The framework: the international arena

For decades, infectious diseases such as HIV and tuberculosis have been on the forefront of the global public health agenda and should rightfully remain high on the list for the foreseeable future.1 Similarly, childhood infectious diseases account for a huge burden of disease and receive enormous support and funding, largely because of the potential for successful intervention.2 For example, campaigns to eradicate polio and guinea worm capture the attention of governments and society because of the potential for eradicating a disease with a defined impact on the health of a population. Consequently, assistance directed toward systems of care in medicine, such as critical care have often been neglected in programmatic initiatives.

However, it has recently been recognized that success, even in disease-specific programmes, is often unobtainable by the independent introduction of a single intervention, such as a vaccine or new medication. For example, in existing HIV intervention programmes, a concurrent expansion of health systems capacity was undertaken along with the introduction of HIV-specific treatments. Without this concurrent support of the local healthcare systems, the delivery of adequate medical care to contain the HIV epidemic and improve survival would have been impossible. HIV public health programmes now routinely include infrastructure development within the hospital systems with which they work. Fortunately, global funds have made possible completion of facility and personnel upgrades, and as a result, systems as a whole have benefited.3

Accordingly, public health has shifted programming strategies to include healthcare infrastructure improvements, including hospital facilities and personnel, as well as disease-focused assistance. In the recent past, maternal mortality programmes focused on traditional birth attendants, education of front-line workers, and health promotion interventions, but with little success.4 Many of the commonest causes of maternal mortality are only averted by implementation of hospital-based ‘curative category’ interventions, such as …