Selective Health Care Research Articles

Peanut anaphylaxis in 2022: Decoupling epinephrine usage from emergency department evaluation

Peanut anaphylaxis in 2022: Decoupling epinephrine usage from emergency department evaluation

The effect of influenza and pneumococcal vaccination in the elderly on health service utilisation and costs: a claims data-based cohort study

BackgroundTo date, cost-effectiveness of influenza and pneumococcal vaccinations was assumed in several health economic modelling studies, but confirmation by real-world data is sparse. The aim of this study is to assess the effects on health care utilisation and costs in the elderly using real-world data on both, outpatient and inpatient care.MethodsRetrospective community-based cohort study with 138,877 individuals aged ≥ 60 years, insured in a large health insurance fund in Thuringia (Germany). We assessed health care utilisation and costs due to influenza- or pneumococcal-associated diseases, respiratory infections, and sepsis in 2015 and 2016. Individuals were classified into four groups according to their vaccination status from 2008 to 2016 (none, both, or either only influenza or pneumococcal vaccination). Inverse probability weighting based on 236 pre-treatment covariates was used to adjust for potential indication and healthy vaccinee bias.ResultsInfluenza vaccination appeared as cost-saving in 2016, with lower disease-related health care costs of − €178.87 [95% CI − €240.03;− €117.17] per individual (2015: − €50.02 [95% CI − €115.48;€15.44]). Cost-savings mainly resulted from hospital inpatient care, whereas higher costs occurred for outpatient care. Overall cost savings of pneumococcal vaccination were not statistically significant in both years, but disease-related outpatient care costs were lower in pneumococci-vaccinated individuals in 2015 [− €9.43; 95% CI − €17.56;− €1.30] and 2016 [− €12.93; 95% CI − €25.37;− €0.48]. Although we used complex adjustment, residual bias cannot be completely ruled out.ConclusionInfluenza and pneumococcal vaccination in the elderly can be cost-saving in selective seasons and health care divisions. As cost effects vary, interpretation of findings is partly challenging.

Disease in a Debt Crisis: Financing Global Health, Development and AIDS between WHO and World Bank, 1978–87

This article examines how international organisations with mandates in health and development interpret global economic crises and respond to disease. It contributes the perspective of World Bank to emerging scholarship on the various factors leading to the decline of the World Health Organization (WHO) and its Health for All (HFA) mission during structural adjustment. It does so by telling a story of collaboration and conflict between WHO and World Bank’s Population, Health and Nutrition (PHN) Department following the ambitious Alma Ata Declaration in 1978 until the initial global AIDS response. As debt crises emerged in Latin America in the early 1980s, WHO tried to find a way forward for HFA. However, the African crisis of 1985 fractured the international community’s support, causing WHO and PHN to dialogue more closely regarding health sector financing. As AIDS became a global crisis, this culminated in their 1987 joint research on the disease’s macroeconomic and demographic impact. However, observing WHO’s continued hesitance regarding financing and its decision to act as a donor gatekeeper, the Bank ultimately opted to work separately in AIDS. Thus, the themes of the Alma Ata versus Selective Primary Health Care debate of the late 1970s continued throughout the 1980s into the early years of the global AIDS response: a perennial conflict of financing within resource constraints and the appropriate role of donors in the grand project of health and development.

PREVENTIVE HEALTH CARE IN RELATION TO HEALTH INSURANCE SYSTEM IN SLOVAKIA

Introduction: Preventive measures in a field of health care are cheaper than addressing the consequences of neglected diagnosis and treatment. Aim of this study is to present the Slovak legislation and national plans in the field of preventive health care. This issue is discussed in relation to financing of health care from the health insurance.
 Methods: This study was conducted by using the method of content analysis of selected legislative and non-legislative documents and statistical reports of the Slovak ministries (finance, health) and of health insurance companies.
 Results: In Slovakia, universal and selective preventive health care is available for health care payers. Number of people who undergo the preventive examination differs in selected areas and the expenditure on medical treatment and addressing the consequences of neglected prevention are still high. Control plans are vague and do not cover concrete steps leading to achievement of goals presented. Access of marginalized groups of population to the preventive health care is still at very low level.
 Conclusion: The system of preventive health care measures in Slovakia is relatively well-defined in legislation and supports the provision of preventive care. However, it is not enforced. There are no serious sanctions in case of neglecting patient´s obligations and people are not motivated to undergo preventive examinations. Only sanctions that in some cases work are financial. The detailed research of access of people from socially disadvantaged environment to the preventive care is desirable.

