Sustaining Health for Wealth: Perspectives for the Post-2015 Agenda; Comment on 'Improving the World's Health Through the Post-2015 Development Agenda: Perspectives from Rwanda'

The sustainable development goals (SDGs) offer a unique opportunity for policy-makers to build on the millennium development goals (MDGs) by adopting more sustainable approaches to addressing global development challenges. The delivery of health services is of particular concern. Most African countries are unlikely to achieve the health MDGs, however, significant progress has been made particularly in the area of child and maternal health due in part to significant external support. The weak global recovery, and persistent inequalities in access to healthcare, however, call into question the sustainability of the achievements made. Building on the principles articulated in Binagwaho and Scott, this commentary argues that addressing inequalities and promoting more integrated approaches to health service delivery is vital for consolidating and sustaining the health sector achievements in Africa.

T he article on "Improving the world's health through the post-2015 development agenda" provides timely commentary on an issue that is central to achieving structural transformation and sustainable development in all its dimensions; economic, social, and environmental. 1 The article articulates 5 principles that should guide the post-2015 agenda in the area of health services delivery namely: equitable access to quality health services, an integrated approach to health delivery, bolstering capacities for evidencebased policy-making, and collaboration among multilateral agencies in improving health outcomes. These principles speak to the issue of sustainability but also raise questions about how this objective can be achieved. Building on these principles this article identifies some of the challenges to the sustainable delivery of health services in Africa and proposes solutions. Most African countries are unlikely to achieve the millennium development goal (MDG) health goals. Nevertheless they have made remarkable progress in a number of key health indicators including substantial reductions in maternal and child health, and reductions in the prevalence of malaria, HIV/AIDS, and tuberculosis (TB). In Africa, excluding North Africa, where the healthcare challenges are acute, progress has been remarkable: the under-five mortality ratio (U5MR) declined 41% from 146 deaths per 1000 live births in 1990 to 65 deaths in 2012; infant mortality rate fell from 90 deaths per 1000 live births in 1990 to 54 deaths per 1000 live births in 2014, an average decline of 40%; and HIV prevalence among adults declined, to 4.7% in 2013 down from 5.6% in 2005 as a result of substantial declines in new infections. 2 Declines in malaria cases and deaths in Africa, excluding North Africa, exceed the global average. Since 2000, malaria cases have dropped by 34% and the death rate by 54%, while the equivalent at the global level are 30% and 47%, respectively. 3 In 2013, Egypt and Morocco were among a group of 11 countries that succeeded in maintaining no cases of malaria. In fact, Morocco was declared malaria free in 2010, while Egypt has eliminated malaria altogether.

Towards Sustainable Health Delivery Systems and Outcomes
Notwithstanding these achievements, the social and economic sustainability of these gains is not assured. The new global development agenda underscores the importance of embedding sustainability in the design and implementation of policy initiatives at all levels. In the context of health, social sustainability includes addressing inequalities in access to quality healthcare. At the economic level it involves sustainable financing of healthcare systems and strengthening their resilience to shocks such as the Ebola pandemic.

Addressing Inequalities in Access -Social Sustainability
Disparities in access to health services occur between and within countries in all regions and mirror trends in global income inequalities. The risk of a woman in a developing country dying from a maternal-related cause is about 23 times higher compared to a woman living in a developed country. 3 Inequalities in access to health services are both income and View Video Summary spatial in character. The disparity is much worse in Africa, excluding North Africa, where a woman is 100 times more likely to die in pregnancy or childbirth than a woman from an industrialized country. 4 Gender-based inequalities are rooted in cultural biases and stereotypes that are manifested in the workplace and households in the form of asymmetrical power relations. Asymmetrical power relations in the workplace reinforce gender-wage disparities and restrict occupational mobility of women. At the household level such asymmetries shape decisions regarding access to productive assets, access to social services and even HIV prevalence among women. A study of 1366 women in Soweto South Africa found that women with violent or controlling male partners are at increased risk of HIV. 5 Spatial inequalities in access to healthcare are stark in Africa and transcend the traditional rural urban divide. Rural urban disparities in access to skilled health professionals are a major challenge. Only 42% of births in rural areas are attended by skilled health personnel, compared to 77% in urban areas. Spatial disparities are not restricted to the rural urban divide. The rapid pace of urbanization in Africa is contributing to the development of slums; 40% to 70% of the African population live in slums. The rapid development of slums and poor urban transport systems are in turn reinforcing intra-urban disparities in access to health services. 6,7 Inequities in access to health across household wealth quintiles are also a challenge; births in the richest quintile are nearly 3 times more likely to be attended by a skilled health professional than births in the poorest quintile. The global figures are just as stark, 85% in the highest income bracket have access to skilled birth attendants versus 31% of households in the lowest income category. 8 Tackling inequalities in access to quality healthcare is not only morally just but it also a more sustainable solution to societal health challenges. The Ebola crisis laid bare the importance of a global response to the challenge of communicable diseases. But beyond communicable diseases, investing in the health of all citizens is vital for their productive contribution to society.

