Financing Common Goods for Health: Fundamental for Health, the Foundation for UHC

Keywords:

• common goods
• public goods
• public health
• universal health coverage

A Special Issue on CGH at a Special Time

This special issue of Health Systems & Reform, sponsored by the World Health Organization (WHO), presents a comprehensive argument that “common goods for health” are a priority for action on the road to Universal Health Coverage (UHC). Its publication is juxtaposed with the September 2019 United Nations General Assembly High Level Meeting on UHC, an event that represents the global community’s commitment to UHC. This special issue proposes a key approach to moving the UHC agenda forward: financing the common goods that form the foundation of health globally.

The world faces formidable, often paradoxical, challenges—population growth and aging, increasing wealth and widening inequities, undernutrition among some and obesity among others, and environmental and pandemic threats that seem to emerge in the wake of fast-paced development.¹ In this, the Anthropocene era, the global human community is reaching the limits of our planet’s capacities, creating a need for all people to become aware, actively engage, and come together to collectively demand action and change from our leaders.² Hundreds of millions, maybe even billions, of our lives are at stake.

In recent decades, overall health outcomes have been improving and spending on health has increased substantially. However, blind spots persist, and these pose substantial risks to human health and economic well-being; indeed, they have the potential to undo recent progress.³ These blind spots include: systems unable to effectively respond to pandemics such as influenza and outbreaks of communicable diseases like Ebola and Zika; health system structures unfit to cope with the rapidly increasing prevalence of non-communicable diseases (NCDs) like type 2 diabetes; threats posed by the emergence of drug-resistant tuberculosis and other evolving diseases; and the complex health impacts of large population movements, environmental degradation and climate change.

Two features are common to all these challenges—they have an enormous impact on human health and welfare, and combating them effectively requires governments to intervene. The combination of those two features is the defining characteristic of common goods for health (CGH). CGH also must meet two other conditions. First, CGH contribute to improving human life and promoting economic progress over the long term. Second, provision or preservation of CGH is subject to market failure, typically because they are either public goods (meaning that they are non-rival and non-exclusionary), or they have large social externalities. Thus, CGH are population-based functions or interventions that only collective arrangements can finance, regardless of whether they are delivered by public or private sector providers.

This special journal issue makes the case that governments should place CGH at the center of public financing for health given that CGH represent services that are the backbone of all health systems and, more broadly, societies. CGH fall under five categories: policy and coordination, taxes and subsidies, regulation and legislation, information, analysis and communication, and population services (see Table 1 in the first paper in this series⁴ for more detailed examples of key CGH). The articles in this series revisit well-known CGH where collective action has been difficult to mobilize, including control of communicable diseases and improving sanitation, managing health emergencies and disaster risk, and protecting health security. The series also challenges entrenched practices by placing new issues on the agenda for CGH financing, including societal risk factors (such as food systems) and the ever-growing health threats posed by environmental degradation and climate change. These are universal problems that affect all countries and populations, rich and poor alike. Promoting financing for CGH requires the global health community to come together to support a set of functions and interventions that are necessary for all societies to protect and promote health and well-being. These population-based functions are essential to making progress towards UHC as well as to tackling some of humanity’s largest challenges related to globalization and environmental health.

Developing the Case for CGH

This call for financing CGH is issued by WHO with firm support from experts who have seen first-hand what happens when provision of CGH is not sufficiently financed. Policymakers, researchers, and practitioners from a range of countries, organizations, and backgrounds came together in April 2018 to explore how to place financing CGH on the agendas of countries and the global community (the list of participating experts is included in the first paper).⁴ The range of experience and breadth of expertise in the group of authors and participants are impressive, including economists, public health specialists, medical doctors, and environmental scientists. Each participant’s entry point to, and perspectives on, CGH is different. Yet in the process of preparing this series of articles, this diverse group managed to converge on key points, including the definition and categories of CGH and the mechanisms needed for governments to act on and effectively finance them.

As advocated by Yamey et al.⁵ in this issue, WHO is proudly acting as a “global ministry of health” to lead this call to action on financing CGH. Indeed, the CGH financing agenda has already catalyzed cooperation and consensus across a wide array of areas of expertise within WHO, including health emergency and disaster risk management, communicable diseases, NCDs, immunization, health financing, governance, environmental health, and water and sanitation.

This special issue is comprised of thirteen pieces. While the issue is a compilation of articles by several authors, great efforts have been made to create cohesion across the articles in order to present a consistent and complete body of work on financing CGH. The articles can be read individually but are also parts of a greater whole.

The first articles in this series discuss the “what,” defining CGH and providing the conceptual foundation for the definition.^4,6 Subsequent papers focus on how to finance and provide CGH,^5,7,8 with focused discussions on health emergency and disaster risk management⁹ and on environmental issues.¹⁰ Commentaries and case examples highlight some challenges to financing CGH, but also present effective approaches that have been taken to prioritizing financing for CGH.^11–16

Financing CGH is Fundamental

Spending on health is increasing rapidly worldwide⁹—these articles show the critical importance of ensuring that financing instruments serve “the commons” as part of a broader agenda to reach UHC and the Sustainable Development Goals. They also highlight that while CGH require relatively modest investments, these yield massive returns. Despite this clear business case for investment, CGH are often underfunded and underprovided; market failures are thus compounded by governments’ failure to act.⁴ The public finance and public health concepts, theories, and arguments that underpin the definition of CGH also demonstrate the imperative for governments to intervene to organize financing instruments that sustain the delivery of CGH. The gaps in evidence that remain only concern identifying the precise economic benefits of specific interventions.⁶