Back to the future with PACK

On 25 October 2018, the world’s governments convene again at Astana on the 40 anniversary of the Declaration of Alma-Ata. The draft Declaration for this Second International Conference on Primary...

Kenneth Warren and the Great Neglected Diseases of Mankind Programme: The Transformation of Geographical Medicine in the US and Beyond by Conrad Keating

Reviewed by: Kenneth Warren and the Great Neglected Diseases of Mankind Programme: The Transformation of Geographical Medicine in the US and Beyond by Conrad Keating George Weisz Conrad Keating. Kenneth Warren and the Great Neglected Diseases of Mankind Programme: The Transformation of Geographical Medicine in the US and Beyond. Cham, Switzerland: Springer International, 2017. xx + 150 pp. Ill. $29.00 (978-3-319-50145-1). Kenneth Warren is a largely forgotten name in global health (GH) circles. But during the 1970s and 1980s, he was a force to be reckoned with. A researcher of some note in the field of parasitology, he was appointed in 1978 as director of health sciences at the Rockefeller Foundation, marking that institution's return, after several decades absence, to intense activity and significant influence in international Health. Under his tutelage, two major programs were introduced. The Great Neglected Diseases of Mankind Program (GND) in 1977, conceived of and led by Warren himself, sought to stimulate sophisticated biomedical molecular research on diseases of the Global South. The program offered ten years of guaranteed funding for handpicked scientists in various fields to work on parasitic and other mainly tropical diseases, with required annual meetings of the entire network. The scientific results were impressive, according to some path-breaking, although critics claimed that Warren took credit for discoveries that had been mainly financed by other agencies, with only minimal contributions from GND. Meanwhile, his deputy, Kerr White, a pioneer of Health Services Research at Johns Hopkins University, set up the International Clinical Epidemiology Network, or INCLEN, to create and strengthen in medical schools training programs providing physicians with the expertise—first in epidemiology, and later also in health economic and social sciences—needed to manage scarce health resources in developing countries. Outside the tropical disease research community, Warren is best remembered as co-author of an influential article offering an alternative to the flagship program of the World Health Organization. Under the direction of its charismatic director general, Halfdan Mahler, the organization developed a proposal for Primary Health Care (PHC) famously endorsed in the Alma Ata Declaration of 1978. This was an ambitious vision for bringing the essential conditions for good health—from sanitation and food supply to family planning and the treatment of common ailments—to even the poorest, of the world's populations. Soon after, Warren and Julia Walsh presented and then published a paper arguing that PHC, as formulated in Alma Ata, was not feasible "in an age of diminishing resources." They proposed an "interim" strategy, Selective Primary Health Care' (SPHC), for identifying a few priority measures on the basis of their low cost and high impact on widespread causes of morbidity and mortality. Although this strategy was taken up by several international donors, notably UNICEF, Warren and his supporters increasingly focused less on specific measures and more on methods of determining both priorities for research and action and the most effective and least expensive solutions to a large variety of health problems. Both judgments were best made through use of metrics. There is a direct link between SPHC and [End Page 402] the World Bank's World Development Report of 1993, widely considered the most influential GH text of the 1990s. Keating's book is a curious hybrid. On one hand it has been funded by a foundation headed by Anthony Cerami, Warren's close friend and colleague. It is clearly meant to re-establish Warren's reputation as a pioneering figure. On the other, it is very professionally done. Keating is Writer-Residence at the Wellcome Unit for the History of Medicine at Oxford University and author of a previous biography of Sir Richard Doll. The result is a book that is heavy on personal recollections of colleagues and friends, with lots of photos, many repetitious but a few quite priceless. (I think especially of the one of Warren in intense conversation with Halfdan Mahler on p.69.) There is much excessive detail based on these recollections. Few readers will care that his wife was an excellent gardener. On the other hand, there is the occasional witty and perceptive image; his friend and colleague Michael Sela said of him that "he was...

What is the difference between comprehensive and selective primary health care? Evidence from a five-year longitudinal realist case study in South Australia

BackgroundSince the WHO’s Alma Ata Declaration on Primary Health Care (PHC) there has been debate about the advisability of adopting comprehensive or selective PHC. Proponents of the latter argue that...

