Investing in Global Health Systems: Sustaining Gains, Transforming Lives (2014)

Summary

The United States has been a generous sponsor of global health programs for the past 25 years or more. This investment has contributed to meaningful changes, especially for women and children, who suffer the brunt of the world’s disease and disability. Women today are far less likely than they once were to die in childbirth; children are more likely to survive to their fifth birthdays. The promise of recent years has emboldened world leaders to identify progressively more ambitious international goals in health: ending preventable maternal and child deaths, eradicating malaria, and halting the transmission of HIV. Such transformative changes in the lives of the world’s poorest people would be possible over the next 25 years, were it not for systemic obstacles that threaten to both impede further success and undo the gains already made.

Most of the world is now at a point where continuing progress depends on building the health system, the administrative and technical infrastructure that underlies all health services. Attention to clinical medicine and technological innovations (things like vaccines, contraceptives, diagnostics, drugs, and oral rehydration therapy) has driven much of the success in global health over the past two decades, but these solutions may be reaching a point of diminishing returns. Continuing progress in the future will not be possible using the same tools that worked in the past. Donors need to revise their strategy to account for epidemiological, economic, and demographic changes in their partner countries.

Now is a good time for the United States government and other donors to take stock of their investments in global health. The timeline on the Millennium Development Goals (MDGs), global targets that have driven international development work for the past 15 years, is running out, and there is ongoing discussion about a new development plan to replace them. With this in mind, the U.S. Agency for International

Development (USAID) Bureau on Global Health commissioned this short report. See Box S-1 for the Statement of Task.

This report sets the discussion of health systems in the context of several important, current themes in global health. Two topics of particular relevance for USAID are ending preventable maternal and child deaths and bringing about an AIDS-free generation. The agency is also part of a global discussion about universal health coverage, the provision of a basic package of essential health services to the entire population. There is an emerging consensus, backed by the World Bank and the World Health Organization (WHO), that universal coverage is the best way to improve population health in poor countries. Growing economies in many middle-income countries make it possible to fund this basic package of services from domestic sources. Such developments change the relationship between USAID and its partner countries, and have broad implications for the future of donor assistance for health.

This report discusses the past and future of global health. First, it gives context by laying out broad trends in global health. Next, it discusses the timeliness of American investment in health systems abroad and explains how functional health systems support health, encourage prosperity, and advance global security. Lastly, it lays out, in broad terms, an effective donor strategy for health, suggesting directions for both the manner and substance of foreign aid given.

THE UNITED STATES’ STRATEGIC IMPERATIVE TO INVEST IN HEALTH SYSTEMS

Development experts have long debated the relative merits of vertical health programming, targeted to a specific service or patient group, and horizontal programming, supporting more comprehensive care. Donors often favor vertical programs, which allow greater financial control and easier impact monitoring; such programs are also useful for acute emergency response. The U.S. government has invested heavily in vertical programs, most notably through the President’s Emergency Plan for AIDS Relief (PEPFAR), its flagship initiative for HIV and AIDS. PEPFAR and programs like it have met with good success. Protecting these successes and continuing progress in the future depends on the judicious integration of vertical programs with local health systems.

Attention to Health Systems Cannot Wait

A strong health system is the best insurance developing countries can have against a disease burden that is shifting rapidly and in ways that history has not prepared us for. In many places, ancient problems such as hunger and infection exist in the same communities, even the same households, as the so-called diseases of affluence, things like diabetes and hypertension. At the same time, climate change is aggravating problems of seasonal disease, and globalization is driving new pandemic risks. In short, there is a tidal wave of health problems facing the developing world. Ministers of health confront increasingly complicated tradeoffs: between treating children and adults, between preventative and curative services, and among different ways to pay for health. There is still time to manage these tradeoffs and to make investments that support a range of health needs. Directing foreign assistance to health system improvements is an efficient way for donors to help their partner countries prepare for changing patterns of disease.

There are also practical constraints driving the need for more efficient donor support. The past 20 years have seen tremendous economic growth—nearly 1 billion people escaped extreme poverty. In 1990, almost 60 percent of the world lived in low-income countries, now only about 12 percent do. Emerging middle-income countries have become better at collecting taxes, making foreign assistance a proportionately smaller piece of countries’ total health spending.

Using donor assistance to improve the lives of the billion people left in dire poverty poses a dilemma to donors. Three-quarters of the world’s

poorest people live in middle-income countries where foreign aid is not necessarily needed or welcome. Many of the rest are in fragile states, where political instability and poor infrastructure can prevent aid from reaching people. The challenge of reaching the poor is forcing governments to re-evaluate their aid strategies, identifying those investments with potential to transform the lives of the world’s most marginalized people.

Functional Health Systems Abroad Encourage Health, Prosperity, and Security

There are bottlenecks in the organization of health services in many developing countries and these bottlenecks allow diseases to spread. Extending health services to rural areas and marginalized people could do much to improve population health, and the cost of doing so is affordable. A modest increase in health spending—less than $2.50 per person per year—could avert 37 percent of the global burden of diabetes and cardiovascular disease and 6 percent of global cancer.

