It is becoming increasingly apparent that the days of ever growing government donor funds for global health have waned. The international community has made tremendous gains in improving global health, particularly in reducing child mortality, deaths from key infectious diseases, and improving access to clean water. Significant challenges, persist however, health disparities between the rich and poor are widening, global maternal mortality ratios remain persistently high in too many countries, most nations are ill-prepared to prevent, identify, or contain infectious disease outbreaks with pandemic potential, and non-communicable diseases are a growing health problem. In light of financial constraints from traditional sources, global health experts are searching for new funding sources. Perhaps the international community could use the funds raised through innovative funding mechanisms to address three issues that have not yet garnered sufficient attention: governance, access, and quality.
Governance: It could be argued that the international community has plucked the low-hanging fruit from the global health solution tree. Mass vaccination campaigns, dissemination of bed nets, and provision of HIV medication, for example, have led to improvements in global health. These efforts have been carried out both in countries that are eager and ambivalent about tackling health challenges. Inadequate capacity or desire to administrate health resources in many countries has prompted several donors to fund health programs through non-governmental organizations (NGOs) both for expediency and to ensure oversight. In the meantime, however, many countries have become no better at health governance and national health systems have continued to erode. Addressing weak governance can no longer be avoided. Rational health policies are critical for ensuring that limited health resources are used efficiently and appropriately. Many countries are in desperate need of skilled health administrators who are experienced at deploying health resources, including health workers, appropriately and efficiently. Statisticians and policy analysts are needed to collect and analyze data that will be used to advise health administrators. Health economists are needed to make financial policy recommendations.
Attracting and retaining these skilled health professionals will be impossible, however, without strong leadership (the other part of health governance). Tackling political ineptitude and indifference is a thorny topic. How should the international community respond to countries that have the capacity to provide more resources towards health but do not? A growing number of countries are employing performance-based financing strategies to improve service delivery. Is the international community prepared to apply this strategy to global health aid? Might we consider commitment as an important criteria for investment? What strategies might be employed to encourage country ownership over health without abandoning the most vulnerable who would surely suffer without international support? What are your thoughts?
Access: Worldwide, health disparities between the wealthy and poor are growing. This is true for industrialized and developing countries alike. These disparities have hindered progress in achieving health-related Millennium Development Goals. Countries that have prioritized expanding access to healthcare have made tremendous advances over the past decade. The maternal mortality ratio in Rwanda, for example, has declined by nearly 80% between 2000 and 2013. Infant mortality disparities between the rich and poor have plummeted in Thailand. In June 2015, the World Health Organization announced that Cuba, one of the most isolated and technologically deprived countries in the Western Hemisphere, had become the first country in the world to eliminate mother-to-child transmission of HIV and syphilis. These laudable gains were achieved not only because of strong political will, but also because of a commitment to equity. Each of these countries have developed innovative strategies for expanding health access to the poorest segments of their population and they have clearly paid off.
Health improvements and financial support tend to be inversely related. This creates a disincentive to improving domestic health outcomes or raising national health budgets. Perhaps its time for a paradigm shift where we maintain support for countries that are demonstrating a deepened resolve to address their health issues. Countries that are experiencing improved health outcomes but have not yet achieved financial stability need sustained support. Innovative funding mechanisms might be a new avenue through which to explore providing support for such countries.
Quality: In the 2010 World Health Report, World Health Organization (WHO) Director-General Margaret Chan estimated that 20%-40% of health spending is wasted on inefficiency. In other words, we could expand health access right now with the same resources by addressing the key drivers of inefficiency: inadequate numbers of skilled health workers, low morale among health workers, weak health administration, medical errors, waste and corruption, duplication and interruptions in supply chain mechanisms, and poor quality control in the use and storage of medicines. Ensuring quality requires a long-term approach that many donor funding mechanisms are not equipped to support. However, quality is a necessary precursor for making advancements in global health. Administrators of the President's Emergency Plan for AIDS Relief (PEPFAR), for example, quickly learned that the poor quality of health facilities encumbered U.S. efforts to provide anti-retroviral medication for needy HIV-positive populations. Health system strengthening, including helping facilities achieve accreditation, has become an important part of PEPFAR (thought there is some debate about whether PEPFAR funds should continue to be used for broader health system efforts). Most health facilities, including medical schools, laboratories, and dispensaries, in developing countries are not accredited and accreditation is rarely built into global health programs. Poor quality, however, erodes investments and stymies progress. Additional resources raised through innovative funding mechanisms might be used to address this fundamental piece of the global health pie.
The global health community is entering a new era where donor and recipient governments are beginning to seek partnerships with other non-governmental actors, especially the private sector. These public-private partnerships are needed to raise additional revenues and expand capacity to tackle ongoing global health challenges. While exploring new funding mechanisms, perhaps the international community could consider a new way of doing business where governance, access, and quality are an integral part of delivering health aid. Integrating these elements will require out of the box thinking and evidence-based rather than political-based programming.
As the world becomes more interconnected, the need to improve global health becomes more urgent. The West Africa Ebola outbreak showed us how quickly a disease can cross shores. The old model of addressing global health is outdated. It is not expansive enough to address the looming health challenges. We can no longer afford to cherry pick which issues we will confront. Now is the time to put all options on the table. This blog will provide a forum to explore these. I'm looking forward to hearing your thoughts.
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