Economic and political challenges have impacted countries’ ability to support their own health systems. The United States, international implementers, and multilateral organizations have made life-saving investments in combating specific deadly diseases. As foreign assistance evolves, translating the impact of these disease-specific efforts into cost-effective, integrated, collaborative solutions is the next challenge to ensure sustained success.
The United States and other bilateral partners have inadvertently contributed to a system where foreign investment is disease-specific (known as a “vertical” model) rather than comprehensive across health systems (known as a “horizontal” model). This makes it difficult to invest across disease areas. Over time, this has created duplication, putting more of a strain on U.S. funding.
Partnerships like the President’s Emergency Plan for AIDS Relief (PEPFAR) have built physical health infrastructure as well as trained and financially supported health care workers to increase technical capacity in resource-limited settings. While U.S. assistance saved lives – in the case of PEPFAR, an estimated 26 million – there are instances where parallel, disease-specific structures have emerged. While most clinic personnel provide care across diseases, community health care workers and some lab personnel maybe funded in a disease specific manner. This creates artificial barriers and clear distinctions between resources afforded to each one. U.S. global health engagement should promote the integration of health services and systems, but not to the detriment of decades of success achieved by vertical health programs.
As the new U.S. global health strategy shifts to support cost-effective platforms that integrate into primary health care, clear metrics are required to ensure sustained outcomes and impact of current programming.
Health integration from a personal perspective
To understand the intricacies and gaps within health systems, policymakers must consider how patients in resource-limited settings navigate them. Individuals and communities use health systems and services according to their habits, environment, and needs. Their ability to access that system is also impacted by a variety of economic, social, geographic, and environmental factors.
Pregnant women in high-disease burden and low-and-middle-income areas have some of the greatest health needs.
Consider the health journey of a young, pregnant woman who lives several miles outside of Kisumu, Kenya, the third largest city in the country, with the highest HIV prevalence in the country of 17.4% (a prevalence rate above 2% is considered high). Kenya also ranks among the top 30 countries in the world with the highest TB burden and a significant percentage of the population is living with undiagnosed TB. Seventy percent of the population lives in high-risk malaria areas. Due to these risk and environmental factors, approximately 70% of all maternal deaths occur in sub-Saharan Africa. This mother needs access to prevention, screening and treatment for each of these health risks to ensure she and her baby can survive and thrive during pregnancy and after childbirth.
However, she faces challenges with each step of her health journey. The following outlines the obstacles posed to the patient and several considerations that are necessary to de-silo and integrate health systems and services into primary health care. These methods will help ensure that she and others like her have healthy babies, that they have more time and resources to contribute to growing economies, and that their country governments foster better use of taxpayer dollars.
Testing
Obstacles
To understand the patient’s HIV, TB, and malaria status, the pregnant woman in Kisumu likely needs to go to different test sites, sometimes on different days, making the process duplicative, costly, and inefficient. It is likely that each clinic she visits uses different methods or devices to collect data. In many places, records are still collected on paper for later input, which increases the chances of errors in her medical history.
Diagnostic equipment, which is used to analyze HIV, TB, and malaria tests, is often provided by external funders. Restrictive rules, perhaps put in place by donors or the national government, may mandate that technicians use each piece of equipment only for certain disease-specific tests, putting unnecessary limitations on their capacity. Local hospitals may also have few personnel on staff trained to perform routine maintenance of the laboratory machines and make expensive repairs to them. This makes it difficult to obtain results quickly.
Opportunities
It is critical that individuals in high-risk areas know their status so that they can access treatment and prevent diseases from spreading. An ideal health system should:
- Ensure testing for HIV and malaria (and the collection of sputum samples for TB, where feasible) is available across all health centers and clinics, and in people’s homes through community health workers; and
- Work alongside influential private-sector partners to ensure that diagnostic equipment and modern technologies are shared across disease areas and are working at their full capacity.
Treatment
Obstacles
Health supply chains can be siloed and disjointed, making procurement, delivery, and disbursement difficult to track. Because of funding restrictions, narrowly focused training, and mandates or regulations, health workers may provide care for only one disease or focus area.
