“Now more than ever”: The World Health Report 2008 calls for a revitalization of the idea and the principles the international community agreed upon at the historic conference of Alma Ata in 1978. Over the past months the international health community has been engaged in an intense dialogue about possible detrimental effects of disease-focused approaches on health systems and the need to support countries’ capacity to provide people centered essential health services. I would argue that there is no dichotomy between a specific disease focus and a broader Primary Health Care approach. They should be regarded as mutually reinforcing and we need to align and strengthen our joint advocacy in order to achieve comprehensive solutions. I would like to make two arguments in this regard:
1. The fundamental principles of Primary Health Care and the Global Fund to Fight AIDS, Tuberculosis and Malaria are very much aligned.
2. The momentum towards Primary Health Care was initiated by a growing recognition that there were tremendous imbalances in the financing of the health care pyramid. I would argue that the Global Fund is addressing exactly this imbalance.
In order to understand the role and potential of the Global Fund for realizing primary health care and community health I’d like to reflect upon the core principles of the Global Fund as well as upon the results and the impact after five years. The concept of primary health care with its important principles of country ownership and participation provide the foundation of the Global Fund which was envisioned as a tool to achieve equitable access to health care. Let me highlight some examples: In Alma Ata the international community agreed to base any health plan on countries’ social and economic conditions; country ownership is one of the fundamental principles of the Global Fund. The Global Fund does not prescribe what a country should apply for. It is up to the country to decide on its strategy and priority interventions. Countries are asked to develop proposals that reflect country needs, local capacity and gaps.
The principle of community participation is central to the Global Fund’s governance structure both at global and at country level. In the Global Fund’s international board civil society and the communities of people living with the diseases are represented with three seats and three voting voices. This model of a participatory decision-making body is mirrored in the country coordinating mechanisms involving governments, civil society and the private sector. While the concept of Primary Health Care calls to formulate national action plans the Global Fund’s Board has decided that the Global Fund should strive towards funding national plans. This will be rolled out from 2009 on. The last key principle I would like to highlight is scientific evidence which is reflected in the Global Fund’s technical review panel that evaluates country proposals on the basis of technical soundness in evidence based interventions.
AIDS as a pathfinder
When the Global Fund was founded in 2002 as a brainchild of Former UN Secretary General Kofi Annan and with strong support from civil society organizations around the world its central task and mandate was to mobilize additional financial resources for the prevention and treatment of HIV, Tuberculosis and Malaria. This focus on the three diseases was due to the fact that people living in poverty did not have access to effective prevention, treatment and care. In many developing countries the health systems were not able to scale up their services because they were not equipped to treat the vast numbers of people who urgently needed and still need life-saving medicine. The health sector suffered and still suffers from lack of funding, migration of personnel (brain drain) and weak management over years and decades. Unlike any other health phenomenon AIDS has revealed these gaps that exist in the health systems. Inequity and the lack of resources were not unique for AIDS. It applies to all health conditions related to poverty. But AIDS has been the first disease to raise awareness of the unacceptable injustices in our global health care system to the highest level of attention with political decision makers and the general public. While it has often been argued that the focus on AIDS and other infectious diseases have crowded out a more general support for health and health systems, we need to ask what would have happened to health care and health systems, if interventions on specific diseases had not been funded and scaled up. Since 2002 the Global Fund has committed more than $ 14 billion to country driven programs in the fight against AIDS, tuberculosis (TB) and Malaria.
Today the Global Fund finances AIDS treatment for 1.75 million HIV-patients, 3.9 million people are receiving directly observed treatment in programs that are supported by the Global Fund and 59 million mosquito nets have been distributed. While the World Health Report 2008 states that “health systems seem to be drifting from one short term priority to another, increasingly fragmented and without a clear sense of direction“ it makes the strong case that individual diseases and especially the social movement behind HIV/AIDS can also “be viewed as a pathfinder to primary health care”. AIDS has indeed enhanced the discussion and the understanding of the role of people living with the diseases, the need for country-based approaches and the focus on science- and evidence based approaches. If we look at the development and the scale up that took place over the past 30 years it is evident that a central novelty that came along with AIDS has been the financial commitment by the international community to significantly scaling up the financial resources. Since the turn of the millennium we have seen a tremendous increase in international aid for health.
Strengthening all levels of the medical care pyramid
If put in place globally primary health care would allow for the highest attainable standards of health prevention and health care for all. However, reality shows that the world has been far too slow in implementing Alma Ata’s values and the principles. If we accept that financial investment has been one of the missing links of the primary health care commitment, I’d like to argue, that the Global Fund represents one of the first global efforts and opportunities to channel international financial resources to all levels of the medical care pyramid. The Global Fund recognized early on that fighting the three diseases and support for health systems go hand-in-hand to achieve impact that is sustainable over time. Strengthening these systems is an important part of delivering health services effectively. While the core mandate of the Global Fund is the financing of disease specific programs it offers a lot of flexibility for horizontal programming and implementation related to the three diseases. Country experience and data show that disease-specific funding has positive effects on the overall health services in partner countries.
Let me highlight some examples how the Global Fund’s investment supports health systems directly with financing, and through reducing mortality among health workers, and tackling the disease causes of hospital burdens:
• In Malawi where HIV/AIDS has acerbated the human resources crises the AIDS program supported by the Global Fund investment has helped to save the lives of a significant number of health workers, providing an 11 percent boost to health workers’ time. The funding channeled through the Global Fund therewith supports the country in gaining ground from which to further build social security systems. Overall the Global Fund has approved to support Malawi with additional financial resources in a volume of $ 590 million. In order to align this investment with wider programs the Global Fund contributes to the pooled funding mechanism through Malawi’s Sector Wides Approach (SWAP) scheme.
