Macroeconomics and Health: Investing in Health for Economic Development
Item
- Title
-
Macroeconomics and Health:
Investing in Health for
Economic Development
- extracted text
-
RF_COM_H_2.1_SUDHA
WHO Asian Civil Society Conference
on Macroeconomics and Health
COLOMBO,
SRI
LANKA,
27-28
World Health Organization
APRIL
2004
This report has been prepared by the two Institutes that organized
the Conference for WHO:
The Royal Tropical Institute, Amsterdam,The Netherlands
Marga Institute
Colombo, Sri Lanka
WHO Library Cataloguing-in-Publication Data
WHO Asian Civil Society Conference on Macroeconomics and Health
(2004 : Colombo. Sri Lanka)
WHO Asian Civil Society Conference on Macroeconomics and Health, Colombo, Sri Lanka, 27-28 April 2004 :
[report].
I.Nongovernmental organizations 2.Organizations, Nonprofit 3 Delivery of health care 4.Poverty 5.Intersectoral
cooperation 6.South-East Asia /.Western Pacific.
ISBN 92 4 159248 6
(NLM classification:WA 30)
©World Health Organization 2004
All rights reserved. Publications of the World Health Organization can be obtained from Marketing and
Dissemination,World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland (tel: +41 22 791 2476; fax:
+41 22 791 4857; email: bookorders@who.int). Requests for permission to reproduce or translate WHO
publications - whether for sale or for noncommercial distribution - should be addressed to Marketing and
Dissemination, at the above address (fax: +41 22 791 4806: email: permlssions@who.int).
The designations employed and the presentation of the material in this publication do not imply the expression of
any opinion whatsoever on the part of the World Health Organization concerning the legal status of any country,
territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines
on maps represent approximate border lines for which there may not yet be full agreement
The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or
recommended by the World Health Organization in preference to others of a similar nature that are not
mentioned. Errors and omissions excepted, the names of proprietary products are distinguished by initial capital
letters.
The World Health Organization does not warrant that the information contained in this publication is complete and
correct and shall not be liable for any damages incurred as a result of its use.
Printed by the WHO Document Production Services, Geneva, Switzerland
■^>cRENCE ON MACROECONOMICS AND HEALTH
Contents
Introduction
3
Process of the Conference
4
Overview of the plenary presentations
6
Overview of the working groups
10
Conclusions and way forward
14
Colombo Consensus
16
Annex 1 - Conference programme
20
Annex 2 - List of participants
22
Annex 3 - Conference materials
30
Conference papers and detailed summaries of the plenary presentations and working groups can be
found on the Macroeconomics and Health website at
http://www.who.int/macrohealth/events/civil_society_asia/en/.
Production:
Valerie Crowell
Acronyms and Abbreviations
Writers:
AIDS
acquired immune deficiency syndrome
Maria Paalman,
Myrtle Perera
CBO
community-based organization
CHCC
CMH
catastrophic health care cost
Commission on Macroeconomics and Health
Executive Secretary
CMH Support Unit:
CSO
civil society organization
Sergio Spinad
GDP
gross domestic product
Art and Design:
GNP
gross national product
Imagic Sari
HIV
human immunodeficiency virus
World Health
Organization
CMH Support Unit
KIT
MDG
Royal Tropical Institute
Millennium Development Goal
20 Avenue Appia
CH-1211 Geneva 27
NGO
non-governmental organization
Switzerland
www.wlio.int/macrohealth
NHA
National Health Account
PRSP
Poverty Reduction Strategy Paper
PHC
SAARC
primary health care
South Asian Association for Regional Cooperation
WHA
World Health Assembly
WHO
World Health Organization
Editorial Contributors:
Silvia Ferazzi
CAGANCAu
GfNFF Au 'Ct ON MACROECONOMICS AND HEALTH
Introduction
the official launch of the report of the Commission on Macroeconomics and Health (CMH) in
December 2001, WHO has undertaken to facilitate the implementation of its recommendations at the
country level. Countries are supported as they analyse the health situation of the poor and produce a
strategic framework for priority setting and a long-term Health Investment Plan for scaling up essential
interventions that will benefit the poor, thereby improving their health as well as contributing to economic
growth and poverty reduction. Apart from a clear focus on the poor, advocacy for more resources for health
and assistance to countries in removing non-financial constraints to increasing health investments are also
crucial components of the WHO Macroeconomics and Health approach.
It is critical to involve civil society organizations (CSOs) in adapting the findings and recommendations of
the Commission, particularly at country level, because their work is central to poverty reduction and the
promotion of equity. They can play an important role in the efforts to scale up resources for health and to
invest them wisely through advocacy, lobbying, contribution to implementation and analysis. They are
therefore important partners in Macroeconomics and Health activities.
On 27-28 April 2004, the World Health Organization (WHO) organized an Asian Civil Society Conference
on Macroeconomics and Health in Colombo, Sri Lanka, with the support of the Royal Tropical Institute (KIT)
in Amsterdam and the Marga Institute in Colombo. The overall objective of the Conference was to inform
CSOs about the Macroeconomics and Health approach and to discuss the challenges and opportunities
related to their potential contribution at country level to improving health outcomes for the poor through
the Macroeconomics and Health processes in which their governments are engaged. The meeting was
intended to contribute to a constructive dialogue between WHO and international and indigenous CSOs,
as well as between them and the governments of the countries they work in, on the important issue of
promoting better investment for the health of the poor.
Some 60 representatives of indigenous and international CSOs, operating in low and middle-income
countries from the WHO South-East Asia and Western Pacific Regions, came together to discuss how CSOs
could contribute to improving the health of the poor in their respective countries within the
Macroeconomics and Health framework. The following countries were represented: Bangladesh,
Cambodia, China, India, Indonesia, Lao People's Democratic Republic, Mongolia, Nepal, the Philippines, Sri
Lanka, Thailand and Viet Nam. In order to facilitate dialogue with the governments of these countries,
which are already involved in Macroeconomics and Health work, government officials also attended.
" ' .
:
.
.
..
■ ■ ,v :
, X ,;.,r I'-.: N: !; ••
'
RO
. . V. '
.
.
Process of the
rl’Conference
W
HO offices in the 12 countries identified a number of CSOs to be invited for the Conference on the basis
of agreed-upon criteria. The final composition of the participants in the Conference was a balance of
organizations involved in advocacy and lobbying, in provision and financing of health services, and in
research. The complete List of Participants is available as Annex 2. Invited CSOs received a brief overview
of the Conference and the brochure Investing in Health: a Summary of the Findings of the Commission
on Macroeconomics and Health. They were requested to fill out an NGO profile, prepared by the
organizers, indicating their involvement in pro-poor health and other development sectors.
WHO commissioned the following two background papers for the Conference, which were also made
available to participants:
1.
Rajiv Misra. The CMH Process and Civil Society.
2.
Nance Upham. Making Health Care Work for the Poor: a Preview of NGO Experience in Selected
Countries.
The plenary presentations by both authors were based on these background papers and are summarised
in this report.
During the two-day Conference, participants received further documentation, including the full CMH
Report, a CD-Rom with all CMH working group papers and reports, the declaration of the 2nd Consultation
on Macroeconomics and Health held in Geneva in October 2003, global and country updates on
Macroeconomics and Health, the People's Charter for Health, the Mumbai Declaration of the People's
Health Movement, a booklet on Government/NGO Partnership in Health Care in Sri Lanka, and the
People's Health Movement Response to the Commission on Macroeconomics and Health.
The Conference programme is attached as Annex 1. On the first day of the Conference, participants were
addressed by key note speakers in a plenary session. Brief summaries of the plenary presentations are
given in this report.
All of these documents and presentations stimulated discussions in four thematic working groups,
for which ample time was reserved. Participants could choose the working group of their preference but
were urged to spread their country team over the different groups. All themes were related to the role
of CSOs and the potential for partnership between CSOs and government in improving the health of the
poor. Participants looked for common ground,- discussed the challenges involved, and debated what and
how CSOs could contribute to the Macroeconomics and Health work in general and in their respective
countries.
PACE 5
gWHO ASIAN CIVIL SOCIETY CONFERENCE ON MACROECONOMICS AND HEALTH
The themes for the four working groups were:
1.
How can CSOs contribute to the policy debate and decision-making on poverty, economic
development and health?
2.
How can CSOs contribute to increasing access to essential health services for the rural and
urban poor?
3.
How can CSOs contribute to giving relief to households that experience catastrophic
health costs?
How can CSOs contribute to analysis and strategic planning of Macroeconomics and
Health issues through research?
In order to facilitate discussion, three objectives were formulated for each group and some background
thoughts, information, and questions for each group were prepared by the organizers. These were meant
to provoke discussion and were not intended to be prescriptive or exhaustive. Each group was encouraged
to come up with additional or different questions and issues.
