Access to care: It’s one of the great enablers of — or impediments to — health. Today, some 1 billion people across the globe lack access to basic health care services. Closing this gap through broader health coverage will ultimately mean healthier populations.
While access is a key ingredient, it’s not necessarily sufficient by itself. Access to a health facility is an enabler for a woman to safely deliver her newborn only if a trained midwife is present, or another health professional who is able to refer the woman to higher-level care in the case of an emergency. Access to a clinic or pharmacy is only effective if it’s stocked with the appropriate treatment. And access to family planning only helps to prevent unintended pregnancy if a woman is able to effectively negotiate the use of those best practices with her partner.
Improving public health means focusing on both the availability and the affordability of care. It involves building the capacity of health workers, scientists and managers. And it requires accountability and effective oversight to ensure quality of care.
All of these components are essential for well-functioning health systems, something the global health community is unanimous in calling for — and working toward — over the past several years. The recent outbreak of Ebola has only reinforced that campaign.
“If ever there was a case for using more of our government aid money to build efficient, smart and reliable comprehensive health systems in countries that don’t have them, this is it,” former U.S. President Bill Clinton told reporters recently.
Access beyond the health sector
Strong, well-run health systems help to advance quality of care. To ensure access to affordable care, meanwhile, governments around the world have been exploring a variety of universal coverage schemes that use insurance or government subsidies — or a combination of the two — to shield patients from the high costs associated with, for instance, maternal or emergency care.
World Health Organization Director-General Margaret Chan once called universal health coverage “the single most powerful concept that public health has to offer.”
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To be sure, conflating population health with improvements in health sector service delivery does a disservice to the decades of advancement in health through nonhealth measures like improved sanitation, clean water, sufficient and nutritious food, education and economic development, to name a few. None of these areas were the workings of a health minister alone, and with looming public health crises stemming from climate change, noncommunicable diseases and civil unrest, the future will likely require more cross-sector collaboration, not less.
As the pioneering work of Michael Marmot and the WHO Commission on the Social Determinants of Health has found, health is largely the product of social, economic and political factors that shape the environment in which individual behaviors and choices are made. Many advocates, including NCD Alliance executive director Katie Dain, believe universal health coverage is a part of the solution, but “we need to be looking at health much broader beyond just the health sector response.”
Evolving roles in evolving systems
Governments, donors, civil society and the private sector are all rallying around the need to improve health systems. They see next year’s culmination of the Millennium Development Goals as a critical opportunity to take stock of what’s worked and what hasn’t, and chart a path forward in global health and development.
The direction seems clear enough: In recent years, there’s been a shift away from exclusively vertical service delivery, which has proven effective in fighting diseases such as malaria. Instead, more integrated, “diagonal” approaches have become more popular. Services continue to target individual health needs, such as high-burden diseases, but at the same time, improvements to the broader system are made.
AIDS is a prime example of where such integration is occurring. The historic and sustained global response around the disease now presents opportunities for expansion. Infrastructure that was created through this unprecedented response in many low-income countries around the world can now be used to deliver additional services such as reproductive, maternal and child health services, as well as potentially some for NCD prevention and control. This type of integration provides a path towards improved access and universal health coverage.
The integration of reproductive health with HIV and AIDS services in Swaziland, for example, allows for a more efficient use of resources that’s also more responsive to community needs. With the help of organizations like UNAIDS and the U.N. Population Fund, health workers are being trained to deliver both family planning and HIV prevention and treatment services.
Such integration in service delivery, however, only expands access if the services are covered through insurance or some other means of financing. Integration cannot be achieved without the appropriate corresponding funding streams. If funding streams are vertical, so will service delivery schemes.
The world’s biggest global health donors, including the World Bank, U.S. Agency for International Development and Global Fund to Fight AIDS, Tuberculosis and Malaria, are increasingly mindful of sustainability, of how health services can effectively be delivered in the long term using primarily country systems. Many of them are now spending more on ways to strengthen health systems.
Moving forward, this will likely mean a continued, and likely increased, emphasis on health worker training, laboratory capacity development, surveillance system improvements and integrated service delivery.
The U.S. government, for instance, has stated that in the absence of strong health systems, the Millennium Development Goals are “unlikely to be met, the return on [U.S.] investment in health will be suboptimal, and U.S. foreign assistance goals will not be easy to achieve and sustain.”
Still, the U.S. global health portfolio remains largely segmented. How the U.S. government will strike a balance between aspirations to strengthen health systems with issue-specific priorities, such as creating an AIDS-free generation and reducing mortality of children under the age of 5, remains to be seen.
