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Introduction¹

The global health landscape will not be the same 5 and 10 years from now. Transitions are occurring in so many ways, in so many contexts, and are creating profound changes in global health, John Lange from the United Nations (UN) Foundation remarked. These interlinked transitions are both economic and programmatic. A cohort of countries that have historically relied on development assistance for health (DAH) is transitioning into higher-income status. Increased income status triggers graduation out of several multilateral health financing initiatives. Additionally, one large program focused on disease eradication is nearing its goal and will soon end. At the same time, countries that have provided DAH are shifting focus away from traditional development assistance in favor of investments focused on value for money and global public goods.

In response, processes are under way to transition countries out of traditional bilateral and multilateral health funding mechanisms, and countries are expected to spend more of their own resources on health systems. These transition processes are often well defined in criteria and approach; however, their implications, particularly when they occur simultaneously, are not well understood. With current trends, there is the

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¹ The planning committee’s role was limited to planning the workshop, and the Proceedings of a Workshop has been prepared by the workshop rapporteurs as a factual summary of what occurred at the workshop. Statements, recommendations, and opinions expressed are those of individual presenters and participants, and are not necessarily endorsed or verified by the National Academies of Sciences, Engineering, and Medicine, and they should not be construed as reflecting any group consensus.

potential for 24 countries to face significant changes in access to global health financing over the next 5 years (Action, 2017). The effects on health outcomes and health systems globally could be large in scale. For example, nearly half of the projected effect of routine vaccination on deaths averted in 2016–2020 is allocated to countries projected to be phasing out Gavi, the Vaccine Alliance, funding within that period (Kallenberg et al., 2016). Some countries’ health systems have been heavily dependent for decades on the “soon to sunset” Global Polio Eradication Initiative (GPEI), with 25–50 percent of staff funded through GPEI spending time on nonpolio activities in support of health systems (TIMB, 2017). The 2017 World Report on Malaria provides a sobering picture of how quickly advances in global health can backslide when resources decline (WHO, 2017).

At the same time that countries are transitioning out of external funding mechanisms, they are facing transitions in the burden of disease, primarily the significant rise in noncommunicable diseases (NCDs) (Bollyky and Shendruk, 2017), while they are still working to control many infectious diseases. To date, DAH has largely ignored NCDs (Dieleman et al., 2015), and countries themselves are often faced with competing demands of immediate importance—often forcing complex NCD challenges to the bottom of their national agendas. As countries transition out of external funding mechanisms, the rising burden of NCDs requires increased and significant attention while, simultaneously, the health improvements supported by DAH over the past several decades need to be sustained and accelerated.

On June 13–14, 2018, the National Academies of Sciences, Engineering, and Medicine convened a multistakeholder workshop to examine the transitions affecting global health and innovative global health solutions (see Box 1-1). The goal of bringing these two topics together was to collectively explore models for innovative partnerships and private-sector engagement with the potential to support countries in transition. As individual speakers at the workshop explained, these transitions can be disruptive, but they also present opportunities. With an increased focus on domestic resource mobilization for health, countries can drive better decision making on priority health investments. Rising income levels in developing countries can create attractive environments for market-based solutions in health with the potential for sustainability and scale. Enabling advances in technology can accelerate process. Local innovators and entrepreneurs can be a source of solutions that are contextually appropriate and locally owned. Funders of traditional DAH can move away from funding direct health services and products to making catalytic investments that support sustainable solutions, and focus on investing in global public goods that require international collaboration and commitment. In this changing landscape, innovative solutions have the

potential to sustainably support countries and maintain health gains during and after transitions.

ORGANIZATION OF THE PROCEEDINGS

An independent planning committee organized this workshop in accordance with the procedures of the National Academies of Sciences,

Engineering, and Medicine. (See Appendix B for the agenda.) The planning committee’s members were Jo Ivey Boufford, Deena Buford, Jennifer Esposito, Renuka Gadde, Trevor Gunn, Ambassador John E. Lange, Amy Lin, Scott Ratzan, Katherine Taylor, and Chris West. This publication summarizes the workshop’s presentations and discussions. The content of the proceedings is limited to what was presented and discussed at the workshop and does not constitute a full or exhaustive overview of the field.

Chapter 2 summarizes the workshop presentations and discussions on demographic and health transitions, multilateral program eligibility and transition policies in practice, bilateral approaches and policies for transitions, and transitions in select countries. Chapter 3 focuses on setting the stage for sustainable investments in health and summarizes workshop sessions on multisectoral engagement and sustainable solutions to support transitions, elevating health on domestic agendas, and market shaping. Chapter 4 introduces four models for sustainable partnerships and private-sector engagement presented and discussed during the workshop. The final chapter, Chapter 5, captures key messages and lessons participants shared at the end of the workshop.

In accordance with the policies of the National Academies, the workshop did not attempt to provide a full analysis of the political context related to global health transitions, a landscape of all possible models to support countries in transition, or any conclusions or recommendations about needs and future directions. The proceedings report focuses on the issues identified by the speakers and workshop participants. In addition, the organizing committee’s role was limited to planning the workshop. The workshop proceedings was prepared by workshop rapporteurs Rachel M. Taylor and John Maurice as a factual summary of what occurred at the workshop.