We believe that systems thinking and complexity science can be transformational in global health by increasing local capacity and shared learning, and minimizing unintended consequences.
The Call to Action was published on-line in the journal Lancet today. It can be accessed here. You can sign onto the Call to Action here, (which is the panel of the article). The correct reference (until print publication) is:
“Call for global health-systems impact assessments
The Lancet, Volume null, Issue null, Page null
R. Swanson, H. Mosley, D. Sanders, D. Egilman, J. De Maeseneer, M. Chowdhury, C. Lanata, K. Dearden, M. Bryant”
Here is the body of the article:
“Despite unprecedented increases in global health funding
in recent years, major challenges remain for reduction
of global health disparities. Methods that anticipate
the effect of targeted global health initiatives on health
systems are needed and will improve health worldwide.
Such methods—or health-systems impact assessments
(HSIAs)—should be developed and used before global
health initiatives are implemented (panel).1,2
A growing body of evidence shows that although
targeted global health initiatives have led to scaling up
of some key health interventions, notably treatment
of AIDS, they might also affect health systems—
sometimes negatively.3–12 At times, the capacity of
people and institutions has been sacrificed for quick
results. Some researchers and practitioners have
recognised the need for HSIAs.5,8–14 Indeed, WHO’s
Maximizing Synergies Collaborative Group recently
published an article in The Lancet that highlighted the
effects of global health initiatives on existing health
systems, and called for “rigorous methods by which to
assess” such interactions.12 We agree with that need,
and echo the call of Ronald Waldman that “A health
systems ‘impact statement’ should be de rigueur for all
disease-specific global initiatives and for local ones as
WHO has identified six health-systems building blocks:
service delivery; health workforces; health-information
systems; medical products, vaccines, and technologies;
health financing; and leadership and governance.15
Global health initiatives can affect all dimensions of
these health systems—in positive and negative ways.
For example, the health workforce is negatively affected
when donors need external contractors instead of using
local workforces, or when disease-specific programmes
divert health workers from other comprehensive health
The methodological challenges that face those who
attempt to predict the effect of programmes on health
systems are complex. Noteworthy contributions have
been made in recent years that will assist in development
of an evidence-based approach. Some impact assessments
already exist across social sectors—most notably environmental
impact assessments. Health-impact assessments
anticipate the health effects of proposals from sectors
outside health,16 whereas health-system assessments
review the various components of health systems. The
health-system-assessment community has developed
an approach that might be useful for development of
indicators and methods for HSIAs, and WHO recently
introduced the draft version of a toolkit to assist in
monitoring health-systems strengthening.17,18
We are aware of two published frameworks that
anticipate the outcome of health programmes on
health systems. In 2003, Bennett and co-workers19
predicted the possible effects of the Global Fund to
Fight AIDS, Tuberculosis and Malaria on the broader
health system. According to recent reports,3,10–12 many
of their predictions were correct. Atun and co-workers’
toolkit14 to analyse the wider health-system context in
disease-specific programmes has been used in various
settings. These HSIA frameworks include or suggest
indicators such as the diversion of health workers,
strengthening of laboratory capacity, and financing
arrangements. These and other indicators will need to
be validated and updated as we learn more about the
ways in which global health initiatives affect health
This call brings with it the risk of too much analysis.
Different degrees of depth and rigour in HSIAs are
needed, depending on the project. Local participation
should be solicited to ensure that assessments are
relevant and effective. Indeed, the development of
HSIAs should strengthen local health systems. Although
HSIAs have not yet been developed rigorously as a
widely accepted evidence-based method, global health
organisations should not wait for their development
before thinking about the effect of their activity on
future health systems. Development and use of HSIAs
should take place in tandem.
Use of HSIAs will often need a change in philosophy
and approach. Every organisation that is planning a
health intervention in a developing country will need
to give thought to the long-term implications of its
actions. Activities should be viewed in the context of
improvement of health rather than being focused on
short-term indicators or a few specific diseases. HSIAs
should be used by all who participate in global health,
including volunteers with small non-governmental
organisations, researchers, and large donors.
Without HSIAs, initiatives targeted at specific diseases
will probably, at best, continue to duplicate efforts within
health systems and divert personnel and resources;
or, at worst, erode long-term capacity. Although
initiatives often focus on and publicise short-term
goals, these interim markers should not obscure longterm
objectives. The aim of WHO, ministries of health,
clinicians, public health promoters, and others who are
connected with global health is, simply, better health.
