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      Synergies and tensions between universal health coverage and global health security: why we need a second ‘Maximizing Positive Synergies’ initiative

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          Abstract

          Introduction A kind of courtship is going on between proponents of universal health coverage (UHC) and proponents of global health security (GHS). In our opinion, efforts to make progress on the path to UHC and efforts to improve GHS can be synergistic, but are not self-evidently so. Making this partnership work will require careful thinking and planning. Several comments on ‘lessons from Ebola’ highlight the potential of UHC as a way to improve GHS.1 Simon Rushton, Louis Lillywhite and Bhimsen Devkota argue that the “[p]romotion of health security therefore entails ensuring that effective health systems exist before a crisis, are sustained during and after conflict and disaster, and are at all times accessible to the population.”1 Rob Yates, Ranu Dhillon and Ravi Rannan-Eliya remind us that several epidemics of global concern ‘occurred in settings without universal health coverage where health systems were unable to perform effective public health functions’.1 In a reaction to these ‘lessons from Ebola’, and a preview to the G7 summit in Ise-Shima of May 2016, Gavin Yamey argued that a way to make the case for UHC more compelling ‘could be to link UHC to the worldwide concern about pandemics in the wake of the Ebola crisis’,2 and he encouraged Japan—a longstanding proponent of UHC and GHS—to ‘rouse the G7 nations into action on universal health coverage’.2 Japan indeed promoted UHC and GHS, as an ‘inseparable couple’,3 and the ‘G7 Ise-Shima Vision for Global Health’ outcome document highlights both.4 Not a new attempt to create an alliance The present courtship is not new. The 2007 World Health Report, on ‘A safer future: global public health security in the 21st century’,5 highlighted the importance of strong health systems to enhance GHS. Without using the expression UHC, this report tried to tie efforts to make progress towards UHC into the GHS agenda. For most low-income and middle-income countries, this was self-evident, but not for high-income countries. As Aldis explains, there was a very different understanding of the meaning of ‘health security’: “Policymakers in industrialized countries emphasize protection of their populations especially against external threats, for example terrorism and pandemics; while health workers and policymakers in developing countries and within the United Nations system understand the term in a broader public health context.”6 The division went as far as causing the banning of the GHS expression from later WHO reports: “At the 122nd EB [Executive Board]—the first EB meeting after the release of the 2007 World Health Report—the delegate from Brazil went to considerable lengths to stress that there was no consensus about the use of the phrase ‘global health security’ or its meaning.”7 Pitfalls In our opinion, efforts to make progress on the path to UHC and efforts to improve GHS are not an ‘inseparable couple’. They can be synergistic. In well-funded, well-staffed and well-equipped health systems, efforts to improve UHC and efforts to improve GHS are indeed inseparable: every dollar spent, every hour of a health worker, every effort, contributes to both, at least indirectly—if only by building trust in the system, which will encourage people to come forward when some new epidemic hits, and to follow the advice of health workers. But especially in an underfunded and underdeveloped health system, the obvious ‘next step’ on the path towards UHC is not always the obvious ‘next step’ in the direction of GHS. For example, if a ministry of health, responsible for an underfunded and underdeveloped health system, must make a choice between improving the laboratory functions, or expanding the health workforce, prioritisation of GHS may lead it in the direction of laboratory functions, while prioritisation of UHC would probably lead it in the direction of expanding the health workforce. Furthermore, the lack of a clear consensus on what UHC means makes it vulnerable to being deeply influenced by being linked with GHS. For some, progress towards UHC requires a substantial increase in public financing, because private financing, even if pooled in the form of voluntary insurance schemes, appears to be most often regressive (‘groups with a lower income contribute a higher percentage of their income than do groups with a higher income’).8 For others, it does not really matter whether additional financing for UHC comes from public or private sources, as long as it is pooled, and moves away from out-of-pocket expenditure.9 As long as no policy agreement is found on this crucial issue, tying UHC and GHS together may come with pressure on low-income and middle-income countries to use their limited public financing resources for efforts to control infectious disease (ie, GHS efforts), while relying on private financing for the rest of UHC. This would take us back to the health sector reform promoted by the World Bank in 1993 (and following years), under which governments should focus their public resources on ‘public health’—and in the fine print, it was clarified this meant infectious disease control—while for the financing of ‘essential clinical services’, the report suggested “[c]ommunity-financing schemes, whereby patients at local health centers and pharmacies pay modest fees.”10 Opportunities How then would UHC benefit from being linked with GHS? As Adam Kamradt-Scott puts it: “it conceivably could still prove to be a very valuable political tool for improving the health outcomes of people all over the world due to the simple fact that security, like sex, sells.”7 However, whether that assumption holds true remains to be verified. This assumption is based on one of the dominant explanations for the impressive increase in international public financing for the global HIV/AIDS response, namely that high-income countries are preserving their own interests by trying to control HIV/AIDS in other parts of the world, but there are alternative explanations for the global HIV/AIDS response, namely the influence of global advocacy networks.11 Furthermore, although the International Health Regulations (IHR) include a section on international ‘collaboration and assistance’,12 achievements in this area (since the revision of the IHR in 2005) are rather disappointing. According to Suman Paranjape and David Franz, the so-called Global Health Security Agenda (GHSA), launched in 2014 by the USA with the explicit intention to promote ‘collaborative, capacity-building efforts to achieve specific and measurable targets around biological threats, while accelerating achievement of the core capacities required by the WHO's International Health Regulations (IHR)’,13 started with a budget of US$63 million in 2014: a small fraction of the $8.5 billion the USA intended to spend on global health in 2014.14 If ‘enlightened self-interest’ were the main driver of international public financing, one would expect to see more. Nonetheless, we presume that when proponents of UHC try to link UHC with GHS, they aim for the kind of political support (of high-income country governments) that UHC alone would not receive, because of being primary focused on the well-being of the inhabitants of low-income and middle-income countries. Likewise, when proponents of GHS try to link their agenda with UHC, they probably hope to attract support from civil society groups and governments of low-income and middle-income countries, who feel that ‘securitization predicates Western, high-income countries’ interests above others’.7 In as much as the ‘triangle that moves the mountain’—a concept originally used to explain how the combination of knowledge, social movement and political support enabled health sector reform in Thailand15—an alliance between the GHS and UHC agendas could create a ‘complete’ triangle: knowledge, social movement and political support. Figures 1 –3 illustrate this. Figure 1 Triangle for global health security. Figure 2 Triangle for universal health coverage. Figure 3 Triangle for universal health coverage+global health security. Conclusion Based on the considerations above, we would conclude that the courtship between UHC and GHS could at best result in a marriage of convenience. And such a marriage of convenience should be properly planned. The challenge or opportunity is not an entirely novel one: when the global AIDS response started becoming serious, everyone agreed that the provision of AIDS treatment in low-income and middle-income countries would require stronger health systems. The global HIV/AIDS response came with opportunities for health systems strengthening, but also with pitfalls; what McCoy et al wrote at the time—“positive benefits will only happen if we explicitly set out to achieve them”16—seems valid too for the potential alliance between GHS and UHC. The question whether AIDS treatment efforts and programmes strengthened or weakened health systems divided the global health community during almost a decade.17 18 It was resolved, at least to some extent, when in 2008, WHO launched the ‘Maximizing Positive Synergies’ initiative, intended to make sure that the disease-specific global health initiatives like, for example, the Global Fund to fight AIDS, Tuberculosis and Malaria, would strengthen health systems, not burden them.19 During a year, more than a hundred scholars, policymakers and civil society representatives worked together, to examine the evidence of synergies and tensions, and to formulate recommendations intended to maximise the synergies and to overcome the tensions. In our opinion, WHO should now do something similar, to maximise the synergies between efforts to promote GHS and efforts to promote UHC.