Each group presented their findings and recommendations during the plenary session on the second day,
and interesting discussions followed each presentation. Brief summaries of the discussions in the working
groups are given in this report.
The outcomes of the plenary and working group sessions were summarized in a consensus statement that
was put together during the two days of the Conference and discussed and agreed upon during the closing
session. After the meeting, the WHO secretariat finalized the consensus statement on the basis of the
discussions and further comments from the participants. The final version is attached at the end of this
report.
The summaries of plenary presentations and working groups in this report and on the event website were
produced by the organizers. Drafts were sent back to presenters and group chairpersons and rapporteurs
for comments. All comments were included so as to make the summaries a true reflection of the
Conference proceedings and recommendations.
All information about the Conference, including full background papers, NGO profiles, programme, participant list,
presentations, and extensive summaries of plenary presentations and working group discussions, can be found on
the Macroeconomics and Health event website (www.who.int/macrohealth/events/civil_sodety_asia/en/).
References to the Conference can also be found in the MacroHealth Newsletter 9, also available on the
Macroeconomics and Health website (www.who.int/macrohealth).
PAGE V
jWHO ASIAN Civil $!.x i! 'lY CONI-'FRENCl-. ON
Overview of the
Plenary Presentations
Inaugural address
The Minister of Health of Sri Lanka, Nimal Siripala de Silva, welcomed the participants on behalf of the
Government of Sri Lanka, the host country. He emphasized the need for increased funding of the health
sector, but also stressed that poverty reduction and sustainable development are essential for improving
health. He went on to say that the efficient use of money in a cost-effective manner is equally important,
maximizing benefits with minimum spending and cutting down waste and corruption. The Minister
perceived a role for the civil society organizations, in their capacity as representatives of the community, in
acting as a pressure group and in raising awareness that spending on health is, in fact, an investment. He
also thought that CSOs could play a role in canvassing funds and in the policy debate on health sector
reforms. Setting an example for other Asian countries, the Minister was able to announce that the
Government of Sri Lanka had recently pledged to increase the current spending of around 1.5% of GNP
on the health sector to 2.5 % within a year, an increase equivalent to what the CMH suggested.
Introduction
On behalf of WHO, Sergio Spinaci, the Executive Secretary of the Coordination of Macroeconomics and
Health Support Unit, welcomed the participants and praised the invaluable involvement of CSOs in
effectively addressing the problems that affect the poor, including assisting displaced populations and those
living in underserved areas. Civil society, in his view, also greatly contributes to linking health and poverty
reduction by putting critical issues, such as debt, human and gender rights, trade, and the environment, at
the centre of national and global agendas. He stressed that equity in health and universal coverage of
health services in low-income countries can be better addressed through closer links and partnerships
between governments and CSOs and expressed his hope that discussions would push forward a common
agenda for better access to health by the poor.
Overview of Macroeconomics and Health work
A review of the follow-up to the CMH work was given in three presentations by WHO representatives: Silvia
Ferazzi's presentation focused on the global process, Bhupinder Singh Lamba presented on the activities in
South-East Asia, and Anjana Bhushan presented on the situation in the Western Pacific. The presentations
highlighted the need for the CMH Report to be adapted to the local contexts through a flexible, lessons
learning-oriented approach and noted that the involvement of the civil society is key to that purpose.
At the global level, after the launch of the CMH report in December 2001, two global consultations for
countries and development partners were held in Geneva. The first took place in June 2002, and the
second in October 2003. As a result of these two meetings, while it was agreed that there is a need for
PAGE 7 | Wl 10 ASIAN CM I SOCIETY CONFERENCT ON MACROECONOMICS AND HEAiTH
additional resources to achieve the CMH objectives, it became clear that the use of existing institutional
mechanisms was preferred to the designing of new ones; the creation of ad hoc national commissions on
Macroeconomics and Health should be promoted only when existing mechanisms that could fulfil the
required functions were not in place or were ineffective.
Work with NGOs started with a briefing on the CMH report at the report's launch in December 2001 and
with a discussion on its follow-up at the World Health Assembly (WHA) 2003. The NGOs considered the
centrality of health as a human right, which links firmly to the Alma Ata principles, to be weak in the CMH
Report. They recommended going beyond selective, vertical programmes, referring rather to a broad
primary health care approach. A reduction in the dependency on external aid was preferred, in order to
strengthen country responsibility and ownership. A wider circle outside the health sector itself,
encompassing non-health sector determinants of health and focusing on synergies with other social
sectors, was considered the most fruitful way forward. These comments have been taken into
consideration in the approach to the country follow-up to the work of the CMH, and should be further
strengthened through common action by WHO and CSOs.
In South-East Asia several high-level regional meetings on MH took place, resulting in a strong interest in
most countries to pursue a Macroeconomics and Health process. Concrete country initiatives include the
setting up of national Macroeconomics and Health mechanisms, stressing the importance of intersectoral
cooperation and collaboration with CSOs, organization of advocacy meetings, preparations for production
of Health Investment Plans and mobilization of additional domestic resources. Some countries have sought
to reposition health in country Poverty Reduction Strategy Papers (PRSPs) and to link up with
complementary initiatives such as the Millennium Development Goals (MDGs).
Some Western Pacific countries are adapting CMH findings through country-specific economic analysis to
examine the linkages between health, poverty and macroeconomics, through costing of essential services
and through analysis of cost-effectiveness of interventions. In health financing, efforts are focused on
policies to reduce financial barriers to equitable access and use of basic health services, through the use
of targeted subsidies or through social health insurance initiatives. WHO assistance to countries focuses on
the development and use of National Health Accounts (NHAs) and capacity building in resource planning
and management.
The CMH process and civil society
The former Health Secretary of the Government of India, Rajiv Misra, discussed the CMH report, the
background to its constitution, the main findings and recommendations, follow-up activities and the role
ItW ASIAN (.ML S;x:ij¥CONFFK>l.-N'
he thought civil society could play in the implementation of the action agenda. He stated that follow-up of
the CMH recommendations has been slow and uneven. No country has yet developed long-term plans,
and external aid is still nowhere near the scale recommended by the CMH. Public interventions still tend
to benefit the rich more than the poor. The neglect of the poor can lead to potentially destabilizing
imbalances in development and cause social tensions and unrest. Investment in the health of the poor is
not only good economics, but good politics as well.
Because civil society is the driving force of public opinion, CSOs can play an important role in advocating
for improvement in the health of the poor. Civil society is well-placed to spearhead the effort to give
health its due status and priority. CSOs also have an important role in service delivery for the poor,
because they are in close contact with the community. Such activities can be expanded by developing
public-private partnerships. Misra advised governments to be flexible in their arrangements with CSOs and
not to stifle their initiative and freedom. CSOs were advised to overcome their differences of opinion, as
they could be more effective if they come together and develop systems of self-regulation.
NGO contributions to health systems for the poor
The President of the Geneva Office of the People's Health Movement, Nance Upham, had a strong
message for the Conference: health systems for the poor need not be and should not be poor health
systems. While governments often do not manage to serve the poor, or provide low quality services, NGOs
are on the record to deliver good primary health care to poor populations, adapted to the local realities of
the communities they serve. However, she asserted that NGOs can only work within the framework of
strong public health services. Upham also stressed that primary health care is best delivered as part of a
broader socio-economic assistance package and backed up by a sustainable secondary and tertiary health
system accessible to the poor. NGOs also have valuable experience in this respect, as many NGOs provide
health care alongside education, micro-credit, agricultural and nutrition support, and insurance, for
example. This kind of synergy between different aspects of a comprehensive development policy is
needed to reduce poverty.
Upham also touched upon community health financing schemes, which have to be further developed to
increasingly cover the very poor and suggested that we need more flexible, mobile and modern health
systems. Rather than expecting people to travel to the health delivery point while they are sick, more
attention should be paid to bringing the services to the people. Besides the more classic outreach services
and mobile clinics, the possibilities telemedicine offers could bring sophisticated diagnosis to the remotest
parts of the world.
SOCIETY CONFERENCE ON MACROECONOMIC'. AND HEALTH
The health transition and economic growth in Sri Lanka
Godfrey Gunatilleke, member of the National Commission for Macroeconomics and Health in Sri Lanka
and Chairman Emeritus and Fellow of the Marga Institute in Colombo, described how at present Sri Lanka
is managing the later stages of the health transition, characterized by the decline in the proportion of
infectious diseases and the rise in non-communicable diseases, with a national health care system which
by international norms is an unusually low-cost system. The total cost of health care has been maintained
at around 3% of GDP over time.