Políticas del sector salud mexicano (1980-2004): ajuste estructural y pragmatismo de las propuestas neoliberales

In this paper we describe and analyze health policies impelled in Mexico during 1980-2004 (decentralization, health expenses reduction, selective primary health care, health services privatization) by neoliberal sectors. We describe the trajectory of these policies in a context characterized by poverty increase and socioeconomic inequalities. This analysis shows that these policies are characterized by their strong continuity, their adaptability, and in paticular their social, ideological and political pragmatism. The latter is evident in the use and appropriation by neoliberal functionaries and executives of concepts and proposals developed by medical and social critical approaches.

Primary health care reform, dilemmatic space and risk of burnout among health workers.

Health system changes may increase primary health care workers' dilemmatic space, created when reforms contravene professional values. Dilemmatic space may be a risk factor for burnout. This study partnered with six Australian primary health care services (in South Australia: four state government-managed services including one Aboriginal health team and one non-government organisation and in Northern Territory: one Aboriginal community-controlled service) during a period of change and examined workers' dilemmatic space and incidence of burnout. Dilemmatic space and burnout were assessed in a survey of 130 staff across the six services (58% response rate). Additionally, 63 interviews were conducted with practitioners, managers, regional executives and health department staff. Dilemmatic space occurred across all services and was associated with higher rates of self-reported burnout. Three conditions associated with dilemmatic space were (1) conditions inherent in comprehensive primary health care, (2) stemming from service provision for Aboriginal and Torres Strait Islander peoples and (3) changes wrought by reorientation to selective primary health care in South Australia. Responses to dilemmatic space included ignoring directives or doing work 'under the radar', undertaking alternative work congruent with primary health care values outside of hours, or leaving the organisation. The findings show that comprehensive primary health care was contested and political. Future health reform processes would benefit from considering alignment of changes with staff values to reduce negative effects of the reform and safeguard worker wellbeing.

Ambiguous Capture: Collaborative Capitalism and the Meningitis Vaccine Project

ABSTRACTThe primary health care approach advanced at Alma Ata to address social determinants of health was replaced by selective health care a year later at Bellagio. Subsequently, immunization was endorsed as a cost-effective technical intervention to combat targeted infectious diseases. Multilateral efforts to collaborate on immunization as a universal public health good ambiguously capture the interests of the world’s governments as well as private, public, and not-for-profit institutions. Global assemblages of scientists, governments, industry and nongovernmental organizations now work in public-private partnerships to develop and make essential vaccines accessible, with vaccines marketed as single fix solutions for global health. Drawing from ethnographic fieldwork in France and Burkina Faso that followed the development, regulation, and implementation of the group A meningococcal conjugate vaccine for sub-Saharan Africa, in this article I describe events during and after the development of MenAfriVac. A technological success narrative steeped in collaborative capitalist rhetoric disguises neglected health care systems.

Review of Selective Primary Health Care Efforts in an Urban Health Center Area in Guntur City of Andhra Pradesh

Review of Selective Primary Health Care Efforts in an Urban Health Center Area in Guntur City of Andhra Pradesh

Assessment of an innovative antimicrobial surface disinfectant in the operating room environment using adenosine triphosphate bioluminescence assay

Terminal cleaning in the operating room is a critical step in preventing the transmission of health care-associated pathogens. The persistent disinfectant activity of a novel isopropyl alcohol/organofunctional silane solution (ISO) was evaluated in 4 operating rooms after terminal cleaning. Adenosine triphosphate bioluminescence documented a significant difference (P < .048) in surface bioburden on IOS-treated surfaces versus controls. RODAC plate cultures revealed a significant (P < .001) reduction in microbial contamination on IOS-treated surfaces compared with controls. Further studies are warranted to validate the persistent disinfectant activity of ISO within selective health care settings.

