Radical or reminiscent? How to improve the current systems-approach to global health

Poverty & Inequality06 May 2009David Stuckler, Sanjay Basu

We welcome the strong case made by Barten, Schrecker and Woodward for addressing health issues through a systems-approach and a focus on the socio-economic causes of health and health inequity. We firmly agree that poverty and inequality, and the overall strength of a medical and public health system, are key challenges to improving the well-being and health of resource-denied populations. But what strategy could be most effective for improving health and health equity?

As the authors note, their proposal is not a new or ‘radical’ idea. Since the Alma Ata Declaration of the 1970’s 1 and Ottawa Charter in the 1980s 2, claims have been made that system-wide approaches, and primary health care for all, are universally agreed-upon goals.

So why haven’t these goals been fulfilled? What went wrong the first time? Certainly much of the problem has been lack of real commitment to a comprehensive approach to reducing health risks and improving primary care. The prevailing ‘neo-liberal’ economic model of development, the so-called ‘Washington Consensus’, which emphasized liberalization, privatization and fiscal austerity, displaced ‘Primary Health Care for All’ with ‘Primary Health Care for Some’ 3. Equity took a backseat to efficiency. Low inflation targets and reigning in budget deficits led to infighting between ministers of finance, seeking to satisfy the global financial community and corporate sources of capital, and ministers of health, aiming to meet their population’s basic health needs.

Should we expect international financial institutions, like the World Bank or IMF, to suddenly chart a radical (new) course in global health? These organizations de-funded the health sector for years, and still choose to make their decisions in Washington D.C. rather than through community-based methods of addressing local health burdens. 4 Even amidst a severe financial crisis, their core economic principles – liberalization, privatization and deregulation – and their relevance for the health sector aren’t seriously being questioned.

These tensions are mirrored in the WHO Commission on Macroeconomic and Health, which argued for a health as a boon to development and advocated scaling-up ‘vertical’ or disease-specific global health initiatives (led by Professor Jeffrey Sachs, consistent with the World Bank and IMF), 5 and the WHO Commission on Macrosocial Determinants of health, which argued that current development was worsening health and called for a return to the ‘horizontal’ or systems-wide global-health programs (led by Sir Michael Marmot, inconsistent with the World Bank and IMF). 6

Could there be a synthesis? (Note: see Gorik Ooms and colleagues for potential solutions)

Let’s suppose the global health community decided to return to the Alma Ata approach whole-heartedly. How would it work?

One longstanding challenge to Barten and colleagues’ vision is that, unlike disease-specific approaches, the systems-approach works behind the scenes and over a longer timeframe for bringing about changes to healthcare practice. Concerns have been raised that this approach may not proceed through clear targets or accountable structures for the spending of funds. 3In a targeted TB program, for example, money is directed for specific drugs, training, and to meet specific time-dependent goals. We can monitor the quality of a program by determining which protocols have been followed or not followed, and determining which part of the medical treatment chain is weakest. We can quickly see whether patients get more or better treatment.

To date, the systems-approach has not done enough to incorporate the advantages of the ‘vertical’ approach. Many public health successes have been sector-specific because of transparency, targeted goals, and clear mechanisms for change. Often the systems-approach offers strong rhetoric about broader bases of care and egalitarianism, but without developing measurable approaches for strengthening health systems. This risks not effectively using the scarce funds, and, perversely, in some cases, has padded the pockets of development agencies.

So while we support system-based and poverty-based approaches, we feel that we must learn from ‘vertical’ disease programs by making solid goals, measurable outcomes, and detailed, rigorous evaluations of our approaches to system issues, not simply throwing money at the development sector and asking for vague improvements to general primary care or health systems. This latter approach resulted in massive embezzlement of funds by foreign consultants and agencies after Alma Ata, rather than removing power from these persons and redistributing the power to communities who have pragmatic strategies for change in their own towns and cities.