At present, the public health care system in Sri Lanka provides nearly 75% of all outpatient and inpatient
health care, while the private sector, mainly serving the needs of the higher income groups, provides about
6% of inpatient and about 19% of outpatient care. For this volume of goods and services the private sector
spends approximately four times as much as the public sector. Household expenditure on health care
accounts for no more than about 25% of total expenditure. Although poverty persists and child and
maternal mortality still pose serious challenges, the health of the population has improved substantially.
The example of Sri Lanka shows that it is possible to improve population health at an affordable price. It
also shows that remaining ill health is clearly related to poverty and that there is an indivisible link between
health, poverty reduction, productivity and economic growth.
According to Gunatilleke, the role of NGOs has changed. During the first phase of the health transition,
community-based organizations (CBOs) made the delivery of health care more cost-effective. They were
involved in health education and public awareness, humanitarian support and in maternal and child health.
The contributions of NGOs in the second phase were characterized by a greater emphasis on research and
advocacy on the public issues of health care in Sri Lanka, budgetary allocation for health, the national
health care system and privatization.
W
ASiAN CiVH SO' 'LTY CON! I RF.NCT ON MA; K •. •
< '■
■ -.
Overview of the
Working Groups
he core of the discussion on the involvement of CSOs in health and poverty reduction activities and in the
Macroeconomics and Health processes took place in the working groups. These centred around the
potential contribution of NCOs in four areas: the policy debate and decision making: access to essential
health services for the rural and urban poor; relief to households that experience catastrophic health costs;
and analysis and strategic planning of Macroeconomics and Health issues through research.
The main conclusions and recommendations with direct implications for the Macroeconomics and Health
process are summarized below;
Working group 1 - The contribution of CSOs to the policy debate and
decision-making on pro-poor strategies to provide and finance health
services
Working group 1 discussed the comparative advantages and constraints that CSOs have as partners in the
policy debate on pro-poor strategies, and focused on issues such as experience in working with
communities, desire to develop innovative approaches, and inter-sectoral scope. Based on the assumption
that governments have the main responsibility for the provision of quality primary health care services for
all, including the poor, working group 1 agreed with the plenary speakers that CSOs have a complementary
role, in particular in providing health services to the poor and the disadvantaged in remote or otherwise
underserved areas. They highlighted that CSOs can effectively bring the voices of the poor to the policy
table, both through formal and informal dialogue, at the local level but also at higher levels of government,
provided they are well organized, have good networks and base their views on solid evidence. By piloting
alternative health financing mechanisms, for instance, CSOs can add to the evidence base for policy
making. Working group 1 also recognized the importance of involving donors in fostering and harmonizing
partnerships between governments and CSOs.
Working group 1 recommended that:
•
CSOs should advocate for governments to invest more in health, as this will improve
economic growth and reduce poverty. CSOs should advocate for simultaneous investment
in other sectors, such as education and employment, in order to render investment in
health sustainable.
•
In order to be more effective counterparts at the policy table, CSOs should develop the
evidence on which their policy viewpoints are based, build up their expertise and strategic
alliances with other stakeholders, and unify their voice.
PAGE I I gWHO ASIAN CIVIL SOCIETY CONFERENCE ON MACROECONOMICS AND HEALTH
•
Governments should regularly involve CSOs in policy debates, as they can effectively help
in addressing, inter alia, the limitations of sector-based ministerial structures. Good
practice participatory mechanisms should be developed. Donors can also be instrumental
in fostering and harmonizing partnerships between CSOs and governments, as has been
the case with the Country Coordinating Mechanisms of the Global Fund for AIDS,
Tuberculosis and Malaria.
Working group 2 - The contribution of CSOs to increasing access to
essential health services for the rural and urban poor
Working group 2 gave an opportunity to explore the relations between CSOs and governments in providing
health services and interventions. It was felt that governments have the primary responsibility for quality
public health services, including to the poor. However, CSOs can usefully enter in collaborative
arrangements with governments to provide complementary, demand-based health services, particularly to
the poor in rural and underserved areas, where fewer public health staff are available to work and where,
therefore, public services are weak or non-existent. Among other issues, and with reference to the problem
of financing CSO activities in provision of health, health-related and relief services, it was concluded that in
addition to funding from government and international agencies or charities, sustainable results can be
achieved through local income generation programmes, community funds, community health insurance,
and links to micro-credit programmes.
Working group 2 recommended that:
•
Governments should support CSOs in the provision of health services to the poor by
creating a conducive environment and providing financial incentives, while ensuring CSOs
operational flexibility and autonomy in implementation.
•
In order to make health service delivery for the poor locally sustainable, dependence on
international agencies should be avoided; local financing of the costs should primarily
take the form of income generation, community funds, community health insurance, and
microcredit programmes.
•
To subsidise the health expenditures of the poor, governments should consider
establishing special equity funds. In order to avoid unnecessary use of services and raise
the value of the product, users of health services, however poor, would be requested to
complement this support with contributions adequate to their means.
Working group 3 - The contribution of CSOs to giving relief to households
that experience catastrophic health care costs (CHCCs)
Working group 3 defined CHCCs and debated the main determinants of households falling into poverty
due to high health care costs, categorizing them into health system-related, patient-related and
environment-related determinants. The group further debated the role CSOs can play in prevention of
CHCCs, as well as in provision of support once households experience CHCCs. Participants noted that
efficient delivery of primary and secondary health care to the poor can prevent CHCCs. Besides direct
service delivery to the poor, CSOs can encourage the development of risk pooling arrangements and other
financing schemes to protect the poor from high health care costs. CSOs can also play an important role
in accident prevention and disaster preparedness, as accidents and disasters are important causes of
CHCCs. Households that have fallen into poverty can be assisted by reimbursement of their health care
costs from private donations, or in case of disaster, by the provision of relief.
Working group 3 recommended Shat:
•
Governments should consider setting up special funds, from which prolonged and
expensive courses of treatment for the poor can be (co-)funded, and/or empower and
assist communities to mobilize resources to this end themselves.
•
Government should develop risk pooling arrangements and financing schemes protecting
the poorest CSOs should collaborate by explaining terms and conditions of insurance and
other risk pooling arrangements and assist members of poor families with generating
more income.
•
CSOs should be involved in educating and informing poor communities about accident
prevention and disaster preparedness.
•
Governments and CSOs should establish grievance address systems to ensure good
governance and quality of services, since the best prevention of CHCCs is the timely
delivery of quality health care.
Working group 4 - CSOs can contribute to analysis and strategic planning
of Macroeconomics and Health issues through research
Working group 4 agreed that health and economics research is crucial for policy, planning and programme
formulation in the area of health and is a strong tool for monitoring the achievements of health goals.
Community-based CSOs can identify issues and areas for research, gather data on attainment of the MDGs
IWHO ASIAN CIVII SOCIETY CONFERENCE ON MACROECONOMICS AND HEALTH
at community level, and also be actively involved in operational, action and policy-related research. CSOs
have a special responsibility in making research more pro-poor. It was felt that CSOs, when joining forces,
have considerable research capacity which can contribute to health policy and strategic planning efforts,
for example by identifying reasons for inadequate access to public health services and evaluating the
impact of health sector reforms.
Working group 4 recommended that:
•
National governments should increase investment in health research and encourage
collaboration with CSOs.
•
CSOs should contribute to building a sound evidence base for policy making by making
data collection and documentation of best practices part of their mainstream activities.
•
CSOs should establish an International CSO Forum for Research on Economics and Health.
In addition, CSOs should link up more closely with the yearly meeting of the Global Forum
for Health Research.
•
Health research in developing countries should move from being donor-driven to people-
driven and contribute to building a country-based empirical evidence for convincing the
governments, thus facilitating the advocacy and lobbying role of CSOs.
; gWHO ASIAN CIVIL SOC(ET>‘CONFERENCE ON MACRC>t C ONOMn.AV '-■: A: A -
Conclusions and
Way Forward
W
there is wide knowledge and consensus on the value of a primary health care approach, and the
interventions, public health measures, system requirements, and cost for scaling up are known,
the world's poor still lack access to essential health services. Towards addressing this situation, participants
considered the findings of the CMH and the ongoing follow-up approaches in countries of the regions and
debated the contribution that CSOs could make towards reaching the poor with essential services.
Over the years CSOs have gained very useful experience in health in relation to poverty reduction. The
following three points are a clear justification for their official involvement in Macroeconomics and Health
work:
•
CSOs have supported national efforts in expanding the scale of primary health care, in particular by
assisting displaced populations and those living in underserved or remote areas (often the poor).
•
On a global level, CSOs greatly contributed to linking health and poverty reduction by putting critical
issues, such as debt, human and gender rights, trade, and the environment, at the centre of national
and global agendas.
•
Many CSOs deal with health not as a separate issue, but as a part of a comprehensive package of
services that also includes education, nutrition and micro-credit, for example. This holistic approach is
better geared to contribute to poverty reduction than a single-sector approach.
