Transitioning from silos to platforms

At the 22nd International AIDS Conference in Amsterdam this week, some themes are already emerging: to reach the end of AIDS, we’ll have to get more serious about tuberculosis (TB) and other coinfections; ending the epidemics will depend on whether we build and sustain strong platforms for universal health coverage (UHC); and the health systems providing UHC need sustainable national-level funding, even while global financing continues to fill gaps.

These points dominated the TB2018 pre-conference as well as early AIDS 2018 sessions, “Eliminating AIDS epidemics on the road to UHC” and “Where will the resources come from to end AIDS?

There seems to be agreement that building strong and integrated national health systems is, over the long term, the surest way to reach the end of TB-HIV. However, it will take a powerful shift in the priority that governments assign to investments in health, both at home and abroad. Advocates are making gains in building that political will — as evidenced by the policymakers echoing these points up on the Amsterdam stage — but it is taking time.

In the short term, local and global leaders still need to make tough choices about how to have the greatest impact for the largest number of people using scarce resources.

Those choices are particularly challenging in middle-income countries (MICs) — where governments’ “ability to pay” has grown dramatically on paper but their on-the-ground capacity to serve the health needs of their people may not have. How can the stewards of global financing such as the Global Fund best support the people impacted by TB-HIV in these MICs without distorting governments’ paths to UHC?

Siloed responses

In a side session on Monday, our civil society colleagues from the TB Europe Coalition, RESULTS UK, Center for Human Policy Bulgaria, Curatio International Foundation Georgia, and Médecins Sans Frontières presented case studies that help answer this question. The bottom line: without careful planning and safeguarding, donors transitioning their funding out of MICs can send a country backwards — and fast. Yet, if done right, transition can support the path forward to UHC.

Bulgaria: From a case study of Bulgaria, we learned that the Global Fund helped catalyze provision of services to key populations by civil society. While that approach had a big impact on making services accessible and people-centered, it was constructed as more of an emergency stop-gap measure than a sustainable approach to social contracting. Though the short-term impact was important, the lack of meaningful transition planning has set people up to lose services — and set the TB-HIV epidemic up to resurge.

Georgia: From a hot-off-the-presses story of Global Fund transition in Georgia, we learned that global mechanisms have filled not only financial gaps, but also programmatic and institutional ones. Access to pooled procurement mechanisms helped make quality-assured drugs affordable for a country with too small a market (and too thin a regulatory environment) to do so on the same scale or timeframe on its own. But, again, by treating access to pooled procurement as a short-term emergency measure, rather than a long-term pathway to stronger market access, donors are about to miss an opportunity for long-term impact — and people may start to miss out on the treatment they need.

Estonia: The lessons from a case study on Estonia rang a more positive note. External financing can help catalyze health system reforms that make UHC sustainable and ending the epidemics feasible. The key factors seemed to be high-level political commitment, coordination across stakeholders, and careful planning — including a costed transition plan.

Building on platforms

At first glance, it might appear that the factors distinguishing Estonia’s positive post-transition trajectory from Bulgaria’s and Georgia’s shaky ones are mere circumstance. One may assume that the 2003–2007 support from the Global Fund had a more catalytic than distorting effect because it was a smaller piece of the pie, or perhaps the looming EU membership created greater political commitment to health system reform, including integrated TB/HIV services.

However, I believe the key takeaways can be translated into and adapted for other contexts if we think about the bigger picture of UHC and health financing.

The most directly translatable piece of Estonia’s experience may be its focus on systems. As advocates, governments, the Global Fund, and other donors seek to replicate the other key factors — political commitment and careful coordination and planning — in other transitioning countries, we should think hard about which elements of the health system most need strengthening before, during, and after transition. Is it procurement systems, as in Georgia? Social contracting, as in Bulgaria? Neither of those challenges is unique to the HIV or TB response; both are fundamental features of the health system, and they are steps on the path to UHC.

If we prioritize using the political and financial leverage of transition to zero in on those system or platform issues, we will do more to sustain progress within each siloed disease response than if we retreat to isolated corners in the face of financing transitions.

Hannah Bowen is director of the ACTION Secretariat.