By the early 1990s, the aggressive war against malaria that had been fought so tenaciously by the global health community for more than three decades had morphed into something more like trench warfare.
The eradication goals set so confidently by the United Nation’s World Health Organization in the mid-1950s had not been reached, and every year the disease, which humans had been fighting in one way or another for millennia, was still responsible for more than a million deaths — mostly of young children in sub-Saharan Africa, and more than 350 million cases worldwide.
But then things began to change. Investments were made in knowledge sharing and the training of researchers in African countries. WHO recognized its inability to fight the disease without partners in both the public and private spheres and was joined by other international organizations, national health and development bodies, foundations, NGOs, and the private sector. With the support of major foundations, private-public development partnerships began to focus on the research and development of new drugs (a process that market forces had failed to drive). In 2002, the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) was founded to provide funding to combat those diseases, premised on the idea that success could come only through the orchestrated efforts of multiple actors at the global, national, and private level.
Malaria continues to kill, but the new approach has enjoyed great successes, including the creation and distribution of new drugs. In fact, the fight against malaria can now be seen as a model of what the global health system of the future could look like, says Professor William Clark of Harvard Kennedy School.
A team of experts, led by Clark together with HKS doctoral students Suerie Moon and Nicole Szlezák, and involving leaders from both Harvard’s and Boston University’s Schools of Public Health, explored the changing nature of global health institutions through the Institutional Innovations in Global Health project. (Their findings were debated at an international workshop and reported in a series of four papers published in January 2010 in Public Library of Science Medicine.) What was once a relatively simple system involving the WHO and its member countries has evolved into a complicated web of public and private actors (see figure below).
“The rise of multiple new actors in the system creates challenges for coordination but, more fundamentally, raises tightly linked questions about the roles various organizations should play, the rules by which they play, and who sets those rules,” the authors write.
The evolution of institutions comes as the nature of diseases being fought changes (non-communicable diseases such as cardiovascular disease and diabetes are on the rise) and as the environment is made even more unpredictable by globalization and climate change.
Among their recommendations, the authors call for new partnerships for setting an agenda for action, in which no single actor should dominate. They urge a strengthening of national health systems, which they describe as connecting global knowledge and best practices with local health needs. And they call for streamlining reporting requirements, among other things, to reduce the burdens placed on national health systems by the proliferation of global actors. — by Robert O'Neill