In the unanimous consensus statement, participants committed themselves to participate in national
Macroeconomics and Health processes and asked their governments to ensure full involvement of civil
society and NGOs. More specifically, CSOs can make the following contributions:
*
CSOs can play an important advocacy role by speaking on behalf of the poor, stressing that health care
is a basic human right, promoting equity in health care, and lobbying politicians to really commit
increased resources for health.
•
CSOs can provide many examples of innovative ways to reach the poor with services, of multisectoral
approaches, of providing quality services in difficult circumstances, and in providing relief to households.
They can document these practices and extract lessons learned, in order to facilitate replication on a
larger scale.
•
CSOs can assist governments by experimenting with alternative health financing schemes, such as
equity funds or community-based health insurance. Specifically, CSOs can look into building safety nets
for the very poor, because user fees and insurance premiums, however low, have undesirable
consequences for health care-seeking behaviour.
PAGE 1'5 w/VHO ASIAN CIVIL SO( IEfY CONFERENCE ON MACROECONOMIC. AND HEALTH
•
CSOs can be instrumental in preventing catastrophic health care costs by advocating for a universal
health insurance system, by delivery of health care themselves (both regular and emergency care), as
well as by organizing disaster preparedness and relief programmes.
•
CSOs are in a good position to identify problems, issues, and areas for Macroeconomics and Health-
related research and can also conduct research themselves, in particular operational research and
applied research.
Participants came up with several recommendations to their respective governments, as well as to their
own constituencies, related to improving engagement and collaboration in areas key to health and poverty
reduction, such as pro-poor policy development, provision and financing of services for the poor,
preventing catastrophic health care costs, and planning and conducting pro-poor research.
Participants concluded that civil society plays a critical role towards strengthening political will by building
awareness of the importance of health and of pro-poor health system reform in economic development
and poverty reduction. Governments, for their part, should facilitate the participation of civil society in
national Macroeconomics and Health mechanisms and involve them in the preparation of Health
Investment Plans. CSOs working internationally should also lobby for increased and better donor assistance
to developing countries, while urging the acceleration of debt relief and ensuring that a major share of
resources so released are used for increased spending on the health of the poor.
The Conference was an important step towards promoting the participation of the civil society and NGOs
in the country work on Macroeconomics and Health in Asia. The next challenging steps, emanating from
the consensus and from the specific recommendations of the Working Groups, will be to keep high the
interest and involvement of CSOs in the Macroeconomics and Health process, to increase collaboration at
country level to advocate for increased pro-poor investments in health, and to promote with governments
the regular participation of the civil society in the national mechanisms on Macroeconomics and Health. It
is now up to the participating CSOs and governments to translate the above conclusions and
recommendations into activities that can be implemented locally. WHO is willing to support this effort
Among immediate follow-up activities, a dedicated Conference webpage has been set up on the WHO
Macroeconomics and Health website. A wide circulation of the consensus document and this report will
be ensured and a discussion space created for information sharing among CSOs on issues and activities
going on in countries.
IWl k-ASiAN CIVIL SOCit'IY COMI LRLNCf ON ,V..a;’R OCX:.'.' ■
AN
{ Colombo Consensus
Asian Civil Society Conference on
Macroeconomics and Health
Colombo, Sri Lanka, 27=28 April 2004
Preamble
We, Asian Civil Society Organizations (CSOs)1 gathered with government representatives in Colombo, Sri
Lanka, on 27 and 28 April 2004 on the occasion of the Asian Civil Society Conference on Macroeconomics
and Health, acknowledge with appreciation the opportunity and facilitation provided by the World Health
Organization to participate and deliberate on issues concerning macroeconomics and health.
Recognizing that CSOs are major, critical and strategic stakeholders in the formulation, implementation and
monitoring of macroeconomic policies related to health, and that they help ensure good governance and
social accountability of governments by servicing and articulating citizens' demands,
Recognizing and emphasizing the right to health as a social, economic and political issue and a
fundamental human right, and that macroeconomics has a critical role in ensuring this right,
We urge that appropriate, equitable and effective macroeconomic policies and increased investments be
put in place to ensure the people's right to health,
We commit ourselves to fully participate in the national mechanisms on macroeconomics and health in
order to meet the health needs of the poor. We shall share these recommendations with other civil society
and non-for profit organizations, at all levels, and with our governments.
By consensus, the following are our conclusions and recommendations:
Theme I. How can CSOs contribute to the policy debate and decision
making?
1.
We recognize that political will is determined largely by public opinion and that the civil society plays a
major role in creating awareness and highlighting the contribution of health in economic development
and poverty reduction.
2.
CSOs should advocate for increased and more equitable investments in health, reforms in the health
systems and a better focus on the poor, vulnerable groups and women. In this context, the civil
society should bring out the existing inadequacies and inequities of the health systems before
1. From Bangladesh, Cambodia, the People's Republic of China, India, Indonesia, the Lao People s Democratic Republic, Mongolia,
Nepal, the Philippines, Sri Lanka, Thailand, Viet Nam. List of participating organizations is included in this report.
PACE '(7 tWHO ASIAN CIVIL S9CIG1Y CONFERENCE ON MACROECONOMICS AND HEAiTH
governments, donors, media and people at all levels, and thereby foster an environment for
addressing critical deficiencies of the health systems.
3.
Governments should facilitate and strengthen
the participation of CSOs in the national
macroeconomics and health mechanisms. CSOs should make a proactive effort to participate in the
preparation of investment plans, in partnership with national health and health-related ministries and
commissions, or equivalent macroeconomics and health mechanisms and planning commissions. They
are key to contribute suggestions and inputs on appropriate and evidence-based policy changes and
systems reforms to improve equity, efficiency, accountability and transparency of the health delivery
systems, particularly for the poor, and to achieve the objective of comprehensive primary health care.
4.
CSOs working in the international arena should lobby for increased donor assistance to low-income
countries for health to promote balanced and sustainable development and human welfare. They
should also create an enabling environment for a coordinated approach, harmonization of procedures
and stability of financial commitments from the donor community in respect of the health sector
development through public-civil society partnerships.
5.
CSOs should strengthen their internal networks and urge donor countries to accelerate the process of
debt relief and ensure that a major share of the resources so released are used for increasing outlays
for the health of the poor.
Theme II. How can CSOs contribute to increasing access to essential health
services for the rural and urban poor?
1.
We recognize the need for a functioning national health policy in place, based on comprehensive
primary health care, as a first priority, which entails the need for strong health systems. We also
recognize that CSOs have knowledge of the deficiencies in the functioning of health delivery systems,
and several of them have a demonstrated capacity in providing basic health services in remote areas.
2.
CSOs, with financial support from public funds, should enter in active partnership with governments to
undertake greater responsibilities in collaborating with them in providing health care and health services
at the primary and secondary level, both in rural and urban areas, more efficiently and cost effectively.
Besides, in remote and backward areas, where public health infrastructure is virtually non-functioning,
governments should provide a liberal package of incentives to motivate and strengthen the capacity of
CSOs to fill the gaps.
3.
Governments should ensure that the CSOs are provided with the required level of operational flexibility
and autonomy in the implementation of programme activities, in order for CSOs to fulfil their
commitments and achieve the performance indicators mutually agreed upon and to be able to make
contributions towards appropriate remedies.
Theme 111. How can CSOs contribute to giving relief to households that
experience catastrophic health costs?
1.
We recognize that the principal instrument for avoiding catastrophic health costs to the poor is to ensure
the efficient delivery of public health care and services at the primary and secondary level. The CSOs
can play an important role in monitoring the functioning of the public health care institutions in respect
of the services to the poor. However, there would be contingencies where the patients and their family
have to bear a major share of the burden, in the case of prolonged and expensive course of treatment.
2.
CSO should advocate with governments for the provision of universal health insurance schemes and enter
in partnership with governments to ensure the efficient delivery of public health and emergency medical
services. CSOs can complement these services by running health services and health care programmes.
3.
CSOs should monitor the functioning of health systems in respect of the quality of services for the poor
and help establish a grievance system that ensure users' feedback and good governance.
4.
CSO should contribute to prevent the occurrence of catastrophic expenses through collaboration with
governments in health education, preventive campaigns, disaster preparedness and management.
5.
Governments should set up special funds for the purpose of addressing households incurring
catastrophic expenditures and empower communities to mobilize resources to make the services
affordable to the poor, including mechanisms for reimbursement of treatment expenses from private
donations, community health financing and micro-credit schemes.
Theme IV. How can CSOs contribute to analysis and strategic planning of
macroeconomics and health issues through research?
1. We recognize that research is imperative for policy planning and programme formulation in the area of
health, and a strong tool for advocacy and monitoring the achievement of country health goals by
governments and other stakeholders. Several CSOs have participatory research capabilities to contribute
to this effort. In the context of the work of the national commissions on macroeconomics and health,
or equivalent mechanisms, CSOs can provide an important input to policy and strategic planning
through research.
