This seminar, held on the sidelines of the 2009 Prince Mahidol Award Conference, was designed to share with a broad group of global health stakeholders the outcomes of a recent report on Global Action for Health System Strengthening produced by an international task force of global health experts.
The first session consisted of five presentations by members of the Task Force on Global Action for Health System Strengthening and comments, while the second session, titled “Toward the Next G8 Summit and Beyond,” provided a venue for discussing priorities and strategies for discussions on global health at future G8 Summits. The Task Force was an initiative of the Executive Committee on Global Health and Human Security.
Professor KEIZO TAKEMI, a senior fellow at the Japan Center for International Exchange (JCIE) and a research fellow at the Harvard School of Public Health, talked about the major role that the G8 can play in catalyzing efforts to reframe the field of global health. In the past decade, several major new stakeholders have entered the global health field, which had previously been dominated by the World Health Organization (WHO), including the Bill & Melinda Gates Foundation; the Global Fund to Fight AIDS, Tuberculosis and Malaria; and the Global Alliance for Vaccines and Immunization (the GAVI Alliance). One of the WHO’s strengths is its constitutional mandate to represent member states. However, this mandate limits its ability to also include representation by nongovernmental actors such as corporations and NGOs. The WHO, therefore, needs to reform and strengthen its legitimacy, in particular focusing on harmonizing the three Cs: communication, collaboration, and consensus building. A multistakeholder approach to global health policy is thus required. The working group on “Challenges in Global Health and Japan’s Contributions” took such a participatory approach and brought together diverse stakeholders, from Japan’s ministries of foreign affairs, health, and finance; international organizations; academia; NGOs; and the media.
The global health agenda is shifting from an overwhelming emphasis on disease-oriented (vertical) approaches to a broader focus that also includes health system strengthening (horizontal). The Toyako Framework for Action on Global Health also proposed taking bold action to strengthen health systems. In response, the project task force, guided by the Takemi Working Group and JCIE, prepared three policy papers on sub-fields that are generally accepted as being core building blocks of health systems, namely health workforce, health finance, and health information. The papers came to three general common conclusions: (1) there is an urgent need both for more resources and for more efficient and effective use of existing resources, (2) country capacity and ownership need to be enhanced, and (3) there is a need to follow through on the G8’s recent commitment to accountability by establishing an annual review on global health commitments.
Professor MASAMINE JIMBA discussed the health workforce component, identifying major challenges facing human resources for health, such as the inappropriate quantity and quality of the existing health workforce, a lack of country capacity to undertake key tasks (such as planning for human resource investments and managing for better performance), international migration, and a lack of donor coordination. He recommended three major actions for the G8 to take to address these problems:
- Strengthen countries’ capacity to plan, implement, and evaluate health workforce programs by developing mechanisms for evaluating health workforce progress, identifying strategies to change macroeconomic policies to reduce constraints on expanding health workforces, and strengthening international networks of higher education in areas with limited resources
- Address the demand-side causes of international health workforce migration by cleaning house in the wealthy countries and using their own resources to increase the number of health workers in their own countries, supporting the WHO code of practice to address migration issues, and seeking practical solutions that protect both the right of individuals to seek employment through migration and the right to health for all people
- Conduct an annual review of actions by G8 countries to improve health workforces by scientifically assessing the current situation using a standard set of common measures and using the review to assess knowledge gaps and increase knowledge about improving health systems by strengthening human resources, as well as to see how well G8 countries are carrying through on what they have pledged to do.
Dr. RAVINDRA P. RANNAN-ELIYA spoke on the topic of health financing, recommending three major actions for the G8 to take to address the challenges of financing for health systems in the developing world:
- Increase money for health with efforts to improve the value of health spending through support for better country-led health financing and systems policies
- Build on the existing consensus among technical experts with an explicit G8 commitment to prioritize support for country health financing policies that place public financing for health, in the form of tax financing and/or social health insurance, at the core of efforts to expand coverage for poor people and vulnerable groups in society
- Invest in the ability of developing country partners to make better financing policies. This will require increased investments in building national capacity for health systems policy assessment and in the mechanisms to understand and share the lessons of best practice countries.
