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Failure to Integrate the UHC, TB, and PPPR Agendas will Squander Resources and Cost Lives

By guest contributors:  Juliana Soares Linn, Director, Infectious Diseases Department, FHI 360, Emily Headrick, Clinical Technical Advisor, FHI 360, Petra Heitkamp, Community Manager, TBPPM Learning Network, McGill University Health Center Research Institute, Blessina Kumar, CEO, Global Coalition TB Activists, Ramya Ananthakrishnan, Director, REACH, India, Robyn Waite, Policy and Advocacy Lead, 2023 TB HLM Affected Communities and Civil Society Coordination Hub, Robert Makombe, Director, TB Division, FHI 360

The World Health Organization (WHO) defines a resilient health system as one that can prepare for and respond and adapt to disruptive public health events while ensuring the continuity of essential health services at all levels of the health system. At the core of health systems resilience lies the promotion of equitable, affordable, high-quality health care service delivery with a focus on integration throughout robust primary health care (PHC). True resilience keeps people, communities, and their health at the center, while the values of universal equitable access to public health systems lead the way forward. The UN political declarations — Universal Health Coverage (UHC), Pandemic Preparedness, Prevention and Response (PPPR) and Tuberculosis (TB) — offer an opportunity to mobilize political and financial resources to promote true health systems resilience and integration. However, on the eve of the United Nations General Assembly (UNGA) this September, the lack of integration across the three political agendas and failure to emphasize resilient PHC systems represent a missed opportunity.

The COVID-19 pandemic was a scenario every public health professional trained for, yet it nearly collapsed systems around the world and resulted in decades of setbacks in almost every health area, including TB. The measures adopted to contain the COVID-19 pandemic and the associated service disruptions caused unprecedented strain on global TB progress and intensified challenges along the TB care continuum. Hard-won global TB progress established prior to the COVID-19 pandemic is off track, with years of gains negated; TB disease burden and mortality were exacerbated as resources were diverted to pandemic response. The pandemic demonstrated the critical need for health systems resilience by showing us, in real terms, what can happen if we do — or do not — invest in it. The pandemic also created an opportunity to mobilize political capital needed to reorganize for more resilient health systems and make bold investments to improve the capacity and safety of health care workers and community workers. The $14.2 billion investment in the replenishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria strategy (2023-2028), with clear targets for health systems strengthening, is a testament to the importance of integrating pandemic preparedness efforts and health systems resilience. Yet, the commitments to pandemic recovery have not been straightforward, as they rely on both adequate investments and forward-thinking policy changes, including investments in community systems. The emergency phase of the COVID-19 pandemic has waned, but the protracted health crisis for TB and other conditions will persist until we leverage the political will to build stronger, more resilient health systems.

UHC offers a platform to strengthen health systems resilience through investments in strong PHC and health systems integration. It has been long established that UHC and TB agendas are mutually supportive. TB programs have demonstrated the importance of community engagement, surveillance, and access to diagnostics and treatment, all of which are crucial components of UHC. Integration of TB services within broader policies supporting the UHC agenda allows governments to build on the strengths of both programs, thus allowing communities to receive comprehensive health services. For this reason, TB-related efforts have often been considered a “canary in the coal mine,” offering early warning signs of dangerous conditions within the health system. TB results have also been considered a proxy of functional capacity for countries with disparate UHC coverage.

Despite these synergies, the reality on the ground is that programs remain vertical and siloed, TB included. While convenient for donors, vertical programs are often successful only when considering discrete indicators and often do not address the increasingly complex experiences of populations. Vertical approaches, while necessary in disease-specific emergency circumstances requiring a laser-focused response, should not be a health system’s standard operating model. Horizontally integrated health programs are needed with the capacity to provide high-quality, comprehensive services, but these programs should also have the staff, skills, spaces, and systems to rapidly flex and apply vertical approaches when needed. The aims of the UHC agenda — rooted in comprehensive primary health care and contingent on receiving the necessary resources and political willpower to execute it — would provide the cornerstone of a robust, equitable health system.  

The renewed PPPR agenda could be the long-awaited catalyst needed to harmonize and energize the UHC agenda, particularly at the PHC level, so that global health challenges can be addressed beyond the listicles of “lessons learned” in the post-pandemic dialogue. Major public health challenges like TB, HIV/AIDS, malaria, and poor maternal/child health that had not been fully addressed even prior to the pandemic will unequivocally see improvements with a well-designed and adequately resourced UHC system.

