New administration must look to recent past for global health lessons

Leading up to the Inauguration of President-elect Trump, experts have made the case for why global health should be a top priority for the new administration. Global health has a long history of bipartisan support and is, frankly, good business.  

However, Ebola in West Africa and Zika in the Americas should teach us something about progress in global health: selective funding for narrow targets do little when unpredicted diseases or ailments emerge. Meaning, we may target Ebola and Zika as global health priorities, but doing so does nothing to prepare us for the next emergent health crisis. 

To truly make a difference, global health initiatives must directly target weakened health systems, not narrow initiatives.

{mosads}As a medical anthropologist I’ve researched the effects of global health funding on health infrastructures in Tanzania since 2008, when I met President Bush during his Tanzania visit as he showcased two signature global health programs: The President’s Malaria Initiative (PMI)and the President’s Emergency Plan for AIDS Relief (PEPFAR).

But, the stated successes of PEPFAR and PMI don’t tell the whole story: selective funding of specific diseases or populations can also harm. Resources pour into HIV, Ebola, malaria, and TB services. Local health workers gain higher salaries and more perks if they specialize in those services, thereby pulling critically-needed workers out of primary care where they are needed most. Meanwhile, those remaining in primary care gain specialized knowledge in a few diseases, but cannot deal with many of the day-to-day issues affecting patients due to lack of equipment, infrastructure, or training. The costs to health systems are high.

For example, in one hospital where I have conducted research for nearly a decade, the vast majority of health professionals know precisely how to dose newborns of HIV+ mothers with antiretroviral drugs based on the baby’s weight. The drugs needed are available, in part due to PEPFAR.

But those same health professionals are unfamiliar with other critical procedures. Many nurses cannot adequately recognize respiratory distress in a newborn. Of those that can, few can apply standard resuscitation procedures. A baby of an HIV+ mom might get the correct dose of antiretrovirals, only to suffer long-term disability or die due to oxygen deprivation. By the rationale of PEPFAR, the infant didn’t die of HIV, so the program did its job.

In countries receiving global health funding, health workers are not paid sufficiently to afford continuing education, even though many would eagerly expand skills. Health budgets are insufficient to provide updated training to their workforce, let alone all necessary equipment. For many health professionals, what they learned in medical or nursing school may be the last formal education they receive.

That is, except for donor-sponsored workshops. Donors like the United States Agency for International Development use your taxpayer dollars to fund trainings on issues relating to American global health interests. However, it’s foreign donors, not recipient countries, setting training priorities. Which is why a nurse knows antiretroviral doses, but not neonatal resuscitation procedures — HIV is a global health priority, while broad improvements to system-wide obstetric care are not.

Innovation around specific problems, instead of effort to address health systems’ systematic weaknesses, often works contrary to expectation. For instance, the Helping Babies Breathe (HBB) initiative was launched to increase newborn resuscitation capacity in low-income countries. When I learned about HBB in Tanzania, it seemed great: the initiative provided resuscitation equipment, trained health staff, tested them at the end of the training, and then tested again six weeks later to measure health workers’ retention of the knowledge. Expected result: lives saved, right?

In theory, yes. But, in practice, trained staff struggled to apply this training in real-world situations. In the U.S., physicians have residency periods enabling them to apply their training in practice, under close supervision. Applying learned skills well, and flexibly based on different patients’ needs, takes mentoring, not merely workshops.

Targeted interventions for HIV, tuberculosis, malaria, and newborn resuscitation do save lives. But at what cost to health systems? More lives would be saved if global health funding went towards strengthening health systems instead of focusing narrowly on specific “magic bullet” interventions. Funding recipients, working on the front lines and possessing direct knowledge of capacity needs of a given location, should direct global health priorities for their health systems. Strong primary care systems can better deal with non-communicable disease and trauma — massive yet neglected global health problems for which there are no “quick fixes” — not to mention the next outbreak or crisis.  

Time will tell how the incoming administration will prioritize funding for global health. However, it’s long been obvious to those of us close to the issue that it’s not just about money, but how money is allocated.

Noelle Sullivan is an Assistant Professor of Instruction in Global Health Studies and Anthropology at Northwestern University, a Board Member of the 501(c)(3) charity Worldview Education and Care, and a Public Voices Fellow with The Op-Ed Project. Twitter: @ncsullivan 

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