We should address the central problems being addressed by the systems-focused group with an approach that is rigorous rather than rhetorical, and this clearly draws out not simply the origins of the problems but also “what works” to resolve them: What approaches have worked best to minimize daily household risks for people who are exposed to environmental pollutants (such as indoor air pollution from wood-burning cooking stoves), alcohol and tobacco, traffic accidents, or conditions of female economic dependency (so tightly related to many health risks, from infectious disease to maternal mortality)? What approaches are best for reducing poor access to health facilities (comparing transportation vouchers to improved roads or mobile community healthcare workers)? What approaches to creating new jobs in poor populations has been most conducive to preserving health and avoiding labour-based health risks (from migration associated with HIV and TB to occupational hazards or destruction of family units)? There is very little literature in this realm, but arguably these very specific and pragmatic questions are more crucial to meeting the health goals of many populations and improving disease prevention than our current literature, typically focused on hospital-based or clinic-based approaches to managing end-stage disease. ,

As history tells us, often those people most targeted by our public health systems – particularly the poor, women, and those of unfavoured skin colour — get left behind no matter what scheme we concoct for them in rich countries, especially when those schemes change with the seasons like fashion or art. Poor country ministers are left with a finger in the wind to find out which fashionable statement is most popular in rich country elite sectors in a given year — new acronyms, ‘bottom up approaches’, ’empowerment’, ‘system level’ — and how budgets will dramatically change, and commitments revoked, given the fashions. Thus, the disease-specific approach risks skewing health system priorities away from community-driven priority-lists and displacing existing capacity, where systems-approach, harder to oversee, could end up funnelling money to global-health consultants rather than local health systems.

Moving beyond such global health rhetoric, we must keep sight of what we’re ultimately trying to do: address the key obstacles faced by people on a daily basis when trying to achieve or maintain health and obtain good healthcare. Our principle must be to transfer power those with vested interests whose rhetoric changes with the wind to people in order to achieve these goals. ‘Empowering’ patients, individuals and their communities was a central concern of the authors of the Alma Ata and Ottawa Charter, but has been the least fulfilled of all the declarations’ goals. The word ’empowerment’ came to be applied in a way that does not actually ask the patient what powers they desire, what powers they need, and how this power could be redistributed from wealthy and powerful of their own and foreign countries to those who are poor and vulnerable.

As Barten and colleagues implicitly point out, one of the most disempowering trends in global health may be the growing role of private donors, or the hidden, yet dramatic, ‘privatization of global health’. WHO’s budget has gone from giving poor countries a voice in setting 75% of its health priorities (in 1971) to less than one-quarter today. Increasingly, private donors are setting the global-health agenda, through WHO, but also through the Gates Foundation, numerous charity organizations, and through the influence of academia and priority-setting of research agendas. Those problems chosen by private donors have been shown to be much further out of sync with real needs of populations than those chosen democratically by communities who request more resources to change unhealthy living conditions 7. Private foundations and donors must become more open both in their internal workings, but also in their priority-setting processes, to know how vast transfers of wealth and decision-making are taking place. It’s a terrible challenge to find out what donors are doing, where money is going, and what conditions are attached to it. To have a democratic approach to global health, we need avenues for the most affected people to gain more power in agenda-setting and review of global health programs.

Even outside of explicit private foundations, the influence of private-sector-like work in global health has been intense, as the field has moved away from community-based epidemiology and public health work on the ground, and relocated to specialist consulting agencies and roving organizations that declare agendas and compete for air-time at conferences before establishing clearly what the communities they work with want. Catch phrases in newspapers overpower hard work on the ground.

Thus, we strongly agree with the critical concerns raised by Barten and colleagues. For any kind of ‘radical’ policy break from the current system, progress is crucially needed on at least four inter-related goals:

  1. Coherence between the global financial and global health communities, such that economic reform measures do not undermine health goals
  2. Democratic and inclusive structures for giving recipient communities and patients decision-making power both in agenda-setting and in review of programs supposed to benefit them
  3. Wider measures of goals, success and failure to track rigorously how well we are addressing socioeconomic barriers to health and healthcare
  4. Accountability and transparency in both private foundations and international decision-making bodies


  1. World Health Organization (WHO). 1978. Declaration of Alma-Ata. Geneva: World Health Organization.
  2. World Health Organization (WHO). 1986. Ottawa Charter for Health Promotion. First International Conference on Health Promotion.
  3. Cueto, M. 2004. Origins of primary health care and selective primary health care. American Journal of Public Health. 94(11): 1864-74.
  4. Stuckler, D., S. Basu, and L. King. 2008. International Monetary Fund programs and tuberculosis outcomes in post-communist countries. Public Library of Science Medicine 5(7): e143.
  5. World Health Organization (WHO). 2001. Report of the Commission on Macroeconomics and Health.
  6. World Health Organization (WHO). 2008. Report of the Commission on Social Determinants of Health.
  7. Stuckler, D., H. Robinson, M. McKee, L. King. 2008. World Health Organization Budget and burden of disease: a comparative analysis. The Lancet. v372(9649):1563-1569.