The long-term improvements in health that we seek will
be reached only through the combined use of effective
technologies and interventions (including addressing
social determinants), with improved individual and
institutional capacity. The time has come for the use of
HSIAs, an idea that will lead to worldwide sustainable
improvements in health.
*R Chad Swanson, Henry Mosley, David Sanders,
David Egilman, Jan De Maeseneer, Mushtaque Chowdhury,
Claudio F Lanata, Kirk Dearden, Malcolm Bryant
Johns Hopkins Bloomberg School of Public Health, Baltimore,
MD 21205, USA (RCS, HM); School of Public Health, University of
Western Cape, Bellville, Western Cape, South Africa (DS); Brown
University, Providence, RI, USA (DE); Ghent University, Ghent,
Belgium (JDM); BRAC University, Dhaka, Bangladesh (MC);
Nutritional Research Institute, Lima, Peru (CFL); Boston
University, Boston, MA, USA (KD); and IDEAS Development
Institute, Boston, MA, USA (MB)
We thank Evan Russell for his suggestions on early drafts of this Comment.
We declare that we have no conflicts of interest.
1 Global Health Systems Impact Assessment. https://ghsia.wordpress.com/
sign-onto-the-call-for-ghsias (accessed July 1, 2009).
2 The NGO code of conduct for health systems strengthening initiative.
http://ngocodeofconduct.org (accessed May 4, 2009).
3 Global HIV/AIDS initiatives network database. Nov 16, 2007. http://www.
ghinet.org/database.asp (accessed May 4, 2009).
4 Oomman N, Bernstein M, Rosenzweig S. Seizing the opportunity on AIDS
and health systems. Aug 4, 2008. http://www.cgdev.org/content/
publications/detail/16459 (accessed May 4, 2009).
5 McCoy D, Chopra M, Loewenson R, et al. Expanding access to antiretroviral
therapy in sub-Saharan Africa: avoiding the pitfalls and dangers,
capitalizing on the opportunities. Am J Public Health 2005; 95: 18–22.
6 OECD. Harmonising donor practices for effective aid delivery. 2003.
May 4, 2009).
7 Pfeiffer J. International NGOs and primary health care in Mozambique:
the need for a new model of collaboration. Soc Sci Med 2003; 56: 725–38.
8 Loevinsohn B, Aylward B, Steinglass R, Ogden E, Goodman T, Melgaard B.
Impact of targeted programs on health systems: a case study of the polio
eradication initiative. Am J Public Health 2002; 92: 19–23.
9 Unger JP, De Paepe P, Green A. A code of best practice for disease control
programmes to avoid damaging health care services in developing
countries. Int J Health Plann Manage 2003; 18 (suppl 1): 27–39.
10 Biesma RG, Brugha R, Harmer A, Walsh A, Spicer N, Walt G. The effects of
global health initiatives on country health systems: a review of the
evidence from HIV/AIDS control. Health Policy Plan 2009; 24: 239–52.
11 Marchal B, Cavalli A, Kegels G. Global health actors claim to support health
system strengthening: is this reality or rhetoric? PLoS Med 2009;
12 World Health Organization Maximizing Positive Synergies Collaborative
Group. An assessment of interactions between global health initiatives and
country health systems. Lancet 2009; 373: 2137–69.
13 Health Systems Action Network. Global leaders views on HSS. 2005.
http://www.hsanet.org/speakout.html (accessed May 4, 2009).
14 Atun RA, Lennox-Chhugani N, Drobniewski F, Samyshkin YA, Coker RJ.
A framework and toolkit for capturing the communicable disease
programmes within health systems: tuberculosis control as an illustrative
example. Eur J Public Health 2004; 14: 267–73.
15 WHO. Health systems topics. Geneva: World Health Organization, 2008.
http://www.who.int/healthsystems/topics/en/ (accessed May 4, 2009).
16 Cole BL, Shimkhada R, Fielding JE, Kominski G, Morgenstern H.
Methodologies for realizing the potential of health impact assessment.
Am J Prev Med 2005; 28: 382–89.
17 Islam M, ed. Health systems assessment approach: a how-to manual.
February, 2007. http://www.healthsystems2020.org/files/528_file_
Manual_Complete.pdf (accessed May 4, 2009).
18 WHO. Toolkit for monitoring health systems strengthening. 2009.
(accessed June 29, 2009).
19 Bennett S, Fairbank A. The system-wide effects of the Global Fund to Fight
AIDS, Tuberculosis and Malaria: a conceptual framework. October, 2003.
(accessed May 4, 2009).”