valueForMoneyInGlobalHealthThe tremendous resources that flowed into global health starting around 2000, with the launch of the Global Fund to Fight AIDS, Tuberculosis and Malaria; followed by President George W. Bush's PEPFAR and President's Malaria Initiative programs; coming on top of the substantial investments being made in global health by actors such as the Bill and Melinda Gates Foundation; meant implementing organizations like PSI and many others were able to help save or improve the lives of millions in the developing world.

Children who 10 years ago, would have been dying from malaria in Africa, now are protected by insecticide-treated mosquito nets, treated by effective anti-malaria drugs, and supported in their care by stronger national health systems. Not everywhere, and not always, but in many places and often, the global community has been able to effectively respond to the disease burden faced by the most vulnerable among us.

The global financial crisis that began to unravel in 2008, and unprecedented budgetary pressures facing all donors, bilateral, multilateral and private, has put much of this forward momentum into neutral, and risks putting it into reverse. The Global Fund's recent decision to cancel the planned Round 11 of funding marks a sobering turn for millions in the developing world in need of HIV treatment, TB screening and treatment, and malaria prevention and treatment efforts.

The global health environment now faces stiff headwinds. Today we must do more with less: provide more value in programming, sustainability in operations, and creatively harness the entire market to better serve the resource materially poor and those able to pay for products and services.

A constrained resource environment is a clarion call for better integration of services. We can no longer afford the softer comfort of vertical programming–we also know that the resource poor don't experience vertical health problems. Their health problems are horizontal.

When Sandra Konjons, a three year-old in rural Cameroon, developed a fever earlier this year, her mother sought care from Desire Andono, a community health worker. Desire treated Sandra with an Artemisinin-based Combination Therapy (ACT), the top-line treatment for malaria. Her mother sought care for Sandra twice more for diarrhea, and Desire promptly provided Oral Rehydration Salts (ORS) and zinc. ORS prevents dehydration, which is the main cause of death when a child has diarrhea, and zinc tablets reduce the severity of the diarrheal episode. Today, Sandra is a vibrant and healthy 3-year-old.

Two years ago, children in Sandra's community who developed fever or diarrhea had very little chance of accessing effective treatment. Now, they can seek help from a cadre of about 1,750 Cameroonian community health workers trained under PSI's Community Case Management (CCM) Impact program, which is funded by the Canadian International Development Agency (CIDA). It makes good sense: integrated care and treatment of integrated health problems, is what Sandra deserves.

We also need to strengthen existing health systems that are working well. More than half the people in the developing world get their health care from private clinics, kiosks and pharmacies.

Social franchising offers significant–scalable–opportunities for integrated services for the resource poor and vulnerable.

Social franchises expand access to health care, train private medical providers to ensure quality care, provide quality and often subsidized products, and are branded as a means to build trust, awareness and demand. Social franchises, like PSI's Sun Quality Health system of more than 1,200 private sector medical providers in Myanmar, offer long-acting reversible contraception, cervical cancer screening, tuberculosis screening and treatment, malaria and pneumonia treatment, anti-retroviral therapy, and so on.

International implementing NGOs like PSI often fall victim to the expectation that global health challenges can be addressed through simple, time-limited interventions. In reality, these development challenges, like all significant development challenges, are long-term and multi-faceted. Institutions need to be similarly oriented toward the long-term. At PSI, this has meant an "institutional development strategy," under which each of PSI's country programs develops deeper national roots, improves local governance structures, invests in the capacity of local staff, and integrates better within the host governments' national health strategies. Sandra and millions like her face long-term health requirements, and we have a long-term commitment to delivering greater value over time.

In every operating environment, the resource poor and vulnerable seek health support from three distinct sources: the public sector, the private sector--including the faith-based community-- and the subsidized --social marketing--sector (Social marketing takes available public subsidies and works to increase access and equity for vulnerable groups, and reduce the need for subsidy over time). A successful total market approach in global health will grow the role of the private sector in a particular intervention, target the available subsidy to ensure that only those truly in need but with some resources can get quality products and services, and reduce the load on stretched public sectors to ensure they can meet the needs of those who truly require free care. A national health system strategy that harnesses all elements–private, subsidized and free–will ensure the best value-for-money in global health programming.

Times of financial restraint and scarcity need not be the excuse for retreat from the last decade's global health successes. Present circumstances are a challenge to all actors in global health to increase the value of our work, the value we deliver to Sandra and to those who fund us, and the efficiencies that translate into bottom-line health impact. Lives saved, cost-effectively and at scale: there is no better success metric for any organization working in global health.