With a High-Level Meeting on universal health coverage (UHC) scheduled for 23 September 2019, the day before the United Nations General Assembly begins, the United Nations could intensify the global movement toward a health-systems approach offering comprehensive basic coverage that is funded by domestic governments.
A transition to UHC would have significant implications for the Global Fund. The meeting is bringing to the fore questions about whether the Fund has a role to play in attaining UHC, but also longer-term considerations, including whether this transition, if it happens, might ultimately render the Fund unnecessary.
A Global Fund spokesperson told GFO that there was no way to separate achieving UHC from the Fund's objectives – and Fund officials, including Executive Director Peter Sands, have voiced support for UHC. "The Global Fund's mission has always been intertwined with improving systems for health, and ultimately with achieving universal health coverage," the spokesperson wrote in an email.
There has been mounting advocacy for UHC within a global health community looking to sustainably deliver basic health services to all patients. That advocacy saw UHC integrated into the Sustainable Development Goals (SDG), which call for concerted efforts "to achieve universal health coverage and sustainable financing for health," and culminated in the General Assembly's resolution to host an HLM on the issue this year.
Broadly speaking, UHC seeks to provide a community with a suite of promotive, preventive, curative, rehabilitative and palliative health care services. And it looks to do so affordably. It is grounded in a primary health care system that is accessible and comprehensive. The global health community is coalescing around a model that would see governments set their own priority services and also take responsibility for the bulk of the costs.
Loyce Pace, the executive director of the Global Health Council, said the discussion around UHC reflects the evolution taking place in global health circles. Emerging from a "golden era" that saw international attention and resources focus on addressing diseases like HIV and malaria, she told GFO that the conversation has shifted toward building a system that can maintain momentum around these specific responses, while providing more holistic coverage.
"Everything we've been doing has made sense," she said. "But we have to think about what's the next thing to build on the progress we've made. It doesn't have to be an either-or scenario. We're asking what one can do for the other."
As attention has centered on UHC, the Global Fund has taken steps to underscore how it contributes to universal coverage. In a May publication, the Fund highlighted how its efforts have strengthened health systems and promoted integrated points of care that offer more than services for HIV, TB and malaria. The Fund has also broadened access to care, especially for marginalized populations, and spurred domestic governments to invest more in health.
The Fund also sees a role for itself in determining what UHC looks like, including ensuring that, in the places where it is important, preventing and treating HIV, malaria and TB remain high on the health agenda.
"It's not as though the Global Fund is operating in a vacuum," Pace said. "They want to be responsible by weighing in on this and having a response to this question." And its input could be critical, especially for marginalized communities that include men who have sex with men, sex workers and transgender people.
"The Global Fund has played a key role in demonstrating how you can involve a marginalized population in governance and decision making," said Marielle Hart, the head of policy in the United States for the Dutch organization, Aidsfonds. She pointed specifically to the inclusion of representatives from key populations in Country Coordinating Mechanisms (CCM).
That inclusion could disappear within a domestically financed health system where governments that actually criminalize some of these populations would be responsible for establishing priorities. Aidsfonds conducted research on this issue in four low- and middle-income countries and "what we are seeing everywhere is these populations continue to face the same barriers to accessing health services as they currently face," Hart said. "The political will doesn't exist to reach these groups."
There are other risks to reducing the Global Fund's presence, Hart said, including governments prioritizing interventions that readily demonstrate a significant return on investment. That would undermine interventions that do not offer easily measurable benefits, like the role of prevention activities in reducing HIV transmission.
If the Global Fund and other multilaterals see their positions reduced or even disappear under UHC, it removes any leverage they have to advocate for human rights-based approaches or for expansive health policies, she said.
"The reality is that we won't eliminate AIDS, TB or malaria without building resilient health systems that are truly universal, that reach the poor, the marginal and vulnerable people who often get left behind," the spokesperson wrote. "The other reality is that a health system that isn't effectively protecting people from AIDS, TB and malaria isn't much good as a health system."