Attention to the financing and infrastructure that support health services would also help grow the global economy. Every year 150 million people, mostly in low- and middle-income countries, fall into poverty because of health expenses; millions more stay poor because they are too sick to work. Health spending poses a financial hardship for about a third of households in sub-Saharan Africa and Southeast Asia. In response, patients may sell assets in distress, borrow at high interest, or forfeit future earning power through debt bondage. Donors can help avert these economically disastrous practices by helping their partner countries develop effective prepayment systems and sustainable revenue sources for health.

Reducing waste is another valuable consequence of investing in health systems. Governments in low- and middle-income countries often face pressure to allocate health monies unfairly, spending heavily, for example, on tertiary care centers that serve the relatively wealthy. Nongovernmental providers are an increasingly important source of care, especially for the poor. While competition from these providers could, in theory, drive broad improvements in service delivery, it is difficult to create market competition in health without extensive regulatory and enforcement capacity. As nongovernmental providers become more important, so does the government’s oversight and management role.

The potential economic payoffs of investing in health systems are substantial. Recent analyses indicate that an increase of only $5 per person per year in the 74 countries that account for 95 percent of

maternal and child deaths would yield nine times that in terms of lives saved, disability prevented, unplanned pregnancies averted, greater workforce participation, and increased savings and investments. A 2 percent increase in current health expenditures would be enough to underwrite this transformative investment. The effects of such spending go beyond health. Healthy workers are more productive; healthy children are better able to learn. In the long term, investment in health drives increased productivity and improves the lifetime earning power of workers and consumers in the developing world.

A strong health system also allows for effective response to pandemic disease, something only 20 percent of the world’s nations are currently prepared for. The tools that enable emergency response—a well-trained workforce, an information system to support surveillance and data sharing, a solid infrastructure for clinical care and laboratory analysis, and strong management of the health sector—are essential pieces of the health system. The same investments that improve daily functioning also build capacity for emergency response. When health systems cannot respond to emergencies, there is a risk that a contained health problem will escalate into a protracted political crisis.

The governments of Guinea, Liberia, Nigeria, and Sierra Leone are currently confronting this risk as the Ebola virus, a disease of uncommon virulence and case fatality, spreads through their countries. Ebola response would tax any health system, but the West African nations affected have particular vulnerabilities. They must now cope with an increased burden on their limited surveillance, laboratory, and clinical infrastructure, while trying to contain what could be a devastating global epidemic. Ebola has drawn attention to the consequences of neglecting health systems development in low- and middle-income countries.

AN EFFECTIVE DONOR STRATEGY FOR HEALTH

The challenge of the future of aid programming is to sustain the successes of the past 25 years, while reducing dependence on foreign aid. The committee suggests changes to the U.S. government’s foreign aid strategy that would build capacity in partner countries and make a clear statement about the United States’ commitment to sustainable development.

The committee concludes that health systems limitations are the binding constraint preventing further progress in global health. Building technical capacity in developing countries would help relieve this constraint and would show the U.S. government’s commitment to a future when countries run their health programs independently.

A Transition in How to Give Development Aid for Health

Donors can foster country ownership of development programs by supporting their partner countries’ national priorities and making donor funding for these priorities additive with local funding. Country ownership requires a complicated balancing of donor and recipient interests. But, when countries own their health and development programs and when their foreign partners set a standard of mutual transparency, citizens are better able to hold their governments accountable for the successes and failures of their health systems.

Improved government accountability is a long-term benefit of development, the sort often obscured by donors’ short funding cycles. Fluctuations in development funding from year to year prevent sustainable programming. They force undue attention on the wrong measures of success, emphasizing what the donor contributes to health, not what that contribution produces. A longer time frame on foreign aid and a transition to measuring the outcomes of donor projects instead of the inputs would contribute to more effective, sustainable development.

A Transition in What to Give as Development Aid for Health

Technical solutions and support for service provision have long been central to the U.S. government’s foreign aid strategy. Over time, this kind of aid can cultivate dependence on foreign assistance. The development of knowledge and public goods, on the other hand, is a transformative investment and one that makes wise use of the United States’ comparative advantage in science and technology. To this end, Congress could direct the attention of American scientists to questions that benefit the poor, especially in the emerging field of implementation research and in the development of medicines, vaccines, and diagnostics. Global health research also has a valuable capacity building component, developing cadres of researchers and managers in low- and middle-income countries.

Training should also be a central piece of the aid strategy, but it should be substantive, advanced training with some emphasis on administrative professions. The United States can help alleviate the health workforce crisis by supporting higher education in developing countries through scholarships and partnerships with American universities. Donors can also help identify innovative ways to make the best use of the trained staff available in countries.

Good project monitoring is a cornerstone of public management. Donors can invest in the capacity for civil registration in developing countries and should require more rigorous monitoring of their own projects. However, monitoring should not be conflated with project evaluation. An independent, formal impact evaluation is an indispensable piece of those health programs that involve technical innovations or new models for service delivery. Only by comparing donor activities to clear counterfactuals can all stakeholders be confident that their investment in health is eliciting meaningful change.

CONCLUSION

Foreign policy decisions are always shaped in part by the current social and political climate, but they are also partially predetermined by the trajectory of commitments already made. Attention to the management, financing, and infrastructure that support health is a priority by either calculation. Building health systems abroad is in the strategic interest of the United States and should be a priority for the U.S. Congress.

This page intentionally left blank.