Several barriers challenge development, adoption and scale-up of diagnostics in low and middle income countries. An innovative global health discussion platform allows capturing insights from the global health community on factors driving demand and supply for diagnostics. We conducted a qualitative content analysis of the online discussion ‘Advancing Care Delivery: Driving Demand and Supply of Diagnostics’ organised by the Global Health Delivery Project (GHD) (http://www.ghdonline.org/) at Harvard University. The discussion, driven by 12 expert panellists, explored what must be done to develop delivery systems, business models, new technologies, interoperability standards, and governance mechanisms to ensure that patients receive the right diagnostic at the right time. The GHD Online (GHDonline) platform reaches over 19 000 members from 185 countries. Participants (N=99) in the diagnostics discussion included academics, non-governmental organisations, manufacturers, policymakers, and physicians. Data was coded and overarching categories analysed using qualitative data analysis software. Participants considered technical characteristics of diagnostics as smaller barriers to effective use of diagnostics compared with operational and health system challenges, such as logistics, poor fit with user needs, cost, workforce, infrastructure, access, weak regulation and political commitment. Suggested solutions included: health system strengthening with patient-centred delivery; strengthened innovation processes; improved knowledge base; harmonised guidelines and evaluation; supply chain innovations; and mechanisms for ensuring quality and capacity. Engaging and connecting different actors involved with diagnostic development and use is paramount for improving diagnostics. While the discussion participants were not representative of all actors involved, the platform enabled a discussion between globally acknowledged experts and physicians working in different countries.

Implementation lessons

• Technology alone does not necessarily lead to improvement in health service delivery, in contrast to the common assumption that advanced technology goes hand in hand with progress.
• Implementation of electronic medical record (EMR) systems is a complex, resource-intensive process that, in addition to software, hardware, and human resource investments, requires careful planning, change management skills, adaptability, and continuous engagement of stakeholders.
• Research requirements and goals must be balanced with service delivery needs when determining how much information is essential to collect and who should be interfacing with the EMR system.
• EMR systems require ongoing monitoring and regular updates to ensure they are responsive to evolving clinical use cases and research questions.
• High-quality data and analyses are essential for EMRs to deliver value to providers, researchers, and patients.

Since 2008, GHDonline.org has provided a platform of professional virtual communities (PVCs) for health care implementers around the world to connect and discuss delivery challenges. Initially focused on low-resource settings internationally, GHDonline received funding from the Agency for Healthcare Research and Quality (AHRQ) in 2013 to expand the platform and launch the US Communities Initiative (USCI), PVCs for US-based health care professionals working with underserved populations.

Since 2007, GHDonline.org hosts a platform of professional virtual communities (PVCs) for thousands of health care implementers around the world to connect, share, and discuss delivery challenges, focusing primarily on low-resource settings. In 2013, we expanded the platform for US-based health care professionals working with underserved populations. We aim to reach a geographically diverse group of 10,000 US health care professionals and increase their understanding and use of evidence-based resources.

Implementation lessons

• Generating demand is an important part of the care delivery value chain. When new health interventions are designed based on recent clinical trial findings, demand generation activities prove all the more critical.
• Demand generation activities need to iterate on their design, and tailor to the risk profile of target populations.
• Leaders need to balance fidelity to a model and local innovation.
• Cultural and contextual factors must be considered in designing public health campaigns.

