Posts Tagged ‘health systems’

The Center for Strategic and International Studies yesterday unveiled  a new “must-read” report for global health advocates, “Smart Global Health Policy.” While a panel at the Congressionally-chartered Institute of Medicine, made up primarily of scientists, issued recommendations on US global health policy last year, the CSIS panel is the first to involve high-level business leaders and sitting members of Congress.

The report drew on observations made during a study trip to Kenya, but it is unclear if consultation in developing countries went beyond that, for instance to include global representatives of affected communities and of developing country civil society, such as those on the boards of UNITAID and the Global Fund.

The report and the webcast of the launch event are available online.  Here are a few highlights:

The report makes a strong case that it is in the interest of the United States to continue and increase  our investment in global health and that the issue should matter to all Americans. It calls for keeping funding for AIDS, TB and malaria on a “consistent trajectory,” doubling spending on maternal and child health to $2 billion a year, forging a collaborative response to emerging heath threats, establishing strong coordination of global health policy across US agencies, and increasing support for multilateral efforts.

In 2009 there was a massive drop off in the expansion of treatment by US programs, and the report notes that AIDS advocates are “particularly anxious” at the slowing growth rate, a stalling that could also impact health systems.  The report suggests that funding is a concern for treatment advocates, yet, in fact, HIV prevention advocates have also been quite alarmed at the essentially flatline funding picture.

Despite World TB Day (March 24) being just a few days away, no mention is made in the report of immediate tuberculosis funding concerns, lowered TB targets in the 6-year Global Health Initiative or USAID’s role in responding to TB.  Instead, the report includes TB within a much longer timeframe, stating that “we can accomplish great things in the next 15 years:  We can cut the rate of new HIV infections by two thirds, end the threat of drug-resistant tuberculosis, and eliminate malaria deaths.”

In terms of overall funding, the report calls for less spending in the near term than either the IOM panel or the Global Health Initiative coalition did; instead, the CSIS document endorses the President’s proposed funding of $63 billion by 2014.  While the IOM called for specific increased funding levels on AIDS, TB and malaria consistent with Lantos-Hyde, the CSIS report does not delve into specific funding levels, with the exception of maternal and child health.  Instead, taking the long view, it calls for $25 billion in annual spending by 2025.

One exciting aspect of the CSIS report is that it endorses innovative financing as a means of raising funds for global health.  The report does not touch on the concept of innovative taxation for health, recently championed by maternal health advocates at Family Care International and many other groups. However, it identifies some specific mechanisms, such as borrowing the money needed through an international finance facility, and it urges the US National Security Council to review the most promising ideas on innovative financing and develop a US position.

Admiral William J. Fallon kicked off the launch event, stating that global health is a “bipartisan enterprise… which can unite US citizens in collective action.”  He stated the importance of maintaining forward momentum, noting that “we do not want to coast or slide backward.”  Helene Gayle said that global health efforts are showcasing the American spirit of generosity and said “we need forward momentum even in a period of constrained resources.”

Jack Lew, the top State Department official developing the US Global Health Initiative, spoke about the Administration’s goals in developing the new strategy. He said that the Administration’s aim was to “challenge a way of doing business by moving beyond a primary focus on disease treatment.”  He said the goal was “not to do harm to existing programs.”

Advocates for effective HIV prevention have felt stymied in recent weeks by the lack of specific HIV/AIDS guidances from the Administration to the field and have noted that Kenya’s Partnership Framework with the US even appears to rule out family planning integration.  Family planning came up at the event when Dr. Michael Merson, of Duke University, criticized the Canadian government’s rejection of the inclusion of family planning as a part of its maternal health initiative.

But Lew’s presentation did not delve into details — and there was no opportunity at the event for questions from the floor.  He stated that program integration was crucial to meet the needs of women, and he commented on the importance of having family planning and HIV/AIDS services in one location.

The report is particularly noteworthy for the very strong focus on measurement for accountability in delivering services. Business leaders at the event decried the reporting burden on health programs and, along with Dr. Merson, called for a common set of impact indicators.

