Emerging Voices: Amit Chandra on New Challenges for the Global Health Agenda

Emerging Voices features contributions from scholars and practitioners highlighting new research, thinking, and approaches to development challenges. This article is from Amit Chandra, an emergency physician and global health specialist who recently completed a two year post as faculty at the University of Botswana School of Medicine. Here, he assesses changes in the global health landscape and urges efforts to build overall health systems alongside disease-specific initiatives.

Today, people in the world live longer than ever before. The 2010 Global Burden of Disease study published in December’s issue of the Lancet demonstrates that improved access to vaccinations, sanitation, and medical care is making a significant impact on communicable diseases, child mortality, and maternal health. Along with these added years of life, however, are alarming increases in the burden of noncommunicable diseases and injuries. Meeting these challenges while sustaining past progress will require a change in the way health aid is coordinated and implemented. So-called “vertical” programs, which target particular diseases or outbreaks, must be accompanied by “horizontal” efforts focused on the development and coordination of overall health systems.

The latest Global Burden of Disease data appear to reflect a success story, proof of an expected epidemiological transition from diseases of poverty to diseases of old age and consumption, including heart disease, strokes, diabetes, and cancer. Expanding vaccination campaigns have made inroads against measles, polio, and other ills. Access to lifesaving antiretroviral drugs to treat HIV has skyrocketed, fueled largely by international aid, leading to a 33 percent reduction in AIDS-related deaths in Africa over the past six years. Malaria, though still a leading cause of death, is being targeted with more effective drugs and strategies.

The horizon for countries at the vanguard of this transition, however, is far from clear. Many nations in sub-Saharan Africa, for example, continue to face high burdens of HIV and other infectious diseases along with the rising rates of the noncommunicable diseases that come with longer life spans. While past success in global health has been driven by disease-focused initiatives like the Global Fund and the President’s Emergency Plan for AIDS Relief, the challenge now is to reform health sectors and integrate disease-focused programs, like HIV care and malaria control, into effective national primary and preventive care systems that address chronic diseases and acute needs.

Instead of facing each day as a new crisis, health sector managers must develop the capacity to predict and analyze shortcomings, devise solutions, and implement them without relying on external partners. This will require a culture of accountability and changes in organizational practices, human resource models, and supply logistics. Developing this health infrastructure is far more difficult than combating diseases in isolation.

Health system development will require training and retaining health managers, expanding access to primary and acute care, and widening the scope of disease prevention to include health promotion. International donors often work parallel to dysfunctional national health systems, filling gaps themselves and hiring away elite public employees to focus on specific health challenges. They can instead assist the public sector with health management, logistical skills, and research training. By developing these capacities, national health systems will be able to devise locally relevant health promotion strategies, retain doctors and nurses in the public sector, and provide rational and consistent medical care.

Rwanda has recently been highlighted as a success story in this regard. Over the past decade, it has used international aid to finance and expand access to a primary care-focused national health system, relying on locally elected community health workers and a national health insurance scheme.

These coordination challenges, however, are stretching many countries’ health and management capabilities. Over the past two years, public sector doctors in four African nations (Botswana, Kenya, Tanzania, and Nigeria) have gone on strike with devastating consequences for patients who depend on government hospitals. Although low pay was a common complaint, doctors also cited frustrations over outdated and malfunctioning equipment and inconsistent availability of medications and supplies.

Traffic accidents sharply illustrate what is needed to build health systems that can deliver quality care. Accident victims in much of sub-Saharan Africa are usually transported by Good Samaritans in the absence of paramedics and ambulances, and they often face critical delays before receiving care. Once they arrive at a health facility, their care may be compromised by shortages of blood products and medical supplies as well as practitioners lacking training in trauma care. This makes accidents deadlier than they need to be.

Reforming health systems to prevent and treat injuries requires high-level coordination both within the health sector and between branches of government dealing with public health, law enforcement, and transportation. These authorities must develop systems of pre-hospital care so accident victims can be transported to health facilities and receive life-saving treatment en route. Doctors and nurses must be trained in trauma and acute care. Referral criteria must be designed to transfer the most critically injured patients to centers with qualified surgeons and advanced equipment. Finally, managers must ensure that facilities maintain adequate medical supplies. Police and transportation authorities can also do their part to create and enforce safe driving practices and improve vehicle and road safety technology.

By focusing attention on health systems infrastructure, countries in Sub-Saharan Africa and across the developing world will be able to build on the successes of disease-focused initiatives while providing integrated and reliable care for the future. International aid can assist this process by rewarding and reinforcing progress towards achieving quantifiable targets--so-called "results-based financing." For developing nations and donors alike, building state capacity to deliver effective and efficient health services will be the central challenge of global health over the coming years.