Initiatives to address the unmet needs of those facing both poverty and serious illness have expanded significantly over the past decade. But many of them are designed in an ad-hoc manner to address one health problem among many; they are too rarely assessed; best practices spread slowly. When assessments of delivery do occur, they are often narrow studies of the cost-effectiveness of a single intervention rather than the complex set of them required to deliver value to patients and their families. We propose a framework for global health-care delivery and evaluation by considering efforts to introduce HIV/AIDS care to resource-poor settings. The framework introduces the notion of care delivery value chains that apply a systems-level analysis to the complex processes and interventions that must occur, across a health-care system and over time, to deliver high-value care for patients with HIV/AIDS and cooccurring conditions, from tuberculosis to malnutrition. To deliver value, vertical or stand-alone projects must be integrated into shared delivery infrastructure so that personnel and facilities are used wisely and economies of scale reaped. Two other integrative processes are necessary for delivering and assessing value in global health: one is the alignment of delivery with local context by incorporating knowledge of both barriers to good outcomes (from poor nutrition to a lack of water and sanitation) and broader social and economic determinants of health and wellbeing (jobs, housing, physical infrastructure). The second is the use of effective investments in care delivery to promote equitable economic development, especially for those struggling against poverty and high burdens of disease. We close by reporting our own shared experience of seeking to move towards a science of delivery by harnessing research and training to understand and improve care delivery.

Investments in global health have more than doubled over the past decade, generating a cadre of new institutions. To date, most of the funded research in global health has focused on discovery, and, more recently, on the development of new tools, which has tightened the implementation bottleneck. This article introduces the concept of global health delivery and the need to catalog and analyze current implementation efforts to bridge gaps in delivery. Global health delivery is complex and context-dependent and requires an interdisciplinary effort, including the application of strategic principles. Furthermore, delivery is necessary to ensure that the investments in research, discovery, and development generate value for patients and populations. This article discusses the application of value-based delivery to global health. It provides some examples of approaches to aggregating implicit knowledge to inform practice. With global health delivery, the aim is to transform global health scale-up from a series of well-intentioned but often disconnected efforts to a value-based movement based upon 21st-century technology, standards, and efficiency.

To make best use of the new dollars available for the treatment of disease in resource-poor settings, global health practice requires a strategic approach that emphasises value for patients. Practitioners and global health academics should seek to identify and elaborate the set of factors that drives value for patients through the detailed study of actual care delivery organisations in multiple settings. Several frameworks can facilitate this study, including the care delivery value chain. We report on our efforts to catalyse the study of health care delivery in resource-limited settings in the hope that this inquiry will lead to insights that can improve the health of the neediest worldwide.

Since 2000, the emergence of several large disease-specific global health initiatives (GHIs) has changed the way in which international donors provide assistance for public health. Some critics have claimed that these initiatives burden health systems that are already fragile in countries with few resources, whereas others have asserted that weak health systems prevent progress in meeting disease-specific targets. So far, most of the evidence for this debate has been provided by speculation and anecdotes. We use a review and analysis of existing data, and 15 new studies that were submitted to WHO for the purpose of writing this Report to describe the complex nature of the interplay between country health systems and GHIs. We suggest that this Report provides the most detailed compilation of published and emerging evidence so far, and provides a basis for identification of the ways in which GHIs and health systems can interact to mutually reinforce their effects. On the basis of the findings, we make some general recommendations and identify a series of action points for international partners, governments, and other stakeholders that will help ensure that investments in GHIs and country health systems can fulfil their potential to produce comprehensive and lasting results in disease-specific work, and advance the general public health agenda. The target date for achievement of the health-related Millennium Development Goals is drawing close, and the economic downturn threatens to undermine the improvements in health outcomes that have been achieved in the past few years. If adjustments to the interactions between GHIs and country health systems will improve efficiency, equity, value for money, and outcomes in global public health, then these opportunities should not be missed.

In recent years interest in medical practice in poor settings has grown considerably. This growth has been fuelled by recognition of health disparities between poor and rich countries and the allocation of new money for global health. Between 1999 and 2005 $40.6bn (£20.7bn; €26.6bn) in new funding was committed to global health.

Medical schools and junior doctors' programmes have responded by establishing clinical rotations in poor settings. Although experience in poor settings is important to educate students about global health, the challenges of providing health care in poor settings require practitioners to learn to think systematically about the delivery of health care. Doctors need to be trained to consider the strategic, organisational, and structural problems involved in delivery of care. The global health practitioner must at once be an astute clinician and an effective manager.