2. Governments should support CSOs' contribution to increase the health research capacity of low and
middle-income countries.
PAGE i't fwi-IO ASIAN ClVll SOCIETY CONFERENCE ON MACROECONOMICS AMD HEALTH
3.
CSOs should evaluate the impact of health sector reforms on access to health, and identify reasons for
inadequate access to public health services.
4.
CSOs should organize themselves and use at best mechanisms to contribute to setting international
research agenda with a participatory and pro-poor approach, which promote transfer of knowledge and
results, assistance to remote areas, pooling of human resources and capacities, grassroots feedback
and influence on the process of resource mobilization for health.
Mindful of the challenge ahead and of the need for forceful action, we close this Conference, and look
forward to continuing this dialogue and interaction on macroeconomics and health within our countries.
jinex 1
onference Programme
WORLD HEALTH ORGANIZATION
Sustainable Development and Healthy Environments Cluster
in collaboration with the Royal Tropical Institute Amsterdam and Marga Institute Colombo
Asian Civil Society Conference on Macroeconomics and Health
27-28 April 2004 - Colombo, Sri Lanka
Day 1
Chairpersons: Mr B.S. Lamba, WHO Regional Office for South-East Asia
and Dr Soe Nyunt U, WHO Regional Office for the Western Pacific
09.00 - 09.15
Welcome by Chairpersons on behalf of WHO Regional Directors
09.15 - 09.30
Inaugural address by Hon. Nimal Siripala de Silva, Minister of Health of Sri Lanka
09.30 - 09.45
Introduction by Dr Sergio Spinaci, WHO CMH Executive Secretary
09.45 - 10.15
The CMH Report, the Macroeconomics and Health process, and civil society
Mr Rajiv Misra, Former Health Secretary, Government of India
10.15 - 11.00
Presentation of the Macroeconomics and Health approach: Overview on MH work
globally and in the WHO South-East Asian and Western Pacific regions
Dr Silvia Ferazzi, Headquarters, Dr B.S. Lamba, Regional Office for
South- East Asia, Ms Anjana Bhushan, Regional Office for the Western Pacific
11.30- 12.00
Review of NGO experiences in health and development in selected Asian countries
Ms Garance Upham, President, People's Health Movement, Geneva International
12.30 - 12.30
Health Transition and Economic Growth in Sri Lanka
Dr Godfrey Gunatilleke, Member of the National Commission for Macroeconomics
and Health, Sri Lanka
12.30 - 13.00
Open stage for discussion and raising of issues/reactions from the floor
f*AC,E 2! |WHO ASIAN CIVIL SOCIETY CONFERENCE ON MACROECONOMICS ANO HEALTH
14.00 - 18.00
Four thematic working groups:
How can CSOs contribute to the policy debate and decision-making?
How can CSOs contribute to increasing access to essential health services for the
rural and urban poor?
How can CSOs contribute to giving relief to households that experience catastrophic
health costs?
How can CSOs contribute to analysis and strategic planning of macroeconomic
and health issues through research?
Day 2
Chairpersons: Mr B.S. Lamba, WHO Regional Office for South-East Asia
and Dr Soe Nyunt U, WHO Regional Office for the Western Pacific
09.00 - 13.00
Working groups, including preparation of recommendations
14.00 - 15.00
Presentation of group work
15.30 - 17.00
Plenary discussion and consensus on recommendations
17.00
Closure
ASIAN CMl SOGHY G'NH RI N(J ON MAC RCFgG
-M<S '
/■ ••:
knnex 2
ist of Participants
WORLD HEALTH ORGANIZATION
Sustainable Development and Healthy Environments Cluster
in collaboration with the Royal Tropical Institute Amsterdam and Marga Institute Colombo
Asian Civil Society Conference on Macroeconomics and Health
27-28 April 2004 - Colombo, Sri Lanka
COUNTRY
ORGANIZATION
NAME & DESIGNATION
OF PARTICIPANT
BANGLADESH
BRAC
Mr Faruque Ahmed
Director, Health and Nutrition
Center for Policy Dialogue
Ms Fatema Yousuf
Head of the Dialogue Division
Conoshasthya Kendra
Dr Abul Qasem Chowdhury
Vice Chancellor GonoBiswabidyalay
Grameen Bank Head Office
Mr Zamal Uddin Biswas
Deputy General Manager
Save the Children-UK
Dr Selina Amin
Programme Manager, Health and
Nutrition Programme
Ministry of Health and Family Welfare
Mr Md. Jahangir
Joint Chief, Health Economics Unit
CAMBODIA
Cambodia Association for Assistance
Mr lyong Suor
to Families and Widows (CAAFW)
Director
Cambodia Family Development
Mrs Samnan Lov
Service (CFDS)
HealthNet International
Dr Fred Griffiths
Programme Manager
COUNTRY
ORGANIZATION
NAME & DESIGNATION
OF PARTICIPANT
MEDICAM
Dr Sin Somony
Executive Director
Reproductive and Child Health
Ms Sun Nasy
Alliance (RACHA)
Deputy Director
Ministry of Health
Dr Lo Veasna Kiry
Deputy-Director, Planning and Health
Information Department
PEOPLE'S REPUBLIC
China Primary Health Care
Dr Yan Xiao Zheng
OF CHINA
Foundation
Secretary-General
Health Technology Assessment &
Dr Jie Chen
Research Center, Fudan University,
Professor and Director
Schoo! of Public Health
Think Tank Research Center
Prof. Wang Ke-An
for Health Development
Director
Ministry of Health
Ms Zhu Peihui
Department of Planning and Finance
INDIA
Gujarat Institute of Development
Dr Leela Visara
Research
Director and Professor
Janani
Mr Krishnamurty Gopalakrishnan
Programme Director
Karuna Trust
Dr H. Sudarshan
President
Sanket Development Group
Ms Maheen Mirza
Programme Co-ordinator (Projects)
SEARCH (Society for Education, Action
Dr Pradeep Prabhakar Paranjpe
and Research in Community Health)
National Commission on
Ms K. Sujatha Rao
Macroeconomics and Health
Secretary-designate
COUNTRY
ORGANIZATION
NAME & DESIGNATION
OF PARTICIPANT
INDONESIA
Indonesian Heart Foundation
Dr Sutedjo
Coordinator, Research and Data
Center
Yayasan Lembaga Konsumen
Ms Sinthia Prideaka Soekarto
Indonesia
Staff Member, Research Department
Ministry of Health
Mr Teguh Budi Santosa
Staff Member, Bureau of Planning
and Budgeting
LAO PEOPLE'S
Central Lao Women's Union
DEMOCRATIC REPUBLIC
Ms Kaysamy Latvilayvong
Deputy Head of Planning Division,
Development Department
Macfarlane Burnet Institute for
Dr Niramonh Chanlivong
Medical Research and Public Health
Country Programme
Manager
Swiss Red Cross
Dr Vannaly Boupha
Ministry of Health
Dr Bouaphat Phonvisay
Ag Director of Health Insurance
Division, Planning and Budgeting
Department
MONGOLIA
Mongolian Anti-Tuberculosis
Dr Naranbat Nymadawa
Association
Chair of Executive Board
Mongolian Association of
Dr Bunijav Orgil
Family Doctors
President
Mongolian Public Health Association
Dr Yondon Dungu
President
Mongolian Red Cross Society
Dr Zambalgarav Jadamba
Under Secretary General
PAGE;'2-5 J-W-IO ASIAN CIVII SOCIETY CONFERENCE ON MACROECONOMICS ANO HEALTH
COUNTRY
ORGANIZATION
NAME & DESIGNATION
OF PARTICIPANT
Mongo! Vision
Dr L Tumurbaatar
Executive Director
Ministry of Health
Mr D. Chimeddagva
Director for Strategic Planning
NEPAL
Family Planning Association of Nepal
Mr Hari Khanal
Ag. Director General
Nepal Health Economics Association
Dr Badri Raj Pande
President
Nepal Red Cross
Dr Vijay Kumar Singh
Member Central Executive Committee
New ERA
Dr Bal Gopal Baidya
Senior Research Associate
United Mission Nepal (UMN)
Dr Maureen Dariang
Women and Children Health
Technical Advisory Team
Ministry of Health
Dr Mahabir Krishna Malia
Chief Specialist, Policy, Planning
& Internationa! Cooperation Division
Ministry of Health
Dr Rita Thapa
Senior Health Policy Adviser
PHILIPPINES
Gerry Roxas Foundation
Mr Henry Pantaleon Vicente
Aguirre Lopez
Manager, GRF Center for Local
Governance
Health Alternatives for Total Human
Dr Maria Eufemia C. Yap
Development Institute
Member, Board of Directors
Maharlika Charity Foundation
Dr Michelle Marie Aportadera
Plastic Surgeon
COUNTRY
ORGANIZATION
NAME & DESIGNATION
OF PARTICIPANT
Philippine Rural Reconstruction
Dr Glenn V. Paraso
Movement
Social Development Specialist,
Health & Family Planning
Department of Health
Dr Liezl Lagrada
Medical Officer VII, Health Policy
Development and Planning Bureau