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          Most cited references7

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          An assessment of interactions between global health initiatives and country health systems.

          (2009)
          Since 2000, the emergence of several large disease-specific global health initiatives (GHIs) has changed the way in which international donors provide assistance for public health. Some critics have claimed that these initiatives burden health systems that are already fragile in countries with few resources, whereas others have asserted that weak health systems prevent progress in meeting disease-specific targets. So far, most of the evidence for this debate has been provided by speculation and anecdotes. We use a review and analysis of existing data, and 15 new studies that were submitted to WHO for the purpose of writing this Report to describe the complex nature of the interplay between country health systems and GHIs. We suggest that this Report provides the most detailed compilation of published and emerging evidence so far, and provides a basis for identification of the ways in which GHIs and health systems can interact to mutually reinforce their effects. On the basis of the findings, we make some general recommendations and identify a series of action points for international partners, governments, and other stakeholders that will help ensure that investments in GHIs and country health systems can fulfil their potential to produce comprehensive and lasting results in disease-specific work, and advance the general public health agenda. The target date for achievement of the health-related Millennium Development Goals is drawing close, and the economic downturn threatens to undermine the improvements in health outcomes that have been achieved in the past few years. If adjustments to the interactions between GHIs and country health systems will improve efficiency, equity, value for money, and outcomes in global public health, then these opportunities should not be missed.
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            The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control.