Global Fund officials will be attending the HLM (including Executive Director Peter Sands) and the spokesperson told GFO that a successful replenishment this year will be an important milestone in the effort to attain UHC.
While the spokesperson argued that it was false to establish a dichotomy between UHC and the goals of the Global Fund, there is the reality that global health funding is plateauing. And though UHC's sustainability will depend on national governments’ taking on the bulk of the cost, some donor money will likely still be needed. International organizations have shied away from putting a price tag on the overall cost of achieving UHC, though ahead of the HLM its organizers have announced goals that include encouraging governments to set nationally appropriate targets for health investments with the idea that aid will then "reduce fragmentation and strengthen national health financing capacities."
That might put the efforts to attain UHC in conflict with the Global Fund and other institutions that are also competing for limited resources, Rob Yates, a champion of UHC and the head of the Centre on Global Health Security at Chatham House, told the GFO.
The continuation of donor activities also pulls emphasis away from increasing domestic funding, he said. "It's not the Global Fund's fault. All of us look at the situation and think, ‘how can we get more aid funding into these countries’, as opposed to, ‘how can we help the ministry of health articulate the case for a bigger funding share’."
There are significant questions still circling the adoption of UHC, though, not least being whether governments will actually pay for it. That means that the need for the institutions that currently dominate the global health landscape is not going away. But that has not stopped experts from beginning to think about how the Fund might evolve within a shifting global health architecture.
Writing in The Lancet last year, the journal's editor, Richard Horton, called on the Global Fund leadership to "seize the opportunity to write a new narrative for the Fund to enable it to adapt to its new political and economic environment." He proposed that the Global Fund adopt an "ATM plus" strategy, that is, an ongoing focus on AIDS, TB and malaria, but also on UHC.
Such a strategy would see the Fund expand to address gaps in achieving UHC and might offer a natural extension to the existing efforts to underscore the work it has already done to help pave the way for universal health coverage.
In response to a question about adopting Horton's model, the spokesperson told GFO, "The Global Fund's impact has always been broader than impact on the three diseases." She also highlighted that the Fund is the largest multilateral investor in grants for health systems at $1 billion per year. That money goes to improving procurement and supply chains; strengthening data systems and data use; building an adequate health workforce; strengthening community responses and systems; and promoting integrated service delivery.
There are also ways in which aspects of the Global Fund system might be retrofitted for a UHC era, which would help preserve some of the ideals the Fund has championed. Hart said there are early discussions in some countries around broadening the CCM's focus beyond Global Fund activities to encompass all efforts under UHC.
"That way civil society and affected communities can really engage in accountability around UHC and monitor the implementation of it," she said.
Overall, though, the international community is just beginning to wrestle with these issues, including how UHC will shape multilateral institutions and vice versa. A key initial blueprint, the Global Action Plan, is set for release ahead of the UN General Assembly and can then be used to help guide the HLM. The Plan grew out of a call for an overarching strategy for achieving the health-related targets under the SDGs. Twelve global health institutions, including the Global Fund, are working to chart the collective actions needed to reach these goals.
Officials working on the Plan told GFO they are not yet in a position to provide details on exactly how it will work or what actions it will require from its partner institutions. Pace, who is involved in a civil society group advising on the Plan, predicted that it will initially spell greater cooperation across the different major global agencies, but probably not any significant overhauls. At least for now.
- The agenda for the High-Level Meeting in September
- The article in this GFO on Global Fund-related activities at the UN General Assembly
- The Lancet on the future of the Global Fund
- The Global Fund on its contributions toward UHC
- Aidsfonds' research on integrating HIV services into UHC
- Available details on the Global Action Plan
- The Sustainable Development Goals
- An article from GFO on Global Fund efforts to enshrine human rights in its programs
- An article from GFO on a special session on UHC at the International AIDS Conference