• In Rwanda the Global Fund supports the improved financial accessibility to health care for the poor, People living with HIV and AIDS and orphans, and also strengthens and improves the performance and quality of the health service delivery system. A key element is the community insurance scheme. The input of the Global Fund has contributed to increasing the health insurance coverage from 44 percent to 73 percent. With Global Fund financing, over 1.5 million annual insurance subscriptions were paid for very poor people and 146,130 annual subscriptions provided for People living with HIV and AIDS. While the relative allocation of finances to combat HIV in Rwanda has been higher than that for other disease outcomes, the HIV program has resulted in a successful health outcome, showing decline in prevalence in recent years and a large increase in AIDS treatment, moving towards universal access. Child mortality is also now declining rapidly towards the targets set by the Millennium Development Goals with the implementation of malaria interventions.
• In Ethiopia the Global Fund and partners expand access. Supporting the HIV program in Ethiopia has had many positive effects on the health system. A total of $ 443 million has been disbursed by the Global Fund in support of AIDS, TB and malaria activities in Ethiopia. 30.000 community health workers have been trained with support from the Global Fund. They are clearly part of the lowest segment of the health pyramid but crucial for the delivery of bednets and the distribution of AIDS treatment.
• In Bangladesh the Global Fund is currently supporting five health programs with the government and BRAC – the Bangladesh Rural Advancement Committee – as principal recipients. These programs and especially the work that is done by BRAC at community level – financed through the Global Fund – has contributed to effective TB control in Bangladesh by involving communities and increasing access to diagnosis and treatment. Currently 70,000 female health volunteers, 17,000 village doctors and cured TB patients are delivering DOTS services in addition to 28,000 government field health staff.
From 2007 the Global Fund has included funding to strengthen broader health systems beyond a single disease. For funding round 8 – which has been approved by the Global Fund’s Board in Novmeber 2008 – 25 distinct requests for health systems strengthening have been recommended for funding. This amounts to a financial volume of almost $ 270 million for distinct health system strengthening measures. In addition health system strengthening components have been included in the diseases specific parts of country proposals. The overall financial volume of the recommended proposals has tripled from last round to $ 2.7 billion.
Sustaining results through impact on health systems
The Global Fund has commissioned an independent Five-Year Evaluation. The first two reports on organizational effectiveness and the functioning of the partnership model are already available. But the most eagerly awaited part is Study Area 3 examining the impact of the Global Fund on morbidity and mortality and the effect on health systems. Teams of public health experts are currently examining the Global Fund’s impact in 18 countries. Whether the disease specific additional investment has negative, crowding out effects on other health is on central question of this ongoing study that will be finalized by March 2009. The evaluation puts special emphasis on maternal and child health as this sector has often been said to suffer from a shift towards disease specific interventions. Results from studies in Tanzania, Zambia, Rwanda and Malawi – countries that all hold a large Global Fund investment portfolio – describe that the investment coming in through the Global Fund did not have a negative effect on the Maternal and Child health sector. To the contrary investment in Maternal and Child health has gone up since 2002. While there is positive and promising development in demand from countries as well as in available financing, we must not lose the focus on the remaining gaps. The Global Fund recognizes that some of the most innovative services are provided by NGOs and community organizations, alongside government and strongly supports strengthening of community organizations to deliver AIDS, TB and malaria services. Programs supported by the Global Fund can include community systems strengthening components in their funding requests. Under “CSS” applicants can for example apply for funding for infrastructure building, development of management skills, information exchange and networking instruments.
In conclusion I would like to make ten points:
1. Over the last six years the world has seen an unprecedented increase in the amounts of resources available for global health.
2. This increase was largely due to very effective advocacy involving community groups affected by the most devastating communicable diseases and political leaders at the highest level.
3. The advocacy was driven largely by the AIDS movement with increasing engagement of a growing malaria movement.
4. There is no doubt in my mind that Primary Health Care, Maternal and Child Health and Health Systems in general need more funding and political attention.
5. Some suggest that slowing down disease specific advocacy might bring more resources to Primary Health Care and Health Systems. I think this is wrong.
6. I have always regarded the AIDS movement as the engine of a train that provides more resources for health in general overcoming outrageous inequalities. Stopping the engine could stop the whole train and there is no guarantee that it will ever pick up speed again.
7. The Global Fund is the primary instrument for a more just and equitable distribution of resources in global health. For its functioning it relies on a unique partnership model that includes WHO, UNAIDS, bilateral partners, NGOs, the Private Sector and many more. I hope I was able to demonstrate that the Global Fund model provides opportunities and flexibilities for access to health far beyond a narrow definition of the three diseases.
8. The Global Fund has never claimed to be a perfect institution. Rather it regards itself as learning and listening organization. Our Partnership Forum in December 2008 in Dakar Senegal inviting more than 400 participants largely from grassroots organizations was held under the theme: “Listening to the voices – Stronger and more effective partnership for sustained impact”.
9. My appeal is that we use the strength of both the Primary Health Care and the AIDS movement to align our advocacy messages and strategies for the benefit of better financed comprehensive health programs.
10. Only as a unified movement we will be able to make progress towards our common goal: “Equitable access to quality health services for all”. Together we can achieve this ambitious goal.
*Dr Christoph Benn is Global Fund’s Director Partnerships, Communications, Resource and Mobilization. Contact: Christoph.Benn@TheGlobalFund.org
