Understanding the dynamic effects of disease-focused global health aid on health systems

摘要

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.