In an opening address at the Third Global Symposium on Health Systems Research in Cape Town last month, Professor Irene Agyepong, Chair of Health Systems Global, spoke of a Nigerian proverb that says that “a goat that belongs to the whole village, belongs to nobody”.
Health systems as a field of policy, programming and research, has been that goat.
The neglect of health systems has been highlighted by the outbreak and spread of Ebola in Liberia, Sierra Leone and Guinea – and shown what this can mean for a population’s health and for its social and economic development.
Across the board, governments and donors have under-invested in health systems. Consider, for example, that only $5-6 billion (10-12%) of the $52 billion spent by PEPFAR since 2004 was spent on horizontal health system development.
According to a recent report from the UK’s International Development Committee, DfID estimated spending £ 370 million on supporting health system strengthening and research since 2013, which represented about 34% of total bilateral health assistance (aid to specific countries).
Taking into account UK aid channelled through multilateral organisations (£1,149 million), the share of health system strengthening expenditure would likely be considerably less than that, even though multilaterals like the Global Fund are committing increasing resources for such investments. This is still far off WHO’s recommendation to allocate 50% of development funds for health to the building blocks of the health systems.
As Professor Agyepong pointed out, the reluctance to invest can stem from the difficulty of identifying specific results. Donors in particular have a disincentive to put resources into broad health systems, as it is difficult to isolate and link the investment to a politically attractive outcome that will appeal to taxpayers.
A functioning supply chain or information system would seem less politically compelling than adding up the numbers of children immunised or the number of people on antiretroviral therapy. However, without that strong basis and building block, vertical disease-specific programmes will only be able to achieve so much. Insufficient human resources for health, bottlenecked drug supply chains and weak regulatory mechanisms continue to constrain HIV, malaria, TB, maternal and child health and NCD programmes across the board.
Yet, financing is mainly channelled to these specific areas, without enough support and attention to the health systems that they rely on.
This may relate to the underlying value-for-money paradigm that is thought to partly guide resource allocation, whereby each programme considers only its direct outcomes, instead of jointly financing systemic interventions that would have multiple benefits across disease areas and health priorities. The RethinkHIV Policy Brief, “Co-Financing” argues that policy-makers need to stop taking a ‘silo’ approach to budgeting, where one health programme’s gain is another’s loss.
A critically important area that requires larger and sustained investments is human resources for health. The current shortages are seriously constraining the scale-up of quality health services, such as antiretroviral treatment.
It is only by going beyond short-term strategies and adopting more long-term, system-wide approaches for the increased production and retention of health professionals that the remaining 16 million people eligible for ART will be reached and retained in care.
Michelle Remme is Research Fellow in Health Economics at London School of Hygiene and Tropical Medicine.
RethinkHIV is a consortium of senior researchers from London School of Hygiene & Tropical Medicine, Imperial College London, Harvard School of Public Health, Centre for the Study of African Economies and Blavatnik School of Government at Oxford University.
The consortium will evaluate new evidence related to the costs, benefits, effects, fiscal implications, and developmental impacts of HIV interventions in sub-Saharan Africa, in order to maximise contributions to the fight against HIV there.
The aim of RethinkHIV is to find ways of creating, optimising, and sustaining fiscal space for domestic HIV investment, as well as exploring long-term, sustainable national and international financing mechanisms. RethinkHIV is funded by RUSH Foundation.