Other donors, like Gavi, the Vaccine Alliance, have integrated health systems strengthening into their funding portfolios. Gavi says it has committed $862.5 million in health system strengthening grants from 2007 to 2017. Also, built into the business model of the alliance are strategies that promote sustainability and greater country leadership, such as its co-financing mechanism.
Agnes Binagwaho, Rwanda’s permanent secretary of health, has stated that Gavi’s co-financing scheme is “an important step towards ensuring that we maintain our current political ownership and commitment to reducing child mortality.”
The private sector’s role in global health
The private sector, and particularly private health providers, present a bit of a wildcard. In many sub-Saharan African countries, private care constitutes almost half of all delivered health services. In the case of antenatal care services, a recent study from 46 low- and middle-income countries found private commercial providers accounted for 36 percent of health market share.
“The private sector exists and people are going there for a reason,” said Michele Teitelbaum, global technical lead for health service delivery at Management Sciences for Health.
Data comparing the cost-effectiveness of care delivered by the public versus the private sector remains limited. A 2012 systematic review of 102 relevant studies concluded that patients experienced financial barriers to care regardless of the type of system, and each performed poorly on measures of accountability and transparency.
A number of global health experts contend that in order to reach universal health coverage, both public and private providers must offer a sufficient floor of quality services. Governments can play an important regulatory role, ensuring consistent regulation that assures a certain standard of care across providers; this will improve both quality and equity of services.
To achieve universal health coverage, as has happened in a number of high-income countries, an either-or paradigm with public and private providers will need to be adapted to a more collaborative and cooperative approach between the two.
Beyond private health care providers, private sector companies — like pharmaceutical, medical technology and insurance companies — are engaging with governments, NGOs and communities in unique collaborations and, in some cases, a reorientation of business models. GlaxoSmithKline, for instance, recently announced a first-of-its-kind “open lab” in Africa to encourage joint research and development on NCDs, along with a greater manufacturing presence on the continent that shortens the supply chain for existing and new medicines. HealthPartners, a U.S.-based health insurance cooperative, is bringing its expertise in social insurance to a project with the Uganda Ministry of Health to limit financial hardship for women of reproductive age through a health insurance cooperative.
The pharmaceutical industry has supported increased access to medicines as a donor of lifesaving treatments for neglected diseases, for example, and now increasingly as a partner. In fact, the industry has pledged to provide 14 million treatments for neglected tropical diseases between 2011 and 2020. Beyond philanthropy, the industry is now involved with some 200 global partnerships, many aimed at building capacity, strengthening health systems and improving access to high-quality care.
Medtronic, through its Health Rise initiative, is supporting demonstration projects in the United States, South Africa, Brazil and India to expand access to those not already connected to the health system. The hope is to use private money to identify community-driven service delivery approaches that governments can then take to scale. In the view of Paurvi Bhatt, program director of global access at Medtronic Philanthropy, the private sector helps to incubate new ideas but “it’s the country’s scale question, not ours.”
Charting a unique path
The notion of “country ownership” has taken root in global health in recent years. Though a single definition of country ownership or corresponding metrics to measure it don’t exist, its basic tenet is for communities and their elected officials to assume a greater degree of financial and priority-setting responsibility. Foreign aid programs should, in turn, support a country’s agenda.
When communities have a seat at the table from the beginning, good things tend to happen. Universal coverage schemes, too, tend to be realized through “organic, domestic processes, which necessarily reflect local historical, cultural, and institutional legacies,” a recent review of UHC reforms concluded.
Local communities may, for instance, be pulled in to determine an essential package of health benefits that should be covered based on country needs. Such an essential package of services will undoubtedly differ from one country to another as health challenges and available resources differ as well.
Aligning supply and demand is at the heart of the so-called people-centered approach to health care, where services are arranged based on individual and community needs.
Health systems will have to reorient to effectively manage the range of emerging health challenges, especially chronic diseases like cancer, diabetes as well as heart and respiratory diseases. All stakeholders can uniquely contribute to the effort, and aligning their resources with community needs will help to improve access to quality health services.
Healthy Means is an online conversation hosted by Devex in partnership with Concern Worldwide, Gavi, GlaxoSmithKline, International Federation of Pharmaceutical Manufacturers & Associations, International Federation of Red Cross and Red Crescent Societies, Johnson & Johnson and the United Nations Population Fund to showcase new ideas and ways we can work together to expand health care and live better lives.