What is true for TB can be applied to the topic of health access across the board. Working toward universal health coverage is not always about reinventing the wheel, but sometimes simply about pushing the rolling wagon and helping people to jump on it.
Indian Minister of Health Dr. Harsh Vardhan agreed: “We have the ways, we have the mechanisms, we have the strategy; so our dream cannot remain unfulfilled.”
But which road should we take? There are several, according to delegates consulted by Devex, but arguably the most important one is to support health systems strengthening and UHC without losing track of the possibility of complementary disease-specific interventions.
Building the foundations for a healthy society
The recent Ebola outbreak has been a painful reminder for decision-makers that it’s impossible to build a healthy society without stabilizing one of its key foundations and pillars: health systems. Economic growth will not magically translate into better health access unless targeted action is taken to support health systems and ensure UHC.
This was underlined by South African Minister of Health Dr. Aaron Motsoaledi.
“Development partners must know that one of the best ways to achieve the goals of the world in eradicating disease is to strengthen health systems,” Motsoaledi told Devex. “This is a call to everybody — not only donors, but also to African countries themselves — to invest in health systems strengthening. You cannot focus development away from health — it is impossible.”
If this is clear, what keeps us from doing it? According to Denis Porignon, a health policy expert at the World Health Organization, health financing and delivering good quality services have been — and continue to be — the most important challenges to address in that context.
“Fortunately, there is an increasing number of partners who are keen to support activities and reforms at country level,” Porignon told Devex. “The share of domestic funding for health has increased significantly in many African countries — including fragile ones such as Chad — in recent years and so has donor money, albeit it still being very disease-focused.”
An effective partnership for HSS
A positive example of an innovative partnership for universal health access is theEuropean Union-WHO-Luxembourg UHC Partnership, launched in 2011 with the goal of supporting policy dialogue on national health policies, strategies and plans as well as UHC in 19 selected countries.
Since its inception, the program attracted not only additional support from EU member states, bringing the total program budget to 37 million euros ($46.26 million), but also garnered interest among non-participating developing countries such as Tajikistan and Bolivia, which are “knocking on the door to at least become part of the network and thinking process,” Porignon said.
At country level, the program is implemented on the basis of country-tailored roadmaps, elaborated in close collaboration with beneficiary country governments, civil society and the private sector. Implementation is facilitated through the placement of full-time WHO technical assistants within the health ministries of most beneficiary countries.
“As the EU and Luxembourg support to this phase of the partnership is currently scheduled to end in December 2015, it is very important for us to assess and demonstrate what has been achieved to date with regard to UHC so that we can hope for continued funding in 2016 and beyond,” noted Porignon.
But how can a program of such magnitude keep track of its results in 19 different countries? One tool successfully tested is the organization of joint annual reviews involving government and WHO representatives from all beneficiary countries, allowing for peer review between countries. The latest review revealed that all involved governments positively evaluated the program’s contribution to HSS in their respective countries.
“While it is — admittedly — difficult to establish a direct link between this work and reduced mortality and morbidity in the beneficiary countries, the program contributes to ensuring the adequate and most effective allocation of national resources, in order to make the overall action of beneficiary country governments respond better to the expectations of their populations,” Porignon explained.
The WHO expert pointed out the program is also promoting community participation.
“What [we] did in Tunisia, for example, was to support the process of consulting the public and civil society on the health system reform,” Porignon said. Public opinion surveys were organized and views were synthesized in a “white book” handed over to Tunisia’s prime minister at the country’s first national health conference in September 2013. “During the event, the prime minister seized the ball,” praising the initiative as “exemplary for the innovative practice of democracy and encouraging other ministries to replicate the exercise within their sectors.”
Capacity building for sustainability
But what about the UHC partnership’s sustainability once donor funding comes to an end?
With Luxembourg’s financial support, specific funding has been set aside for the elaboration of training modules on strategic policy setting and planning, Porignon explained, with training of ministry of health personnel set to start in 2015. One key challenge is the high turnover affecting many partner countries’ ministries of health, meaning that training will need to be continuous.
“If we have a few more years in the program, there will be time to monitor and evaluate activities in a way to effectively contribute to capacity building of engaged stakeholders,” the WHO expert said.
The UHC partnership echoes WHO’s key objectives for 2014 to 2018 and its main message to the international aid community, namely to “help the ministries of health in partner countries to build a vision and a plan about what they want to do and align to that plan.”
So how about the many remaining single-disease approaches of global development partners?
