Interviewed By Stephanie Main.
With less than 2 weeks to go until Global Ideas Forum 2017, we caught up with keynote speaker, Elya Tagar, Senior Director at Clinton Health Access Initiative Australia, to talk all things global health equity and this year’s theme, Global health in a volatile world: People, Politics & Planet.
Global Ideas: Global health means a lot of things to a lot of different people. What does it mean to you?
Elya Tagar: To me, global health represents one of humanity’s ultimate tests. We all say, and personally believe, that a life is equally valued, no matter skin colour, race or income. Global health tests us to prove that we mean it.
It is less about testing each of us as individuals, because there is only so much any one of us can do, even if we donated all our life savings to MSF or dedicated our entire life to working on public health. It’s more about testing us as a society. In recent years, we have done much better against this test than we have in the past. We have made sweeping commitments through the MDGs and SDGs, and have made incredible progress against them on many fronts. The coming decade will show whether or not we as a society are up to the task we have articulated to ourselves, or whether we will let the tremendous challenges ahead get the better of us.
GI: In your opinion what are some recent successful responses to global health inequity?
ET: The Global Fund to fight AIDS, Tuberculosis and Malaria (GFATM), alongside PEPFAR (President’s Emergency Plan For AIDS Relief ) and PMI, as well as Gavi (the Vaccine Alliance), provide some of the most striking examples of the global community getting together to say “the current state is unacceptable, we need to make a fundamental shift”, and following up on it.
These organisations raised billions of dollars in less than two decades, and achieved some of the most rapid and striking rates of progress in tackling diseases that kill millions, primarily in the developing world. If anyone would have said 20 years ago that we will have almost 20 million people on HIV treatment in the developing world, they would not have been believed.
GI: On a more personal level, can you share a story from your work at Clinton Health Access Initiative (CHAI) that you feel made a positive impact on health inequity?
ET: In my first week at CHAI, in the Democratic Republic of Congo, I was invited to see a children’s choir in an HIV treatment facility in Kinshasa, the capital. There were maybe 20 children on stage, singing sweetly as only a choir of children can. And at some point our program director, a local Congolese doctor, leaned to me and whispered, “Each one of them would be dead by now if it wasn’t for the medications we provide them”. It was such a striking thing to hear, and it was hard to keep a dry eye as they kept singing.
Paediatric HIV is an area CHAI played a pioneering role in. When we started this work, few people thought about children and HIV. The virus was associated with gay men, sex workers and drug users. But of course many children were born with HIV. At the time, this was the epitome of inequality: vulnerable children of vulnerable adults in vulnerable societies, dying because the life-saving medications that existed were not formulated for their little bodies, and because the tests often missed them.
Children were not a priority for many, because their chance of long-term survival seemed low, and because they did not transmit the disease. But there was no good reason for us as a community to ignore their health, and we worked on reformulating medications, reducing their costs, improving their availability, developing national guidelines and training programs, and improving tests. When this work started there were fewer than 10,000 children on treatment. Today there are over 800,000, and they have the prospects of a full and relatively healthy life.
GI: There are many ways to tackle health inequity, what do you think are key aspects to a successful global health equity response?
ET: At CHAI, we strongly believe that the key to an effective and sustainable approach to health inequity is working alongside the national and sub-national government, to help them take a leadership role in owning the response.
It can be easier and faster, and at times cheaper, to create parallel systems that reach out to patients and communities directly. But at the end of the day, it is the role and responsibility of societies, through their (hopefully) elected governments, to own and manage their own health systems. No external charity or development agency has the reach, capacity, and legitimacy to provide long-term care for entire populations. Individual actions, like setting up hospitals in under-served locations, or driving a specific intervention across larger geographies, can provide band aid solutions, and at times those are critical. I sit on the Board of Directors of an NGO that provides life-saving medical care to populations in conflict and other challenging areas, and without a doubt this work saves many lives. But they will never reach the entire population, and they are often dependent on the whims of donors, and as such cannot provide a lasting solution to addressing health inequity.
GI: What are the biggest threats to health equity in our region today?
ET: In the short term, health financing is a critical concern. Many of the countries in the region are wealthy enough, on paper, to begin “graduating” from donor assistance. And donors are rightly trying to direct resources towards countries like Malawi and DRC and Mozambique, where GDP per capita is a quarter of what it is in countries like Cambodia and Myanmar, and a sixth or less of what it is in countries like Laos, Papua New Guinea, or Vietnam. But countries in this space, moving from Low- to Middle-income status, are especially vulnerable. Their societies have growing expectations, but their ability to capture tax revenues are still limited, so the task of growing health budgets enough to offset reduced donor funding becomes very challenging. And these societies have massive, urgent and competing priorities for these limited revenues, including education and basic infrastructure. Donors have taken a critical role in supporting health priorities, and their exit can create real vulnerabilities.
In addition, GDP per capita as a statistic hides tremendous variations within a country – oil revenues are rarely well-distributed internally, for example, and large proportion of the population in many countries in the region remain both under-served and vulnerable due to low income and limited coverage.
There are several other threats to watch for: the growing burden of non-communicable diseases like diabetes and heart disease, the risk of drug-resistance infections, and the impact of global warming on health.
GI: What is your perspective on Australia’s current R&D funding and foreign aid expenditure? Are we relying too heavily on NGOs and NFPs?
ET: Australia is one of the wealthiest countries in the world, and truly one of the luckiest. Coming back here after 15 years of living in the US and Africa, it is stunning to me how lucky this country is. By almost any indicator (including the under-appreciated miles of swimmable beach per person), Australia has simply won the lottery.
Australia has now experienced 26 years of uninterrupted economic growth, which might just be unprecedented for a developed economy. And yet our foreign aid budget is going down any way you look at it: in absolute terms, as a percentage of GDP, and a percentage of government budget, or in dollars per person. This is short sighted, sad, and to my mind close to immoral. We spend less than 0.2% of our national income on aid – less than a third of the 0.7% goal we committed to in 1970 alongside other rich countries. The UK managed to hit 0.7%, despite a double-dip recession, lower GDP per capita and a higher unemployment rate than Australia. We have no excuses.
GI: What is your best advice for young leaders seeking to improve global health equity?
ET: There is no one way, no one path, and no one end goal for a career in public health or development. We need people who are good with numbers and we need people who can write. We need people with specialised skills and we need good generalists. We need artists and doctors and thinkers and policy aides. We need you to be as effective as you can be, in what you are best at. Know what you are good at, know what makes you energised, and know what the world needs. Look for the sweet spot where the three meet, and there you will be most effective
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