The Best Buys in Global Health: Striking the Effective Balance

To have real and lasting impact, we must step back from the intervention level of analysis to understand how we can mold entire ecosystems to better serve the health of broad populations.
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In this issue of PSI's Impact magazine, Devex, Merck for Mothers and PATH joined my organization PSI and a team of experts to uncover some of global health's best investments. This post appears as the magazine's "Final Word."

A 'best buy' in global health is an idea that can easily lead us to focus on a single intervention, a silver bullet in the fight to improve health outcomes around the world. And clearly, there are some notable interventions that truly do represent huge impact per dollar invested in terms of lives saved. Take an insecticide-treated net -- an effective tool to prevent malaria, but made exponentially more effective when delivered nationwide in a short period of time.

Innovation in both the development of new technologies and better delivery methods is critical. But here's where it gets more complex: An intervention must be designed from the perspective of the health consumer, and it must be affordable and have an effective delivery system. There must be political will and the right policies must be in place. And yes, there must be adequate and flexible funding available. To achieve this, we're tasked with being good advocates, fundraisers, inventors and systems thinkers.

To have real and lasting impact, we must step back from the intervention level of analysis to understand how we can mold entire ecosystems to better serve the health of broad populations. Sometimes this is called 'health systems strengthening', and sometimes it might be seen under the even broader rubric of 'capacity building'.

No matter how we describe the work, it presents challenges for the aid and development sector, from three basic perspectives:

1. Attribution of Impact

The people charged with appropriating public funds to address global health challenges often expect investments to be calibrated in terms of lives saved. Money in, life out. It's appealing and sometimes it's even necessary to avoid wastage. But building a national health system with all its component parts -- public sector, private sector, faith-based sector, NGOs -- is a long-term and multifaceted exercise and much harder to measure. It's definitely not linear. How do we attribute impact and sustain support for investments in strengthening health systems?

2. External Factors

We may spearhead the best and most impactful investment in building national capacity to deliver better health outcomes, but it's in South Sudan. Or the Central African Republic. Or Syria. Huge 'systems' investments can be lost in a heartbeat. Will we regret not having focused on simply saving lives through more direct means when national systems are upended by factors that can't be foreseen and if the approach is unbalanced?

3. Narrow Definitions

Too often, 'systems strengthening' is synonymous with building the capacity of only one part of a complex system. For example, how effective is it to strengthen the capacity of the public sector to deliver health care and services to the underserved in a particular country, when those same people get a disproportionate share of their care from a mediocre and often unregulated private sector? A 'systems' lens requires comprehensive thinking, planning, budgeting and execution that often elude even the most well-meaning donors, implementers and policy makers in development.

The challenges of attribution, external factors and narrow definitions mean we must be humble and cautious when deciding to embrace a systems-wide approach to solving complex development challenges. We know that a holistic approach can be better, more lasting, more comprehensive -- and also often much, much harder. We also know that direct interventions to save and improve lives make attribution easier and often are the key to sustaining political support for what we are trying to do. The question becomes one of balance, or we may be forever treating rather than preventing the problem at hand.

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