Rajeev Venkayya, Director of Global Health Delivery at the Bill and Gates Melinda Foundation, said that measurement matters because it allows us to maximize efficiency and stretch dollars while identifying what works and what doesn’t.  In addition, measurement allows us to hold accountable institutions, organizations, and even individuals, which in turn allows for greater project improvement.  Exxon Mobil Chairman and CEO Rex Tillerson agreed, and cited a Lancet article which said that evaluation must be a top priority for global health.

Robert Rubin, former US Treasury Secretary and former head of Citigroup and Goldman Sachs, told the audience that global health leaders “face wrenching choices” as a result of US fiscal problems.  He asked two members of Congress, Rep. Keith Ellison and Senator Jeanne Shaheen, whether global health is an issue that can “break through the mire” on Capitol Hill.

Senator Shaheen said that the issue can succeed, but it is crucial to explain to Americans that international affairs spending is only a tiny fraction of the US budget, much less than people realize.   She said it was cheaper to spend on global health than on war, noting Bill Clinton’s recent statement about the appreciation of PEPFAR expressed by Muslim residents of Tanzania.  She also said the current committee structure in Congress is an impediment and endorsed the recommendation included in the report for a consultative body that would work across committees.

Congressman Ellison also voiced strong support for greater US action on global health, stating that “infectious diseases know no borders.”  He said that while in Kenya, he made good progress in persuading Kenyan leaders of the necessity of stepping up their own contributions.  He suggested that by reducing US spending on outmoded weapons systems the US could improve its budget outlook and make global health spending easier.

Gayle Smith, the NSC official leading the development of the US Global health Initiative, was the concluding speaker at the event. She said global health was a bipartisan issue and that in fact President Obama specifically directed that the achievements of the previous Republican Administration be recognized.  She praised the CSIS report, and said that its ideas were remarkably congruent with those of the Administration.

She said the Administration’s commitment to fighting global HIV/AIDS was “absolute” and, she added, “this will grow over the life of the initiative.” She said the Administration’s plans for the Global Health Initiative “include an ambitions set of targets in terms of outcomes.”

She did not respond to concerns submitted to the Administration by the Global Center, TAG, the Global Health Council, and the GHI Working Group that the Administration’s targets regarding tuberculosis contradict a directive from Congress approved in 2008 as a part of Lantos-Hyde.  In fact, it was surprising that the event unfolded without  reference  to the consultative process which numerous NGOs have engaged in regarding the US Global Health Initiative or to the detailed analyses these groups have submitted to the Administration.

There were a range of reactions from health NGOs to the event.  Eric Friedman at Physicians for Human Rights noted the “surprisingly little attention in the report to human resources for health and health systems, and no mention of including civil society in the development of country compacts.” He praised the report for “proposing that the Administration develop a long-term, 15-year framework for making progress in and committing the United States to improving global health, a good idea so long as it does not set the stage for underambition, and is flexible to respond to changes in the years ahead. ” He also would have liked to see “a recommendation that the United States should deliberately integrate a right to health approach throughout U.S. global health programs, including the consistent focus on equality, accountability, and participation that this entails.”

Matt Kavanagh at Health GAP praised what he heard from the report, which included an emphasis on keeping up the fight against HIV/AIDS, especially important for the health of African women. But he noted with concern that “some of the Administration comments that seemed to favor prioritizing ‘cheap’ interventions that do not work in the long term, such as single dose nevirapine instead of treatment for HIV positive mothers, an approach abandoned long ago as ineffective in wealthy nations.”

The American Medical Students Association’s Farheen A. Qurashi said that the report “takes a bold, but necessary, approach to U.S. global health planning by insisting upon a 15-year comprehensive plan.”  She said, “Unfortunately, the Commission’s report does not appear to specify the need for scaling-up of PEPFAR investments versus the dangers of flat-funding, and instead uses language that suggests that a continuation of current levels of funding without annual growth is sufficient.”

On health systems, she said that “though integration and health systems strengthening is mentioned in general terms, and the need for training and retention of health care workers is noted, there is no detailed analysis of the measures, funding, and support necessary to establish and retain adequate numbers of health professionals and other health care workers.”

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A new issue brief released today by the Center for Global Health Policy and amfAR, The Foundation for AIDS Research, highlights the transformative success of the global AIDS response in changing the trajectory of the epidemic and improving health outcomes beyond AIDS.

