Policy coherence: Effective partnership for global health

How can public–private partnerships (PPPs) address the needs of low- and middle-income countries (LMICs) for effective responses to health-related threats? A panel discussion during the recent Prince Mahidol Award Con-ference explored this question, highlighting examples and ideas for effective policy coherence at all levels.

The session was co-organized by the Access and Delivery Partnership (ADP), a United Nations Development Pro-gramme (UNDP)-led strategic initiative that aims to optimize the uptake of new medicines, vaccines and diagnostics in LMICs. The discussion is summarized in this article.

Framing the health challenge

The 2030 Agenda for Sustainable Development set ambitious health-related targets to ensure healthy lives and promote well-being for all at all ages and strengthen the means of implementation and revitalise the global partnership for sustainable development.

"If you look back at the history of drug discovery over the past hundred years or so, it is apparent that almost no medicine, vaccine or diagnostic test has ever been discovered or developed, tested, perfected and brought to market by a single institution. Each and every one has come about as a result of collaboration among multiple actors."

Dr Hayato Urabe

Attaining the Sustainable Development Goals (SDGs), including the health related targets such as universal health coverage (UHC), ending the epidemics of AIDS, tuberculosis, malaria and neglected tropical diseases, as well as effectively tackling the threat of emerging infectious zoonotic diseases, require substantial policy coherence, and the scaling up of partnerships and investment.

While many global efforts have focused on increasing research and development for new health innovations, it is now clear that there must also be a corresponding emphasis on strengthening of system-wide capacities to deliver the range of needed health services and products within countries.

The Ebola outbreak in west Africa was an important reminder of the importance of effective, and sustained, core government functions within and beyond the health sector.

Health challenges are becoming both more complex and broader, as emerging infections, antimicrobial resistance, humanitarian crises, environmental health impacts and the movement of people continue to increase. These collective challenges highlight the need for coordination between an ever-growing range of actors, as well as stronger partnerships between public, private and community actors at the local, national and global levels.

We have a long way to go to overcome these challenges: The 2017 UHC tracking report1 shows that half of the world’s population still does not have access to essential health services.

While improved coordination and partnership are clearly vital, it is important to acknowledge that inadequate health system performance is, at least in part, a direct consequence of deep-rooted incoherence: The common failure to achieve a shared vision, responsibility and accountability, because of an isolated focus on the health sector.

Where does incoherence come from?

The SDGs bring together two established arms of development thinking: one addressing major social development challenges and promoting equity; the other focused on protection of the human environment and natural resources. Even at a top level, this duality is suggestive of the difficulty of achieving coherence among multiple priorities.

One of the major principles underlying Agenda 2030 is that the 17 SDGs are interlinked and indivisible: progress in one goal will be made only with simultaneous progress in all goals. Drill down to the interconnected health consequences of individual SDGs, and many of the factors that threaten health and well-being – and cause people to fall sick and die – do indeed lie outside of the scope of the health sector. We know, for example, that much of the global burden of human disease has environmental roots, and that many emerging diseases arise from people’s contact with wildlife or domesticated animals. Policy coherence must also look at where these interactions take place (e.g. air pollution, changes in land use and animal health practices).

In many instances, there are only thin lines separating potential synergies among different SDGs from viewing them as contradictory policy priorities. For example, two goals (SDGs 8 and 9) seek to perpetuate existing models of economic growth (gross domestic product), production and consumption patterns that have fuelled over-use of natural resources and climate change, which today jointly underpin many social, environmental and political determinants of health. Tension between conflicting policy priorities are major barriers to countries achieving policy coherence for health.

In this light, policy coherence is not something that should be pursued universally or for its own sake, but to achieve a defined set of objectives simultaneously. Defining and protecting health as a human right, therefore, re-quires some form of prioritization or balancing of related policies before coherence can be sought and assured.

"[From my observation], different ministries have different mandates, so it is a big challenge for them to cooperate. They need to [work on improving] better interlinkages and cooperation, in order to have better coherence between them...If not, we will never reach the sustainable development goals."

