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

1 WHO. World health statistics 2008.
http://www.who.int/whosis/whostat/EN_WHS08_Full.pdf. (accessed March 17, 2009).

2 Hill K, Thomas K, AbouZahr C, et alon behalf of the Maternal Mortality Working
Group. Estimates of maternal mortality worldwide between 1990 and 2005: an
assessment of available data. Lancet 2007; 370: 1311-1319. Summary | Full Text |
PDF(133KB) | CrossRef | PubMed

3 Loaiza E, Wardlaw T, Salama P. Child mortality 30 years after the Alma-Ata
Declaration. Lancet 2008; 372: 874-876. Full Text | PDF(72KB) | CrossRef |
PubMed

4 UNAIDS. 2008 Report on the global AIDS epidemic.
http://www.unaids.org/en/KnowledgeCentre/HIVData/GlobalReport/2008/2008_Global_r\
eport.asp. (accessed March 17, 2009).

5 Commission on Social Determinants of Health. Closing the gap in a generation:
health equity through action on the social determinants of health.
http://whqlibdoc.who.int/publications/2008/9789241563703_eng.pdf. (accessed
March 17, 2009).

6 WHO. Maximising positive synergies between health systems and global health
initiatives. http://www.who.int/healthsystems/MaximizingPositiveSynergies.pdf.
(accessed March 17, 2009).

7 High Level Taskforce on Innovative International Financing for Health Systems.
Terms of reference and management arrangements.
http://www.internationalhealthpartnership.net/pdf/IHP%20Update%2013/Taskforce/TF\
%20REVISED%20Press%20statement%20(2008%2011%2030)%20v%206.pdf. (accessed March
15, 2009).

8 Lob-Levyt J, Kazatchkine M. Letter to the High Level Taskforce on Innovative
International Financing for Health Systems.
http://www.internationalhealthpartnership.net/pdf/IHP%20Update%2013/Taskforce/lo\
ndon%20meeting/new/GAVI%20and%20GFATM%20letter.pdf. (accessed March 21, 2009).

9 Taskforce for Innovative International Financing for Health Systems. Working
group 2: raising and channelling funds. Progress report to Taskforce.
http://www.internationalhealthpartnership.net/pdf/IHP%20Update%2013/Taskforce/lo\
ndon%20meeting/new/Working%20Group%202%20First%20Report%20090311.pdf. (accessed
March 17, 2009).

10 Gordon JG. A critique of the financial requirements to fight HIV/AIDS. Lancet
2008; 372: 333-336. Summary | Full Text | PDF(70KB) | CrossRef | PubMed

11 Shiffman J. Has donor prioritization of HIV/AIDS displaced aid for other
health issues?. Health Policy Plan 2008; 23: 95-100. CrossRef | PubMed

12 Individual Members of the Faculty of Harvard University. Consensus statement
on antiretroviral treatment for AIDS in poor countries.
http://www.cid.harvard.edu/cidinthenews/pr/consensus_aids_therapy.pdf. (accessed
March 17, 2009).

13 Travis P, Bennett S, Haines A, et al. Overcoming health-systems constraints
to achieve the Millennium Development Goals. Lancet 2004; 364: 900-906. Summary
| Full Text | PDF(188KB) | CrossRef | PubMed

14 Médecins sans Frontières: Help wanted: confronting the health care worker
crisis to expand access to HIV/AIDS treatment. MSF experience in southern
Africa.
http://www.msf.org/source/countries/africa/southafrica/2007/Help_wanted.pdf.
(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@...