Jennifer Prah Ruger Advocates for a Global Health System That Benefits All

Healthcare is something that everyone around the world needs, but in some parts of the globe, there are few or no resources available to deliver that necessary care.

Finding ways to reduce those disparities in healthcare — particularly among women, adolescents, minorities and other groups — is the focus of work being done by Jennifer Prah Ruger, assistant professor at the Yale School of Public Health and co-director of the Yale/World Health Organization Centre for Health Promotion, Policy and Research.

Ruger is working to promote the creation of clinical and public health programs that make more efficient use of scarce resources while improving current healthcare practices. The Institute of Medicine (IOM), a national advisory board on health-related matters, recently invited her to testify about how the current management of global health institutions and governance might be improved.

Here, Ruger shares some of her insights on the global healthcare system.

Describe the state of global health governance today. Is it working?

Global health governance is becoming more complex with the increase in the number of actors, funding and programs available. This unprecedented influx has led to fragmentation and lack of coherence in the system. Creating a framework for distributing resources, setting priorities and allocating responsibility is crucially important.

The current focus on donor-driven development has limited the effectiveness of global health investments, and we need to chart a more equitable and cost-effective way forward for the United States and other partners.

What does this mean for people depending on these health services?

There are widening disparities in access to, and quality of, services in the global North and South, and a disconnect between needs “on the ground” and how priorities are set when allocating scarce resources. An example of this is the much higher mortality rates and lower life expectancies in parts of sub-Saharan Africa and countries such as Afghanistan, which have lagged behind even as global life expectancy has increased by 20 years over the last 50 years. The failures in global health governance have limited the benefits that could accrue to the worst-off populations in key areas such as maternal and child mortality.

What steps need to be taken to change the status quo?

There must be strong and stable partnerships formed among donors, as well as between donors and recipient countries. These partnerships should be characterized by shared goals, clearly articulated objectives and accountability, with roles of the various actors clearly delineated.

I strongly advocate what I call a “shared health governance” paradigm, where governments, institutions, providers and individuals work together to create an environment where all have the capability to be healthy. This framework removes health and disease control from the interests of powerful countries and institutions, and grounds global health governance in principles of global health justice. Under this approach, in the end, powerful players are better off anyway, since greater health improvement results in a safer, more prosperous world for all.

Can this be done?

There is no quick fix to the current problems, which are strongly embedded in the day-to-day operations of global and domestic health institutions. However, it is important to acknowledge that there have been successes under the existing framework — the problem is that much more could be done.

The challenge is to change the way people think about and go about delivering health to populations at both the global and domestic levels. For example, many domestic health systems need to shift from a focus on the health of an elite group or a particular disease to creating health systems that reduce the enlarging gap between the worst and least healthy groups in their own societies. This can be achieved through universal health systems and facilities, and health providers who are well-trained and qualified.

Who are the major players in global health today? Who shapes current global health policies?

Global health policies are generally shaped by powerful countries and institutions that provide funding and oversight of global health programs either directly or multilaterally — through, for example, the U.N. system, which includes the World Health Organization (WHO), the World Bank and other U.N. agencies such as UNICEF and UNAIDS.

There also are a number of major U.S. agencies engaged in global health activities, including the United States Agency for International Development (USAID), the Center for Disease Control and Prevention (CDC), the National Institutes of Health (NIH) and the Department of Defense.

The private sector — including the Kaiser Foundation, Rockefeller Foundation, Bill and Melinda Gates Foundation, CARE, Oxfam and Médecins sans Frontières — is also more visible. The United States, European and East Asian governments as well as governments of emerging economies such as Brazil, China and India are also major players.

Where is the money coming from to fund these programs?

The World Bank is currently the largest contributor to health spending, but various U.N. agencies have made health investments, as have governments, foundations and NGOs.

Global health problems are targeted from multiple fronts — for example, in the case of HIV and AIDS, the President’s Emergency Plan for AIDS Relief is U.S.-funded — but there is also the WHO, UNAIDS and the Global Fund that employ resources from WHO member states.

A glaring deficiency is the less-glamorous, but considerably important, funding of health systems to create a suitable infrastructure for delivery of services. Here there is a particularly important role for the World Bank, to scale up its multilateral investments and to work with donor countries on direct bilateral assistance.

What is right with global health policy today?

Global financial investments in health more than doubled from $6 billion in 2000 to nearly $14 billion in 2005, indicating the success of efforts such as the WHO Commission on Macroeconomics and Health in motivating greater global funding of health programs. Other programs, such as the Gates Foundation $100 million Grand Challenges Explorations, are encouraging transformative innovation in global health.

Moreover, effective public health initiatives — such as vaccination programs for polio, measles and small pox — and health care interventions — such as those focusing on safe motherhood, vitamin supplements and medication to control onchocerciasis — have significantly improved life expectancy. The ultimate goal is to generate sufficient capacity within countries so that progress in health is sustainable.

The United States can obviously be an important factor in global health. What do you see as its role?

The U.S. has an instrumental role in making more funds and expertise available, and ensuring that there is more research into health systems and controlling other factors affecting global health. However, defining the role of the U.S. is more complex when viewed in the light of the problems that exist within our own health system.

Nonetheless, the U.S. can play a critical role in investing in the development of health systems and in the creation of systems to finance, organize and improve access to public health and healthcare programs in developing countries. Moreover, the U.S. can better coordinate the activities of such agencies as USAID, the National Institutes of Health, the Food and Drug Administration and the Centers for Disease Control, and forge better collaborations with global health partners. The United States must also focus on improving its financial and technical support and assuring the effectiveness of multilateral institutions such as the World Bank and WHO.

How will the IOM help inform U.S. global health policy?

The IOM deliberations will culminate in a brief report available in December 2008 to coincide with the U.S. presidential transition. A 150-page report is slated for April 2009. We hope the IOM debate and report will provide a sound foundation to inform U.S. decisions about commitments in global health governance and provide a platform for the new administration and Congress.

I’ve been asked to continue to be involved in reviewing and contributing to the ongoing dialogue and report and I am looking forward to seeing the results of these efforts.