In 2011, Dr Gijs Walraven, AKDN Director for Health and Aga Khan Health Services (AKHS) General Manager, won first prize at the British Medical Association Annual Book Awards for Health and Poverty: Global Health Problems and Solutions. The book combined patient narratives with analysis to examine how poverty and ill health perpetuate one another, drawing on Dr Walraven's 15 years working in African healthcare systems and his early years with AKDN.

Fifteen years on, he shares in-depth insights on what has changed. What diseases have been addressed – and has anything got worse? Are the medical innovations we see in the news making a difference for the poorest? And what is still needed to ensure “health for all”?

Contents

Aisha's story
Are malaria, unsafe motherhood, undernutrition, lack of clean water and sanitation, tuberculosis and HIV still key concerns? How significant are the new threats to health, such as climate change?
What has changed about the factors that cause disparities in health?
Are innovations reaching the areas where they are most needed?
Was the optimism you hoped to generate with the book justified?
What have been some successes for AKHS – and what has been learned along the way?
What is most needed to provide “health for all”?
(How) can a single organisation like AKDN make a difference?

Aisha

Aisha lives in a village on the edge of Salamieh District in Syria, where distances are measured less in kilometres than in costs and time to travel.

A few years ago, her son Omar began waking at night gasping for breath. Aisha did what many mothers do when the clinic feels out of reach. She waited. She tried home remedies. She waited longer. The illness worried her, but the cost of seeking care frightened her more. The bus fare to the health centre would take a week's worth of income. Medicines, if prescribed, would not be free. If Omar needed follow-up, the costs would multiply. Her reality was that availability of health does not mean affordability, and affordability determines whether care is used at all.

What Aisha did have was Layla, a volunteer community health worker chosen by the village itself. Layla lived in the same neighbourhood, attended the same weddings and mourned at the same funerals. She had been trained through a local primary healthcare programme to recognise danger signs, encourage early care-seeking, and most importantly, educate families about the community health insurance scheme.

Layla was not only instrumental in seeking help and organising financial support for Omar to be seen at the Salamieh district hospital, she also gave Aisha a safety net for future health needs. She encouraged Aisha to enrol in the community health insurance scheme. Its purpose was simple: to prevent families from delaying care because of costs.

Before the scheme's introduction, many other mothers in this village avoided seeking health care in fear of deepening their poverty. A modest contribution allows them to share risk at the community level to prevent catastrophic expenditure in times of need. Affordability comes from community governance, trust and integration with the formal health system. This is universal health coverage in practice.

Are malaria, unsafe motherhood, undernutrition, lack of clean water and sanitation, tuberculosis and HIV still key concerns? How significant are the new threats to health, such as climate change?

The problems described in Health and Poverty in 2011 are still very much relevant in 2026, but the global health community has new tools, better data, different funding landscapes and evolving challenges. Progress has been real and measurable, yet it is fragile and uneven, and many countries are still far from global targets set under the Sustainable Development Goals.

Climate change

Across the world climate change is now widely evident as a systemic health risk, directly worsening nearly every condition I wrote about in 2011. It expands exposure to vector-borne diseases such as malaria, and there are now measurable geographic shifts in malaria-prone zones. Climate change increases undernutrition via crop failure, food price shocks and drought. It also raises maternal and neonatal risk, as well as for other groups such as the elderly, through heat stress, dehydration and disrupted services.

There is clear epidemiological evidence linking excess mortality to heat, which is now recognised as a leading climate-related killer. Water and sanitation systems are damaged, increasing diarrhoeal disease while fragile health systems are overwhelmed by floods, storms and heatwaves. In other words, climate change amplifies risk for all ill health.

COVID-19

The COVID-19 pandemic served as a warning, revealing key structural vulnerabilities. The new disease disrupted health services globally, including the vertical disease programmes with dedicated staff and funding and separate management for diseases such as malaria, tuberculosis or HIV. Countries with weak health systems, especially in primary health care (PHC), suffered the most indirect mortality. COVID-19 increased poverty, food insecurity, school dropout and teenage pregnancy, and exposed the fragility and inequality of global supply chains for medicines, materials and vaccines.