Promoting Integrated Approaches -Economic Sustainability
Exploiting Synergies A multisectoral and integrated approach to healthcare delivery promotes economic and financial sustainability by leveraging the knock on effects of interrelated interventions. For instance, tackling HIV/AIDS has a knock-on effect on TB since HIV/AIDS treatment interventions lower the risk of death among people who have both HIV/AIDS and TB by 50%. Similarly, among TB-free HIV/AIDS patients, antiretroviral treatment reduces the risk of contracting the TB by 66%. 9 In effect, improving access to anti-retroviral therapy reduces the risk of dying from HIV as well as the TB incidence rate. Studies have also highlighted the links between HIV/AIDS prevention and access to essential sexual and reproductive health care. 10,11 Investments in skilled health workers can yield significant payoffs. Indeed, it is estimated that investing in midwives yields a 16-fold return on investment in terms of lives saved and costs of caesarean sections avoided. 4 Unsurprisingly, in 2004, the Joint Learning Initiative-a consortium of more than 100 health leaders-warned in their analysis of the global workforce that: "The only route to achieve the health MDGs is through the health worker: there are no shortcuts. " 12 In this context, Ethiopia's community health programme has yielded multiple benefits including in the area of sanitation. The country has made enormous progress, cutting the prevalence of open defecation from 94% in 1990, to 37% in 2012, partly by enlisting an army of health workers to engage with communities and promote sanitary practices, alongside other interventions such as breastfeeding, and routine immunization. 13 The pioneer community health scheme in the Tigray region in northern Ethiopia started in 1992 and over a period of 8 years, contributed to a 40% reduction in death rates among children under five, most of which would have resulted from malaria. The scheme used village networks of community health volunteers including traditional birth attendants and mothers to provide health education which helped to improve the identification and home treatment of malaria; supervise and ensure regular supply of preventive malaria drugs for pregnant women; and helped to organize vector control activities like insecticide spraying and environmental management to destroy and prevent the increase of mosquito breeding sites. 14 In effect improving access to skilled birth attendants, has the multiple effect of improving the detection of pregnancy related health risks such as malaria which has the knock on effect of reducing neonatal deaths, under-five mortality and maternal mortality.
Strengthening Healthcare Systems Through Horizontal Programmes Global funding targeted at specific diseases from sources such as the Global Fund to Fight AIDS, Tuberculosis, and Malaria and the GAVI Alliance have contributed in no small measure to the achievements in the health sector. Such programmes have been justified on the grounds that they provide visibility to high profile diseases, deliver more rapid results compared to programmes that focus on strengthening the health sector in general, and ensure greater accountability in the delivery of health services by clearly delineating roles and responsibilities. Vertical programmes are delivered largely by a specialized service using dedicated workers to target the delivery of specific services (eg, reproductive health) specific populations or both. 15 In the context of the MDGs, vertical programmes were disease-specific, targeting immunization, TB, HIV/ AIDS and malaria to mention a few. The changing development landscape however calls for a rethinking of health service delivery in Africa. First, the sluggish global recovery from the financial crisis and the sovereign debt debacle in a number of European countries has been associated with a decline in official development assistance (ODA), particularly to African least developed countries and adversely impacted on the level of vertical funding. The Global Fund experienced a $1.3 bilion funding gap over the period 2011-2013. 16 Secondly, the weak capacity of African countries to contain the recent Ebola outbreak not only exposed the weakness of health systems in several African countries but underscored the interrelatedness of the global health ecosystem; left unaddressed, communicable diseases in one country can quickly spread to others. In effect, the global health ecosystem is only as strong as its weakest link. Strengthening national health systems is therefore vital for sustainability but in reality it receives very little funding from vertical funds. Cumulatively, signed funding expenditures by the Global Fund on health system strengthening account for 2.5% of the total for the period 2002-2013. 16 These developments raise 2 important issues: the sustainability of healthcare programmes dependent on vertical funding; and the sustainability of the vertical funding approach in general in a context of weak health systems. Zambia's experience in malaria control is instructive. Between 2006 and 2008, malaria deaths fell by more than 40%, prevalence by more than 50%; prevalence in children under 5 from 22% to 10.2% as a result of focused malaria control interventions which were largely donor funded. 17 However, a delay in external financing between June 2009 and December 2010 slowed the implementation of the interventions, which led to a loss in the gains that had already been made in parts of the country. Between 2008 and 2010, malaria resurged especially in rural areas and among the poorest populations who could not afford mosquito nets. 18 These trends reinforce the call for more sustainable financing mechanisms to fund development programmes. The limited capacity of health systems in Ebola-affected countries to contain the spread of the disease points to the limitations of the vertical funding approach in such situations; there is no evidence to suggest that victims of diseases targeted by vertical funds were less vulnerable to Ebola compared to others. A more balanced approach that prioritizes strengthening health systems may be more costly and less high profile but will likely deliver more sustainable outcomes over the long term. Sustainable approaches to health system financing could include the use of ODA to catalyze domestic resource mobilization thereby strengthening the fiscal capacity of governments. This includes strengthening capacities for tax administration; and targeted investments in health enablers such as sanitation, water and adolescent pregnancies.

Conclusion
African countries have gained momentum in tackling some of their most challenging healthcare challenges. Sustaining progress will however require the adopting of more sustainable approaches to healthcare delivery. Vital to sustainability are issues of equitable access and sustainable financing. The SDGs intergovernmental negotiations provide a platform for frank and honest debate of these issues.

Ethical issues
Not applicable.