Time for a Global Fund for health

The following is an article, originally published in The Lancet in May, written by Giorgio Cometto, Gorik Ooms, Ann Starrs and Paul Zeitz . To view the full article, with footnotes and author bios, visit The Lancet website.

The world is off track to achieve the health-related targets of the Millennium Development Goals (MDGs) by 2015. Maternal mortality has stagnated for two decades, child mortality is not declining fast enough, HIV/AIDS still infects people faster than the pace of antiretroviral treatment roll-out, and inequalities are widening within and across countries.

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", 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.

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". 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; 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. 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". 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.

Only by comprehensively strengthening health systems will it be possible to overcome structural challenges to service delivery, in particular the shortage of health workers. 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.