Health Systems Support Needed for Enhanced Global Disease Prevention
October 24, 2014
U.S. Needs to Provide More Health Systems Support to Enhance Global Disease Prevention
The Ebola epidemic in West Africa has taught us many lessons, among them that weak health services anywhere are a potential threat to everyone everywhere. While even the most advanced countries have been challenged by the virus, the fact that the outbreak is occurring in some of the frailest health systems in the world led to the enormous size, scope, and death rate associated with the crisis.
Health systems strengthening has been paid a lot of lip service over the years, but little progress has been made in many places that need the most help. Blame often falls on donors who tend to concentrate funding on specific diseases, like HIV or malaria, or, to a lesser extent, populations, like women and children. Frequently this funding establishes separate units and programs that just address their own specific issue, not the health burden at large or the system needed to treat it. These “vertical” programs show more immediate, tangible results that can be counted in numbers of individuals receiving treatment or giving birth with a qualified attendant.
Cause and effect are less clear when dealing with health systems. If donors invest in health worker training, for example, there is no guarantee the worker will finish the course or remain in his or her country of origin. Even harder to quantify are results from investments in critical system components like drug safety and information networks.
But the problem goes beyond donor preferences for tidy measurement tools. Health systems need adequate personnel and supplies, good governance, infrastructure, information systems, financing, and effective service delivery. Each element is in itself a difficult endeavor. While building a clinic may be relatively easy, more complicated is ensuring it has sustained, adequate staff, electricity, and a reliable supply chain. Ensuring proper administration and management is even harder.
Engaging adequate numbers of health personnel is notoriously challenging. Those trained to a high enough level are courted by richer countries and frequently leave, especially if their home countries face instability. Liberia, the hardest hit of the countries now facing the Ebola epidemic, was estimated to have fewer than 50 physicians for a population of 4.3 million.
Beyond the health system itself, building functional service delivery in poor countries can be stymied by lack of an adequate tax base, frequent turnover in government positions, lack of accountability and corruption, poor transportation, and general infrastructure weaknesses--daunting challenges all.
All that said, the problem deserves heightened efforts to provide resources and expertise if we are to avoid the devastating consequences we are now seeing in West Africa. The challenge is more complex than just providing funding since countries must develop management skills and create complex systems. Some innovative approaches are being tried. The Harvard School of Public Health and the Kennedy School sponsor a Ministerial Leadership in Health program that has involved 56 health and finance ministers from 40 countries to increase domestic political commitment for health systems improvements as well as enhancing efficiency and quality of services. Global movement toward universal health coverage focuses on improving access to quality health services at a price all can afford, an advance that requires functional health systems. New tools are being applied there too, including peer-to-peer learning for ministerial staff so they can share successful approaches (see the Joint Learning Network for Universal Health Coverage).
While the major push for systems improvement has to come from the countries themselves, the international community has a stake and a role too. International organizations like the Global Fund to Fight AIDS, Tuberculosis and Malaria and Gavi, the Vaccine Alliance, offer systems strengthening support generally focused on bolstering elements related to their primary missions; the Global Fund provides funding primarily to enhance provision of services related to its three-disease focus while Gavi offers support to improve immunization system functions such as cold chain capacity and vaccinator training.
The U.S. has long supported health systems strengthening through provision of technical assistance and funding, but these efforts pale in comparison to the need, and agencies responsible are hampered in their efforts by congressional mandates to produce results in the short term. Similar to many other donors, Congress appropriates funds largely based on infectious diseases, maternal and child health, and reproductive health. Money often must be siphoned off those accounts to support broader systems efforts. Despite the lack of specific funding, the U.S Agency for International Development (USAID) has developed an Office of Health Systems to coordinate efforts. The agency begins by assessing a system’s current capacities, including its ability to properly use any external funds given to it. It then offers what aid it can in areas such as health financing arrangements and governance, promoting quality medicines, and improving access to pharmaceuticals and services.
The United States can and should do more. These are not glamourous activities, and they have long been a difficult sell to Congress. They are hard to explain and quantify and lawmakers are under constant pressure to justify foreign aid to a deeply skeptical public. But the Ebola outbreak provides a glaring example of the need. While the global health appropriations process is not likely to reform itself out of its current funding methodology, Congress can act to send a strong message that health aid can be used more broadly and with a focus on long term results. This would give USAID and other agencies the authority they need to give health systems strengthening the priority it deserves and provide an extra layer of health protection for citizens in developing countries as well as here at home.