This week we go for a short newsletter as we’re in Cape Town for the 2013 EV venture. All apologies. Also, we just learnt that Nelson Mandela passed away, after a long struggle. Even the best of us die someday, sadly. In fact, at this very moment, people are singing outside, remembering the man who meant so much for this country. They won’t forget him, for sure, and neither will the world.
The EV face to face training (25 Nov – 4 Dec), in preparation of the ICASA conference, and pre-conference (5 Dec) just finished. Early last night, EVs had a party to celebrate their time together so far, with the West Africans taking the lead. People were not aware yet of Mandela’s death, obviously. Later today, all of us will move downtown from the UWC campus (where the EV training programme took place). Icasa is about to start; EVs will present, blog and also tweet frantically – using the hashtag #ev4gh (which was also already used for coverage of the past two weeks, do check it out to get a flavor of discussions so far at UWC). Much of next week’s issue will be dedicated to the Icasa conference, which will no doubt partly be shaped by the memories Mandela leaves.
In this newsletter, we focus on the Global Fund replenishment and the Lancet Commission on Investing in Health. Meanwhile, far away in Tokyo, the World Bank holds a conference on UHC – Rob Yates and Lara Brearley are tweeting about the meetings there.
This week’s guest editorial is from Stephanie Topp, EV 2013. Based on her experience, she wonders whether HIV Scale up & UHC can be partners in health, rather than adversaries.
Enjoy your reading.
Kristof Decoster, An Appelmans, Peter Delobelle, Basile Keugoung & Wim Van Damme
HIV Scale up & Universal Health Coverage – Zero Sum Game or Partners in Health?
Stephanie M. Topp
Research Associate and Health Systems Advisor
Centre for Infectious Disease Research in Zambia (CIDRZ) and
School of Medicine, University of Alabama at Birmingham (UAB).
As part of the current cohort of Emerging Voices (in residence in Cape Town preparing for the upcoming ICASA conference) those of us in the Health Systems track have been engaging in a lively debate around post-2015 HIV financing and policy options. As we approach the MDG target date and move towards the post-MDG era, many questions are being posed about the threats to, and opportunities for, disease-specific programs. Front and centre in this debate is the future of financing and technical support to maintain and continue scaling up HIV prevention, care and treatment services in high-burden countries, and how these HIV-specific needs will be influenced by the gathering momentum to invest in Universal Health Coverage (UHC).
In 2012, following the AIDS conference in Washington, human rights lawyer and global health researcher Gorik Ooms described what he saw as a conscious distancing of AIDS practitioners and activists from the UHC agenda. He noted that this trend appeared to be linked to AIDS activists’ concern over the weak articulation of the need for continued global financing by the UHC movement. As many of us would be aware, the global HIV community continues to argue strongly for increased (versus static or reduced) commitments from bilateral and multilateral funders to close the estimated US$4-5 billion gap between current HIV/AIDS expenditure and the global target of US$22-24 billion. As demonstrated at the Washington event, part of their fear seems related to a perception that a shift of momentum towards UHC, and particularly a focus on potentially more cost-effective interventions would crowd out or require ‘rationing’ of funds for HIV prevention and treatment.
But let us step back for a minute. In high-prevalence settings such as sub-Saharan Africa, HIV prevention and treatment services will likely remain highly cost-effective interventions in both short- and longer-term. These interventions have, moreover, evolved from what was initially a semi-targeted service (testing for all, but initiation of treatment only for those meeting eligibility criteria) into an increasingly population-level approach. In the last two years for example, PMTCT B+ has emerged and seems set to become (albeit controversially) the policy norm in many low- and middle-income countries with full or partial adoption by Malawi, Zambia, Zimbabwe, Mozambique, Uganda, Cameroon and many others. Similarly, there is ground-swell of support for earlier initiation of HAART for all HIV-positive individuals that suggests a move towards policies enabling a test-and-treat approach within many HIV treatment programs.
PMTCT Option B+ and test-and-treat policies are most frequently promoted for their population-level benefits including reduced HIV incidence and the possibility of ‘ending the epidemic‘. Less often articulated, is that for these policies to have the full impact attributed to them, UHC will be a necessity. Without universal coverage (financial and service-related) Option B+ and test-and-treat will likely become another sub-optimally implemented and potentially damaging health intervention; damaging both in clinical terms due to the potential for drug resistance, and in health engagement terms, due to the inequity of service availability and further marginalization of geographically or socio-economically vulnerable populations.