An effective comprehensive response to health system strengthening in crisis-affected fragile states demands coherent action by all participating actors. Coordinating the desired outcomes and the actions of the humanitarian, development, and security communities required to meet them is a particularly complex challenge.

A team from NATO's Joint Analysis and Lessons Learned Centre and Harvard Medical School is engaged in a project whose overarching aim is to infer elements of a strategic framework for health system strengthening in crisis-affected fragile states, focusing on the optimal use of all global contributions. The approach adopted by the team to meet this aim relies predominantly on research using four case studies (Haiti, Kosovo, Afghanistan, and Libya). This report details the results of the Kosovo case study.

A team from NATO's Joint Analysis and Lessons Learned Centre and Harvard Medical School engaged in a project with the overarching aim to infer elements of a strategic framework for health system strengthening in crisis-affected fragile states focusing on optimal use of all global contributions. The approach adopted by the team to meet this aim relies predominantly on research using four case studies.

This report documents the results of the Libya case study. Libya’s health system was threatened by an 8-month civil war during which the international military community intervened under a UN mandate to protect civilians. During and after the conflict, the international community contributed to strengthening the Libyan health system. However, the difference between this case study and the other three case studies supporting this project—Haiti, Kosovo, and Afghanistan—is that no multinational military force with a peacekeeping/building or stabilization mandate was present during the international community’s military intervention, and the present UN support mission does not include any international military force.

Four key issues were investigated during this study: the impact of the conflict on Libya’s health system; security community participation in health system recovery and reconstruction; the coordination mechanisms that facilitated or directed the security community’s involvement; and the information generating and sharing mechanisms that allowed the security community to best participate in health system strengthening. Investigations were focussed through the use of two narratives given in the Annexes to this report. 

Effective comprehensive response to health system strengthening in a crisis-affected fragile state demands coherent action by all participating actors. Coordinating the desired outcomes and the required actions of the humanitarian, development and security communities presents a particularly complex challenge.

A joint team from NATO's Joint Analysis and Lessons Learned Centre and the Harvard Medical School is engaged in a project with the overarching aim of inferring elements of a strategic framework for health system strengthening in crisis-affected fragile states: one which focuses on the optimal use of all global contributions. The team decided to use four case studies of international interventions in crisis-affected fragile states as the primary foci for their research.

As a record of the second case study, this working paper documents the results from investigation in Afghanistan, a country that is experiencing the cumulative effects of over three decades of war and instability. Since 2001, the international community has contributed billions of dollars and much human effort towards stabilizing and rebuilding Afghanistan, including the health system. The NATO-led International Security Assistance Force (ISAF) has supported the government of Afghanistan in multiple ways in their attempt to re-establish viable health systems in both the military and civilian sectors.

Four key issues were investigated during this study: the impact of the crisis on the Afghan health system; the security community’s participation in health system recovery and reconstruction; the coordination mechanisms that facilitated or directed the security community's involvement; and the information generating and sharing mechanisms that allowed the security community to best participate in health system strengthening. Investigations were further focussed through the use of three narratives, which are given in the Annexes to this report. 

The past decade has seen major advances in global public health, enabled by unprecedented levels of new financing, particularly for HIV services. This mobilization accelerated the scaling up of treatment and prevention interventions. Successes in scaling up and funding challenges have raised new questions. Policymakers, practitioners and communities want to know how programs that grew rapidly can be sustained and program achievements replicated in other settings. These questions take on increased urgency as programs and donors consider the transfer of large HIV programs to the public sector.

In October 2009, the Bill & Melinda Gates Foundation granted Dr. Rebecca Weintraub and the Global Health Delivery (GHD) Project support to study the relationship between scale, value and strategy for HIV prevention. This document summarizes GHD’s research and early findings presented to a group of 50 experts for their input on July 15, 2010 in Vienna, Austria and Boston. During the peer review session, GHD sought feedback and promoted knowledge exchange around programs, policies and investments focused on sustaining scaled HIV prevention programs. The meeting had three objectives:

1. Test and refine strategic tools to guide delivery of large-scale HIV prevention programs.
2. Generate a list of activities and capabilities enabling programs to sustain delivery at scale.
3. Discuss how a strategic framework for sustaining delivery of HIV prevention at scale could inform decision making by global health leaders and researchers. 

