The resourcing – or lack of it – for global health is an ongoing and increasingly urgent concern. There has been a steady decline in overseas development assistance (ODA) for health over a number of years and, even within this shrinking pot, spending is often far from reflective of the global burden of disease: less than 2% of health ODA, for example, is spent on non-communicable diseases.
However, a disease-specific approach – pitching health conditions against each other in attempts to get a larger share of already constrained funding – has led to patchy progress, leaving many of the world’s most vulnerable people behind. And today, many hard-won global health gains are threatened by Covid-19 and the economic downturn that it has precipitated.
Action for Global Health along with co-hosts UK Working Group on NCDs and The George Institute for Global Health – held a webinar in January 2021 to discuss how current ineffective and inefficient approaches can be transformed to ensure better resourcing for global health.
The start of 2021 is a unique confluence of shrinking economies worldwide coupled with a vast injection of resources for Covid-19, so can this funding be spent in a way that achieves its primary task of tackling the pandemic while also finding and exploiting win–win health outcomes? This could be the opportunity of our generation to reset global health, creating a system that looks holistically across infectious/non-communicable disease and physical/mental health, within which resources are spent in smarter ways that maximise ‘bang for buck’.
The event had wide appeal, with participants joining from 33 countries (including Argentina, Barbados, the DRC, Ecuador, Egypt, India, Nigeria, Norway, South Africa and the United States) and with participants from government (including the UK’s Foreign, Commonwealth and Development Office), academia, the World Health Organization, World Bank and many NGOs.
The report of the webinar below by Katy Cooper, Chair of the UK Working Group on NCDs, highlights some of the key messages from the event. It ended with a clarion call for action by civil society neatly summarising what needs to be done:
Get political, find efficiencies, question what you read and see, investigate, get the information, link health to human rights, don’t get bogged down in systems and structures, think big, advocate and get noisy! – Allison Beattie, UK Working Group on NCDs.
Action for Global Health and the fellow webinar hosts would like to thank all the speakers for their contributions, and hope that the conversation started at this webinar can continue, including at the hashtag #ResourcingForHealth.
The webinar began with the moderator, Dr Allison Beattie (UK Working Group on NCDs), clarifying that the primary source of health funding is not funding from external sources such as ODA, but from domestic resource mobilisation: direct taxes on individuals/companies, indirect taxes (such as sales tax), non-tax revenue such as that from state-owned companies, and some external sources (such as loans from development banks).
Rob Yates (executive director of the Centre for Universal Health at Chatham House) strongly stated that universal health coverage can only be achieved through public financing. Times of crisis can be times of change – the UK’s National Health Service was established just after the Second World War; Thailand’s prime minister put 1% of GDP into health and scrapped user fees in the aftermath of the Asian financial crisis; and, today, South Africa’s President Ramaphosa is using Covid-19 to accelerate UHC reforms and the introduction of a national insurance scheme. Rob called on civil society not to assume that budgets are already stretched, and instead actively leverage the sudden awareness of the shortfalls in health systems worldwide to push for UHC: ‘I suggest that this is a massive opportunity for civil society organisations to be campaigning for equitable UHC reforms… Now is the time to be pushing much harder and faster for the benefit package to be extended to NCDs.’
This was echoed later in the webinar by Javier Hourcade Bellocq, who suggested that, although there is the fiscal space in middle-income countries to do much more towards UHC, too often there is insufficient political will. Civil society can do much more to call for greater political commitment: ‘The money is there but isn’t properly allocated!’
Three case studies, drawn from the networks of the co-hosts of the webinar, illustrated three ways in which even limited funds can be better spent: more efficient pooling of resources, tackling corruption, and making efficiencies across disease areas.
- James Sale (United for Global Mental Health) gave a whistlestop tour of mental health financing. Mental health has never had relative parity with physical health, but ‘Covid-19 has brought mental health out of the shadows in global health’. The return on investment on mental health is estimated at 5:1, but the returns go beyond the dollar value to improve society, physical outcomes and the person: the ‘return on the individual’. In a West African example, he showed that with incremental increases in health-budget spending on mental health, even modest projections show significant cumulative returns.
- Jonathan Cushing (Transparency International) turned to the impact of corruption and inefficiency on the health sector: an estimated 10–20% of government expenditure on public procurement is lost to corruption each year. This is hard to detect in health systems because of their complexity, but Covid-19 has highlighted poor procurement in high-income as well as lower-income countries. Where systems are made more transparent (as is the case in Uganda, where the number of tenders, the volume of awards, the procuring agencies etc. can be readily identified), government and civil society can interrogate the system to track issues, find blockages and drive efficiencies forward.
- Dr Jane Hirst (University of Oxford and The George Institute) presented on SMARThealth Pregnancy, a smartphone app that integrates the prevention of NCDs into pregnancy care, combining critical care in the short term with prevention of other conditions in the future. Community health workers identify and register pregnant women and undertake simple screening such as blood pressure, and the app provides clinical decision support and advice for at-risk women. A five-year trial is following 20,000 women in India to see if this approach has helped participants to achieve better health outcomes following pregnancy.
Javier Hourcade Bellocq presented on how the resources of the Access to Covid-19 Tools Accelerator (ACT-A) can be put to best use. ACT-A’s explicit ‘health systems connector’ pillar crosscuts across the other pillars of diagnostics, treatment and vaccines. The health systems connector promotes coordination rather than providing direct finance, focusing on ensuring that country plans are fully integrated and bottlenecks avoided, particularly provision of adequate PPE and oxygen in low-income countries. Civil society plays a role in all ACT-A’s work and people with long Covid must be meaningfully involved as part of this engagement – as was the case with people with HIV.
Dr Jo Keatinge (Foreign, Commonwealth and Development Office, UK) welcomed the discussion and called on all those on the call to think about efficiencies, including in how pandemic-response tools are delivered: ‘We really need to use [the Covid-19 crisis] to scrub the way that we are delivering services, making them as efficient as possible to meet those who are most left behind’, using a health system strengthening approach.
A key theme in the discussion was the need to drive political will, whether this is to encourage governments to spend more than the tiny proportion of GDP that many lower-income countries invest in health systems, to highlight how the unacceptable impact of corruption in the health sector, or to encourage governments to invest in women’s health. Civil society has an opportunity to use the heightened awareness of health during the Covid-19 crisis to make the case for action – so, in closing, each speaker was asked to suggest one way in which civil society organisations can advance the agenda for better resourcing for health:
- Rob Yates: ‘Quite simply: get political!… Now is the time for us to unite, particularly behind the UHC campaign – and then we will have a bigger cake to share out!’
- James Sale: Look to government departments beyond the health ministry: ‘It’s got to be a cross-governmental approach to cross-societal problems.’
- Jonathan Cushing: Start questioning where public money goes: ‘this will build a culture of accountability and drive the efficiency gains that we need’.
- Jane Hirst: Integrate human rights and sexual and reproductive health rights into this agenda as part of the discussion on distributing resources.
- Javier Hourcade Bellocq: ‘Keep advocating and watchdogging and barking, because this is our added value [as civil society organisations]!’