Thus it seems that for those countries most effected by the HIV epidemic, the future of HIV financing and service scale-up on the one hand, and UHC on the other hand, are not a ‘zero sum game’. Rather, in these high-prevalence settings, HIV scale-up and UHC are intricately linked and even co-dependent elements of a broader strategic push to ensure health for all.
Various commentators have made observations relating to the potential for a symbiotic relationship between disease-specific, and more broad-ranging health initiatives. In this article, for example, Kent Buse articulately points out how HIV scale-up has created the space and opportunities in areas ranging from strengthening local capacity for pharmaceutical manufacturing to the contribution HIV treatment services have made in terms of establishing or re-establishing a model of chronic care at the primary level. Nor is it so difficult to imagine the ways in which UHC – if developed with appropriate nuance – could facilitate people’s access to, and retention in, HIV treatment programs in countries most affected by the disease. Perhaps the more pertinent question, then, is not whether there is common ground between the two agendas, but rather, for countries experiencing generalised HIV epidemics, how this common ground can be used to underpin policy and programmatic reform leading to more equitable and responsive health systems?
Reflecting on some aspects of these questions, the Global Health 2035: A World Converging within a Generation report has just been launched. The report includes a review of trends and context of global health investment over the last two decades and advocates for a new investment framework that the authors claim will help achieve dramatic health gains (for all) by 2035. However, it remains to be seen whether stakeholders positioned on either side of this debate will be willing to challenge and overcome the path-dependency of current financing and governance arrangements to make HIV and UHC true partners, not adversaries, in health.
Global Fund Replenishment
1. KFF : brief overview of the pledges
This short KFF article gives an overview of the pledges made, in total 12 billion for the next three years, 3 billion less than hoped for. The article also provides coverage by media of commitments.
2. GF – Global Fund Donors Pledge US$12 Billion
Jeffrey Sachs considers the 12 billion a disgrace for the poor in the world (in the Huffington Post). (He’s right. Having said that, there was a lot of talk here at the EV meeting in Cape Town that the transition towards an Africa without donors needs to start now, albeit in a staged way)
In the run-up to the Replenishment meeting, a campaign was launched by civil society in Uganda to urge China to give more to the Global Fund. (Fat chance.)
As for the ‘left over’ 1 billion of US funds (the US made a commitment of 4 billion for the time being), Scott Morris writes on the CGD blog what will happen to it, if other matching donors don’t come forward. He also offers a suggestion of his own.
Lancet Global health 2035: a world converging within a generation
Prompted by the 20th anniversary of the 1993 World Development Report, the latest Lancet Commission revisits the case for investment in health. The Commission points to the possibility of achieving dramatic gains in global health by 2035 through a “grand convergence” around infections, maternal and child mortality, major reductions in the incidence and consequences of non-communicable diseases and injuries, and the promise of universal health coverage. With the report and Comments by some of the big shots in global health, like Horton, Dybul, Kim, Chan, …. (Compulsory reading, obviously.)
For some coverage in the Guardian, see here. “Health disparities between nations could be eliminated within a generation if around $60bn a year was injected into healthcare systems.”
3. BMJ blog – Can the Grand Convergence replace the MDGs?
Richard Smith summarizes the report from the Lancet Commission on Investing in Health, also highlighting comments made by Larry Summers, co-chair of the commission, and others at a London meeting launching the report. Very nice and insightful analysis. At some point, when he says: “Something’s gone awry when the Economist is taking a tougher line on climate change than the Lancet”, he nails it. As for Feachem’s claim at the meeting that the GF will soon become the ‘Global Fund for the Grand Convergence’, I have my doubts.
Health policy & financing
4. WHO Bulletin December issue
This issue includes articles on protecting public health during mass gatherings, with the Saudi experience with MERS-CoV, and an interview with Hans Rosling on the joy of statistics and more.
5. Medact – Economics – the biggest fraud ever perpetrated on the world?
David McCoy comes back on the discussion on economics, started off by a series of tweets by Richard Horton a while ago.
