Public Health Department, Institute of Tropical Medicine, Antwerp, Belgium.
PLoS Negl Trop Dis. 2010 Aug 17;4(8):e798. doi: 10.1371/journal.pntd.0000798.
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.
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.
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.
最近，为了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，创建了多个全球卫生倡议 (GHI)。关于此类 GHIs 对当地卫生系统影响的实证证据仍然很少。本文探讨了 2007 年首次在马里实施的综合被忽视的热带病 (NTD) 控制倡议的积极和消极影响，该倡议包括针对五种目标 NTD 的大规模预防性化疗。
通过在两个农村地区（每个地区 8 个卫生中心）的参与式观察评估了运动进程及其与卫生系统的相互作用。通过与国家、地区和地区各级的马里当局进行反馈会议，对信息进行了补充。采访了主要信息提供者、网站搜索和文献综述。初步结果在与马里当局的反馈会议中得到了验证。我们使用世界卫生组织基于六个相互关联的要素的分析框架来展示 NTD 运动对卫生系统的积极和消极影响：卫生服务提供、卫生人力、卫生信息系统、药物采购系统、融资和治理。在服务提供点，与运动相关的工作量严重干扰了常规护理的提供，在运动期间，护士因与运动相关的活动而不在其卫生中心，常规护理被削减或完全中断。只有 16 个卫生中心中的 2 个，其特点是拥有合格、稳定和有动力的劳动力，能够维持常规服务的运行，并将运动作为提高质量的机会。增加的工作量通过津贴得到补偿，这大大提高了工作人员的收入，但也导致他们的注意力从核心常规活动上转移开。虽然运动增加了国家一级 NTD 药物的可获得性，但并行的药物供应和评估系统需要额外的努力，给当地卫生系统带来负担。运动预算几乎没有为机构加强提供资金。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导致精力从其他优先事项上分散，包括整体卫生系统的加强。
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与非目标卫生服务之间更有可能产生积极的协同作用。在脆弱的卫生服务中作为并行活动实施的针对特定疾病的干预措施可能会进一步削弱其对社区需求的响应能力，特别是当同时开展多个 GHIs 时。卫生系统的加强不会来自于有选择的全球干预措施的总和，而是需要采取全面的方法。