SRI LANKA
Asian Community Health Action
Mr Niranjan Udumalagala
Network
Community Development Services
Ms Nilani Wijeysinghe
Family Planning Association
Mr PJ. Karunaratne
Deputy Director,
Youth Reproductive Health
Health Action International-Asia Pacific
Dr K.Balasubramaniam
Advisor and Co-ordinator
Helpage Sri Lanka
Mr N.W.E. Wijewantha
Executive Director
Management Sciences for
Mr Vimal Dias
Health (MSH)
Marga Institute (co-organizer)
Dr Godfrey Gunatilleke,
Member, National Commission on
Macroeconomics and Health
Marga Institute (co-organizer)
Mrs Myrtle Perera
Senior Research Fellow
Marga Institute (co-organizer)
Ms Dineshini Jayawardana
Sarvodaya Shramadana Movement
Dr Vinya S. Ariyaratne
Executive Director
PAGE 27
WHO ASIAN CIVIL SOCIETY CONFERENCE ON MACROECONOMICS AND HEALTH
COUNTRY
ORGANIZATION
NAME & DESIGNATION
OF PARTICIPANT
Ministry of Health, Nutrition
Dr S. M. Samarage
and Welfare
Director, Organization Development
Management Development and
Planning Unit
THAILAND
Anti-Tuberculosis Association
Dr Nadda Sriyabhaya
of Thailand
Executive President
Thai Health Promotion Foundation
Dr Viroj Na-ranong
Thai Health Promotion Foundation
Dr Chartri Charoensiri
Ministry of Public Health
Dr Orasa Kovindha
Chief, Macrohealth Policy Section,
Health Policy Group, Bureau of Policy
and Strategy
Ministry of Public Health
Dr Luecha Wanaratna
Chief of Technical Office
VIET NAM
Institute for Social Development
Ms Nguyen Thi Van Anh
Studies
Head of Soc. Dev. Section
Research and Training Centre for
Dr Tran Tuan
Community Development (RTCCD)
Director
Viet Nam Family Planning Association
Prof. Pham Song
(VINAFPA)
President
Viet Nam Women Union
Ms Chu Nhi Ha
Department of Family and Society
Communist Party of Viet Nam
Prof. Pham Manh Hung
Vice Chairman,Committee for
Education and Sciences
PAGE
BWHO ASIAN CIVIl SOCIE fY COWER! :NCt
COUNTRY
:N MA
ORGANIZATION
NAME & DESIGNATION
OF PARTICIPANT
OTHER
People's Health Movement
Ms Garance (Nance) Upham
ORGANIZATIONS
Geneva International
President
Royal Tropical Institute Amsterdam
Ms Maria Paalman
(co-organizer)
Senior Health Adviser
World Health Organization
Dr Palitha Abeykoon
WHO Office - Sri Lanka
Dr Lin Aung
WHO Health Planner - Nepal
Ms Anjana Bhushan
Technical Officer Poverty and
Gender - Western Pacific Regional
Office
Dr Silvia Ferazzi
Partnerships Advisor
Coordination of Macroeconomics and
Health Support Unit
Mr B.S. Lamba
Sustainable Health Policy Officer
Southeast Asia Regional Office
Mr Rajiv Misra
WHO Consultant
Dr Soe Nyunt U
Director, Health Sector Development
Western Pacific Regional Office
PAGE 29
iWI IO ASIAN CIVIL SOCIETY CON!T-RLNCE ON MACROECONOMICS AND
COUNTRY
ORGANIZATION
'L AL ■ n
NAME & DESIGNATION
OF PARTICIPANT
Dr Sergio Spinaci
Executive Secretary
Coordination of Macroeconomics
and Health Support Unit - Geneva
Sustainable Development and
Healthy Environments Cluster
Dr Kan Tun
WHO Representative - Sri Lanka
‘•VH'D AS
StXjl.-lY CONFERENCE ON MACROECONOMICS AND HFAI.TI t
Conference materials
All materials listed below are available on http://www.who.int/macrohealth
1.
Macroeconomics and Health: Investing in Health for Economic Development. Report of the
Commission on Macroeconomics and Health. WHO Geneva, 2001.
2.
Investing in Health: A Summary of the Findings of the Commission on Macroeconomics and Health.
WHO Geneva, 2003.
3.
The Commission on Macroeconomics and Health: Working Group Papers and Reports on CD-Rom.
Royal Tropical Institute Amsterdam, 2003.
4.
Declaration, The 2nd Consultation on Macroeconomics and Health: Increasing Investments in Health
Outcomes for the Poor. WHO Geneva, 28-30 October 2003.
5.
Macroeconomics and Health: an Update. WHO Geneva, April 2004
6.
Status reports on Macroeconomics and Health. WHO SEARO & WPRO, April 2004. (Profiles from
12 countries)
7.
Information on Health Activities by CSOs participating in the Asian Civil Society Conference on
Macroeconomics and Health. Amsterdam/Colombo, April 2004.
8.
Rajiv Misra. The CMH Process and Civil Society, 2004.
9.
Nance Upham. Making Health Care Work for the Poor: a Review of NGO Experience in Selected
Countries, 2004.
10.
People's Charter for Health. As amended and approved at the People's Health Assembly. Savar
Bangladesh, December 2000.
11.
The Mumbai Declaration of the People's Health Movement. Mumbai India, 14-15 January 2004.
12.
Potential for Government/NGO Partnership in Health Care. WHO Sri Lanka, 2003.
13.
People's Health Movement Response to Commission on Macro-economics and Health, April 2004.
14.
Sergio Spinaci. Introductory Remarks to the Asian Civil Society Conference on Macroeconomics and
Health. Colombo, 27 April 2004.
15.
Rajiv Misra. The CMH Process and Civil Society. Powerpoint presentation. Colombo, 27 april 2004.
16.
Silvia Ferazzi. The Macroeconomics and Health Country Follow-up and the Civil Society. Powerpoint
presentation. Colombo, 27 April 2004.
17.
D. Bayarsaikhan. Anjana Bhushan. CMH in WPRO: an Overview. Powerpoint presentation. Colombo,
27 April 2004.
18.
B.S. Lamba. Macroeconomics and Health in the South-East Asia Region. Powerpoint presentation.
Colombo, 27 April 2004.
19.
Nance Upham. NGOs Contributions to Present and future Health Systems for the Poor. Powerpoint
presentation. Colombo, 27 April 2004.
20.
Dr. Godfrey Gunatilleke. The Health Transition and Economic Growth in Sri Lanka: Lessons of the Past
and Emerging Issues. Powerpoint presentation. Colombo, April 2004.
Participating Organizations
Bangladesh
BRAC
Center for Policy Dialogue
Gonoshasthya Kendra
Grameen Bank
Save the Children-UK
Cambodia
Cambodia Association for Assistance to Families
and Widows (CAAFW)
Cambodia Family Development Service (CFDS)
HealthNet International
MEDICAM
Reproductive and Child Health Alliance (RACHA)
Philippines
Gerry Roxas Foundation
Health Alternatives for Total Human Development
Institute
Maharlika Charity Foundation
Philippine Rural Reconstruction Movement
Sri Lanka
Asian Community Health Action Network
Community Development Services
Family Planning Association
Health Action International-Asia Pacific
Helpage Sri Lanka
Marga Institute (Conference organizer)
Sarvodaya Shramadana Movement
People's Republic of China
China Primary Health Care Foundation
Health Technology Assessment & Research Center,
Fudan University, School of Public Health
Think Tank Research Center for Health
Development
India
Gujarat Institute of Development Research
Janani
Karuna Trust
Sanket Development Group
SEARCH (Society for Education, Action and
Research in Community Health)
Indonesia
Indonesian Heart Foundation
Yayasan Lembaga Konsumen Indonesia
Lao People's Democratic Republic
Thailand
Anti-Tuberculosis Association of Thailand
Thai Health Promotion Foundation
Viet Nam
Institute for Social Development Studies
Research and Training Centre for Community
Development (RTCCD)
Viet Nam Family Planning Association (VINAFPA)
Viet Nam Women Union
Other Organizations
People's Health Movement Geneva International
Royal Tropical Institute Amsterdam (Conference
organizer)
Government Representatives
Mongol Vision
Bangladesh
Cambodia
People's Republic of China
India
Indonesia
Lao People's Democratic Republic
Mongolia
Nepal
Philippines
Sri Lanka
Thailand
Viet Nam
Nepal
World Health Organization
Central Lao Women's Union
Macfarlane Burnet Institute for Medical Research
and Public Health
Swiss Red Cross
Mongolia
Mongolian Anti-Tuberculosis Association
Mongolian Association of Family Doctors
Mongolian Public Health Association
Mongolian Red Cross Society
Family Planning Association of Nepal
Nepal Health Economics Association
Nepal Red Cross
New ERA
United Mission Nepal (UMN)
INVESTING IN HEALTH
A Summary of the Findings
of the Commission on Macroeconomics
and Health
WORLD HEALTH ORGANIZATION
WHO Library Cataloguing-in-Publication Data
Investing in Health: A summary of the findings of the Commission on Macroeconomics and Health.