“Without an integrated management of diseases, we are not going to win the battle,” said Motsoaledi. “If a partner decides on a single disease approach, the government needs to find a way to coordinate this.”
This coordination exercise may however sometimes be necessary, for diseases that deserve the world’s special attention, not least because they mainly affect the poor and marginalized in our societies.
Disease-tailored interventions for better access
“Let’s develop a ‘killer instinct’ for eradicating poverty-related diseases,” said Vardhan.
Taking TB as a reference, as the second leading cause of death from an infectious disease worldwide after HIV, in India alone TB claims the same number of victims as the 2004 tsunami year upon year. Yet, according to Motsoaledi, “the biggest challenge continues to be raising the necessary national and international awareness about what is essentially an invisible disease … of which people die silently, in their corners.”
In order to address and eradicate health emergencies that ultimately threaten our “interconnected, global village,” long-term approaches to HSS may need to go hand in hand with targeted and coordinated efforts to help countries tackle diseases that tend to escape the public eye.
Michel Kazatchkine, the U.N.’s special envoy for HIV and AIDS in Eastern Europe and Central Asia and former director of the Global Fund, told Devex how his former organization aimed at doing just that.
“Fifteen years later [after the Global Fund’s creation], against the skeptics of the early days, we know that prevention and treatment can be delivered at large scale, even in poor settings and in settings with failing health systems,” he said. “Scaling up prevention and treatment has resulted in decreasing mortality, morbidity and incidence of the diseases.”
In Barcelona, however, activists urged the Global Fund to “rethink its newfunding model towards a more needs-based allocation, as opposed to the World Bank’s economic classification of countries into lower, middle and upper income.” Arguing that MICs “disproportionately bear the burden of TB, are home to large number of poor people and often have health budget similar to those of LICs,” they called for the international community to “make the cake bigger” for TB, malaria, and HIV and AIDS.
Responding to that criticism, Dybul explained that existing resources also need to be used more efficiently and effectively, so as to justify demands for new funding.
“If we continue to have merely a 1.5 percent decline in TB infection rates per year, how can we ask for a 25 percent increase in funding?” he asked.
A needs-based approach
“A paradigm shift in thinking is needed to move from coverage rates and control to elimination of poverty-related diseases,” Dybul suggested, by making the most cost-effective use of existing resources. This can be done by focusing on those areas and populations most in need, by using data-driven interventions as well as innovation for integrated cures, among other means.
Interventions also need to be tailored to their particular contexts. Studies have shown, for example, that TB and HIV can almost be seen as “one single disease” in certain areas of the world, whereas as in others, there is no such interlinkage.
“You have to be not only country-specific, but go district by district, population by population, to really understand the drivers behind a disease — you need to be that refined to be effective,” Dybul said.
Reaching those most in need can be done in different ways. Using examples of Global Fund-supported TB programs, Dybul explained how Ethiopia significantly expanded its health extension network in recent years in order to have two community health extension workers per village, to get into homes of rural communities to reach the people who may have been left behind. And in Nigeria, he explained, tribal leaders played a key role in ensuring that TB-affected nomadic populations could be reached, thus increasing the number of detections by 50 percent in a very short period of time.
Many countries have also started using mHealth to better detect and follow up on TB cases via mobile phone technology. Such low-cost initiatives have already led to very good results in terms of health access.
The overall message is clear: When there’s a will, there are many ways. “If we use the money well, we can be ambitious,” said Dybul. After all, and against all expectations, polio was eradicated in India thanks to will power and effective vaccination through routine services and campaigns.
We should, he explained, therefore get over the black-and-white rhetoric of either health systems or disease-specific support, recognizing that our global health realities are much more complex: They can only be addressed by choosing from all available means to find the most effective solution for each particular context.
Naturally, country governments and local authorities, in consultation with local communities and civil society, should be in the driving seat when it comes to choosing the best path to choose for health access. As underlined by Dybul himself, vertical mechanisms, such as the Global Fund, therefore need to ensure their way of working is aligned with government policies, plans and coordination mechanisms.
However, let’s accept that “many roads lead to Rome” — and let’s take those that allow us to reach the most vulnerable.
Sibylle Koenig is a development consultant and policy adviser with 10 years of experience in managing, monitoring and evaluating international aid programs and grant schemes, as well as advocacy. She has worked for a variety of organizations, including the European Commission, U.N. and bilateral aid agencies and NGOs in Latin America (4 years) and Europe, with extensive work travel to Africa (Tanzania, Uganda, Mozambique, Kenya, Botswana) and Asia (Cambodia, Vietnam, Thailand, India, South Korea).
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