Turning quicksand into bedrock : understanding the dynamic effects of disease-focused global health aid on health systems

Abstract

This thesis asks one basic question: how do "vertical" disease- or intervention-focused global health programs impact the underlying health systems of the nations they serve? Vertical programs-health aid focused on a particular disease, such as HIV, or type of intervention, such as immunization-receive the lion's share of global health aid dollars, and yet we know uncomfortably little about their long-run impact on broader health systems. Many speculate that vertical aid undermines health worker effectiveness, distorts national policies, and disrupts the supply chain for drugs and medical products. Unfortunately, a lack of hard data makes quantitative analysis extremely difficult. Using the tools of system dynamics, this thesis consolidates the collective wisdom of previously published investigations and anecdotal observations to reveal the field's prevailing "mental model" of the dynamic in question. The result is a set of diagrams that describe the known impacts of vertical programs on health systems, and also reveal dynamic effects not yet explicitly identified in the literature. These effects fall into four sub-systems of impact: care delivery specialization and fragmentation, care delivery development and mediocritization, health policy development and mismatch, and market development and distortion. These models are then used to better understand the effects of recent contextual developments-the HIV/AIDS epidemic and the emergence of large Global Health Initiatives.

(cont.) Through expert interviews, this thesis identifies the most pressing system stresses in this contemporary context: the commitment to chronic care delivery which HIV/AIDS intervention creates, and the critical need for harmonization between donors which this commitment reveals. Using case examples from Kenya, these dynamics are shown to be active today, and to have instigated mitigation strategies by practitioners in the field. Finally, the systems identified above bring into focus key leverage points, including donor coordination, health worker augmentation, and engagement of local markets, which can "tip" the impact of vertical programs from harming health systems to strengthening them. In doing so, this thesis provides guidance to policymakers and program implementers who seek to use their resources to strengthen systems and eventually obviate health aid entirely.