The issue brief details the diverse impacts of the intensive response to the AIDS pandemic, including reduced mortality; benefits in addressing other diseases, such as tuberculosis and malaria; in strengthening health systems; and building a strong emphasis on accountability and outcomes in global health initiatives. A sidebar addresses flaws in current arguments for shifting global health priorities based on cost-effectiveness considerations. 

The report’s recommendations include keeping U.S. commitments on the global AIDS response by expanding investment in AIDS and other global health initiatives, and using PEPFAR programming and principles as a foundation for broader health service delivery.

The full report, titled, “Smart Investments in AIDS and Global Health: Building on What Works,” is available at www.idsaglobalhealth.org or http://www.amfar.org/hill/article.aspx?id=8222.

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HIV is not to blame for the ills, figuratively or literally, of developing world health systems, and funding for AIDS programs can’t take a hit in favor of other health threats.

That’s the take-home message of a statement issued last week from 87 civil society, research and other health groups from more than two dozen groups around the world. The statement condemns the notion that donor countries should siphon funding from global HIV programs to address other health problems in resource-poor countries.

“The neglect of health systems in general, and particular health challenges such as tuberculosis and diarrhea, is not a recent phenomenon and certainly cannot be attributed to one disease that is obsessively touted as the culprit-namely, HIV,” the statement reads.

The proclamation—titled “HIV is not over-funded: Health is under-funded”—rejects the notion that other health threats can or should be addressed by pitting AIDS funding against other needs, such as child and maternal health.

“This competition is completely irrational,” Paula Akugizbwe, of the AIDS and Rights Alliance for Southern Africa, said at a press conference in Cape Town last week.

“We cannot keep shuffling our scanty resources from one disease to another and expect to see lasting change,” said Akugizbwe, a key player in organizing the statement. “Health, a vital requirement for stable societies and socio-economic development, needs to be prioritized and funded appropriately. But this cannot be at the expense of HIV, which underpins so many other health challenges.”

As the statement says: “More resources for health overall are desperately needed – not only for the humanitarian and health systems benefit, but also to lessen the destabilizing impact of poor public health on socio-economic progress, particularly in low-income countries.”

It continues: “Shifting funding from HIV will not fill the yawning gaps in resources for health – this move is a cheap diversionary tactic that offers no genuine or long-lasting solutions for health systems. What is required is a shift in political will to prioritize and invest vigorously in health. Until this happens, neglect and dysfunction will continue to pervade health systems irrespective of what specific health needs we focus upon.”

 Read the full statement and see the list of endorsers by clicking below.

HIV Is Not Over-Funded Health Is Under-Funded_19 11 09

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For decades, global health experts, policymakers, and others have been debating the merits of disease-specific initiatives versus broader efforts to strengthen health systems. It’s the old the vertical vs. horizontal argument.

No one has settled that debate. But maybe we should stop asking that particular question. Or at least start asking some new ones.

 “It’s not a helpful way to frame the issues,” Peter Berman, a lead economist on the health, nutrition and population team at the World Bank said today at a brown bag lunch exploring what TB and AIDS programs can contribute to health system strengthening in Africa.

He said all health initiatives, whether focused on one disease or on something broader, are aimed at improving results, i.e. health outcomes. So it’s not productive to engage in a debate that pits one approach against another. Instead, Berman suggested, we need to start asking more “why” questions. Why is the quality of a country’s TB program so poor? Why are the primary care clinics in another resource-poor country crumbling?

“We need to think more about the casual analysis,” he said. If we don’t ask the why questions, he said, we’re at risk of introducing “technical solutions” that improve things in the short term, but that fail to make enduring fundamental change.

Berman’s remarks came near the end of the World Bank session, which featured two experts from Family Health International. (more…)

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As Obama’s new global AIDS coordinator, Dr. Eric Goosby has no shortage of burning issues on his plate—from reports of ARV stock-outs in the developing world to questions about the long-term sustainability of PEPFAR. At a 1 ½ hour community meeting at the State Department Friday, the unassuming California doctor tried to reassure the global AIDS community that he has his eye on both the immediate and the far-reaching.