COVID-19 re-emphasised an important argument made in Health and Poverty: poverty is still the dominant risk factor for ill health, even for “new” threats.

Conflict

Unfortunately, since 2011 the number of people living in fragile or conflict-affected settings has risen sharply, leading to the collapse of health systems and vertical disease programmes, large underserved displaced populations, and long-term trauma and mental health burdens. In some countries, conflict now outweighs disease biology as the main determinant of health outcomes. It is also unsurprising that conflict and tensions over resources – including water and arable land – often have a direct connection to climate change.

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What has changed about the factors that cause disparities in health?

Since Health and Poverty, the drivers of health disparities have not disappeared, but they have shifted in form, scale and interaction. In 2011 disparities were largely driven by physical inaccessibility of health services, shortages of staff, equipment, medicines and facilities, weak referral systems and vertical, disease-specific programmes substituting for system capacity.

Now, global access to health services has improved substantially but quality, continuity and resilience differ sharply. Many countries have expanded nominal coverage, yet poor populations receive lower-quality care and have diagnostic delays. Low adherence and inadequate follow-up persist. Skilled staff including health professionals concentrate in urban and wealthier settings. Preventable mortality increasingly reflects poor care, not no care.

Fifteen years ago, patients were often described as lacking knowledge, facing financial and geographic barriers, and dependent on informal care or traditional healers. Now patients are more informed but poorly protected. Awareness of rights and treatments has increased but unmet expectations deepen distrust.

Even with national health insurance schemes or free services, the out-of-pocket cost of transport, diagnostics, medicines and informal fees remains catastrophic, and chronic diseases such as HIV, cardiovascular disease and diabetes impose long-term economic strain. Patients now more often live with multiple conditions – infectious and non-communicable diseases, mental health issues and physical illnesses. Health systems rarely manage these combinations well. Patients today are not simply excluded, they are included on unequal terms.

Institutional factors are important as well. In 2011, disparities were linked to underfunded ministries of health, donor-driven vertical programmes and weak regulation of private providers. Now institutions are more numerous, but less coherent in meeting health needs. Accountability is often less than desirable and hard to enforce, policies are often misaligned, institutional silos undermine equity even when intent is progressive, and there is donor fatigue as well as shifting priorities.

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Are innovations reaching the areas where they are most needed?

The short answer is partially, unevenly and too slowly. Innovation in global health has accelerated since 2011 and in several areas. These include biomedicine (vaccines, long-acting HIV prevention, rapid diagnostics); health service delivery (task shifting, community health workers – or CHWs, differentiated care models); digital health (telemedicine, AI diagnostics, digital health records); health financing (insurance schemes, results-based financing, pooled procurement); and institutional approaches (public-private partnerships, social enterprises, global platforms).

Who benefits?

The critical question is not whether innovation exists, but where and for whom it actually delivers. Innovations that are reaching high-need populations include community-based and low-tech appropriate innovations such as CHW models, simplified treatment protocols, point-of-care diagnostics (rapid tests), and integrated and patient-centred health service delivery for chronic conditions such as HIV, hypertension, diabetes and mental health issues.

Digital health has great potential, but we need to ensure that it does not exclude rural, older, poorer, undocumented, or low-literacy groups. Tools that improve quality rather than coverage (e.g. clinical decision support, diagnostics, or referral systems) often require stable infrastructure, depend on skilled staff and are hardest to implement in fragile settings.

It is in such settings where scaling up is seen as “too risky”. Here we need to go the extra mile as these settings are exactly where poor populations are most exposed to unsafe care. It is also here where innovation pipelines more often break down. Other hindrances are the prioritisation of short-term humanitarian response over system innovation. Sometimes innovations are layered onto weak systems rather than strengthening them.

The bottom line is that those most in need benefit mostly when innovations are simple, publicly financed, embedded in primary health care and designed for low-capacity environments from the start.

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Was the optimism you hoped to generate with the book justified?

