Paul Jensen, The Union's Director of Policy and Strategy, reflects on the themes that arose in speeches and conversations throughout the week.
Paul Jensen, The Union's Director of Policy and Strategy, reflects on the United Nations (UN) General Assembly and High-Level Meeting on Universal Health Coverage (HLM on UHC):
The annual UN General Assembly convened last week, and this year's meeting included the first-ever HLM on UHC. I participated in the meeting on behalf of The Union, along with a number of side events focused on tuberculosis (TB), innovation and UHC. Across the formal UN proceedings, side events with members of civil society and the private sector, and hallway discussions, the following themes arose in speeches and conversations throughout the week.
The pendulum toward health systems strengthening keeps swinging. When it comes to ending TB, we need to strike the right balance. At the UN HLM on UHC, there was a consistent call for integrating vertical programmes into health systems. While it is important to recognise the limitations of vertical disease programmes, it is also important to recognise that some functions within national efforts to end TB need to be safeguarded and even strengthened. Mario Raviglione and Antonio Pio published an important paper in 2002 that takes a historical perspective on World Health Organization (WHO) TB policies. They lay out a compelling case that the shift between vertical and horizontal TB approaches has been ongoing for decades, going back at least to the 1940s. As they show, both disease-specific "vertical" approaches and "horizontal," systems-wide approaches have their limitations. The key, they propose, is to offer people-centered TB care that is fully integrated into the health system through primary healthcare, while maintaining strong programmes for TB surveillance, supervision, programme monitoring, and training.
We need to meet new innovations with a sense of urgency. It was brought up in more than one side event that the pace of innovation in TB is too slow and must be sped up in order to end TB by 2030. As Peter Sands, Executive Director of the Global Fund to Fight AIDS, Tuberculosis and Malaria pointed out at the annual TB Innovation Summit, even when we have new innovations in TB, those innovations don't get rolled out and scaled up quickly--especially compared with the pace of innovation in the fight against HIV/AIDS. I believe Peter was making a general comment about the tendency for the TB community to be overly cautious in embracing new innovations, but the point could be made for national governments as well. The pace of progress in TB prevention, especially, is one area we need to work together to accelerate.
Countries need to prepare now for new innovations. Another issue, related to the point that Peter Sands made above, that came up in various discussions was the issue of "country readiness," which relates to the efficiency with which governments are prepared to integrate new tools that come out of the TB R&D pipeline over the next several years. If countries are going to make the most use of shortened treatment regimens, better diagnostics or even a new vaccine, it's critical to do the prep work in advance. This discussion reminded me of a 2010 study showing that once countries committed to considering making a change in the TB treatment regimen, it took one year on average for decision-making processes to play out, followed by two years to roll out the change. The question is, how can we speed that process while ensuring its integrity and maintaining quality of care?
New funding is critical. Economist Jeffrey Sachs made the most impassioned remarks I saw at the HLM on UHC, which focused on a single message: the most critical piece of the solution to UHC is resources. (Note: I was sitting in the room where the interactive multi-stakeholder panel discussions were held, not the room where heads of state and government were delivering speeches.) The funding requirements to achieve UHC are significant, but Sachs was compelling in reminding the global health community that the resources required are still a very small fraction of the funding available globally. I found it interesting that, while at the UN, he made a plea for high-net-worth individuals to contribute more resources to help achieve UHC, in addition to governments. Brazil's Minister of Health, Luiz Henrique Mandetta--who's the incoming Chair of the Stop TB Partnership board--also stressed the importance of improving management capacity within health programmes, so that they can absorb more resources and allocate them well. As governments have made specific, high-level commitments to treat and prevent TB, to invest in new R&D, to take concrete steps to achieve UHC while ensuring no one is left behind, ensuring the availability and sound use of new funding will determine whether recent political declarations on health ultimately become more than just promises. The next opportunity for governments to commit resources to fulfill their promises will happen soon, as the Global Fund seeks to raise at least US$14 billion in its next replenishment round.