Opinion: The false dichotomy between ending epidemics and building health systems

A health worker takes a blood sample for a malaria test in the Dominican Republic. Photo by: PAHO / CC BY-ND

Is it better to improve people’s health by tackling specific diseases or by strengthening health systems? That’s a perennial debate in the global health community — between those enthusiastic about the power of disease-focused “vertical” programs, and others who stress the sustainability of system-oriented “horizontal” interventions.

If you’re relatively new to the global health world, this argument may seem like one of those obscure theological schisms that generates huge passions, but is sometimes divorced from reality.

The Global Fund is — from the perspective of this debate — the archetypal “vertical” player, given our explicit focus on AIDS, tuberculosis, and malaria. But in reality, the Global Fund also provides funding for “horizontal” interventions to strengthen health systems.

This dichotomy between disease-specific strategies and the pursuit of universal health coverage is simply false. The reality is that we won’t eliminate AIDS, TB, or malaria without building resilient health systems that are truly universal and reach the poor, the marginal, and the most vulnerable people who often get left behind. The other reality is that a health system that isn’t effectively protecting people from AIDS, TB, and malaria isn’t much good as a health system.

At the World Health Summit in Berlin on Oct. 14-16, we are likely to see strong evidence that we need both: a results-driven approach to fighting AIDS, TB, and malaria as a crucial part of the pathway to the Sustainable Development Goal of universal health coverage, and sustained investment in health systems that underpin efforts to eliminate the epidemics.

We need partnerships that reflect this reality — and that’s what we strive for at the Global Fund. Whether it is health extension workers in Ethiopia, community health insurance in Rwanda, or supply chain diagnostics in Tanzania, we are investing to build more resilient and sustainable health systems. It adds up. We invest about $1 billion per year in strengthening health systems, making the Global Fund the largest provider of grants to build health systems among the multilateral institutions.

It’s also important to catalyze domestic investment in health. Through co-financing obligations, we can leverage investment to encourage greater domestic resource commitments. This works. In the 2017-2019 cycle, governments in the countries in which we are active are committing roughly 40 percent more financial resources than in the previous cycle. We also invest heavily in health information systems and health accounting systems to ensure the money is well targeted and properly controlled.

Should even more investments be shifted from disease-specific priorities to building the health system as a whole? We believe in a country-by-country approach. Some countries need investment alongside them in strengthening components of their health system. Others want a focus on purchasing medical products, such as antiretrovirals and mosquito nets, while freeing up domestic resources for investment in health systems strengthening. These trade-offs are very country-specific, and it would be a mistake to assume that there’s a single answer.

Ultimately, we need more money for both. To end the epidemics, we need to step up investment. To achieve universal health coverage, we need to step up investment in strengthening health systems. And while international partners, such as the Global Fund, will continue to play a crucial role, most of the incremental money will need to come from domestic resources.

We also need to get smarter in how we invest. There are still too many silos in health care provision, still too many one-size-fits-all solutions. We need to become much more patient-centered, treating the person, not the disease. We need to better use data to target interventions more effectively.

One thing global health needs is a focus on results. In general, health system development projects have had a mixed record of success. We need to focus on delivering impact — saving lives, reducing prevalence, and increasing access to services. We believe investments in health systems should be made with the same relentless focus on value-for-money, outcomes, and impact.

The interdependence between ending the epidemics and building the health system isn’t just theory. Take Japan as an example. Following World War II, TB was the biggest killer in Japan, and the government launched a massive campaign against TB in 1951. It was ultimately highly successful and it eventually became the platform for Japan’s system of universal health coverage.

After last month’s United Nations high-level meeting on TB — where many countries made bold commitments to tackle the infectious disease that kills the most people — it’s time to recognize that conquering TB requires investment in strengthening health systems, and can be a compelling pathway to universal health coverage.

To achieve the SDG 3 goal of greater health and well-being for all, we must both end the epidemics of AIDS, TB, and malaria and build stronger health systems that can deliver universal health coverage. The debate should not be about which to do, but about how we achieve both.

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About the author

  • Peter%2520sands

    Peter Sands

    Peter Sands became executive director of the Global Fund to Fight AIDS, Tuberculosis and Malaria in March 2018. A passionate advocate for global health, Sands leads work at the Global Fund to end epidemics and build stronger health systems. Sands served as chief executive of Standard Chartered Bank from 2006 to 2015, and in recent years has immersed himself in global health issues. He supports more international and domestic investments for greater global health security, and he often highlights the economic impact of infectious diseases.