Globally, the Covid-19 pandemic has had devastating effects on economies, putting millions of people at risk. Now is the time to think about initiating reforms in the global health agenda. The WHO faced serious criticism from all walks of life over the handling of Covid and could do little to facilitate the delivery of vaccines to populations in need.
The activities of international health agencies like the WHO are targeted at two different health approaches, one focused on the vertical campaign against the management of specific diseases (e.g. smallpox, malaria, etc.), and the another with a social perspective or a horizontal approach targeting poverty, inequality, … (eg the Alma-Ata declaration with the goal of health for all). These can be qualified respectively as biomedical and social medicine approaches. The biomedical or vertical approach, being a specialist approach, is performed by health workers and may not be successful if there are no permanent health services in specific areas for follow-up. The horizontal approach, like a mass campaign, involves a large part of the population. The allocation of resources by economies plays a key role in both of these cases and therefore these approaches are not mutually exclusive and require coordination and combination in various ways. Thus, WHO may need to draw a clear line on where mass campaigns are successful, taking into account the disease being targeted and the availability of resources.
Another serious constraint to achieving health and development goals is the shortage of health workers and their vital role, especially in the fight against communicable diseases. The WHO in its 2006 health report highlighted a shortage of four million health workers with critical shortages reported in 57 countries, mostly in Africa. He also estimated that 18 million more health workers are needed by 2030, mostly in low- and middle-income countries. The imbalance is more marked in rural areas than in urban areas. The high salary of these professionals in advanced countries pushes them to go abroad. Adverse working conditions, the impacts of climate change and an aging population contribute negatively to this problem.
The vagueness of priorities among a multitude of programs is another major challenge. The prioritization process involves selecting the best option to meet the most important health need. The WHO has identified “universal health coverage” as the most powerful concept public health can offer. Studies from around the world estimate that out-of-pocket payments push 100 million people into poverty each year and that the most effective way to provide universal coverage is to share the costs among the population. Overall, 12.67% of people spend more than 10% of their income (out of pocket) on health expenses. One of the areas where this rate is above average is the Southeast Asia region (India included), where it is 16%. The Western Pacific region comes second in this list. This means that these regions do not have universal health coverage. A strong, effective and well-managed system that meets priority health needs through integrated, person-centred care is the need of the hour. Sustainable health systems that promote universal access to care can be facilitated by appropriate application of digital technologies.
The Covid crisis had laid bare the risks of corruption prevailing in the health sector as well as its fragile systems which 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 audit findings were rated as “satisfactory” or “partially satisfactory”, suggesting improvements. Compared to 478 fraud, corruption and misconduct cases reported in 2014, 520 were reported in 2019. Identified priority areas for improvement include strengthening implementation, strong vendor management, responding to human resource needs and improving resources for key underfunded programs. It is therefore high time that good governance practices were integrated into this organization.
Recently, multilateralism entered into crisis. There is a decline in commitment to multilateral/UN action after the end of the Cold War and in the current geopolitical climate of rising nationalism. The UN and its agencies are criticized for their lack of efficiency and many other problems. The WHO has also shown its limitations and shortcomings in containing the spread of the virus during the pandemic, and the world has also witnessed political pressure from powerful member states and commercial interests. There are also growing calls for social justice in a context of accelerating economic globalization.
Global health governance encompasses formal and informal institutions as well as norms and processes that directly govern or influence international health policy and outcomes. A multitude of diverse actors are involved in financing global health and have far more resources than the WHO. In addition to international organizations such as 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 and civil society initiatives (e.g. MSF, Oxfam ) that undertake many health financing activities.
Thus, there are various financing actors, fragmented due to lack of coordination and duplication with top-down and donor-driven approaches, which negatively impact countries with fragile health systems. There are a lot of funds flowing into the health sector, but the same is unbalanced in the allocation to “big” diseases (vertical) but not to the health system for strengthening (horizontal). There is also a lack of evaluation, accountability and sustainability, which requires major overhaul and changes in traditional donors and funding models for the optimization of existing health resources.
(Deputy Secretary, Ministry of Finance. Opinions are personal)