Disease v. Disease Advocacy
Ruth Levine, senior fellow and director of programs at the Center for Global Development, knows quite a lot about global health. She has been instrumental in efforts to set up a worldwide independent evaluation body for aid and health projects, in negotiating the difficulties of drug provision to the developing world and in thinking through solutions to the AIDS epidemic. Levine sees close up -- and writes compellingly about -- the problems that plague global health advocacy. Not least of these, as she writes in Perspectives Magazine, is a strange sort of competition between diseases.
Global health advocacy has an oddly competitive tone. Those who argue for investments in life-saving interventions often cite estimates of lives saved or diseases averted as if they were part of a high-scoring football match.More money for immunization, the argument goes, would yield 3 million children’s lives a year. More for diarrheal disease control would yield another 2 million. AIDS claims 3 million lives a year, and tuberculosis takes 2 million. New “causes” are rarely welcomed in an already crowded field of injunctions to buy more medicines, train more health workers, spend more money. New priorities find they must use the same metrics of importance and urgency—a count of deaths or some measure of the burden of illness—if they are to get the attention and resources they seek.
The problem, as you may have guessed, with this approach is that when one disease receives a surge in attention, advocates tend to neglect the others. If the overall goal is greater health and well-being, trading one ailment for another isn't a very cheerful outcome. And of course, there is overall health infrastructure to think about too.
These are problems you've probably considered before. But since we're all about solutions at the GII, I'm most intrigued by Levine's four recommendations:
Address underlying system weaknesses. Identify the gaps in a country’s ability to carry out essential public health functions, including disease surveillance, health education, monitoring and evaluation, workforce development, enforcement of public health laws and regulations, public health research, and health policy development. Recognize that key shortcomings in these functions must be addressed to respond to virtually any major health problem that merits public policy attention, whether at the international or the national level.Invest in systemic improvements. Use new resources to strengthen and build upon existing systems, including information and monitoring systems, supply chains, delivery of services, and others. Design any new program within a long-term framework for strengthening of health system capacity and with short- to medium-term operational plans. The long-term framework can include centrally managed programs—some public health interventions are best organized through such approaches—but these should contribute to the development of essential public health functions, not operate in parallel or for specific, short-term gains.
Measure both operational achievements and health impact. Monitor changes in a country’s capacity to carry out essential public health functions, but also measure changes in health conditions. Include routine monitoring of population health status as part of established information systems, as well as through focused, rigorous impact evaluations of particular programs.
Declare a truce in disease-versus-disease advocacy. Mobilize resources using any and all arguments that work. These may include current health impacts as well as potential ones, ethical imperatives and costs to the health system, worker productivity, or other economic outcomes. In some cases, the most effective approach may indeed be disease-specific advocacy, but this should be paired with strong arguments against earmarking funds so narrowly that larger, system-wide objectives cannot also be addressed.