I Financing, Health 2.Investment in Health 3. Major communicable diseases 4.Life expectancy 5.Economic develop'.
6.Poverty Reduction /.Delivery of health care 8.Developing countries 9.Developed countries
i.WHO Commission on Macroeconomics and Health
ISBN 92 4 1 5624 1 2
(NLM classification: WA .
© World Health Organization 2003
All rights reserved. Publications of the World Health Organization can be obtained from Marketing and
Dissemination, World Health Organization, 20 Avenue Appia, 1211 Geneva 27, Switzerland
[tel: +41 22 791 2476; fax: +41 22 791 4857; email: bookorders@who.int). Requests for permission to
reproduce or translate WHO publications - whether for sale or for noncommercial distribution - should be
addressed to Publications, al the above address (fax: +41 22 791 4806; email: permissions@who.int).
The designations employed and the presentation of the material in this publication do not imply the expression of ar.opinion whatsoever on the part of the World Health Organization concerning the legal status of any country,
territory, city or area or of its authorities, or concerning the delimitation of its frontiers or boundaries. Dotted lines on
maps represent approximate border lines for which there may not yet be full agreement.
The mention of specific companies or of certain manufacturers' products does not imply that they are endorsed or
recommended by the World Health Organization in preference to others of a similar nature that are not mentioned.
Errors and omissions excepted, the names of proprietary products are distinguished by initial capital letters.
The World Health Organization does not warrant that the information contained in this publication is complete and
correct and shall not be liable for any damages incurred as a result of its use.
Printed in India by WHO/SEARO
INVESTING IN HEALTH
A Summary of the Findings
of the Commission on Macroeconomics
and Health
WORLD HEALTH ORGANIZATION
' CMH SUPPORT UNIT
INVESTING IN HEALTH
A Summary of the Findings of the Commission on Macroeconomics and Health
Page
Contents
List of Commissioners...................................................................................................................... 5
Foreword ......................................................................................................................................... 7
The Commission on Macroeconomics and Health ..................................................................... 8
Poverty and ill health are closely linked .................................................................................... 10
Making a difference: Preventing eight million deaths a year by 2010...................................12
...and generating at least US$ 360 billion annually by 2015-2020 ................................... 14
The extra funding required is unaffordable for poor countries ................................................16
Increased investment in health is urgently needed ................................................................... 18
The supply of global public goods in poor countries .............................................................. 20
Access to essential medicines ..................................................................................................... 22
New ways of investing in health for development ................................................................... 24
Initiating macroeconomics and health work at country level .................................................. 26
How countries are moving forward ............................................................................................ 28
The production of this booklet "Investing in Health: A Summary of the Findings of the
Commission on Macroeconomics and Health" was made possible with funding from the Bill
and Melinda Gates Foundation.
3
List of Commissioners
Jeffrey D. Sachs, Chair
Isher Judge Ahluwalia: Chair of Working Group 4: Health and the International Economy
K.Y. Amoako: Commissioner
Eduardo Aninat: Commissioner
Daniel Cohen: Commissioner, Co-Chair of Working Group 1: Health, Economic Growth and Poverty Reduction
Zephirin Diabre: Commissioner, Co-Chair of Working Group 6: International Development Assistance and Health
Eduardo Doryan: Commissioner
Richard G.A. Feachem: Commissioner, Co-Chair of Working Group 2: Global Public Goods for Health
Robert W. Fogel: Commissioner
Dean Jamison: Commissioner, Member of Working Group 3: Mobilization of Domestic Resources for Health
Takatoshi Kato: Commissioner
Nora Lustig: Commissioner, Member of Working Group 1: Health, Economic Growth and Poverty Reduction
Anne Mills: Commissioner, Co-Chair of Working Group 5: Improving Health Outcomes of the Poor
Thorvald Moe: Commissioner
Manmohan Singh: Commissioner
Supachai Panitchpakdi: Commissioner, Member of Working Group 4: Health and the International Economy
Laura Tyson: Commissioner
Harold Varmus: Commissioner
5
Foreword
A year and a half year ago, Professor Jeffrey Sachs presented me with the Report of the Commission on Macroeconomics
and Health. The Report shows, quite simply, how disease is a drain on societies, and how investments in health can be a
concrete input to economic development. It goes further, stating that improving people's health may be one of the most
important determinants of development in low-income countries.
The Commission's Report argues for a comprehensive, global approach to health with concrete goals and specific time
frames. It wants to see the forces of globalization harnessed to reduce suffering and to promote well-being. It is the first
detailed costing of the resources needed to reach some of the key goals set in the Millennium Declaration: an annual
investment of $66 billion by the year 2007. Much of this will come from the developing countries' own resources. But
about half must be contributed by the rich countries of the world - in the form of effective, fast and results-oriented
development assistance.
The proposed investments fund well-tried interventions that are known to work. Their impact can be measured in terms of
reducing the disease burden and improving health system performance. The emphasis throughout is on results; on
investing money where it makes a difference. Three diseases - HIV/AIDS, tuberculosis and malaria - are overwhelmingly
important. Maternal and child conditions, reproductive ill-health and the health consequences of tobacco, are also global
health priorities. Any serious attempt to stimulate global economic and social development, and so to promote human
security, must successfully address the burdens caused by this range of diseases and conditions.
Since the launch of the Commission's Report, CMH work has started to bear fruit. Governments have taken action, trying
to mobilize funds and develop efficient mechanisms to move funds rapidly to where they are needed. They are
increasingly using global standards to report results. More than a dozen countries have set up national commissions or in
other ways begun work to assess how to integrate updated health needs into their national development plans. It is hoped
that this summary of the CMH Report will act as a spur for yet more work in countries to examine the findings of the
Report and its implications for the health and economic challenges that lie ahead.
Dr Gro Harlem Brundtland,
Director-General,
World Health Organization
7
The Commission on Macroeconomics
and Health
The Commission on
To arrive at its conclusions, the Commission planned its research and analysis within six working groups which
in turn engaged a worldwide network of experts in public health, economics, and finance.
Macroeconomics and Health
was launched by
WHO Director-General,
Dr Gro Harlem Brundtland in
2000 and was chaired by
Professor Jeffrey Sachs.
Working Group 1: Health, Economic Growth, and Poverty Reduction addressed the impact of
health investments on poverty reduction and economic growth. Co-Chairs: Sir George Alleyne and Professor
Daniel Cohen.
Working Group 2: Global Public Goods for Health examined multicountry policies, programmes and
initiatives having a positive impact on health that extends beyond the borders of any specific country.
Co-Chairs: Professors Richard Feachem and Jeffrey Sachs.
Working Group 3: Mobilisation of Domestic Resources for Health assessed the economic
consequences of alternative approaches to resource mobilisation for health systems and interventions from
The Commission's
mandate was to
examine the links
between health and
macroeconomic issues.
domestic resources. Co-Chairs: Professor Alain Tait and Professor Kwesi Botchwey.
Working Group 4: Health and the International Economy examined trade in health services,
commodities and insurance; patents and trade-related intellectual property rights; international movements of
risk factors; migration of health workers; health finance policies; other ways that trade may be affecting the
health sector. Chair: Dr Isher Judge Ahluwalia.
Working Group 5: Improving Health Outcomes of the Poor addressed the technical options,
constraints and costs for mounting a major global effort to improve the health of the poor dramatically by
2015. Co-Chairs: Dr Prahbat Jha and Professor Anne Mills.
Working Group 6: International Development Assistance and Health reviewed health implications
of development assistance policies. Co-Chairs: Mr Zephirin Diabre and Mr Christopher Lovelace and
Ms Carin Norberg.
8
The Ten Recommendations
The recommendations of the Report are summarised into an agenda for action, providing the conceptual framework for review and open debate. Each country is
invited to assess and analyse the CMH recommendations and to adapt them to their own socio-economic situation.
The main recommendations of the CMH Report are:
1.
