A truly radically innovative approach to global health

Like Barten, Schrecker and Woodward we believe that health is not about health care only, and optimal health care is not the sum of interventions against health problems. Consequently we believe that the current international global health promotion and protection system requires radical reform. However, we fear that the authors might be too optimistic about the innovative character of the three reports that should bring about the ‘radical new approach to global health’.

We should not forget that the original ideals of Alma Ata were abandoned because they were considered too expensive: between US$5.4 to 9.3 billion per year by 2000. Of course this level of spending was perfectly feasible for the global economy, but probably not for the national economies of poor nations. The ideals of Alma Ata were thus largely abandoned because they could not be achieved through national financial self-reliance.

The current development assistance paradigm still focuses on nationalistic solutions and thus the approach focuses on the sustainability of interventions. Barten et al. mention that “talk of making health systems sustainable without relying on external resources is delusional.” We would agree with this. However we would argue that this “delusion” is a widespread and strongly believed norm that lies at the heart of the development assistance paradigm. This general norm results in policies to develop self-sufficient primary health systems within a limited financing window. If we take progress on the Millennium Development Goals as an indicator of progress in developing primary health systems then the current approach is failing. When every year more than half a million prospective mothers in developing countries die in childbirth or due to complications of pregnancy we are clearly failing.

The fight against AIDS, and the Global Fund to fight AIDS, Tuberculosis and Malaria has explicitly abandoned the conventional sustainability norm. Michel Kazatchkine, the executive director of the Global Fund, explained in his speech closing the XVII International AIDS Conference: “The Global Fund has helped to change the development paradigm by introducing a new concept of sustainability. One that is not based solely on achieving domestic self-reliance but on sustained international support as well.” This might be the real ‘radical new approach to global health.’ It is based on the normative belief that there are global responsibilities for global health rights, and that it is therefore no longer necessary to aim for national self-sufficiency. As such, this ‘global responsibilities for global health rights’ approach is therefore fundamentally different from the conventional development assistance approach.

Unfortunately, Kazatchkine’s comment might be true for the Global Fund, but not for development assistance in general. A truly radically innovative approach to global health would expand this new ‘global responsibilities for global health rights’ approach to comprehensive primary health care.

Do the three reports do that? The Global Health Watch 2 report provides the arguments for such a radically innovative approach; it explains how a global economy that is based on competition inevitably creates winners and losers. This is also true of national economies. Within wealthy nations the solution to avoiding great inequities and guaranteeing that vulnerable people can prosper in the future is social protection or distributive justice. One would therefore expect the Global Health Watch 2 report to promote a kind of global social protection or permanent redistribution of wealth between nations, on which national social protection mechanisms can be built. But the Global Health Watch 2 report does not do that; on the contrary it blames the Global Fund for providing unsustainable solutions.

The Commission on Social Determinants of Health emphasises the importance of sustainability, without questioning its usual aiming-for-self-reliance meaning: “Acknowledging the problem of sustainability in the context of a call for equitable health care is a vital first step in more rational policy-making, as is strengthening public participation in the design and delivery of health-care systems.” Acknowledging the problem of sustainability was also the first step in the introduction of selective primary health care.

This dualistic approach to global health; HIV/AIDS exceptionalism and the national sustainability paradigm for primary health care means that in many countries people encounter a horrific paradox. Their health system provides complex and costly interventions to save the lives of persons living with HIV/AIDS, thanks to unconstrained international funding, but cannot provide a skilled health worker during a delivery. This paradox has led to calls for money currently being spent on HIV/AIDS to be redirected towards maternal or child health. However we agree with the WHO’s Dr Isabelle De Zoysa that this is not a time for competition between the maternal, newborn child health and HIV/AIDS communities. In winning the fight to expand antiretroviral treatment to resource constrained developing countries HIV/AIDS activists demonstrated to the global community that a new path could be taken. We would argue this approach should be expanded not restricted.

We fear that history might repeat itself if the conventional development assistance approach is again applied to the fight against AIDS: AIDS treatment might be scaled down for the sake of efficiency combined with self-reliance. Is this an imaginary fear? The World Health Report 2008 asserts that the additional international health aid of recent years – including the international health aid earmarked to fight AIDS – will “need to be progressively re-channelled in ways that help build institutional capacity towards a longer-term goal of self-sustaining, universal coverage”. In other words: rather than expanding the new ‘global responsibilities for global health rights’ approach from the fight against AIDS to the struggle for comprehensive primary health care, the fight against AIDS needs to be squeezed into the conventional development assistance approach.

For this reason alone, there is no widespread support for the comprehensive approaches promoted by these three reports. Too many people legitimately fear that the comprehensiveness will exclude the treatment for the particular disease they happen to have: AIDS. If and only if the movement for comprehensive primary health care embraces the new ‘global responsibilities for global health rights’ approach, will it be able to count on the widespread support it needs.

Footnotes