The optimism in Health and Poverty was not naïve; it was grounded in real momentum. What history has shown since then is that progress has been possible, but that it is conditional, and easier to stall or reverse than I anticipated. Since 2011, the world has demonstrated that HIV is manageable as a chronic condition with massive mortality reductions, malaria deaths can fall when tools are financed and delivered, maternal mortality can decline rapidly with skilled care and system investment, and tuberculosis can be detected and treated at population level when services function.

The most durable messages of Health and Poverty include that gains through vertical programmes are fragile without system capacity, that community-level and patient-centred delivery is decisive, and that equity is a systems property, not just a programme feature. Equity is not something you add to a programme – it is something a system either produces or it does not. One can remove fees for delivery through a donor-funded voucher scheme, but if the ambulance does not come, the midwife is not there and the hospital charges for treatment of complications during the delivery, poor women are still excluded.

In hindsight my 2011 optimism underestimated some major obstacles, including that political commitment has proved less durable than technical success; my assumption that evidence would mostly drive policy was proven wrong. In reality funding plateaued or declined once crises faded, health lost political salience outside emergencies, redistribution remained politically fragile. Progress was reversible, not cumulative.

Unfortunately, inequality has adapted faster than health systems. As systems expanded, better-off groups captured quality and choice, private-for-profit provision siphoned off political support, poor populations gained access but not power. This dynamic was, at least to me, less visible in 2011.

I also underestimated external shocks. Few anticipated that a pandemic would shut down routine care globally, climate change would accelerate health risk so quickly, and prolonged, multi-region conflicts would disrupt services. My optimism assumed a more stable world than we now inhabit.

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What have been some successes for AKHS – and what has been learned along the way?

A systemic approach

Our successes are not primarily technological breakthroughs, but institutional and service-delivery achievements sustained over decades. This is rare in global health.

AKHS has successfully established and sustained “hub and spokes” networks of hospitals, PHC centres and outreach services, including in remote and difficult environments. AKHS has invested simultaneously in community care, primary care and secondary/tertiary hospitals; and linked prevention, diagnosis, treatment and follow-up. It has avoided the trap of single-disease silos. I think we can say that patients experience a system, not a patchwork of services.

Quality care

AKHS stands for prioritising clinical standards and accreditation, continuous training and professional development, patient safety and quality improvement. We’ve been able to demonstrate that high-quality care is possible in low-income and rural settings, countering the idea that the poor must accept “good enough”.

Financial discipline

AKHS has pioneered cross-subsidisation between services and patients, where revenue from those who can pay supports care for those who cannot; modest user fees combined with safety nets; and philanthropy leveraged to strengthen institutions, not just cover deficits. Charging modest fees, cross-subsidising and maintaining cost discipline were sometimes controversial, but AKHS has learned that financial collapse is the greatest equity failure and long-term presence matters more than short-term generosity.

Building trust

Our experience also shows that institutions that endure, learn and adapt are essential. AKHS learned early that poor populations value respectful, non-judgmental and competent care and that low quality erodes trust faster than lack of access. This insight is now widely accepted, but AKHS operationalised it decades ago.

Adaptation

AKHS does not pursue scale for its own sake. Instead, we learned to adapt service models to geography, culture and political reality. It accepts slower growth in exchange for deeper roots. Close engagement with governments, regulations and policies in this regard is essential.

If Health and Poverty argued that health improvements for the poor are possible, AKHS shows how, but also why it is hard. Our story suggests that health for all is less a triumph of ideas than of patience, governance and moral consistency over time. In that sense, AKHS represents a living rebuttal to fatalism, and a caution against quick fixes.

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What is most needed to provide “health for all”?

Equitable systems through primary health care

Technology, money and knowledge exist in far greater abundance than when Health and Poverty was written. What is most lacking is the ability to organise these assets in ways that consistently serve the least advantaged. What we need is a shift from programmes to systems that deliver equity. This requires strong PHC that is the first point of contact, integrates across life course and conditions – and is oriented to continuity, not episodes. PHC is no longer a technical preference; it is the only scalable equity platform.

A family medicine approach can anchor care in longitudinal, trusted relationships, allowing health systems to move from episodic treatment to life-course management of risk, illness, recovery and care. It can be uniquely designed to manage diagnostic uncertainty, multimorbidity and the interaction between physical, mental and social health – challenges that define the burden of disease.

