Increasingly aid is moving towards a bilateral partnership model of institutional health partnerships to complement multi-lateral efforts through bodies such as the World Health Organization (WHO).¹ The UK government, in its recent aid strategy², set out a move towards partnership approaches such as the Better Health Programme (BHP); a co-developed programme of technical collaboration between the UK and eight other countries to strengthen health systems in their response to the growing burden of non-communicable disease; part of the cross UK government Prosperity Fund portfolio. We discussed some key considerations of how to learn from partners in strengthening health systems and building towards UHC at the recent Prince Mahidol Award Conference 2020 (PMAC).

The Institutional Health Partnership model

Countries face similar challenges in implementing or maintaining UHC, despite differing starting points and maturation of the system; this enables shared learning. Immature systems can learn from the mistakes of advanced systems. Mature systems, whose historical structures may not be suitable for modern needs, can learn from innovation in developing systems especially in the use of new technologies, in new ways of achieving efficiencies and effective solutions to what may have been intractable challenges. Institutional Health Partnerships (IHPs) aim to build capacity and strengthen health institutions, through this shared learning, to improve delivery and outcomes. Evidence shows that such partnerships are a promising model for aid and development, although more research is needed.³ Technical collaborations such as those as part of the BHP should aspire to benefit all partners equitably, with collaborative decision-making and design of the workplans. The long-term sustainability and the evaluation of the partnership in terms of its process and outcomes should be considered during the inception phase. Such partnerships could help meet Sustainable Development Goal 3.8 – Achieving Universal Health Coverage.

Workforce quality and distribution

Workforce development and retention was a theme throughout the PMAC conference. The reality of brain drain from lower income countries to higher income countries and from rural areas to urban areas is inescapable. Investing in training and resources into people who are from rural areas and wish to stay there may be one way of combatting this. We heard from academics about the importance of the multi-disciplinary team in order to re-orientate primary health care to chronic disease management in such settings. And how health technology assessment and economic evaluation approaches could be used to assess the cost effectiveness of workforce models or multi-sectoral interventions.

UHC and prevention

Sustainable financing of UHC centres on reducing the burden of disease through population level prevention. Participants agreed that across the world people are living longer lives, but these extra years are often spent in ill health and disability, particularly for those in lower socio-economic groups. As we heard during our session, prevention of non-communicable disease must include tackling the commercial determinants of health, as products deleterious to health have increased in availability due to the globalisation of trade and marketing. Some BHP partner countries are leading the way in prevention with Thailand spending up to 15% of their healthcare budget on prevention, with the estimated spend on prevention in the UK being around 5%. As part of the multi-directional flow of knowledge envisaged through partnership working, the UK can learn from the health promotion efforts and innovative approaches shown in partner countries.

Public and private engagement

The role of non-governmental organisations, the general public and private corporations in UHC was discussed extensively at PMAC. Civil society organisations were powerful advocates for minority and underserved populations. Private companies presented innovative financing methods for UHC and service provision models pioneering the use of new digital technologies. Government has an important role in regulation, setting the parameters to ensure that private sector involvement results in improved health outcomes for the whole population and that innovation does not result in better services for the motivated and wealthy at the expense of the vulnerable and ill served.

Opportunities

IHPs provide a range of opportunities to strengthen health systems globally and advance UHC. The trust developed through IHPs enables sharing of experiences about successes and challenges. Even throughout the PMAC event, BHP partner countries shared invaluable insights and identified opportunities for collaborative working. Country delegates referenced the WHO best buys for NCD prevention, but for them the issue is not that they do not know what to do. The question is how to do it and adapting the experience of others to their context using local evidence. Virtual learning environments offer a shared space for partners to communicate with each other and provide a repository of learning. Clearer governance, accountability and deliverables across partnerships could increase trust and sustainability beyond the limitations of funding cycles. There still also remains an evidence gap in evaluating IHPs.

Conclusion

IHPs are a model of health system strengthening which could provide a basis for equitable, context-specific transfer of knowledge between healthcare systems moving on from the traditional, top-down, paternalistic models of the past. As the world moves towards achieving UHC, IHPs provide a sustainable, long-term option for sharing innovation and improving global health.

Competing Interest

We declare working for Public Health England, a member of the NHS Consortium, part of the Better Health Programme.

About the author

Ahmed Razavi is a Public Health Registrar with an interest in non-communicable disease, global health and development, and health policy. He has worked for a range of organisations including Public Health England, Chatham House, the Faculty of Public Health and local authorities.

Tazeem Bhatia is a Public Health Consultant with expertise in the public health approach; Universal Health Coverage; community engagement and primary care. She has worked in diverse environments and resource settings from NGOs, think tanks, Local Government, the NHS and UK Civil Service. Tazeem currently leads Public Health England’s global engagement on non-communicable disease with a focus on obesity.

References:

1. Global Health Partnerships: The UK contribution to health in developing countries. Crisp, N (2007).
2. UK aid: tackling global challenges in the national interest. UK Government (2015).
3. Kelly, E., Doyle, V., Weakliam, D. & Schönemann, Y. A rapid evidence review on the effectiveness of institutional health partnerships. Health 11, (2015)