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Last Word Unhealthy Competition Global health advocacy has an oddly competitive tone. Those who argue for investments in life-saving interventions often cite estimates of lives saved or diseases averted as if they were part of a high-scoring football match. More money for immunization, the argument goes, would yield 3 million children’s lives a year. More for diarrheal disease control would yield another 2 million. AIDS claims 3 million lives a year, and tuberculosis takes 2 million. New “causes” are rarely welcomed in an already crowded field of injunctions to buy more medicines, train more health workers, spend more money. New priorities find they must use the same metrics of importance and urgency—a count of deaths or some measure of the burden of illness—if they are to get the attention and resources they seek. Such has been the case since at least the mid-1990s, when the publication of the World Bank’s 1993 World Development Report: Investing in Health introduced the concept of disability-adjusted life years (DALYs), a measure that combines years of potential life lost due to premature death with years of productive life lost due to disability. Many in the policy community adopted a naïve interpretation of how the concept should be applied to resource allocation: the more DALYs, the more money. Advocates who had earlier focused on specific populations (children or women of childbearing age, for example) or types of health care delivery (such as primary care) quickly learned the new vocabulary of priority-setting and started toting up the DALYs to support arguments for spending on particular types of services, from immunization to bed nets. The DALY made a major contribution to sound policymaking. By going beyond mortality as the sole metric of health impact, it gave a more balanced perspective to the burden of chronic and nonfatal diseases. It focused decisions about resource allocation on health impact rather than on dubious counts of health system inputs, such as arbitrary ratios of health facilities or medical professionals per inhabitant. Yet there are logical flaws in the way DALYs are often applied, and these can be profoundly misleading. DALYs estimate the burden of a particular health condition in a population, but they tell us nothing about the difficulty or cost of addressing that health problem. Without complementary information about cost-effectiveness, they provide little guidance on how societies can make the most of every health dollar spent. Ignoring the broader social benefits of addressing particular health problems, they do little to help sort out what governments ought to finance and what is best left to individuals and their families. Naïve use of DALYs—and advocacy-by-numbers in general—can push priorities toward health problems that currently exact major tolls but away from efforts to sustain past achievements or to prepare for future, hard-to-quantify threats, such as pandemic influenza. When the metric of priority is burden of disease, and the goal is to score the highest DALYs to preserve or enlarge a budget, there are unintended consequences. One serious result can be the fragmentation of both financing and delivery of services. Funding is earmarked for dedicated staff and facilities, or particular drugs or interventions, often yielding poor results for the overall functioning of a system that needs to respond to a diverse population with a whole range of personal and public health needs. Health care management becomes distracted by each new, noisy priority, and opportunities for jointly addressing multiple health problems are lost.
In the scramble for
attention and resources, global health advocates too often find themselves promoting one cause over another... at the expense of the larger needs of health systems. The most prominent examples of this problem today can be found in the fight against HIV. The scope and threat of HIV are real, and the urgency of addressing it makes efforts that bypass existing systems and ignore other health care issues somewhat understandable. However, when funding for HIV prevention and treatment is used too narrowly, it can undermine provision of care for other major health problems or for populations not affected directly by HIV. In the past few years, as funding for global HIV programs has risen dramatically (from $300 million in the late 1990s to $8.3 billion in 2005), so have concerns that health personnel are being diverted from routine care by high-profile HIV programs that offer better salaries, and that parallel supply chain management, monitoring, and accounting systems are being created within the health sector, ignoring existing ones. The impact of this kind of pressure on other health problems or populations has rarely been adequately taken into account in the design of disease-specific programs. Not all disease- or intervention-specific programs have this effect. In the elimination of poliomyelitis from the Americas, for example, an ambitious program that was nominally focused on a particular health problem (polio) and intervention (mass administration of the oral vaccine) also strengthened the capacity of the public health systems of the region in a number of areas: management of immunization program logistics, disease surveillance, public health information, and others. Clearly, any additional resources that are generated—whether from international or national sources—in response to a particular health threat have the potential to confer broader benefits for the functioning of health systems, including both government and private components. This being the case, HIV program advocates should welcome new attention to pandemic flu, and those who care about childhood immunization should root for more money for prevention and mitigation of the impact of diabetes. Increasingly, the global health community is embracing the challenge of using “vertical” disease-specific dollars to support “horizontal” systemic capacity. Some high-profile initiatives that focus on particular health conditions—including the Global Fund to Fight AIDS, Tuberculosis and Malaria and the Global Alliance for Vaccines and Immunization—have invited recipient countries to use resources for “health system strengthening,” though there is little clarity so far about how to do this. Progress depends on many things, but addressing the vertical-horizontal debate is essential. Advocates, policymakers, and program managers should do the following to ensure that any public health resource mobilization—for whatever cause—also serves to strengthen countries’ health systems overall: Address underlying system weaknesses. Identify the gaps in a country’s ability to carry out essential public health functions, including disease surveillance, health education, monitoring and evaluation, workforce development, enforcement of public health laws and regulations, public health research, and health policy development. Recognize that key shortcomings in these functions must be addressed to respond to virtually any major health problem that merits public policy attention, whether at the international or the national level. Invest in systemic improvements. Use new resources to strengthen and build upon existing systems, including information and monitoring systems, supply chains, delivery of services, and others. Design any new program within a long-term framework for strengthening of health system capacity and with short- to medium-term operational plans. The long-term framework can include centrally managed programs—some public health interventions are best organized through such approaches—but these should contribute to the development of essential public health functions, not operate in parallel or for specific, short-term gains. Measure both operational achievements and health impact. Monitor changes in a country’s capacity to carry out essential public health functions, but also measure changes in health conditions. Include routine monitoring of population health status as part of established information systems, as well as through focused, rigorous impact evaluations of particular programs. Declare a truce in disease-versus-disease advocacy. Mobilize resources using any and all arguments that work. These may include current health impacts as well as potential ones, ethical imperatives and costs to the health system, worker productivity, or other economic outcomes. In some cases, the most effective approach may indeed be disease-specific advocacy, but this should be paired with strong arguments against earmarking funds so narrowly that larger, system-wide objectives cannot also be addressed. None of these tasks is easy. They require focused and sustained effort at the political, managerial, and technical levels. But given its success during the past decade in obtaining greater visibility and financial support for health in developing countries, the global public health community must now rise to the challenge of spending its resources well—not just for one disease, but for many generations. is a senior fellow and director of programs at the Center for Global Development in Washington, D.C. |
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