To better comprehend the direct impact of high-level meetings, policies, and funding decisions on the daily lives of people on the frontlines of the global TB pandemic – and future pandemics, just as we recover from the past one – clearer throughlines are needed about how these decisions play out in real people’s lives.
The following exercise will take us through the daily lives of people living with and affected by TB, and delineate how policies, decisions and purported calls to action could actually make a difference if they were implemented effectively.
“A Father’s Journey”  illustrates how the priorities, policies, and commitments in the UHC, PPPR and TB declarations directly impact the outcomes of Tarak’s health journey. Resilient, person-centered, and integrated health systems require adequate financing, dedicated leadership, and real accountability. Only if we ‘walk the talk’ and put as much energy and resources into implementing the policy recommendations as we put into discussing them will our health systems achieve the health outcomes we dream of. Image used with permission from FHI360 and TBPPM.

The mutual benefits of attaining the goals of these three agendas is so intuitive that it begs us to wonder why there isn’t more alignment among them. The slow and incongruent progress in integrating these three high-level agendas demonstrates a failure to sufficiently emphasize the real-world struggles of people and communities. With virtually no meaningful mechanism of accountability and no clear mandate to operationalize the recommendations, the UN political declarations are at risk of squandering a valuable opportunity to overcome the deadly divide that perpetuates inefficiencies and illness.

Breaking down siloes requires more substantive and direct connections between policies and the lived experience of individuals and communities. The UNGA must offer a clear and feasible way forward to make the collective goals under the political declarations more attainable. Yet, the language of the high-level political declarations remains vague. This is a pivotal moment. The political declarations must connect the concepts of resilience, equity, and the common sense of well-equipped PHC systems directly to tangible resources and actionable steps. Saving lives requires political leaders to deliver on the high-level declarations and remain accountable to global communities. If they do not seize this opportunity, the effects will ripple for decades to come.

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About the authors:

Dr. Juliana Soares Linn is the Director of the Infectious Diseases Department at FHI 360. She is a global health leader with extensive experience working collaboratively across sectors to address the most pressing health issues. A patient and communities’ advocate, for over two decades Juliana has championed innovative models and health systems strategies to improve the quality of care. Early in her career, Juliana spent five years in Mozambique supporting the first efforts to scale-up life-saving antiretroviral therapy for children and adults. Lessons learned from communities and providers in Mozambique have shaped her vision of an equitable public health system.

Emily Headrick, is a Clinical Technical Advisor for the EpiC Project and the COVID-19 Division at FHI 360. She is a Family Nurse Practitioner with over a decade of experience as a nurse, a primary health care provider, and a leading member of high performing teams in health care, emergency response, research, quality improvement and community development settings.

Petra Heitkamp is the community manager of the TBPPM Learning Network, an online community of over 2500 people engaging private health providers to EndTB, based in McGill University Health Center, Research Institute. With 25 years of experience in global health, she has worked at the Stop TB Partnership, WHO/HQ and in India, Indonesia and many other countries forging partnerships and knowledge management among stakeholders from global agencies to grassroots tribal leaders.

Blessina Kumar is a health activist and presently heads the Global Coalition of TB Advocates (GCTA), a global movement with over 600 members bringing the voices of the affected to the decision-making table and inform policy ensuring a people centred and rights-based TB response. For the last 18 years, Blessina’s work has focused on TB and TB advocacy, serving on many global and regional advisory boards and committees bringing the community perspective to the table.

Dr. Ramya Ananthakrishnan is the Director of a non-profit Organization REACH. She is a medical doctor with a postgraduate Master’s degree in Community Medicine. She has been working for the last 19 years in the field of tuberculosis, and currently heads several initiatives across the country including public private partnerships models, community systems strengthening initiatives, empowerment of TB survivors and their engagement in improving quality of TB care and quality of TB services, use of innovative approaches to TB care and prevention etc.

Dr. Robyn Christine Waite is an independent consultant working to equip, support, and mobilize advocates in the fight against TB. She is currently working as the Policy and Advocacy Lead for the #2023TBHLM Affected Communities and Civil Society Coordination Hub hosted by the Global Fund Advocates Network.

Robert Makombe is the Director for the TB Division at FHI 360 and holds a medical degree from the University of Zimbabwe and a Masters in Community Health from the University of Edinburgh. He has over 25 years’ experience in clinical and programmatic management of tuberculosis in resource-constrained settings. Robert has worked in the public sector in Zimbabwe and held assignments as a technical advisor for the World Health Organization (WHO) Africa Regional Office (AFRO), the U.S. Centers for Disease Prevention and Control (CDC) in Botswana and with several international NGOs and served as a TB expert in the Global Fund’s Technical Review Panel (TRP).

Disclaimer: Views expressed by contributors are solely those of individual contributors, and not necessarily those of PLOS.

  1. The biggest threat to UHC is the treatment room syndrome mindset, which overlooks the importance of prevention being better than cure. Access to information plays a key role in UHC, yet it has often been neglected, despite the fact that it encourages individuals to take proactive measures, such as seeking early treatment and engaging in preventive actions within their communities.

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