Three ages of global health assistance

The global priorities are prevention and management of non-communicable diseases

The world of global health assistance today bears little resemblance to that of the post World War II (WWII) era when international global assistance began. During the decade after WWII, the United Nations, World Health Organization, World Bank, International Monetary Fund and other international agencies were created, designed to nurse back to health a devastated world. In concert with the Marshall Plan, President Truman's Point 4 program included a Technical Cooperation Administration lodged in the Department of State, designed to help struggling states; health was part of that portfolio.

A humanitarian commitment and selective primary care

Several iterations later, in 1961, international aid disbursed by the United States was centred in the Agency for International Development (USAID). As the repository for American — if not Western — assistance, USAID had two major drivers. The political goal was to counter any efforts by the Communist bloc to gain allies, supporters and trade partners. There was, however, a genuine humanitarian commitment. No one wanted to repeat the tragic consequences of the vengeance-driven resolutions that followed WWI. The US and the WHO, the other significant health donor, were characteristic of the age in their view of the world. There were donors and recipients; management and priority-setting were central, with little local input; and it assumed a dependency relationship that did not anticipate an end.

This pattern of health assistance was effective, however, and this approach dominated global health assistance into the 1990s. Maternal and child health, under-five mortality, sanitation, water quality and nutrition improved. In the late 1970s and 1980s, the debate between comprehensive or selective primary care as the operative standard was decided in favour of selective primary care. This was likely the correct response, even with the well recognised weaknesses of paternalism, project silos, duplicative efforts and major issues not being tackled. The low hanging fruit needed to be picked.1

Prevention, advocacy and political activism

In the 1990s, HIV/AIDS arrived and changed everything.2 This second stage of global health assistance not only reordered priorities but also transformed the scope, reach and magnitude of assistance. Because HIV/AIDS affected both wealthy and poor nations, it created a common goal that merged traditional donors and recipients. Because of the epidemic, global health now embraces patient advocacy and political activism to make drugs and therapy affordable and available and endorses human rights as core components. It created an awareness of global health issues that triggered funding orders of magnitude greater than anything ever seen and generated support from agencies and philanthropies that formerly saw health as peripheral to their efforts. And perhaps most importantly, it fused prevention and care to create a new global health.2

The result has been truly remarkable. As UNAIDS clearly demonstrates,3 the past decade has witnessed a dramatic tipping point. The incidence, prevalence and transmission from mother to child of HIV/AIDS have fallen, the adherence to medication has improved, and even the sexual practices of those at risk have changed. Now, more than half of the funding for HIV/AIDS in emerging economies comes from in-country sources. While HIV/AIDS will be a major global problem for decades to come, as will the dominant issues of the first stage of assistance, the developing world is taking ownership of the problem, training a cadre of professionals to manage it and developing a sophistication in health care delivery that can, hopefully, carry over into other aspects of care.

Five drivers for improved health care

Public health has been preoccupied with ameliorating upstream drivers or policies that lead to poor health outcomes. However, from another perspective, there are five drivers for improved and sophisticated health care: increasing wealth, an expanding civil society, urbanisation, an ageing population, and higher levels of education. The number of low-income countries has plummeted in the past 20 years, falling from around 60% to about 15% of all nations.4 Headlines notwithstanding, the number of democracies has leaped in the past two decades.5 The world passed the 50% urban mark during the first decade of this century and seems headed for 70% or higher in the coming few decades;6 and urbanisation is associated with higher incomes.6 Neonatal and under-five mortality rates continue to fall, along with the global fertility rate, now approaching replacement value.7 And education levels, particularly for girls and women, have accelerated.8 The better off a society sees itself, the better the health care it demands. This conflation of societal changes creates a powerful force for change. This set of phenomena, all accelerating nearly in step, could be enough to inaugurate a new global assistance paradigm.

Emerging economic trends and non-communicable diseases

However, there is another set of events that could also serve as a marking point for the onset of this third stage of global assistance. The Global Alliance for Chronic Diseases was founded in 2009.9 While its funding is miniscule compared with that for HIV/AIDS, tuberculosis and malaria, it did engage many important organisations. In 2011, the UN General Assembly meeting on chronic disease attracted wide global attention; and in 2012 the release of the 2010 Global Burden of Disease dataset offered a hard base on which to build a campaign.10 The combination of the emerging economic and democratising trends in developing countries and this trio of official recognitions of the severity of the problem of non-communicable diseases (NCDs) certainly offer a critical mass that can, and likely will, herald the onset of a new paradigm.

NCDs are now recognised as the dominant health concern in emerging economies.10 In all but low-income countries, the dominant causes of death are cardiovascular diseases, encompassing diabetes and chronic lung disease, with cancer not far behind. From 1990 to 2010, deaths from communicable diseases fell by 13.5% while deaths from NCDs increased by 30%.10 In sub-Saharan Africa, the cardiovascular risk factor profile presages a similar pattern.11 In developing economies that are ageing but not aged, these diseases will strike middle-aged workers and parents, with profound impact on social structure and economics. Because treatment for these disorders after they are expressed illnesses is prohibitively expensive, the only rational approach is to prevent them. Also, older people are more attentive to voting and political engagement in general, so an older generation stricken with disease will exercise its political clout to get the treatment it needs, consuming, as it has in the US, enormous funds and leaving little for extensive prevention programs. The dependency ratio in many developing countries is now as low as it ever will be, suggesting that the budgetary capacity for inaugurating prevention programs is more readily available now than it will ever be again.12

Prevention of non-communicable diseases

This third stage of global health assistance is centred on the prevention of NCDs. The concept is not new, being introduced over 40 years ago by Omran,13 but new ideas and paradigms take time to embed themselves in societal action unless introduced with cataclysmic threats. HIV/AIDS created a second stage of global health this way; and now that it has been converted to being a manageable chronic disease, the less overtly threatening but potentially overwhelming NCDs need to assume their rightful role on the top of the priority list. NCDs are gaining visibility in developing economies, owing to an increasing volume of surveillance data, appointment of NCD experts to prominent leadership roles, and high-level publications.10,11 As with HIV/AIDS, the emerging economies are assuming leadership roles in confronting NCDs. The global assistance community will be called on for technical and educational assistance in addition to financial support. The public health education community needs to awaken to this reality, as do the dominant global health funding institutions. One can only hope that both groups learn to listen to the communities they purport to serve.