Quality

Health care access or universal coverage without quality has reached its limits. What is most needed now are minimum quality standards that apply to everyone, investment in diagnostics, supervision, referral and learning systems, and accountability for outcomes, not just utilisation.

Resilience

We need resilient health systems that withstand shocks. Health for all in an unstable world requires systems that continue essential services during pandemics, climate events and conflict, protect health workers from burnout and attrition, maintain supply chains under stress. Resilience is no longer optional; it is core to equity.

Redistributive financing

Health for all cannot rely on volatile aid, out-of-pocket payments, fragmented insurance schemes. What is needed is progressive domestic financing, risk pooling that truly cross-subsidises the poor and incentivises quality and responsive PHC, and global financing mechanisms for global public goods. Equity requires intentional redistribution, not trickle-down coverage.

Addressing social and environmental factors

Health services alone cannot deliver health for all. Addressing the social and environmental determinants remains vital. Safe water and sanitation, decent housing, nutrition, education, climate mitigation and adaptation, and social protection linked to health risk are some of these. The difference from 2011 is that these determinants now move faster than health systems can compensate.

Leadership

Ultimately, health for all is a political choice. It requires leaders willing to prioritise long-term population health, public trust in institutions and civic space for accountability. In 2011, “health for all” implied expanding access to essential services. In 2026, it must mean protecting everyone from avoidable suffering across the life course, regardless of income, gender, geography, religion, or crisis.

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(How) can a single organisation like AKDN make a difference?

A single organisation like AKDN cannot, on its own, deliver health for all. But it can change what is considered possible, and that is often how large-scale change begins. AKDN’s significance lies not in scale relative to governments, but in its ability to demonstrate, institutionalise and sustain alternatives in environments where markets and states face challenges.

AKDN is relatively unique in that it operates simultaneously across domains: not only health, but also water and sanitation, nutrition, education, economic development and culture. Health outcomes are improved not only through health care, but through income, education, infrastructure, gender equity and social cohesion. Few organisations have operated credibly across these domains for decades.

In health, AKDN institutions including the Aga Khan University (AKU) and the Aga Khan Foundation set clinical and educational standards, ethical and professional norms, and models of accountability. These raise expectations – among patients, professionals and policymakers – about what quality is achievable in low-resource settings.

AKDN reaches where others do not stay, including in remote, mountainous, or marginalised regions, politically sensitive or conflict-affected areas, working with communities underserved by both state and private providers. Our presence over time builds trust, continuity and resilience – key determinants of health equity.

AKDN’s influence extends well beyond its direct service footprint through training health professionals, teachers, managers and AKU’s alumni who move into public service, NGOs and the private sector. This is a major pathway for AKDN’s norms and practices to diffuse outward.

Rather than advocacy alone, AKDN shows what works in practice, provides credible evidence to governments and de-risks reforms by piloting them responsibly. Examples include:

• the CHWs, who during COVID-19 were best equipped to focus on prevention and care within communities, thus keeping patients away as much as possible from health facilities and with that reducing the spread of the virus;
• the introduction of SafeCare certification in public and private healthcare facilities in several countries; and
• the conception and implementation of a facility-based carbon emissions monitoring system, with action plans to achieve net-zero health facilities.

AKDN plans in decades, not grant cycles. This allows incremental system strengthening, learning from failure and adaptation to political and environmental change. Few actors in global health have this patience.

AKDN cannot and does not aspire to replace the state, scale nationally without public adoption, nor fully insulate itself from macroeconomic or political shocks. But this is precisely why its role is valuable: it can show what is possible if political and institutional conditions allow.

In a world of fragile states, marketised health systems, donor fatigue, and climate and conflict shocks, AKDN demonstrates the feasibility of resilient, ethical, non-profit institutions, the importance of trust and legitimacy, and the value of integrated, long-term development.

Health and Poverty argued that poverty is not destiny if institutions work. AKDN’s experience adds that institutions do not emerge spontaneously – they must be designed, protected and sustained. In that sense, AKDN’s greatest contribution in health is not the number of patients served, but the proof that equity-oriented development can endure.

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