CGH by definition require collective action by many actors. Yet political incentives frequently work against CGH, compounding the challenges of financing and providing CGH. Societies underinvest in CGH for human behavioral reasons, such as underestimating risk and short-term thinking, and economic reasons, such as externalities and free-riding. These tendencies create incentives for people to act without regard to the full social effects of their decisions.¹¹ Furthermore, population-based and preventive services typically take a back seat to disease-based and individual services, as the latter have stronger and more immediate attraction for citizens and as a consequence for politicians. Consequently, governments may not act to fully finance CGH. As noted in the account of the interview with Honorable Tolbert Nyenswah, Liberia is still struggling to fully mobilize high-level political support to finance systems for CGH, even after its experience of being ravaged by Ebola.¹³

Positive examples of providing CGH, however, are also shown by articles in this special issue. The article by Bump et al. examines four cases where governments have supported CGH,¹⁶ and offers a roadmap for future action. Another notable example is Sri Lanka’s experience investing in population-level prevention and disaster preparedness¹⁵; these investments are proving to also be effective platforms for addressing increased demands on the health system due to the growing burden of NCDs. Sparkes et al.⁷ highlight constraints to financing CGH posed by structural fragmentation at various levels, including across the health sector, among government sectors, and across levels of government. Their analysis shows that aligning budgets and governance coordination can effectively overcome those constraints. However, as underscored by Shah et al., in India “the CGH agenda involves engaging with a sprawling organizational diagram spread across an array of government agencies.”¹² Targeted policy interventions, backed by strong political commitment, will be needed to implement financing mechanisms that enable the provision of CGH. Mexico’s experience with establishing a social protection system for health in the early 2000s provides a case example of implementing these concepts to complement other UHC policies focused on personal medical services.¹⁴

The final articles in this special issue return to the global-level view. Yamey et al.⁵ consider CGH that require financing and action at the global level, including sustainable global mechanisms and targeted resource mobilization efforts, pooled funding, and strategic purchasing. Schäferhoff et al.⁸ provide empirical evidence by tracking expenditures to global CGH in recent years. Their analysis shows that increases in funding following the Ebola crisis have already begun to show a decreasing trend.

Taken together, the articles in this special issue demonstrate that CGH are critical to improving and protecting human and planetary health. They also show that the costs of funding CGH, particularly those related to health emergency and disaster risk management, are affordable to most governments, while the financial and human costs of inaction are massive.¹⁰ Finally, a clear message emerges: CGH functions are essential to protect against the many looming threats to human health emanating from environmental drivers, including climate change. In some cases, funding is not the primary constraint—rather, political action and prioritization are critical to ensuring these CGH are fully financed and effectively provided.¹⁷

What Comes Next?

The publication of this special issue represents the completion of an initial phase of a broader and more ambitious program of work on financing CGH. This initial phase focused on establishing the conceptual foundations, definitions and case examples that can serve as the basis for subsequent work.

So now, the real work begins. The global community must consider how to take action on the ideas, concepts and policies discussed in the articles that follow this introduction. A range of stakeholders must work together to ensure that funding is made available and is effectively aligned to enable the provision of CGH. Of particular importance, the CGH financing agenda must be integrated into dialogues on health financing and national budgets. Financing for CGH must be mainstreamed across entire governmental budgets. Further, CGH must be accompanied by regulation, monitoring, and accountability measures to ensure that political and funding commitments result in the provision of CGH.¹² Reforming the global financing architecture will also be key to assuring stable and adequate financing of global public goods in an increasingly globalized world.

The CGH financing agenda is fully consistent with the UHC agenda—and provides the foundation for UHC. As the global community moves forward with the Sustainable Development Goals, we need system-wide approaches in health and more broadly throughout the public sector.^18,19 Population health has progressed extraordinarily over the past three decades. Thanks to economic growth, the uptake of new technologies and increased global assistance for health, certain specific health problems have been successfully targeted. But these achievements cannot be maintained without support for CGH. Financing for CGH is necessary to build the resilience and flexibility required to manage new and emerging risks and threats. We need to move from focusing on externally-driven interventions to domestic financing for health systems starting with its foundation: Common Goods for Health.

WHO, together with the authors of the articles in this journal special issue, invites countries and the global community to join together to protect the health and well-being of current and future generations by financing action on CGH. Each sector and stakeholder have important roles to play—we recommend the following:

• Countries must establish financing mechanisms for CGH as step one of the UHC financing agenda and make sure funding is linked to delivery;

• International donors and technical agencies must support CGH, including pooling resources to enable strong institutions and delivery platforms at country level;

• The public health research community must urgently build performance monitoring metrics and expand the evidence base on cost and effectiveness of interventions and impact of financing CGH; and,

• Individuals and communities must come together to demand that our leaders provide funding and take action for CGH, and then hold our leaders accountable for following through on these commitments.

ACKNOWLEDGMENTS

The author wishes to express gratitude to participants from the Financing Common Goods for Health technical expert group, colleagues across the World Health Organization, and in particular other authors in this series, whose active engagement and constructive comments greatly facilitated the development of the concepts presented in this introduction. The author also thanks Susan Sparkes and Alexandra Earle for inputs into this introduction and the overall series. The author gratefully acknowledges Anya Levy Guyer and Michael Reich for their extensive efforts in editing the revised version of this article.

Additional information

Funding

This article was supported by the World Health Organization. Funding from Finland’s Ministry of Social Affairs and Health, the UK Department for International Development, and the European Commission is gratefully acknowledged.