            This paper reviews country-level evidence about the impact of global health initiatives (GHIs), which have had profound effects on recipient country health systems in middle and low income countries. We have selected three initiatives that account for an estimated two-thirds of external funding earmarked for HIV/AIDS control in resource-poor countries: the Global Fund to Fight AIDS, TB and Malaria, the World Bank Multi-country AIDS Program (MAP) and the US President's Emergency Plan for AIDS Relief (PEPFAR). This paper draws on 31 original country-specific and cross-country articles and reports, based on country-level fieldwork conducted between 2002 and 2007. Positive effects have included a rapid scale-up in HIV/AIDS service delivery, greater stakeholder participation, and channelling of funds to non-governmental stakeholders, mainly NGOs and faith-based bodies. Negative effects include distortion of recipient countries' national policies, notably through distracting governments from coordinated efforts to strengthen health systems and re-verticalization of planning, management and monitoring and evaluation systems. Sub-national and district studies are needed to assess the degree to which GHIs are learning to align with and build the capacities of countries to respond to HIV/AIDS; whether marginalized populations access and benefit from GHI-funded programmes; and about the cost-effectiveness and long-term sustainability of the HIV and AIDS programmes funded by the GHIs. Three multi-country sets of evaluations, which will be reporting in 2009, will answer some of these questions.
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              Health security as a public health concept: a critical analysis.

              W Aldis (2008)
              There is growing acceptance of the concept of health security. However, there are various and incompatible definitions, incomplete elaboration of the concept of health security in public health operational terms, and insufficient reconciliation of the health security concept with community-based primary health care. More important, there are major differences in understanding and use of the concept in different settings. Policymakers in industrialized countries emphasize protection of their populations especially against external threats, for example terrorism and pandemics; while health workers and policymakers in developing countries and within the United Nations system understand the term in a broader public health context. Indeed, the concept is used inconsistently within the UN agencies themselves, for example the World Health Organization's restrictive use of the term 'global health security'. Divergent understandings of 'health security' by WHO's member states, coupled with fears of hidden national security agendas, are leading to a breakdown of mechanisms for global cooperation such as the International Health Regulations. Some developing countries are beginning to doubt that internationally shared health surveillance data is used in their best interests. Resolution of these incompatible understandings is a global priority.
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                Author and article information

                Journal
                BMJ Glob Health
                BMJ Glob Health
                bmjgh
                bmjgh
                BMJ Global Health
                BMJ Publishing Group (BMA House, Tavistock Square, London, WC1H 9JR )
                2059-7908
                January 2017
                25 January 2017
                : 2
                : 1
                : e000217
                Affiliations
                [1 ]Department of Global Health and Development, Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine , London, UK
                [2 ]Institute of Public Health, Heidelberg University Hospital , Heidelberg, Germany
                [3 ]Center for the Study of Equity and Governance in Health Systems , Guatemala, Guatemala
                [4 ]Center for Health, Human Rights and Development , Kampala, Uganda
                [5 ]Oslo Group on Global Health Policy, Department of Community Medicine and Global Health and the Centre for Global Health, University of Oslo , Oslo, Norway
                [6 ]James P. Grant School of Public Health at BRAC University , Dhaka, Bangladesh
                Author notes
                [Correspondence to ] Professor Gorik Ooms; gorik.ooms@ 123456lshtm.ac.uk
                Author information
                http://orcid.org/0000-0002-9804-0128
                http://orcid.org/0000-0001-9487-2333
                Article
                bmjgh-2016-000217
                10.1136/bmjgh-2016-000217
                5321394
                202e8e39-e77c-4d7b-83ce-6f3a0753b076
                Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

                This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/

                History
                : 21 October 2016
                : 3 January 2017
                : 4 January 2017
                Categories
                Editorial
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