“And we won’t confront illnesses in isolation – we will invest in public health systems that promote wellness, and focus on the health of mothers and children.”
These are words spoken by President Obama in his speech in Ghana on July 11, 2009. 2 points stand out in this statement – the need to focus on health systems and the need to address maternal mortality. The debate that ensues is the value of a Global Fund for Maternal Health. A frequently-discussed topic in the blogosphere, some are in favor and others opposed. Despite the potential challenges and historical weaknesses of such global initiatives, I am in favor of such a movement as long as we learn from the lessons of other Global Health Initiatives (GHI).
It is now well understood that to bring about sustainable progress in the health of developing countries, we need to invest in improving the health systems. The WHO for years has been harping on the need to invest in health systems and now has started to discuss the interplay between Global Health Initiatives (GHI) and health system development. The challenges of using a GHI to fund health systems are documented. Prior GHIs have been vertical and disease-specific which has had a negative impact on horizontal aspects of the health care system. GHIs have often left the country’s health systems in worse shape than when they started. As Obama said in his speech, “…because of incentives – often provided by donor nations – many African doctors and nurses understandably go overseas, or work for programs that focus on a single disease. This creates gaps in primary care and basic prevention. Ironically, ineffective health systems have often proven to be a hurdle for disease-specific GHIs to implement their activities effectively.
The other challenge of GHIs is that the private organizations feel accountable to their donors and therefore prioritize the donor’s expectations over the long-term health needs of the country. Success is measured by reducing the burden of a specific disease, not increasing the health or life expectancy in the country. If donors have paid to reduce HIV, they want to see less burden of HIV in the population. They aren’t so interested in how many people in the population have access to primary care, regardless of how critical this access is to the well being of the people.
Why should we use a Global Fund as the means to address a global health issue? In the case of maternal health, I think these challenges are surmountable. Maternal health is not vertical, it’s horizontal. Addressing this issue is multi factorial and includes adequate access to primary care and acute care, it requires the availability of trained health care providers, and appropriate physical infrastructure to handle childbirth and it’s complications. Where disease-specific initiatives were funnelling people into specific parts of the health care system, a fund designed to address maternal health would need to address all critical components of the health care system. The brain-drain that Obama described would be plugged. As for competing priorities between pubic and private stakeholders, I think governments of developing countries and the WHO need to be major players in these GHIs to provide strategic direction not driven by donors but rather by the overall health of a country.
Why should we not just create a Global Fund to Improve Health Systems. Well, I’m not a marketing expert but it’s just not a romantic cause. Imagine trying to advocate to US citizens that they should spend on health systems around the world when even our own health system in the US is under fire. At least when advocating for maternal health you can bring to the table emotional cases of maternal mortality that present compelling reasons why health systems need to be fixed. Second, we have a moral obligation – no mother should die giving birth to a child. Giving life should not take a life. Third, it’s all in the numbers – childbirth is the leading cause of death for women in the developing world.
Global health issues are often interconnected, I think in this case we can capitalize on the complex nature of maternal health to improve much neglected health care systems in the developing world.