The patient may need to go to different clinics for HIV, TB, and malaria care and to receive her medication. These visits are often separate from her antenatal and pediatric wellness visits. Furthermore, bed net distribution campaigns – the primary method for preventing malaria among pregnant women and young children– typically occur outside the clinic environment.
Due to funding restrictions, training and mandates, health workers may provide care for one disease or focus area. This not only makes the process more difficult for the patient but also limits the return on investment on her country’s workforce.
Opportunities
Country governments, the U.S. government, and other partners must drive greater innovation and efficiency in community engagement and service delivery by encouraging and supporting adoption of proven reforms that save lives and money. This should include:
- Providing joint access to HIV, TB, and malaria care while integrating antenatal support into the same visit for pregnant women.
- Merging and coordinating supply chains, data and lab systems, and human resources for health and monitor aggressively for inefficiencies.
- Ensuring that health workers are trained across diseases and conditions to perform various tasks.
- Allow community health workers (including NGOs and faith-based groups) to perform more tasks in patients’ homes, including testing and the delivery of treatment for various diseases.
- Support methods, such as encouraging entrepreneurship, combating sexual violence, and bolstering democratic participation, that will positively affect patient behaviors and support positive health outcomes in the long term.
Monitoring/oversight
Obstacles
Once the patient’s information is collected at different locations, it may be put into separate databases. If the patient visits a faith-based hospital or private pharmacy, her records may not follow her. Without a unified patient identifier, many of the visits and records remain siloed. This makes it difficult for health care workers, country governments, the U.S., and other partners to know the patient’s medical history and ensure she gets the care she needs in the future. It also makes it challenging for country governments and their partners to track progress toward the goals of ending HIV/AIDS, TB, and malaria as global health threats.
Opportunities
Once health systems and services are integrated, there must be assurance that they are effective, high-quality, and will be maintained to avoid inefficiencies and duplication. The U.S. governments and partners should:
- Merge disease-specific databases into or under one national health database (especially those that already exist) and ensure country governments, investors, and partners have access to the data in real time. Interoperable programs and platforms that can collect, store, and share data securely and compatibly will ensure resources are directed to where they’re needed most and foster coordination, collaboration, and accountability.
- These data should be publicly available so communities can hold their government accountable and see how they compare to others. This would also improve the quality of the data and can attract additional global investors.
- Ensure proper long-term health system monitoring and oversight from the local to national levels.
Financing
Obstacles
For the patient, making sure she and her baby receive the care they need can be prohibitively expensive. Transportation to each clinic visit can be expensive and time-consuming. She may have to pay for some tests and drugs out of pocket. If money is tight, she may even forgo treatment for other needed resources, such as food or rent.
Country governments cannot afford to support several disease-specific health networks forever. They must make difficult financing and budgeting decisions as they try to assume responsibility for and sustain decades of successful HIV, TB, and malaria programming.
Opportunities
National budgets and other financial mechanisms must support the HIV, TB, and malaria integration process and sustain that integration well into the future. The U.S. government, country governments, and partners must integrate various streams of financing to tackle multiple diseases at once. This includes ensuring more flexible funding that fosters integration through bilateral health agreements with the United States and the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The private sector also has the opportunity to invest in innovations that foster long-term success.
Implications for health system and service integration
Partner governments, the U.S. Department of State’s Bureau for Global Health Security and Diplomacy, and the U.S. Congress should look to implement policies that foster these recommendations. This includes:
- Providing adequate resources and funding through the America First Global Health Strategy and the appropriations processes to foster smooth integration of care.
- Monitoring early warning signs such as rises in HIV, TB, and malaria cases.
- Make immediate, data-driven changes when backsliding occurs.
The Bush Institute would like to thank Neeta Bhandari, Senior Program Officer, Global Health at the Gates Foundation; Chris Collins, President and CEO, Friends of the Global Fight Against AIDS, Tuberculosis, and Malaria; Dr. Jennifer Kates, Senior Vice President, Director of Global Health and HIV Policy, KFF; Amb. (ret.) Mark Lagon, Chief Policy Officer, Friends of the Global Fight Against AIDS, Tuberculosis, and Malaria; Dr. Ani Shakarishvili, former Special Advisor, Integrated Services and Systems for HIV and Health, UNAIDS; and Bill Steiger, CEO, Malaria No More for their review of this project.
