Reshaping Global Health
by Mark Dybul; Peter Piot; and Julio Frenk
Time for a structural and philosophical shift
Movement along the arc of development has been propelled by new worldviews and the creation of institutions to respond to them. In the 19th and 20th centuries, development efforts evolved from colonial expansion to missionary zeal, the aftermath of two world wars, the Cold War, economic self-interest, and postcolonial guilt. Numerous private and public organizations were created to respond to shifting demands, including multilateral and bilateral organizations wholly or partially dedicated to global health.
The opening ten years of the 21st century arguably were the decade of global health. Resources increased significantly and many millions of lives were saved and improved. The rapid expansion in global health was part of a broader conceptual movement that created core principles for the use of resources in a new era in development. The first expression of new thinking was the historic Monterrey Consensus, which was later refined by the Paris Declaration and the Accra Accord. The foundational principle outlined in those agreements is a move from paternalism to shared responsibility and mutual accountability. Key to shared responsibility are leadership and strategic direction for the use of resources by the country in which they are deployed (“country ownership”). Achieving country ownership requires good governance, a results-based approach, and the engagement of all sectors of society.
The focus on specific diseases has exposed fault lines in delivering services in places where people suffer from multiple health issues.
Several large global health institutions were born out of the heady days of the opening of this century; they were intended to reflect and be responsive to the demands of a new generation in development. Governments in emerging economies such as Mexico, Thailand, China, and Brazil have developed innovative models and invested significant resources in the health of their people. Although governments in many middle-income countries provide a great share of health resources, many of the gains in low-income countries and aspects of gains in middle-income countries have been financed and supported by newly created disease-specific programs including the Global Fund to Fight aids, Tuberculosis, and Malaria (the Global Fund); the U.S. President’s Emergency Plan for aids Relief (pepfar) and Malaria Initiative (pmi); and the Global Alliance for Vaccines and Immunizations (gavi). In addition, the Bill and Melinda Gates Foundation and other philanthropists became major investors in global health, and numerous public-private partnerships and product development partnerships were created. The large funding organizations have supported many country-owned programs that have saved and lifted up millions of lives while being the driving force in shifting the benchmark of success in global health — and development — from the amount of money committed to results achieved. Furthermore, health became part of the world’s top agendas, including at the g8, the un Security Council, caricom, and the African Union.
However, the focus on specific diseases has imposed and exposed fault lines in delivering services in places where many suffer from multiple health issues at the same time or at varying points in their lives. Although studies have shown that hiv interventions have reduced overall mortality and that malaria and immunization programs have reduced childhood mortality in the near term, it seems highly likely that more lives will be durably saved if a person afflicted by different health problems has access to services for all of them. Although there are limited supportive data, we believe it is likely that an integrated approach focused on the health of a person and community is more cost-effective than a silo approach focused on a specific disease or health threat. Yet, existing global health institutions were designed for specific diseases and have not effectively shifted to embrace a broader vision.
It is time for a Bretton Woods-style agreement to guide a new international health strategy and rationalize its structure.
The resources currently available could have significantly greater impact with a more rational global health strategy and institutional structure focused on stewardship of available resources to achieve public goods — what is commonly called global health architecture. Put more directly, today and every day, people will die and lives will not be improved because of the way global health is governed and implemented. Therefore, there is an urgent moral imperative that we act now. But there is also a complementary aspect of realpolitik to reorient global health architecture to the public good: Economic and political realities make financing of inefficient programs and institutions unsustainable. Support for a radical change in the current global health architecture is therefore in the interest of every disease- or issue-specific advocate….