Setting a course for sector transformation

Joe Biden and Kamala Harris have stated their priorities—COVID-19, economic recovery, racial equity, and climate change—and each intersects with global public health. PATH’s advocacy and policy team recently outlined key objectives and policy asks for the new US administration.

We sat down with Heather Ignatius, PATH’s senior director of policy and external affairs, to discuss the new administration, PATH’s key objectives, and hopes for the future of global public health.

Any transition of power is an opportunity to revisit policy priorities and ask ourselves and our elected leaders: are we focusing on the right things?

In this particular case, the Biden-Harris administration is taking the helm amidst the worst pandemic in a century and global health is top of mind. We should be challenging our assumptions about the priorities we’ve pursued in global health and asking ourselves where the US government should be engaging differently to advance the types of policies and priorities that create sustainable change.

Now more than ever, I think we can look beyond what is expected and redraw the lines around the scope of global public health to include root causes of health inequity—like racism and other forms of discrimination—that have been excluded in the past. Lately, PATH has been more intentional in the way we acknowledge these factors, and I think that needs to continue.

In addition to redrawing lines around what we advocate for, I also want to see an evolution in how our sector advocates.

First and foremost, this will mean greater inclusion and representation in how policies are conceived, forged, and fought for. All too often, global and donor health strategies are written by experts and advocates in high income countries, with minimal input from decision makers in countries that will utilize them and the communities they are accountable to. But I’m imagining a future for priority setting—even for donor policies, like the US government’s—where stakeholders in the countries where assistance is utilized have agency in determining where investments are directed. That feedback loop doesn’t exist today, and we need to build it.

Secondly, the focus on increasing countable outputs—like bednets distributed or people on antiretrovirals—as the marker of good stewardship of US taxpayer dollars has created a dynamic where broad investments in the systems that deliver health outcomes are actually deprioritized. We need to form a constituency of advocates to make a convincing case for the long game: strong resilient health systems without which improved health outcomes cannot be sustained.

Investing in systems rather than silos means shifting away from health-area-specific funding in favor of more flexible and comprehensive approaches to funding. Essentially, we want to make investments that foster health system resiliency and give public health authorities more flexibility, not less.

The COVID-19 pandemic has demonstrated the need for a shift in focus from strengthening individual functions of the health system to a focus on outcomes. We need a common vision to ensure the resilience of health systems that provide preventative, promotive, and curative care.

Current funding models were never intended to create barriers, but the reality is that their siloed structure has done exactly that in some cases.

For example, with funding from the President’s Emergency Plan for AIDS Relief (PEPFAR), you end up with some investments that can only be used to advance HIV/AIDS outcomes. Though the program has made a tremendous impact for people living with HIV, the fact that the funding can limit strategic improvements to the broader public health system is a real drawback.

At PATH, we’ve already been shifting to a more comprehensive, systemic approach to better meet the needs of the countries and communities we serve.

In Senegal, for example, our malaria team had been establishing disease surveillance systems for control and elimination efforts. Those systems were quickly adapted to COVID-19 when the pandemic began. That kind of flexibility is essential for health systems to grow and endure through challenges.

We also recently launched a Primary Health Care (PHC) Program that will unite many of our health-area experts in a single, comprehensive team.

It might seem hard to believe right now, but yes, we really can.

First, we have to end the current pandemic and prepare for the next one. That means the global community will have to continue engaging and investing in multilateral solutions like the World Health Organization and the Access to COVID-19 Tools Accelerator. We have to keep working together to accelerate the global development of resilient, community-centered, PHC systems that can prevent, detect, and respond to outbreaks.

We also need to respond to climate change as the public health crisis it is. In the 21st century, we’re going to see dramatic increases in the frequency and intensity of wildfires, hurricanes, droughts, famines—and so also in refugee and humanitarian crises. There will be less food and water for more people, and there will be more mosquitos to transmit disease. The public health implications of climate change are massive. Taking the lead from the Biden-Harris administration, which has already issued a clear call to reframe climate as a central concern in foreign policy, development partners urgently need to start integrating climate considerations into programs for global health and development.

Tackling emerging challenges, as well as those that have threatened humanity for decades (or in some cases, millennia) will require increased investments in the research and development of science and health technology. At PATH, we’re working to ensure global health research and development is prioritized within US foreign assistance agencies, the US Development Finance Corporation, Health and Human Services, the Department of Defense, and within national development, health and security policy frameworks.

COVID-19 has made it clear the world doesn’t have the tools in place to deal with a pandemic. There’s lots of bread-and-butter product development work to be done—from diagnostics and disease surveillance to medical oxygen and masks—and we need better policies and public sector investments to drive this work.

At the most basic level, we need to do no harm. Absolutely everything—from our funding mechanisms to our program design—must be reviewed with a critical eye for unintentional damage to the very people we are trying to support. The best way to do this is to make sure all our work is vetted, co-created, and ideally, led by the communities our programs are designed to serve.

After “do no harm,” I circle back to my first answer about our opportunities: are we focused on the right things? Too often we look for a quick return-on-investment in health policy and funding. But those quick fixes often miss the hard-to-reach, worsening disparities between those with access to health care and those without, because they fail to address the problem at its source.

Instead of responding to symptoms, I am hoping we can look further upstream to the root causes of health and health inequity—including racism, gender bias, and weak social safety nets—to create truly sustainable change. It’s a tall order, but I have never been more hopeful.