and organisational, economic and geographical barriers.ConclusionsApproaches to thinking about universal access frequently assume increased availability of services means increased accessibility of services. Our study demonstrates that while there is greater availability of HIV/AIDS services in Ukraine and Kyrgyzstan, this does not equate with greater accessibility because of multiple, complex, and interrelated barriers to HIV/AIDS service utilisation at the service delivery level. Factors external to, as well as within, the health sector are key to understanding the access deficit in the FSU where low or concentrated HIV/AIDS epidemics are prevalent. Funders of HIV/AIDS programmes need to consider how best to tackle key structural and systemic drivers of access including prohibitionist legislation on drugs use, limited transparency and low staff salaries within the health sector.

'BRICS without straw'? A systematic literature review of newly emerging economies' influence in global health

BackgroundSince 2010, five newly emerging economies collectively known as ‘BRICS’ (Brazil, India, Russia, China and South Africa) have caught the imagination, and scholarly attention, of political scientists, economists and development specialists. The prospect of a unified geopolitical bloc, consciously seeking to re-frame international (and global) health development with a new set of ideas and values, has also, if belatedly, begun to attract the attention of the global health community. But what influence, if any, do the BRICS wield in global health, and, if they do wield influence, how has that influence been conceptualized and recorded in the literature?MethodsWe conducted a systematic literature review in (March-December 2012) of documents retrieved from the databases EMBASE, PubMed/Medline, Global Health, and Google Scholar, and the websites of relevant international organisations, research institutions and philanthropic organisations. The results were synthesised using a framework of influence developed for the review from the political science literature.ResultsOur initial search of databases and websites yielded 887 documents. Exclusion criteria narrowed the number of documents to 71 journal articles and 23 reports. Two researchers using an agreed set of inclusion criteria independently screened the 94 documents, leaving just 7 documents. We found just one document that provided sustained analysis of the BRICS’ collective influence; the overwhelming tendency was to describe individual BRICS countries influence. Although influence was predominantly framed by BRICS countries’ material capability, there were examples of institutional and ideational influence - particularly from Brazil. Individual BRICS countries were primarily ‘opportunity seekers’ and region mobilisers but with potential to become ‘issue leaders’ and region organisers.ConclusionThough small in number, the written output on BRICS influence in global health has increased significantly since a similar review conducted in 2010 found just one study. Whilst it may still be ‘early days’ for newly-emerging economies influence in global health to have matured, we argue that there is scope to further develop the concept of influence in global health, but also to better understand the ontology of groups of countries such as BRICS. The BRICS have made a number of important commitments towards reforming global health, but if they are to be more than a memorable acronym they need to start putting those collective commitments into action. Keywords BRICS, global health, influence, newly emerging economies, Brazil, Russia, India, China, South Africa.

Has Global Fund support for civil society advocacy in the Former Soviet Union established meaningful engagement or 'a lot of jabber about nothing'?

Although civil society advocacy for health issues such as HIV transmission through injecting drug use is higher on the global health agenda than previously, its impact on national policy reform has been limited. In this paper we seek to understand why this is the case through an examination of civil society advocacy efforts to reform HIV/AIDS and drugs-related policies and their implementation in three former Soviet Union countries. In-depth semi-structured interviews were conducted in Georgia, Kyrgyzstan and Ukraine by national researchers with representatives from a sample of 49 civil society organizations (CSOs) and 22 national key informants. We found that Global Fund support resulted in the professionalization of CSOs, which increased confidence from government and increased CSO influence on policies relating to HIV/AIDS and illicit drugs. Interviewees also reported that the amount of funding for advocacy from the Global Fund was insufficient, indirect and often interrupted. CSOs were often in competition for Global Fund support, which caused resentment and limited collective action, further weakening capacity for effective advocacy.

Understanding change in global health policy: Ideas, discourse and networks

Abstract How is radical change in global health policy possible? Material factors such as economics or human resources are important, but ideational factors such as ideas and discourse play an important role as well. In this paper, I apply a theoretical framework to show how discourse made it possible for public and private actors to fundamentally change their way of working together – to shift from international public and private interactions to global health partnerships (GHPs) – and in the process create a new institutional mechanism for governing global health. Drawing on insights from constructivist analysis, I demonstrate how discourse justified, legitimised, communicated and coordinated ideas about the practice of GHPs through a concentrated network of partnership pioneers. As attention from health policy analysts turns increasingly to ideational explanations for answers to global health problems, this paper contributes to the debate by showing how, precisely, discourse makes change possible.

Democracy – the Real 'Ghost' in the Machine of Global Health Policy; Comment on 'A Ghost in the Machine? Politics in Global Health Policy'

Politics is not the ghost in the machine of global health policy. Conceptually, it makes little sense to argue otherwise, while history is replete with examples of individuals and movements engaging politically in global health policy. Were one looking for ghosts, a more likely candidate would be democracy, which is currently under attack by a new global health technocracy. Civil society movements offer an opportunity to breathe life into a vital, but dying, political component of global health policy.

Reforming the World Health Organization: what influence do the BRICS wield?

The World Health Organization (WHO) is currently undergoing fundamental reform that is intended to impact its programmes and priority setting and its financial and governing structures. Within the reform debates, new relations of powers are emerging among traditional donors and emerging economies such as the ‘BRICS’: Brazil, Russia, India, China and South Africa. These five emerging economies have formally committed ‘to strengthen and legitimise the WHO as the coordinating authority in global health’ through the principle of multilateralism. In this paper, the results of a qualitative study – based on 21 key informant interviews – that seeks to better understand BRICS’ engagement in this organisation and the extent to which their action enables these countries to influence the reform process were presented. The results show that individual BRICS countries found natural pairings with each other on both particular elements of the reform, notably governance and WHO financing, and specific health issues. While numerous examples of individual BRICS countries seeking to raise the profile of specific health issues were found, some evidence of a coordinated effort to influence reform as a bloc was also found. Although this was largely limited to rhetorical announcements of support in formal Declarations and Communiqués, it nevertheless articulates a vision of the WHO as an organisation with a broad mandate delivered with sufficient, predictable funding.

Ten years of the Global Alliance for Vaccines and Immunisation

Successes of immunisation are tempered by slow progress in strengthening health systems