Professor KENJI SHIBUYA spoke about health information, identifying two major types of challenges: technical and allocative inefficiencies. He recommended the following three major actions for the G8 to take:
- Implement a G8 annual review to assess progress toward achieving the G8’s commitments to health systems and programs
- Establish a digital commons using a network of global and regional centers of excellence to improve access to, and the quality of, datasets and analyses at the country and global levels
- Pool resources for health metrics at the global and country levels to create a Global Health Metrics Challenge by developing the capacity of countries and data producers to produce better-quality data, making health funding contingent upon third-party evaluation, prioritizing development of civil registration systems in countries where such systems are incomplete or nonexistent, and invest in a series of nationally representative household surveys for multiple diseases and risk factors
The discussion that continued throughout the seminar addressed these three building blocks of health systems (people, money, and data) but also focused on future research priorities and further work to be undertaken in preparation for the next G8 Summit, as described below:
Human resources: The G8 should believe that countries can improve their health workforces. There are several major challenges to improving health workforces. Retention, deployment, and additional sources of workforce incentives are among the most prominent. The ultimate outcome should be strengthening of countries and of their self-reliance. Capacity building should be done both at the individual and institutional levels. Community empowerment should be considered as one way to build up capacity. On the other hand, community paralysis due to corruption should be addressed. Society more broadly can be partners in the policy-making process. Capacity building at an individual level requires people who can play a campaign role to facilitate behavioral changes. Strengthening of the health workforce should be at all levels, not only practitioners but also those at the technical and policy-making levels.
Health financing: The G8 should provide appropriate and practical advice to countries on a proper mix of financing sources within a specific country context. Public financing should be the main source of funding for health systems. But, they can still have an appropriate mix of financial contributions from private and public sources at the household level. Particular attention in health financing should be given to those who are vulnerable due to the global economic crisis, such as the unemployed.
Health information: Raising country awareness will benefit both the G8 and partner countries. Currently, there is little knowledge among people at the local level of what the G8 is doing and what will be carried out. Clear agendas of what the G8 will do can be very useful in raising support within the G8 countries. In many developing countries, surveillance systems are poor. Therefore, funds need to be allocated and support given to countries to improve their surveillance systems. The main objective of improving health information should not be the collection of health statistics themselves; rather the performance of health systems, as a whole as well as the strengthening of social safety nets as a critical means of protection for the people, especially vulnerable groups, needs to be the ultimate aim. Investment in health information systems could mainly support health system research, especially for both the generation of new knowledge and a process of learning. New knowledge could also be generated using various means, such as combining primary research and synthesizing existing information.
Future research priorities for the G8: There are many suggestions that have been put forward for G8 consideration, such as conducting a review of existing work by other institutions at the global and national levels in order to avoid duplication of efforts. The recommendations put forward at this seminar dealt only with the three building blocks of health systems, which might be considered essential elements on the global health agenda. However, they do not constitute a complete model of health system performance. We need, therefore, a thorough understanding of other important elements and their capacity to contribute to health system performance. Examples of those uncovered elements are health service delivery systems, medical products and technologies, and governance. The G8 should also consider other social determinants of health system performance as well as the impact of non-health sectors. Future research should provide concrete strategies that are more pragmatic and move in realistic ways to be compatible with specific country contexts. When strategies and activities are already functioning at the county level, the G8 should emphasize scaling up cost-effective interventions and, at the same time, abolish or minimize interventions that are not cost-effective.
Further work in preparation for the next G8 Summit: At the global level, the G8 should harmonize its recommendation and pathways with other international organizations, such as the World Bank, the GAVI Alliance, and the WHO. This is not only to build partnership with these other institutions but also to minimize hurdles for countries that get support from various international organizations. Interaction between the G8 and NGOs, both at the international and country levels, c
ould be carried out. At the country level, the G8 should align its actions with national policies and listen to host countries, rather than just sending G8 messages. The G8 should also reconsider reporting processes. The G8 could incorporate key messages, especially on emergencies to help countries prepare to deal with emergencies in order to minimize negative consequences. The G8 could consider human security, which emphasizes community empowerment and protection. An English-language site where G8 members and developing countries can access G8 information on the most effective ways of dealing with challenges is necessary.
Importantly, a sustainable scheme for the G8 to take global action on health system strengthening is essential. So, an annual review can help monitor and evaluate G8 actions. The G8 will continue playing a role in primary healthcare and health system strengthening, in accordance with a WHO resolution. Continued efforts on participatory and evolutionary processes between the G8 and its partners are vital. The G8 will retain global health as an issue on its agenda for the upcoming summit, in addition to discussions of other resources, which will need to look at the implications of the Italian chair.
Report written by Thai technical coordinator—International Health Policy Program, Ministry of Public Health, Thailand; and edited by JCIE.