Global Health Summit: The Grand Convergence

October 27/2014

By Elaine Smith

The issue: In a widely read 2013 article, "Global Health 2013: The Grand Convergence," The Lancet revisited the case for investment in health and developed a new investment framework to achieve dramatic health gains by 2035.

The lead author, Dean T. Jamison, now a professor emeritus at the University of Washington, and his co-authors wrote: "A unique characteristic of our generation is that collectively we have the financial and the ever-improving technical capacity to reduce infectious, child, and maternal mortality rates to low levels universally by 2035, to achieve a “grand convergence” in health. With enhanced investments to scale up health technologies and systems, these rates in most low-income and middle-income countries would fall to those presently seen in the best-performing middle-income countries."

The article inspired part of the agenda of the University of Toronto’s Global Health Summit, Creating a Pandemic of Health, hosted by the Dalla Lana School of Public Health.

Here, Professor Jamison and three U of T global health professors discuss whether a grand convergence is possible and the barriers that must be overcome to achieve it.

Dean T. Jamison, Professor Emeritus of Global Health at the University of Washington:

Viewpoint: Political will is required to succeed in convergence.

As recently as 250 years ago, despite major economic disparities between countries, there was relatively little variation in mortality. Between 1800 to 1850, we began to see divergence. Some countries, mostly those in Western Europe, saw their mortality rates start to decline at a fairly rapid rate, probably due to better hygiene and some technology, such as the smallpox vaccine. These declines continued throughout the first half of the 20th century.

As more countries adopted such practices, it led back to convergence at a lower level of mortality, although the convergence has had major setbacks and is far from complete. However, with money focused strategically on a limited set of interventions for a couple of decades, we could complete the re-convergence and see an extraordinary improvement in health conditions.

If the politics are right and the money is there, it can happen in a few decades. It is technologically feasible; we have the tools, drugs and diagnostics. The cost is noticeable, but increasingly affordable by most countries. It's not rocket science at this point. However, there must be the political will and focused attention on these things. We in the west can do the technological things and write cheques, but we can't generate the political will.

The Creating a Pandemic of Health Global Health Summit can provide examples of other countries with similar budgets doing it and show that there is no excuse for not getting it done. People need to hold their governments accountable."

Dr. Zulfiqar Bhutta, Global Health Professor at the Dalla Lana School of Public Health and Co-Director at the SickKids Centre for Global Child Health

Viewpoint: Allow for contingencies when you plan.

"Convergence is entirely possible, but it is not as simplistic as people make it out to be.

We can't really project what will happen in the future using a linear measure. We have to make allowances for things like outbreaks and climate change so we are more pragmatic in our planning. We must invest resources in risk mitigation.

In the geographies where I work — Pakistan and Afghanistan — you can't talk about grand convergence without discussing a range of other issues, such as security or displaced populations.

There is a lot of incomplete thinking, and perhaps deliberately so, because lots of people are working from an advocacy perspective. But planning for contingencies is linked to accountability. If an organization makes an investment and doesn't get the results they expect, they can't then draw in contingencies such as climate change, the scarcity of water or floods.

Working toward a climate change strategy, for example, is not something someone else does. It is part of the health agenda. People won't refute the importance of these areas; they just say they are outside the purview of the health sector. However, we don't work in silos; as academics, we ought to have a broader perspective.

My objective is not to belittle the importance of investing in health for development, but to make people aware of some of the critical conditions surrounding it, including those I mentioned and others that are critical to sustaining gains such as education, poverty alleviation, female empowerment and focusing on the built environment."

Dr. Ophira Ginsburg, Assistant Professor of Global Heath at the Dalla Lana School of Public Health and Scientist at Women’s College Research Institute:

Viewpoint: Take into account the realities on the ground.

"When I look at the 2035 piece, it is a great document to aspire to, but we must also address the realities on the ground. I am looking through the nano-lens at the health sector realities that often get ignored.

There are also some simple solutions to complex health concerns, but it can be a struggle to get that story out. For example, by leveraging existing resources, you can piggyback cervical cancer screening onto maternal-child health programs, or you can piggyback women's cancer services onto an HIV/AIDS program. Cancer is a big cause of premature death that has a huge social and economic impact. We need to show governments as well as non-governmental organizations and donors what can be done. We need to illustrate that you can get a lot of return on an investment.

I've seen firsthand why things don't happen. We must address issues of governance and corruption; we can't pretend it's a perfect world.

In Bangladesh, for example, the biggest problems are related: partisan politics and corruption. There is a National Cancer Control Plan, for example, and if you ask the World Health Organization, everything is under control and aligns with the framework. On the ground, however, the reality is that the plan came about under a previous government and the current government doesn't want that stamp on any programs, so it is sitting on a shelf collecting dust while people are dying.

One factor which greatly improves the odds of success and sustainability of a public health intervention is when local people have real ownership of a program. It is much more sustainable if they take it on. For example, Bangladesh is a very conservative Muslim society, but birth control pills and other methods of family planning are now widely used. Despite poverty and other complex problems, they’ve made great strides in tackling Millennium Development Goals 4 and 5, which concern maternal and child health. You can't just mandate that. You need a homegrown solution that understands the socio-cultural implications of discussing family planning.

Convergence is possible, but not without political will and non-partisan, multi-sectoral political engagement. We need people in the region who understand the challenges and opportunities — not just in health, but in governance."

Arjumand Siddiqi, Assistant Professor of Epidemiology and Social and Behavioural Health Sciences at the Dalla Lana School of Public Health:

Viewpoint: Talking about health inequities is integral to any discussion of convergence.

"When we discuss convergence, we need to consider two issues:

What constitutes a reasonable standard for populations to converge to? It is important to think about setting out items that are not just limited to ill health, but a fuller set of well-being issues that have more human developmental connotations.

Making sure we face persistent health inequities head on. It's hard to have a conversation about convergence without discussing inequities, which perhaps best represent our failures. There are large gaps at every point along the socio-economic spectrum in outcomes in almost every society at almost any time in history: race/ethnic groups, male/female, income, etc.

My research looks to see which societies are better than others with policies that lead to convergence, and there are examples of both rich and poor countries that do really well. The most striking societal example is the Scandinavian countries, where there are governance committees tasked with examining policies in all areas of government through the lens of childhood equality to see whether any policy — seemingly unrelated or not — mitigates it or exacerbates it.

In Eritrea [a country in the Horn of Africa], there is a similar inter-sectoral way of approaching child development. The government has made a commitment to look at policies that affect early childhood development from a holistic perspective. They don't relegate it to any one particular sector of the government. Such whole-of-government approaches seem to be a way to get traction that we need to examine.

When you converge around a common goal, you can structure many aspects of society to meet it, because you've decided it's an important goal. We need to look not only at convergence, but at the mechanisms we need to put in place to make it sustainable over time."