Over the last decade, Global Health Initiatives (GHIs) have mobilized substantial new resources for health action in many low- and middle-income countries. The expansion of key services, particularly the provision of HIV/AIDS treatment, has been striking, and millions of people have benefited. But the scale-up of selected services by GHIs has placed new demands on national health systems, revealed weaknesses in those systems, and rekindled debates on how countries can best combine disease-specific programmes with broader agendas to improve the health of their people. 

Background: International funding for HIV care has increased in the last five years due to new Global Health Initiatives (GHI) such as the Global Fund to fight AIDS, TB and Malaria (GFATM) and the United States President's Emergency Fund for AIDS Relief (PEPFAR) Though these GHI are targeted to specific disease entities, increasing attention is being paid to the impact that such initiatives have on the health system as a whole. Our objective was to evaluate the impact of GFATM and PEPFAR on the health system in Haiti since their introductions in 2003 and 2004 respectively. 

Methods: We used mixed qualitative and quantitative methods, including semi-structured interviews, observation, examination of documentary material, and collection of quantitative data. Twelve key informants from nongovernmental organizations (NGOs), international organizations and the Ministry of Health (MOH) participated in semi-structured interviews. We used NVivo8 software to analyze the transcripts. Quantitative data from 1998-2008 from five representative health facilities triangulated the qualitative findings.

Results: Preliminary analysis demonstrates a complex interaction between GFATM/PEPFAR and Haiti's health system as a whole. GFATM /PEPFAR were largely associated with strengthening of the health system, particularly in geographic areas and in programs where NGO leaders and/or MOH officials specifically designed and coordinated their interventions to have such an impact. Where deliberate planning and coordination did not exist, the GHIs had a more 'vertical' effect, impacting primarily the targeted diseases. GFATM/PEPFAR were associated with overall improvement in human resources capacity and retention, but the influx of funding did cause some tensions due to salary inequities. GFATM/PEPFAR funds were not received directly by the government of Haiti, and this empowered NGOs to work independently of the MOH. 

Conclusions: Targeted GHI such as GFATM and PEPFAR can successfully strengthen health systems if this objective is included in planning and design and if leadership and coordination are ensured. 

Health care providers in resource-limited settings around the world have a wealth of practical knowledge but often work in isolation, with little opportunity to learn from the experiences of colleagues or share their own best practices. To address this problem, the Global Health Delivery Project (GHD) has launched GHDonline, a webbased tool designed to provide timely assistance to and forge substantive connections among global health practitioners and experts worldwide. GHDonline currently hosts four communities of practice, one of which is Adherence & Retention, where implementers and practitioners discuss strategies and methods for tracking and improving adherence to HIV/AIDS treatment and retention within HIV/AIDS programs. The community is moderated by three HIV/AIDS experts, and its members include but are not limited to physicians, program managers, researchers, nurses, public health and MOH officials, educators, community health workers, and adherence specialists.

Less than six months since its launch, the Adherence & Retention community has already facilitated the exchange of a variety of different kinds of resources and information - from advice on how to expand a CHW program in Lesotho to guidelines for measuring LTFU while controlling for differences between treatment access, adherence, and failure. These kinds of conversations that take place among implementers and experts daily, but by hosting them in a public space, GHDonline captures and preserves this information so that others can access and build on this knowledge, learning from the successes and failures of colleagues with whom they might not otherwise have had the occasion to connect. Moving forward, the GHDonline Adherence & Retention community will aim to engage more implementers who are working in extremely resource-limited settings to gauge: a) usability of the site in areas with limited internet connectivity, and b) uptake and active use of the site by individuals working in these settings.