UNITED NATIONS — The campaign for universal health coverage is gaining momentum and influencing the direction of organizations, including the Global Fund to Fight AIDS, TB and Malaria, the organization’s interim executive director told Devex.
There are many challenges in ensuring that all citizens, everywhere, have access to health care, but first, a basic platform of care must be established, said Marijke Wijnroks in the interview.
But what can be done when there’s no common definition of universal health coverage and different countries are operating at different capacities? “It sometimes means different things in different countries, so it’s about trying to find a common understanding of what it means for every one of us and trying to work on it,” she said.
Wijnroks spoke shortly before she joined world leaders as they called for universal health coverage at the U.N. Headquarters, reaffirming the need for one of the global goals targets that they said could “unlock the potential” of the 2030 development and health agenda.
“It is a pre-condition, an outcome, and an indicator of progress,” U.N. Deputy Secretary-General Amina Mohammed said of health during the high-level U.N. Headquarters event. She was joined by UNICEF Executive Director Tony Lake, World Bank CEO Kristalina Georgieva, WHO Director-General Tedros Adhanom, and Rockefeller Foundation President Rajiv Shah.
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“Achieving it is a moral imperative. At a time when far too many health systems continue to fail, we need progress for all citizens and all incomes,” Lake said.
As health leaders are considering practical issues of whether a top-down or bottom-up approach of designing health systems should be implemented, Wijnroks also discussed the various challenges of implementing her organization’s work. The fund continues to think long term, with the goal of saving 36 million lives by the end of 2019. Their programs have saved more than 22 million as of 2016.
Wijnroks talked with Devex about how the fund’s work continues to transform, keeping in mind the 2030 development and health care agendas. Here’s our conversation, edited for length and clarity.
What are you hoping will come out of this high-level event on universal health coverage?
I think the UHC agenda is increasingly gaining momentum and I hope the event will solidify that momentum. It sometimes means different things in different countries, so it’s about trying to find a common understanding of what it means for every one of us and trying to work on it.
For you, what does this strategy, and the idea of universal health coverage, mean exactly? Is it making sure everyone has proper access to medications or health care?
When the Global Fund started in 2002, there was hardly any treatment available for HIV in low-income countries. When I started as a medical doctor in South Sudan, we could see the treatment that was then used for malaria was, in quite a few cases, not effective anymore. But new medications were not available. They then became available — but they were unaffordable for people who needed them the most. Very few people were protected by bed nets. TB was stubbornly high, and, really, no new tools and diagnostics had become available in those years when the fund really gave a boost to fight these diseases that were a real public health emergency 15 years ago. Initially, what we did was to roll out access to commodities, to bed nets, to treatments.
After 15 years, we come to the stage where we have achieved a lot of successes and saved a lot of lives, but we also have to think long term and move from emergency response to a more sustainable response.
When you start implementing programs, the first bit is always the easiest, but if you really want to reach the most marginalized groups, you really have to build a system and work with communities.—
That is how I see our strategy making a lot of logical sense: the focus on human rights. Women and girls in key populations are the ones — whether it is TB or malaria — who are really most affected. We need to build the systems to sustain and we need systems to deliver. So when you start implementing programs, the first bit is always the easiest, but if you really want to reach the people in the most remote areas, if you really want to reach the most marginalized groups, you really have to build a system and work with communities to make sure that you get your commodities there.
Does the idea that UHC doesn’t always mean the same thing to different people come up in conversations you have on the issue?
We need to define UHC in every country, given the country context.—
We have worked very closely with Dr. Tedros [Director General of the WHO] when he was minister of health of Ethiopia. What he did in Ethiopia — which was supported by GAVI and the Global Fund — was to build a network of community health extension workers so every community has one or two workers who had knowledge of basic health care and preventive and health promotion for the community.
For me, it was a huge investment. It depends on what is available, what countries can afford, and access, because we need key access to quality health care. We need to define UHC in every country, given the country context.
How do you see your goals and work with the Global Fund shifting, now keeping the SDGs in mind?
The Global Fund is very often first perceived as a Millennium Development Goal fund, so it’s a question of how do you position yourself in the SDG arena. If you look at the SDG agenda, it is a very long agenda with many targets and goals. But if you look at some of the key messages coming out of the agenda, it is interconnected and all related with the mutual partnerships that are needed to address some the biggest problems of our times.
All of that resonates very much with our vision to end these diseases and public health threats by 2030: by maximizing impact to sustain directly [and meet] the universal health coverage agenda; by addressing rights that are linked to leave no one behind; and by mobilizing sufficient funding both from external funding and importantly from domestic funding.
So part of it is about building up the domestic health infrastructure to ensure that it’s there and not going to collapse when you need it the most?
Exactly. And, increasingly, there is a focus on domestic resource mobilization. For me, that is very much linked to the UHC agenda. Countries have increasingly committed to invest more in health, in general. For the low-income countries, we are really looking at an increased investment in health. As countries move up in income, some upper, middle-income countries really should fund the programs that target the most affected populations and groups and help sustain that response. We are trying to be much more adaptable to the country context.
How are you thinking about antimicrobial resistance and drug resistant TB?
TB predominantly affects poor people; it affects migrant laborers. The whole thinking of TB and key population groups is quite new. We are starting to understand more and more who are most affected and who needs to be targeted. It is something we need to monitor and prevent by making sure we support treatment and introduce new treatment regimes that are easy to adhere to. To a large extent, it is a failure of treatment where too many people drop out because they find it difficult to sustain treatment for a long time.
If you look at the antimicrobial resistance agenda and the worst case scenarios, if you don’t take action now, 25 percent of the AMR mortality will be TB-related.—
A lot of countries in Southeast Asia are developing really interesting public-private models, and a lot of the TB treatment takes place in private clinics. People have to pay for every consultation, so after a month or so when people feel better, they stop treatment. So, there is a public-private partnership where the public tries to work with the private sector to make sure that data [on the patients] are entered in public sector systems and people are followed. So there are red flags for the people who drop off treatment. If you look at the AMR agenda and the worst case scenarios, if you don’t take action now, 25 percent of the AMR mortality will be TB-related.
Do you see more opportunities like this for public-private partnerships?
I think it depends very much country to country. As we have the malaria cases, there is the risk of drug resistance and that has spread to other countries. We really focus on malaria elimination, and we are really sharpening our thinking on what we can do. There are things such as malaria elimination and TB-diagnostic roll-out of AMR treatment programs. There are a number of things we can do that are directly relevant for the AMR agenda, but there is a very large amount of things we can do to support program quality, to support adherence that is not linked directly to the AMR agenda, but is extremely important to the AMR agenda.
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