Performance-based financing: the need for more research

While several developing countries have been implementing PBF as a strategy to finance health services, a polarized debate between the “proponents” and “opponents” of this approach is gaining prominence.1–4 Ireland et al.5 provide a critical view on the paper by Meessen et al.,6 mainly opposing the argument that PBF, on its own, can be considered as a strategy to reform health systems in developing countries. One of their main criticisms is the lack of evidence. Evidence, of course, should ideally be central to any health sector reform but applying this rule rigorously can lead to inertia. Looking back on the history of public health, we note that many important health reforms implemented in Africa – such as selective primary care for child survival or the health district strategy – were not developed based on recommendations from rigorous experimental studies.7 Health reformers should carefully consider different opportunities based on their potential to maximize the delivery and uptake of proven maternal and child health interventions.8 As African public health experts, we believe that PBF is interesting due to its potential. Having said this, we agree that implementing health reforms based on evidence is crucial. For example, some components of selective primary health care, such as growth monitoring, were implemented even though little was known about their cost-effectiveness.7 However, a recent evaluation of the primary-care approach has shown interesting results9 and the global public health community has since gained important knowledge on successful interventions in primary health care. We think that Ireland et al. minimize the growing body of evidence on PBF implementation produced in recent years. Many studies have been published providing details on how to implement PBF and one experimental study has been published on the impact of the approach.10 Clearly, rigorous research is still needed, especially more theoretical and qualitative studies that address the “how and why” and test hypotheses of potential adverse effects of PBF. Continuous checking and integration of the PBF approach is needed during implementation and this should be informed by operational research aimed at aligning PBF with the existing health system. The World Bank, through a grant from the Government of Norway, has launched several PBF initiatives in developing countries, systematically accompanied with an impact evaluation strategy using different innovative research designs.11 These initiatives should include formative research to address the rapidly changing social and political context that may influence policy implementation.12 The debate around PBF should be evidence-based with critical appraisal. Both proponents and opponents should avoid taking a dogmatic position. Both parties have agreed that PBF is not a panacea. The provision of input items and other key interventions, such as provider training, supervision and health-system strengthening, should continue with the aim of producing results. A research agenda and an effective community of practice embracing all views on PBF is critical to understanding more about its potential for helping developing countries to reach some of the United Nations Millennium Development Goals.

Primary Heealth Care Development: Where is Nepal after 30 years of Alma Ata Declaration??

The year 2008 has witnessed the global conversation to return to tenets of Alma-Ata and to review its 30 years of journey. We reviewed Nepal's journey on Primary Health Care development: policy formulation, structure development, progress and constraints. Though Nepal has institutionalised the PHC approach in health policy, strategy and health care delivery system, this has not been effectively translated into actions, and the results are mixed. Nepal has gained impressive achievements in selective primary health care markers: 45.43% maternal mortality and 62.34% child mortality reduction during 1990-2005. But gain in comprehensive health care markers is not impressive: 18.7% Skilled Birth Attendant (4% in poorest quintile and 45% in richest quintile), 39% having access to improved sanitation and 55.7% of females are literate as compared to males. Socio-political environment until recently was not favourable for comprehensive primary health care, allowing limited health sector decentralisation and community empowerment. Health activities were focussed more on selective health care strategy in the form of disease control, immunisation, vitamin A supplementation, oral rehydration solution use and contraceptive use. Nepal's rural hilly geography posed great challenge on logistic supply, communication and retention of health workers rendering public health centres of low quality with negative perceptions of consumers. Nepal is on the pathway to build equitable comprehensive primary health care.

Primary Healthcare: People, Practice, Place

Contents: Thinking geographically about primary health care, Valorie A. Crookes and Gavin J. Andrews Geographical perspectives on health care: ideas, disciplines, progress, Gavin J. Andrews and Valorie A. Crookes Part 1 Practice and Delivery: Access and utilization reconsidered: towards a broader understanding of the spatial ordering of primary health care, Neil Hanlon The effects of population density, physical distance and socio-economic vulnerability on access to primary health care in rural and remote British Columbia, Canada, Nadine Schuurman The role of scale in conceptualizing primary health care practice: considering social and institutional structures and systems, Janine L. Wiles and Mark W. Rosenberg Cloaked selective primary health care? Local observations of rural primary health care clinics in PerA * , Leah Gold. Part 2 People: Geographies of family medicine: describing the family doctor's practice-based landscape of care, Gina Agarwal The place of nursing in primary health care, Jennifer Lapum Sandra Chen, Jessica Peterson, Doris Leung and Gavin J. Andrews Reinventing primary care: the New Zealand case compared, Ross Barnett and Pauline Barnett New health geographies of complementary, alternative and traditional medicines in primary health care, Daniel Hollenberg and Ivy Bourgeault. Part 3 Places and Settings: Considering the clinical environment: implications for practice and primary health care, Valorie A. Crookes and Gina Agarwal Within and beyond clinics: primary health care and community participation, Robin Kearns and Pat Neuwelt Providers of care in the home: sustainable partners in primary health care?, Nicole M. Yantzi and Mark W. Skinner On the street: primary health care for difficult to reach populations, David Conradson and Graham Moon. Part 4 Agenda Setting: The geographies of primary health care: a summary and agenda, Valorie A. Crookes and Gavin J. Andrews Index.

