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Global Health Initiatives (GHIs) have ushered in revolutionary changes in the international public health architecture, providing clinical services that would have been unthought of a decade ago. But, the news is not all good. The more GHIs try to do, the clearer it becomes how much their work is constrained by endemic weaknesses within the health systems of most developing countries. Worse still, these fragile systems can be damaged by the distorting effects of GHIs attempting to work through and sometimes around them. The solution is to seek greater “positive synergies” between the objectives of GHIs and the objectives of Health System Development (HSD). Indeed, no challenge is more central to the lives of disadvantaged people around the world than the challenge of constructing a new science of HSD, in real time, as GHIs continue to design and implement more effective public health programming. In relatively short order, the World Health Organization's (WHO) Positive Synergies Campaign (PSC) has elevated the issue of HSD and its relationship to GHIs to the top of the global health agenda. PSC has further forged a political strategy and has begun to outline an intellectual framework that should lead to a better understanding of what future steps should be taken. This article gives the reader a comprehensive understanding of the current quest for positive synergies, as well as the numerous difficulties such efforts face. In examining the relationship between GHIs and HSD, we have settled on five interrelated challenges: political challenges, theoretical challenges, administrative challenges, community challenges and historical challenges. Part II (Political Challenges) places the story of the WHO PSC at center stage, highlighting its effort to create the political space necessary for effective international cooperation. Part III (Theoretical Challenges) explores efforts to address the question of what health systems are and how one might develop a conceptual framework that could forge better synergies between GHIs and HSD. Limitations in existing theoretical understandings place serious constraints on future planning and action. Part IV (Administrative Challenges) provides a case study of the difficulties the Global Fund has encountered in attempting to implement policies that pursue its own objectives, while trying to be sensitive to the needs of HSD. The Global Fund got off to a slow and unsuccessful start, and is only now beginning to make meaningful progress on the HSD front. Part V (Community Challenges) considers where civil society and efforts at Community System Strengthening (CSS) fit within HDS. Part VI (Historical Challenges) ends with a cautionary tale of the primary health care movement, which serves as a counterpoint to Part II’s optimistic assessment of PSC. The 1970s was another era of ambition and optimism at the WHO, accompanied by a similar awareness of the need to seek new answers to old questions. These efforts faltered, as underdeveloped notions of primary health care became enshrined in the 1978 Declaration of Alma-Ata. The pre-history of Alma-Ata illustrates how these types of process-oriented policy initiatives are inherently difficult to sustain.

Global Health Initiatives and Health System Development: The Historic Quest for Positive Synergies