Interactions between Global Health Initiatives and Country Health Systems: The Case of a Neglected Tropical Diseases Control Program in Mali
Interactions between Global Health Initiatives and Country Health Systems: The Case of a Neglected Tropical Diseases Control Program in Mali
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DOI：
10.1371/journal.pntd.0000798
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发表时间：
2010-08-01
影响因子：
3.8
通讯作者：
Van Dormael, Monique
中科院分区：
文献类型：
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作者：
Cavalli, Anna;Bamba, Sory I.;Van Dormael, Monique
背景：最近，为解决低收入国家的单一疾病问题，如脊髓灰质炎、沙眼、新生儿破伤风等，制定了若干全球卫生倡议。关于这种全球卫生保健系统对地方卫生系统影响的经验证据仍然很少。本文探讨了2007年首次实施的被忽视热带病综合控制计划（NTD）对马里卫生系统的积极和消极影响，该计划包括针对5种被忽视热带病的大规模预防性化疗。方法和发现：通过参与观察，在两个农村地区（每个地区8个卫生中心）评估了运动过程和与卫生系统的相互作用。通过与主要举报人的访谈、网站搜索和文献综述补充了这些信息。初步结果在与马里国家、区域和地区各级当局的反馈会议期间得到验证。我们利用世卫组织基于卫生服务提供、卫生人力、卫生信息系统、药品采购系统、筹资和治理六个相互关联要素的分析框架，介绍了非传染性疾病运动对卫生系统的积极和消极影响。在分娩时，与运动有关的工作量严重干扰了日常护理的提供，在运动期间，由于护士不在保健中心参加与运动有关的活动，日常护理的提供被减少或完全中断。在16个保健中心中，只有2个拥有合格、稳定和积极的工作人员，能够维持日常服务，并利用该运动作为提高质量的机会。增加的工作量由津贴补偿，津贴大大提高了工作人员的收入，但也分散了对核心日常活动的注意力。虽然该运动在国家一级增加了非传染性疾病药物的可得性，但平行的药物供应和评价系统需要额外的努力，给地方卫生系统带来负担。竞选预算几乎没有资助机构的加强。最后，尽管该倡议至少部分依赖于国家结构，但吸收捐赠药物和实现短期覆盖结果的压力，分散了人们对其他优先事项的注意力，包括全面加强卫生系统。结论：我们的研究表明，在健全的卫生服务和系统中，针对特定疾病的干预措施和非针对性卫生服务之间的积极协同作用更有可能发生。在脆弱的卫生服务中作为平行活动实施针对特定疾病的干预措施，可能进一步削弱其对社区需求的响应能力，特别是在几个全球卫生服务同时运作的情况下。加强卫生系统不是通过选择性的全球干预措施的总和来实现的，而是需要一种全面的方法。
Background: Recently, a number of Global Health Initiatives (GHI) have been created to address single disease issues in low-income countries, such as poliomyelitis, trachoma, neonatal tetanus, etc.. Empirical evidence on the effects of such GHIs on local health systems remains scarce. This paper explores positive and negative effects of the Integrated Neglected Tropical Disease (NTD) Control Initiative, consisting in mass preventive chemotherapy for five targeted NTDs, on Mali's health system where it was first implemented in 2007.Methods and Findings: Campaign processes and interactions with the health system were assessed through participant observation in two rural districts (8 health centres each). Information was complemented by interviews with key informants, website search and literature review. Preliminary results were validated during feedback sessions with Malian authorities from national, regional and district levels. We present positive and negative effects of the NTD campaign on the health system using the WHO framework of analysis based on six interrelated elements: health service delivery, health workforce, health information system, drug procurement system, financing and governance. At point of delivery, campaign-related workload severely interfered with routine care delivery which was cut down or totally interrupted during the campaign, as nurses were absent from their health centre for campaign-related activities. Only 2 of the 16 health centres, characterized by a qualified, stable and motivated workforce, were able to keep routine services running and to use the campaign as an opportunity for quality improvement. Increased workload was compensated by allowances, which significantly improved staff income, but also contributed to divert attention away from core routine activities. While the campaign increased the availability of NTD drugs at country level, parallel systems for drug supply and evaluation requested extra efforts burdening local health systems. The campaign budget barely financed institutional strengthening. Finally, though the initiative rested at least partially on national structures, pressures to absorb donated drugs and reach short-term coverage results contributed to distract energies away from other priorities, including overall health systems strengthening.Conclusions: Our study indicates that positive synergies between disease specific interventions and nontargeted health services are more likely to occur in robust health services and systems. Disease-specific interventions implemented as parallel activities in fragile health services may further weaken their responsiveness to community needs, especially when several GHIs operate simultaneously. Health system strengthening will not result from the sum of selective global interventions but requires a comprehensive approach.