Globally, the Covid-19 pandemic has had devastating effects on economies, placing millions of people at risk. This is the time to think of initiating reforms in the global health agenda. The WHO has faced serious criticism from across the spectrum on the management of Covid and could not do much in facilitating provision of vaccines to the needy populations.
The activities of international health agencies like the WHO are targeted across two different health approaches, one focused on vertical campaign against management of specific diseases (e.g. smallpox, malaria, etc.), and the other one having a social perspective or a horizontal approach targeting poverty, inequality, … (e.g. Alma-Ata declaration with the objective of health for all people). These may be termed as biomedical and social medicine approaches respectively. The biomedical or the vertical approach, being a specialised one, is executed by health workers and may not be successful unless there are permanent health services in specific regions for monitoring. The horizontal approach, like a mass campaign, involves a significant proportion of the population. The resource allocation by economies plays a key role in both these cases and thus these approaches are not mutually exclusive, and require coordination and combination in various ways. Thus, the WHO may need to draw a clear line on where the mass campaigns are successful, taking into consideration the disease being targeted and the resource availability.
Another serious constraint on the achievement of health and development goals is the shortage of health workers and their vital role especially in fighting communicable diseases. The WHO in its 2006 health report highlighted the shortage of four million health workers with critical paucity reported in 57 countries, mostly in Africa. It also estimated a requirement of 18 million more health workers by 2030, primarily in low- and middle-income countries. The imbalance is more severe in rural areas compared to urban places. The high salary for these professionals in advanced countries makes them go abroad. Unfavourable working conditions, climate change impacts and ageing population adversely contribute to this issue.
Unclear priorities among a multitude of programmes is another major challenge. The priority-setting process involves selecting the best option for addressing the most important health need. The WHO has identified “universal health coverage” as the single-most powerful concept that public health has to offer. Studies conducted across the world estimate that out-of-pocket payments push 100 million people into poverty every year and the most effective way to provide universal coverage is to share the costs across the population. Globally, 12.67% of the people spend more than 10% of income (out of their pocket) as health expenditure. One of the areas where this rate is higher than the average is the South East Asian region (India included), where it is 16%. The Western Pacific region comes second in this list. This means that these regions don’t have universal health coverage. A strong, efficient and well-run system that meets priority health needs through people-centred integrated care is the need of the hour. Sustainable health systems that promote universal access to care can be facilitated through appropriate application of digital technologies.
The Covid crisis had exposed the risks of corruption prevalent in the health sector as also its fragile systems that threaten its sustainability. The Office of Internal Audit and Oversight report submitted to the World Health Assembly in 2019 reveals that a total of 81% of overall conclusions on audits were assessed as either “satisfactory” or “partially satisfactory” suggesting improvements. Compared to 478 cases of fraud, corruption and misconduct reported in the year 2014, 520 were reported in 2019. The priority areas identified for improvement include strengthening implementation, robust vendor management, addressing human resource needs and improving resources for key underfunded programmes. Thus, it is high time that good governance practices get incorporated into this organisation.
Recently, multilateralism has been in a state of crisis. There is declining commitment to multilateral action/UN after the end of the Cold War and in the current geopolitical climate of rising nationalism. The UN and its agencies are being criticised for lack of efficiency and a whole lot of other issues. The WHO has also shown its limits and shortcomings in containing the virus spread during the pandemic, and the world too witnessed political pressure exerted by powerful member states and corporate interests. There are also growing calls for social justice amid accelerating economic globalisation.
Global health governance encompasses formal and informal institutions along with norms and processes that govern or directly influence international health policy and outcomes. A diverse plethora of players are involved in global health funding and have much more resources than the WHO. In addition to international organisations like the World Bank and WHO, there are multilateral entities (e.g. G8, G20), multilateral global health initiatives (e.g. GFATM, GAVI), international development agencies (e.g. USAID, DFID), bilateral initiatives (e.g. PEPFAR, GHSA), philanthropies (e.g. Gates, Carso, Clinton), global public-private partnerships, private sector-industry initiatives, and civil society (e.g. MSF, Oxfam) undertaking a whole lot of health funding activities.
Thus, there are diverse funding players, fragmented due to lack of coordination and duplication with top-down and donor-driven approaches, leading to a negative impact on countries with fragile health systems. There are plenty of funds flowing into the health sector but the same is imbalanced in allocation to “big” diseases (vertical) but not to the health system for strengthening (horizontal). There is also lack of evaluation, accountability and sustainability, which necessitates the need for major overhaul and shifts with regard to traditional donors and models of funding for optimisation of the existing health resources.
(Deputy Secretary, Ministry of Finance. Views are personal)