LiST: using epidemiology to guide child survival policymaking and programming

in the series 2 included a formal attempt to estimate how many deaths could be saved by each intervention then available. This modelling exercise took into account the levels and causes of deaths in 42 low- and middle-income countries, and the effectiveness of interventions against each of these causes, providing estimates of how many lives could be saved if the current coverage levels could be scaled up to reach all mothers and children. These calculations were carried out using a series of spreadsheets where the best existing data were inserted. 2 The results were remarkable—no fewer than two-thirds of all under-five deaths or 46 million a year could be saved if every mother and child received a handful of proven interventions. The Bellagio spreadsheets were sufficiently accurate for the purposes of this initial exercise, and made an important contribution to placing child survival back on the international agenda. However, from a methodological standpoint there was substantial room for improvement. The articles in the recent supplement of the International Journal of Epidemiology report on the methods and assumptions behind the Lives Saved Tool (LiST). This software was inspired by the Bellagio exercise, but went much further in terms of the background mortality data used, the quality of the literature reviews on intervention effectiveness and of the modelling process itself. LiST is relatively userfriendly and is becoming widely used at country level to identify how much impact can be achieved by scaling up different interventions. 3 A potential critique of LiST is that, by estimating the likely impact of each intervention, it would contribute to the implementation of vertical programmes in the spirit of what used to be known as selective primary health care. 4 As such, it would detract from efforts to build up horizontal, primary health-care systems providing multiple preventive and curative interventions against multiple diseases. However, recent experience of countries that have managed to reduce child mortality rapidly, shows that initial focus on a few priority diseases and interventions is not incompatible with the strengthening of health systems for providing universal primary health care—the combination of these strategies has been described as the ‘diagonal approach’. 5–7 Furthermore, use of LiST can counteract current emphasis on one-size-fits-all intervention packages, by suggesting which specific interventions are more likely to have an impact under different conditions.

Commentary: LiST: using epidemiology to guide child survival policymaking and programming

Commentary: LiST: using epidemiology to guide child survival policymaking and programming

Celebrating the World Health Organization

On April 7, 2008, World Health Day, the World Health Organization (WHO) will mark its 60th anniversary. What better occasion to celebrate WHO’s major contributions to international and global health? Several items in this issue relate to this celebratory theme. Fitzgerald, for example, indirectly underscores WHO’s critical role in monitoring international weapons conventions in his gripping essay on the history of chemical warfare. Bu et al.’s Voices From the Past offering focuses on a selection from John B. Grant’s presentation to a 1951 WHO staff meeting, which provides important historical insights into the organization’s longstanding interest in the most effective models for the organization of health services. A more direct celebration of WHO is Fee et al.’s “birthday card” in the form of an extended Images of Health essay. Here we find visual evidence and supporting text for some of WHO’s most notable achievements: the creation of a global network for the facilitated communication of epidemiological information, the impressive campaign to reduce malaria worldwide, the successful promotion of both comprehensive and selective primary health care, the mobilization of extensive immunization programs, the control of onchocerciasis (“river blindness”) and other tropical diseases, and the leadership in recent decades of efforts in global public health. These achievements over the course of its first 60 years have established WHO’s unquestioned importance as the preeminent international health agency and augur well for the future. There is, however, still more about WHO that we should celebrate on this occasion. These are its lofty ideals captured in the language of the preamble to its constitution, now 60 years old, and of the Alma Ata Declaration, now 30 years old. The former declared that “The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being,” (http://www.who.int/governance/eb/who_constitution_en.pdf), and the latter stated that “economic and social development . . . is of basic importance to the fullest attainment of health for all and to the reduction of the gap between the health status of the developing and developed countries” (http://www.who.int/hpr/NPH/docs/declaration_almaata.pdf). These stirring words have captured the attention of people all over the world and have inspired several generations of health workers. They helped forge an image of WHO as an agency aspiring to the highest idealism, well above the budget-constrained pragmatism and realpolitik that often, of necessity, mark its daily operations. Perhaps no one captured the ideals of WHO better than did Frank G. Boudreau in a December 1951 Journal essay (1951:41;1477–1482): Two-thirds of the world’s population is crying for relief from disease, hunger, premature death, and poverty but does not know where to turn for relief. WHO, above all other international agencies, is fitted to show the way, for its jurisdiction is in one of the few areas where men of all races and creeds can work easily together. . . . Joining hands with our colleagues in other countries, we must take our people up to the mountaintop where they can see the promised land of good health, peace, and freedom stretching before them. Now, we too need to remember not only what WHO has done but also what it has inspired. If its ideals are taken as seriously as they should be, WHO will contribute not only to achieving better health for all but also to creating a better world in which all can live.

