The recent change in global health policy and priorities, as heralded in three key reports published recently, revitalizes the PHC paradigm to provide ‘health for all’ and is characterized by a strong focus on equity and people-centred health services addressing health problems in a comprehensive and empowering manner. So how can this ‘new’ approach be translated into action, in order to achieve some real and sustained impact on the ground and successfully reduce inequities in health?
Ask what is needed
The answers to what is really needed cannot be found in Geneva or Washington, but ultimately lie with the people and communities themselves. We should hence begin by asking what is needed, and then listening to what is said. The need expressed by communities themselves will go beyond disease-specific interventions and include social and physical aspects to help improve their health, and will require inter-sectoral action to implement interventions in health, livelihoods, gender, using innovative approaches. Giving a (greater) voice to communities and their representatives will also help shape the agenda of donors and other foundations, which are – either through lack of information or interest – not always aligned to respond to the actual needs of the people. An IV drug user in Eastern Europe may not be vocal about his or her real needs, or the provision of food may not be seen as a core objective of an HIV-programme. However, interventions may provide ARVs where safe needles are needed, or condoms instead of maize, which makes both the uptake as well as the impact minimal.
It is therefore crucial that this process is designed in such a way that it gives voice to population groups that may be in a minority or stigmatised for different reasons (ethnicity, extreme poverty, social exclusion) and ensures that their needs are accommodated. At the same time, frontline health care professionals should also be given a voice and opportunity to influence how health services are financed and delivered. These people are confronted daily with the reality of health service provision, and ultimately determine how a policy is implemented and if it reaches its originally stated objectives. Understanding the conditions in which they work, their incentives, and preferences could influence the ability of an often overstretched and under-resourced health systems to deliver equitable outcomes.
Put the money where the needs are
If we know what people are suffering from and match available human and financial resources accordingly, even a little money can go a long way. The TEHIP program in Tanzania is an excellent example of how priority setting based on local evidence can have a real and cost-effective impact on the population. In TEHIP’s two Tanzanian test districts, modest funding increases and sweeping organizational changes contributed to decreases in child mortality of more than 40%. This is accomplished through, among others, a significant focus on human resource development, health spending based on local disease burden, and local ownership.
All the additional money that has become available over the past decade provides great opportunities; however much of these funds are earmarked to specific programs, and thus leave little room for governments to fund national priorities as outlined in the national action plan or overall poverty reduction strategies. In Zambia for instance, total per capita budget spent on health has increased to reach 54 USD today, well above the 34 USD recommended by the Committee for Macroeconomics & Health (Sachs 2001). However, only $12 of this money is actually provided as flexible money, whereas the vast majority ($42) is tied to programmes, mainly for HIV/AIDS and malaria. Hence, national priorities like the urgent need to address the dire human resource crisis in the health sector – identified as one of the main bottlenecks to providing quality health care to the population – receive vastly inadequate funding. In addition, despite the increased funding for health systems by donors such as the Global Fund and GAVI, there is limited information on how it is allocated and what its effects really are.
Work together
Initiatives like the recently launched International Health Partnership (IHP+) aim to strengthen health systems and to ensure that resources invested are spent in equitable and sustainable manner. This represents a shift from vertical, disease-specific models of funding, to horizontal system-building according to long-term strategies. Success thus far has been varied; several country compacts (Nepal, Ethiopia) have been signed, but the US government has not endorsed the process, and donors are still not fully disclosing funding flows. Even though these are laudable initiatives, should there be sticks or carrots to hold people and organizations accountable to their mission statement? Different options to achieve that have been suggested, like creating a new multilateral body that can have the power to monitor donor behaviour and impose penalties, increased transparency (including ‘naming and shaming’), and civil society action. It may come across as too idealistic, but perhaps we should ask ourselves what is needed to create a true partnership at all levels – from local to global – and truly work together towards a commonly defined goal. Many would argue this is essentially a high-level political issue, which is beyond the remit of the global health community. However, ultimately it is a matter of shared values. If everyone puts the people’s interest first, ‘health for all’ is within reach.