So even as he’s pushing aggressively forward to develop country ownership and building capacity for taking over AIDS programs, Dr. Goosby said he’s also urgently aware of the need to scale up prevention of mother to child transmission, to find ways to expand ARV treatment in a tight budget climate, and to meet new PEPFAR mandates, including recruiting 140,000 new health care workers.

In a wide-ranging session with more than 100 advocates and experts, Dr. Goosby said his overarching goal as head of PEPFAR is to build an enduring program that will be there to serve the sick and poor in developing nations for decades. “We are at an exciting point in PEPFAR’s evolution,” he said from the dais of an auditorium in the State Department. “Our charge now is to make sure that contribution is realized into the future, not for five years but for 25.”  

“… The economic downturn has created an urgency to this discussion that wasn’t there before,” Dr. Goosby said. But he acknowledged the country-ownership effort will take a decade or longer to achieve.

“No country is in a position to take over” these PEPFAR programs, but US and other leaders need to start the dialogue now, he said. (more…)

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For anyone concerned about a pullback in funding for global AIDS programs, this commentary in The Lancet Infectious Diseases is a must read. It addresses the apparent wavering commitment of donor countries amid the economic downturn and touches on the unfolding debate about the merits of disease-specific initiatives, such as PEPFAR, versus efforts to efforts to strengthen health systems. Here’s what the editorial has to say on that point:

“Although programmes that focus on single diseases are under increasing criticism as being too narrow in focus to bring about sustainable changes to health, efforts funded by the Global Fund to Fight AIDS, Tuberculosis and Malaria, GAVI, and the US President’s Emergency Plan for AIDS Relief have not only enabled countries to start tackling their HIV/AIDS problems over the past 9 years, but also helped to strengthen health systems generally. These initiatives also have the potential to help tackle the problems of malnutrition and gender and social inequality.” (more…)

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Dr. Luis Sambo, the WHO’s regional director for Africa, sought to draw attention this week to the growing threat of drug-resistant strains of HIV, tuberculosis and malaria on the continent, calling for aggressive action “before the situation gets out of hand.”

Sambo made his comments during the 59th session of the WHO regional committee meeting in Kigali, with Rwanda getting some praise for progress in improving its health services. But more broadly, Sambo said African countries needed to respond forcefully to the emergence of virulent new strains of TB and other deadly diseases. He called for a nine-point plan that includes developing human resources, strengthening lab capacity, and bolstering drug supply chains, among other steps.

All those concepts go to the very core of health-system strengthening, a fresh point of focus in the US, where the Obama Administration is reshaping US global health priorities. On that front, there was this very interesting blog post on the Center for Strategic and International Studies’ website today about broader benefits of the US global AIDS program in Kenya to that country’s health system. (more…)

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With PEPFAR seemingly at risk of being shortchanged by the Obama administration, there was a special urgency to Wednesday’s Capitol Hill briefing about the future of global health programs.

The debate was framed, in health advocate speak, as vertical vs. horizontal. In other words, are vertical programs like PEPFAR, focused specifically on HIV/AIDS, draining money and talent from developing-country health systems? Or are such efforts strengthening health systems by building new lab capacity and training community health workers?

The panel tilted heavily toward the latter argument, fearing Joanne Carter of RESULTS and Paul Farmer of Partners in Health.

Farmer said the argument over whether HIV/AIDS, thanks to PEPFAR, is getting too much money and attention is “silly” when examined in a historical context. “Before we decide its overkill, we need to realize this program is brand new,” Farmer said.

Pat Daoust, of Physicians for Human Rights, said in the beginning, vertical programs like PEPFAR did drain resources from developing country health systems. But that has now changed dramatically, with much more emphasis on integrated care, developing a health care workforce, and other strengthening elements.

“It was the Trojan Horse that opened our eyes to the extreme need,” she said. PEPFAR taught us “how to launch effective health programs” and to pull back now would be devastating.

Farmer said that comprehensive integrated care should be the ultimate goal and that PEPFAR is one way of working toward that. Ultimately, he said, the debate should be further broadened to look for ways of breaking the cycle of poverty.

“Why is AIDS more important than maternal and child health? The answer is it’s not,” said Farmer. “When you’re dead, you’re dead.”

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