Leadership in primary health care: An international perspective

A primary health care approach is essential to contemporary nursing roles such as practice nursing. This paper examines the evolution of primary health care as a global strategy for responding to the social determinants of health. Primary health care roles require knowledge of, and a focus on social determinants of health, particularly the societal factors that allow and perpetuate inequities and disadvantage. They also require a depth and breadth of leadership skills that are responsive to health needs, appropriate in the social and regulatory context, and visionary in balancing both workforce and client needs. The key to succeeding in working with communities and groups under a primary health care umbrella is to balance the big picture of comprehensive primary health care with operational strategies for selective primary health care. The other essential element involves using leadership skills to promote inclusiveness, empowerment and health literacy, and ultimately, better health.

Effectiveness of global health partnerships: will the past repeat itself?

Introduction It is to be hoped that past mistakes are not going to overshadow the effectiveness of global health partnerships (GHPs), as they provide valuable lessons that should be taken into account. The Bulletin publishes a fascinating series of public health classics, consisting of a commentary doing a reality check on what has happened since publication of major public health landmarks. In 2005, Anne Mills commented on a landmark paper on mass campaigns and general health services of 1965. (1) One could get a bit depressed reading her article, because the bottom line is that not much has changed in the past 40 years, which have confronted believers in vertical and horizontal approaches. The terminology has changed, though. Some 20 years ago the topic shifted from vertical versus horizontal programmes to the dispute over the advantages of comprehensive versus selective primary health care. In the 1990s, this discussion cooled down and a combination of the two approaches was translated into health sector reform efforts, with widespread consensus to integrate health actions at district level. This development has been supported by changes in aid modalities such as the sector-wide approach (SWAp) funding mechanism, This evolution has come under threat, however, with the appearance of global health initiatives at the beginning of this millennium, (2) which have brought back this old controversy opposing today's approaches: those that have a more systemic focus or those with a more selective, often disease, orientation. With more than 70 GHPs in existence today, the former selective/ vertical party is seemingly gaining the upper hand again. The difference from before, however, is that aid effectiveness is now receiving more attention. It is noteworthy that in 2005, for the first time, a large group of donor and recipient countries, international organizations and also civil society organizations agreed in the Paris Declaration on Aid Effectiveness to set targets for aid effectiveness and to define a set of indicators to measure progress towards these targets (3) The main argument of this paper is that we should avoid the conflicts of the past. We must strive to achieve a balance between the selective approach of many GHPs and the strengthening of health systems, as they are interdependent. Effectiveness of global health partnerships Although the evidence is still scarce, there are some indications that individual GHPs have had a positive impact in some settings. (4) In many countries, they have helped--albeit in specific areas--to strengthen planning expertise. The focus of major GHPs on performancebased funding has forced countries to improve administrative transparency and strengthen their monitoring capacities. It is also worthy of mention that, through their efforts, awareness of specific health problems has been raised at national and international levels. Last but not least, GHPs have clearly brought to light important health problems, and some headway has been made in fighting AIDS, poliomyelitis and other communicable, otherwise neglected, diseases. Major challenges and questions remain, however. Even though there are good arguments for almost all GHPs, their large number raises the question whether the priorities thus determined for a given country really do respond to the national problem areas. The magnitude of the resources can put a considerable strain on the capacities of countries to absorb the influx of financial resources, particularly with the major bottleneck in many countries caused by the lack of local professional expertise in both quantity and quality. There is also the potential risk of an impact on the economic stability of a country. Another important concern about GHPs is sustainability. In poor countries, health systems are seriously under-funded; even if improvements can be achieved with targeted external support, they cannot easily be sustained after the period for which donor agencies are usually ready to commit funding. …