Despite many efforts to achieve better coordination, fragmentation is an enduring feature of the global health landscape that undermines the effectiveness of health programmes and threatens the attainment of the health-related Sustainable Development Goals. In this paper we identify and describe the multiple causes of fragmentation in development assistant for health at the global level. The study is of particular relevance since the emergence of new global health problems such as COVID-19 heightens the need for global health actors to work in coordinated ways. Our study is part of the Lancet Commission on Synergies between Universal Health Coverage, Health Security and Health Promotion. We used a mixed methods approach. This consisted of a non-systematic literature review of published papers in scientific journals, reports, books and websites. We also carried out twenty semi-structured expert interviews with individuals from bilateral and multilateral organisations, governments and academic and research institutions between April 2019 and December 2019. We identified five distinct yet interconnected sets of factors causing fragmentation: proliferation of global health actors; problems of global leadership; divergent interests; problems of accountability; problems of power relations. We explain why global health actors struggle to harmonise their approaches and priorities, fail to align their work with low- and middle-income countries’ needs and why they continue to embrace funding instruments that create fragmentation. Many global actors are genuinely committed to addressing the problems of fragmentation, despite their complexity and interconnected nature. This paper aims to raise awareness and understanding of the causes of fragmentation and to help guide actors’ efforts in addressing the problems and moving to more synergistic approaches.

中文翻译：

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“这太复杂了”：全球健康中为何仍然存在零散问题。

尽管进行了许多努力以实现更好的协调，但是分散化是全球卫生格局的持久特征，破坏了卫生计划的有效性，并威胁到实现与卫生有关的可持续发展目标。在本文中，我们在全球范围内确定并描述了健康发展助手中碎片化的多种原因。这项研究具有特殊意义，因为出现了诸如COVID-19之类的新的全球卫生问题，加剧了全球卫生参与者以协调方式开展工作的需求。我们的研究是柳叶刀全球健康覆盖，健康安全和健康促进之间的协同作用委员会的一部分。我们使用了混合方法。这包括对科学期刊，报告，书籍和网站上已发表论文的非系统性文献综述。在2019年4月至2019年12月之间，我们还与来自双边和多边组织，政府以及学术和研究机构的个人进行了二十次半结构化专家访谈。我们确定了五种截然不同但相互关联的因素导致分化：全球卫生参与者的扩散; 全球领导力问题；利益分歧；问责问题；权力关系问题。我们解释了为什么全球卫生行动者努力协调其方法和优先事项，未能使其工作与中低收入国家的需求保持一致，以及为什么他们继续采用造成支离破碎的供资工具。尽管全球行为者既复杂又相互联系，但它们确实致力于解决分裂问题。