Mr Chalermsak Kittitrakul

As countries ask how they can achieve UHC, complex questions must be answered in order to manage multiple health factors and determinants, as well as ensuring that people can access life-saving health services, medicines, vaccines and diagnostics. It is critical to embed health at the core of national and local SDG strategies and imple-mentation plans that are currently under development.

Suggested solutions

One important entry point for promoting policy coherence for health is to have a common language, a shared understanding and an awareness of the varying interests that surround a given priority; only then attempting to identify a joint vision that matches those interests.

One good working example that was cited is the local resilience forums that have been established and now operate in many parts of the United Kingdom.

Another suggested route is to develop and begin carrying out health impact assessments for major projects and initiatives, in much the same way that we already conduct environmental impact assessments.

In each of these approaches, many of the broad sectors relevant to health are readily predictable: Notably SDG2 on food production, agriculture and animal health; SDG6 on water; SDG7 on energy; SDG13 on climate change; SDG14 on marine conservation; and SDG15 on terrestrial ecosystems.

At the local level, policy coherence in health can also be promoted through specific capacities to systematically identify and address barriers to health service implementation in district or community contexts. Many such barriers go beyond technical or sectoral dimensions, to include political and/or economic challenges, and serve as a reminder of the underlying importance of political economy. Adopted political and economic systems reveal the policy priorities that they are actually designed to meet. Recognizing and navigating the political economy surrounding health is critical to achieving policy coherence.

Dr. Chutima Akaleephan introduces the ‘triangle that moves the mountain’ approach which ensures policy coherence in Thailand.
Dr. Osman Dar talks about the need to strengthen public-private-community partnerships in the context of land use change and emerging infections.
Dr. Yodi Mahendradhata highlights the need to address the various policy tensions and political economy that hinder policy coherence for health.
Prof. Richard Kock talks about the multisectoral approach and a coherent policy framework to address environmental impact on human health.

Concluding remarks

For years we have sought to build integrated multisectoral approaches to health. Policy coherence can be viewed as the other side of that same coin. Like multisectoral approaches, today’s multipolar societies require policy coherence to succeed, but they can also be leveraged to help drive policy coherence: by bringing more diverse voices, including those of affected communities, to the table.

"Policy coherence is [based on] building a shared vision and understanding, and about achieving some shared responsibility and accountability. We have had limited success to date because we were too focused on our own sectors."

Dr Mandeep Dhaliwal

A fundamental political and economic shift is required to loosen today’s ubiquitous commercial constraints to health and restore the underlying value system that supports policy coherence for health, rather than for the free market and profit.

Policy coherence requires genuine dialogue across sectors. For technically-inclined health specialists, that can feel like stepping outside of their comfort zone, and requires continuous learning, broad issue literacy and a common language.

Each of the steps along the health system continuum should engage multiple actors, and this should define how we think about partnerships for more effective health systems that leave no one behind in accordance with the commitments made by UN member states as part of the 2030 Agenda.


The panel discussion was a parallel session at the recent Prince Mahidol Award Conference, held in Bangkok in February 2018. The panel comprised:

Moderator

Ms Nadia Rasheed
Asia Pacific Team Leader, HIV, Health and Development Group, United Nations Development Programme (UNDP).

Speakers

Dr Mandeep Dhaliwal
Director, HIV, Health and Development Group, United Nations Development Programme (UNDP).
Dr Hayato Urabe
Director, Investment Strategy & Management, Global Health Innovative Technology (GHIT) Fund.
Mr Chalermsak Kittitrakul
AIDS Access Foundation.

Commentators

Dr Yodi Mahendradhata
Director, Center for Health Policy and Management, Universitas Gadjah Mada, Indonesia.
Dr Chutima Akaleephan
Senior Researcher, International Health Policy Programme, Thailand.
Prof Richard Kock
Professor of Wildlife Health and Emerging Diseases, Royal Veterinary College, University of London, UK.
Dr Osman Dar
Project Director, One Health Project, Centre on Global Health Security, Chatham House.