[health-vn] A global fund for the health MDGs?

Sun May 3 02:58:47 EST 2009

Subject: 	[AIDS ASIA] A global fund for the health MDGs?
Date: 	Sat, 02 May 2009 05:21:33 -0000
From: 	AIDS ASIA<AIDS_ASIA at yahoogroups.com>
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A global fund for the health MDGs?

Lancet, Volume 373, Issue 9674, Pages 1500 - 1502, 2 May 2009
doi:10.1016/S0140-6736(09)60835-7 Cite or Link Using DOI

Giorgio Cometto a , Gorik Ooms b, Ann Starrs c, Paul Zeitz d

The world is off track to achieve the health-related targets of the
Millennium Development Goals (MDGs) by 2015.1 Maternal mortality has
stagnated for two decades,2 child mortality is not declining fast
enough,3 HIV/AIDS still infects people faster than the pace of
antiretroviral treatment roll-out,4 and inequalities are widening within
and across countries.5

Addressing these crises will require increased funding and more
efficient spending. The next Board meetings of the Global Fund to Fight
AIDS, Tuberculosis and Malaria and the GAVI Alliance, scheduled for May
and June, respectively, present an opportunity to tackle these issues.

There is widespread recognition of the need for bold action to
streamline the global aid architecture for health. Last year WHO
launched an effort to "Maximise positive synergies between global health
initiatives and health systems",6 whose conclusions will be submitted to
the G8 in late June.

A Taskforce on Innovative International Financing for Health Systems was
established in September, 2008, to explore new strategies to mobilise
and channel resources for health systems.7 The executive directors of
the GAVI Alliance and the Global Fund recently wrote to the Taskforce
co-chairs that "It is time to take a comprehensive approach with the
necessary support from key donors to refocus on all of the
health-related MDGs".8

An interim report from one of the Taskforce working groups suggests
considering "the Global Fund and GAVI as a conduit for additional
resources for health systems [to achieve] MDG 4, 5 and 6".9

The scene is set: now is the time for explicit discussion of a global
fund for the health MDGs.

In the past ten years global health aid has increased substantially, in
particular for HIV/AIDS;10 while HIV/AIDS funding is still inadequate,
the resources committed to other health needs or to strengthen health
systems have seen only modest increases, or a relative decline.11

Development assistance for health has been constrained by the aim of
national financial autonomy—the expectation that nations receiving
assistance should eventually finance health services from domestic
revenues. This model is a major constraint to scaling up service
provision in countries where public services rely heavily on
international resources.

International aid to fight AIDS has escaped this constraint. Grounded in
a right to health approach, the so-called Harvard Consensus Statement,
while acknowledging that antiretroviral treatment would remain
unaffordable for some countries, argued that the international community
should support the rapid scale-up of AIDS treatment "on moral, health,
social and economic grounds".12

Another exceptional feature of the AIDS response has been its
multisectoral nature, which has allowed more effective action on the
social determinants of HIV transmission.

The idea that the aim of national financial autonomy should be set aside
for AIDS was based on the assumption that health systems were working
reasonably well, or could be improved with conventional development
assistance, but could not afford bulk procurement of antiretroviral
drugs. If that assumption had been correct, it would indeed have been
sufficient to create an exceptional funding channel for expensive drugs.
The reality, however, is that the health systems of many countries lack
basic capacity in governance, health financing, procurement, human
resources, and information systems.

Therefore health systems have often been unable to take full advantage
of the new funding channels, or, paradoxically, might have been weakened
by over-concentrating human and financial resources in specific
initiatives.13

Only by comprehensively strengthening health systems will it be possible
to overcome structural challenges to service delivery, in particular the
shortage of health workers.14 Some lament that a decade of
disease-specific attention was a lost opportunity, because better
results would have been possible had greater resources been invested in
health systems. For others, the pressure to save lives through
disease-focused programmes was needed to overcome decades of
underinvestment in health systems.

We can agree to disagree on the past, but must start a constructive
discussion about the future. We propose that the exceptional approach
created for the fight against AIDS should be expanded: the entire global
health agenda must adopt a rights-based approach, which in some
countries requires challenging the model of national financial autonomy.

We therefore recommend that the Global Fund and the GAVI Alliance
gradually move towards becoming a global fund for all the health MDGs,
which will require substantially greater resources to address the
broader mandate. As a first step the next Global Fund and GAVI Alliance
board meetings should expand the review of their architecture to provide
greater support to national health plans, including co-financing
non-disease-specific human resources for health.

The desirable features of a global fund for the health MDGs are listed
in the panel. Such a fund should sustain the successful programmes and
expand the effective approaches pioneered by the Global Fund and the
GAVI Alliance, while extending the same principles to other health needs
and to general health system strengthening. A global fund for the health
MDGs would eventually allow the delivery of prevention and treatment
services for specific diseases through revamped general health services,
reducing transaction costs and streamlining the global health architecture.

Such radical, yet rational, action is our best chance of meeting—or at
least making significant progress toward—the health-related MDG targets
by 2015.

Panel

Desirable features of a global fund for the health MDGs

• Focus on measurable improvements in health outcomes, with performance
evaluation framework that looks at coverage with services relating to
reproductive, maternal, newborn, and child health, HIV, malaria and
tuberculosis, other infectious and non-communicable chronic diseases,
quality of care, and fairness of financial contribution to the health system

• Clear mandate and funding criteria that address key bottlenecks in
health systems (including long-term predictable support for recurrent costs)

• Rights-based approach to health supported by new model of globally
shared financial sustainability

• Capacity to disburse resources beyond public system and beyond health
sector when this represents appropriate and cost-effective approach to
improve health outcomes

• Governance and accountability structure open to civil society at
global and country levels

• Flexibility to provide support to public sector on-budget or
off-budget, in form of grants and not loans, unconstrained by financial
ceilings

• Independent mechanism that judges proposals exclusively on technical
grounds

GC is a member of the GAVI Health System Strengthening Task Team; his
views are not necessarily those of Save the Children UK or of the GAVI
Alliance. GO, AS, and AZ declare that they have no conflicts of interest.

References

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2 Hill K, Thomas K, AbouZahr C, et alon behalf of the Maternal Mortality
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7 High Level Taskforce on Innovative International Financing for Health
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<http://www.internationalhealthpartnership.net/pdf/IHP%20Update%2013/Taskforce/TF%20REVISED%20Press%20statement%20>(2008%2011%2030)%20v%206.pdf. 

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14 Médecins sans Frontières: Help wanted: confronting the health care
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(accessed March 17, 2009).

a Save the Children UK, London EC1M 4AR, UK
b Institute of Tropical Medicine, Department of Public Health, Antwerp,
Belgium
c Family Care International, New York, NY, USA
d Global AIDS Alliance, Washington, DC, USA

E-mail: giorgiocometto at hotmail.com <mailto:giorgiocometto%40hotmail.com>

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