6. BMC International health and human rights – What could a strengthened right to health bring to the post-2015 health development agenda?: interrogating the role of the minimum core concept in advancing essential global health needs
Lisa Forman et al.;
Global health institutions increasingly recognize that the right to health should guide the formulation of replacement goals for the MDGs. However, the right to health’s contribution is undercut by the principle of progressive realization, which links provision of health services to available resources, permitting states to deny even basic levels of health coverage domestically and allowing international assistance for health to remain entirely discretionary. Enter the idea of minimum core obligations. The authors believe that if the “minimum core” concept is strengthened in a number of ways, it will produce a more feasible and grounded conception of legally prioritized health needs that could assist in advancing health equity, including by providing a framework rooted in legal obligations to guide the formulation of new health development goals, providing a baseline of essential health services to be protected as a matter of right against governmental claims of scarcity and inadequate international assistance, and empowering civil society to claim fulfillment of their essential health needs from domestic and global decision-makers.
7. WHO – Executive Board 134th session – 20-25 Jan 2014
The annotated agenda & some first documents for the EB Board meeting in January can be found here.
8. Lancet (Viewpoint) – Child labour must be on the post-2015 agenda
Although the number of child labourers is unknown, the International Labour Organisation (ILO) estimates that there are 215 million. Of these children, 115 million are in the worst forms of child labour—“work which, by its nature or the circumstances in which it is carried out, is likely to harm the health, safety or morals of children”. In this Viewpoint the author sets out the health risks of child labour and makes suggestions for the post-2015 agenda.
9. Lancet (Editorial) – The global crisis of severe acute malnutrition in children
This Lancet editorial discusses the newly released WHO guidelines for the management of Severe Acute Malnutrition in young children.
10. Lancet (Editorial) – Violence against women in Syria
“Dec 10 marks Human Rights Day, which this year celebrates 20 years since the Vienna Declaration and Programme of Action—a reaffirmation of the global community’s commitment to human rights. It is also two decades since the UN General Assembly’s Declaration on the Elimination of Violence against Women. The anniversary represents a time to reflect on how far the world has come in protecting the rights, safety, health, and dignity of women, and—in complex conflict situations like Syria—how far we have to go.” A new report has evidence on targeted abuse of women in Syria.
11. Lancet (Offline) – The dangers of a new epidemic—pessimism
An Offline contribution that for sure will be read by many EVs. “Last month, three distinguished scientists published (in Nature) “Twenty tips for interpreting scientific claims”. … It was a pessimistic view of science, scientists, and the users of science. Science cannot solve all the world’s problems. But can we not do more to provide reasons why good science can be an indispensable aid for decision makers?” Horton, for sure, doesn’t buy this pessimism, and thinks we have a great opportunity before us. “We have a mature and successful public health research community. It is one we should celebrate and one whose contributions we should better articulate to those with political power.”
12. IS Global (Working paper) – The Fundamentals of an Equitable Health Financing System
The rationale for an equitable health financing system is based in both economic and human rights arguments. The paper asks some basic questions about emerging policy lessons for (health) equity in low- and middle-income countries, such as: how much does it cost? Who should pay? What should we buy?
13. Science & Diplomacy – Making PEPFAR
Vamur gives the health diplomacy story behind Pepfar, in a lengthy essay.
14. Guardian – The lies behind this transatlantic trade deal
In a second instalment, Monbiot lashes again out against the Transatlantic trade deal.
Check out also a new IHP blog post by Daniele Dionisio on the TPP talks, and the threat they involve for health.
In other trade related news, you might probably also want to follow the news on the WTO summit in Bali. Food security is a divisive issue, the BBC reported.
15. WHO – Spinal cord injury: as many as 500 000 people suffer each year
As many as 500 000 people suffer a spinal cord injury each year. People with spinal cord injuries are 2 to 5 times more likely to die prematurely, with worse survival rates in low- and middle-income countries. The new WHO report, “International perspectives on spinal cord injury“, summarizes the best available evidence on the causes, prevention, care and lived experience of people with spinal cord injury.
16. Guardian Global Development – How Africa’s researchers are solving Africa’s health problems
Researchers are pioneering treatments on the continent, for health challenges unique to the continent – but despite the successes African research institutions continue to lag behind.
17. BMC Health Services – Assessing responsiveness of health care services within a health insurance scheme in Nigeria: users’ perspectives.
Shafiu Mohammed et al.;
This article, by EV 2012 Mohammed Shafiu, was just published. The study examines insured users’ perspectives of their health care services’ responsiveness – in a Nigerian state.