Developing countries should begin to map out a path to universal access for essential health services based on epidemiological evidence and the health
priorities of the poor. They should also aim to raise domestic budgetary spending on health by an additional 1% of their GNP by 2007, rising to 2% in 2015,
and use resources more efficiently.
2.
Developing countries could establish a National Commission on Macroeconomics and Health or similar mechanism to help identify health priorities and
the financing mechanisms, consistent with the national macroeconomic framework, to reach the poor with cost-effective health interventions.
3.
Donor countries would begin to mobilize annual financial commitments to reach the international recommended standard of 0.7% of OECD countries' GNP,
4.
The WHO and the World Bank would be charged with coordinating the massive, multi-year scaling up of donor assistance for health and with monitoring
5.
The WTO member governments should ensure adequate safeguards for developing countries, in particular the right of countries that do not produce the relevant
in order to help finance the scaling up of essential interventions and increased investment in health research and development and other "global public goods".
donor commitments and funding.
pharmaceutical products to invoke compulsory licensing for imports from third-country generic suppliers.
6.
The International Community and agencies such as WHO and the World Bank, should strengthen their operations. The Global Fund to Fight AIDS, TB,
and malaria (GFATM) should have adequate funding to support the process of scaling up actions against HIV/AIDS, TB and malaria. A Global Health
Research Fund (GHRF) is proposed.
7.
The supply of global public goods should be bolstered through additional financing of agencies such as WHO and the World Bank.
8.
Private-sector incentives for drug development to combat diseases of the poor must be supported. The GFATM and purchasing entities should establish
pre-commitments to purchase new targeted products (such as vaccines for HIV/AIDS, malaria, and TB) as a market-based incentive.
9.
The international pharmaceutical industry, in cooperation with WHO and low-income countries, should ensure that people in low-income countries have access to
essential medicines. This should be achieved through commitments to provide essential medicines at the lowest viable commercial price in poor countries and to
license the production of essential medicines to generic producers.
10.
The IMF and the World Bank should work with recipient countries to incorporate the scaling up of health and other poverty reduction programmes into a viable
macroeconomics framework.
CMH Report p 18-19 and p 108-111
9
Poverty and ill-health are closely
linked
Ill health undermines
economic development and
The links between ill health and poverty are now well known. Poor and malnourished people are more likely to
become sick and are at higher risk of dying from their illness than are better off and healthier individuals. Ill
health also contributes to poverty. People who become ill are more likely to fall into poverty and to remain
there than are healthier individuals because debilitating illness prevents adults from earning a living. Illness also
efforts to reduce poverty.
Investments in health are essential
for economic growth and should
be a key component of national
development strategies. The
keeps children away from school, decreasing their chances of a productive adulthood.
Today the epidemics of HIV/AIDS, malaria, and TB are worsening, and developing countries are experiencing
a rapid erosion of the social and economic gains of the past 20 years. Childhood diseases, compounded by
malnutrition, are responsible for millions of preventable child deaths and there has been little progress in
reducing maternal and perinatal mortality.
In 2000, the Commission on Macroeconomics and Health set out to examine the links between health and
poverty and to demonstrate that health investment can accelerate economic growth. The Commission focused its
greatest achievements can be
work on the world's poorest people in the poorest countries. It demonstrated that impoverished people share a
disproportionate burden of avoidable deaths and suffering; the poor are more susceptible to diseases because
made by focusing on the health
of the poor and on the least
developed countries.
of malnutrition, inadequate sanitation, and lack of clean water, and are less likely to have access to medical
care, even when it is urgently needed. Serious illness can impoverish families for many years as they lose income
and sell their assets to meet the cost of treatment and other debts. The Report also signalled that existing, life
saving interventions, including preventive measures and access to essential medicines, do not reach the poor. The
Commission states that over the coming decade the world can make sizeable gains against the diseases which
have a disproportionate impact on the health and welfare of the poor by investing more money in essential health
services and by strengthening health systems.
Until recently, economic growth was seen as a precondition for real improvements in health But the
Commission turned this notion around and provided evidence that improvements in health are important for
economic growth. It confirmed that in countries where people have poor health and the level of education is
low it is more difficult to achieve sustainable economic growth. High prevelance of diseases such as HIV/AIDS
exnamlah?ahmaa|SaSOC
7
In some areas, for
example, high malaria prevalence is associated with reduced economic growth of at least 1% a year.
10
Health is a cornerstone of economic growth and social
development. The Commission showed that increased
Health-related Millennium Development Goals
life expectancy and low infant mortality are linked to
economic growth. Healthy people are more productive;
At the Millennium Summit in September 2000 the UN reaffirmed its commitment to working toward a world
healthy infants and children can develop better and
in which sustaining development and eliminating poverty would have the highest priority.
become productive adults. And a healthy population
can contribute to a country's economic growth. The
Commission says that increased investment in health
would translate into hundreds of billions of dollars per
Goal 1: Eradicate extreme poverty and hunger - Target 1: reduce the proportion of
people living on less than US$ 1 a day to half the 1990 level by 2015. Target 2: reduce the proportion
of people who suffer from hunger by half the 1 990 level by 2015.
year of additional income which could be used to
improve living conditions and social infrastructure in
Goal 2: Achieve universal primary education - Target 3: ensure that, by 2015, children
poorer countries.
everywhere, boys and girls alike, will be able to complete a full course of primary schooling.
Improving people's health and life expectancy is an
disparity in primary and secondary education, preferably by 2005, and to all levels of education no later
Goal 3: Promote gender equality and empower women - Target 4: eliminate gender
end in itself and one of the fundamental goals of
economic growth. It is also of direct relevance to the
achievement of the MILLENNIUM DEVELOPMENT
than 2015.
Goal 4: Reduce child mortality - Target 5: reduce by two-thirds, between 1990 and 2015, the
GOALS (MDGs), set by world leaders in 2000 for
under-five mortality rate.
reducing poverty, hunger, disease, illiteracy,
Goal 5: Improve maternal health - Target 6: reduce by three-quarters, between 1990 and
environmental degradation, and discrimination against
2015, the maternal mortality ratio.
women by 2015.
Goal 6: Combat HIV/AIDS, malaria and other diseases - Target 7: have halted by
2015 and begun to reverse the spread of HIV/AIDS. Target 8: have halted by 2015 and begun to
reverse the incidence of malaria and other major diseases.
CMH action in countries
During the biennium 2001-2003, the CMH Report
was introduced in many countries. The CMH
Goal 7: Ensure environmental sustainability - Target 9: integrate the principles of
sustainable development into country policies and programmes and reverse the losses of environmental
resources.
process and follow-up initiatives have been
Goal 8. Build a global partnership for development: to help poor countries eradicate
providing opportunities to national groups - from a
poverty, hunger, and premature death will require a new global partnership for development based on
range of ministries to academic groups, civil
stronger policies and good governance. Target 17: provide access to affordable, essential drugs in
society, NGOs, and the private sector - to debate
developing countries, in cooperation with pharmaceutical companies.
their vision for health and plans for incorporating
the promotion of better health into national
development strategies.
1 1
Making a difference: Preventing
eight million deaths a year by 2010...
A few diseases and
Only a handful of diseases and conditions are responsible for most for most of the world's health deficit:
HIV/AIDS; malaria; TB; diseases that kill mothers and their infants; tobacco-related illness; and childhood
conditions account for most of the
avoidable deaths in
low- and middle-income
countries. Efforts to scale up
access to existing
interventions against
infectious diseases, to address
diseases such as pneumonia, diarrhoea, measles, and other vaccine-preventable diseases — all of which are
aggravated by malnutrition. Together, they account for around 14 million deaths a year in people under 60
and for 16 million deaths a year among all age groups. Most of these deaths occur in developing countries,
which spend the least on health care, and where the poorest people are worst affected.
CMH Report p 104-105, Working Group 5 Report p 161-170
However, the high death toll from major diseases (often linked to malnutrition) is only part of the story. The
scale of individual suffering and pain inflicted by illness is tremendous. At any one time, hundreds of millions of
people — mainly in developing countries — are sick. As a result, children are kept away from school and
adults prevented from working or caring for their children.
Most deaths and disability can be prevented. Effective health interventions already exist to either prevent or
cure the diseases which take the greatest toll on human lives. But the fact remains that these interventions do
reproductive and child health,
and to confront malnutrition will
prevent millions of deaths in poor
countries and considerably
improve health.
not reach the billions of the world's poor. The Commission argues that by taking essential interventions to scale
and making them available worldwide, eight million lives could be saved each year by 2010. A scaled-up
response would alleviate countless suffering, dramatically reduce illness and deaths, and provide a concrete
and measurable way of reducing poverty and ensuring economic growth and security.
CMH Report p 31-53, Working Group 5 Report p 20-54 and p 55-76
A scaled-up response will require not only a major increase in funding for health but also strong commitment by
governments to specific actions for reducing health inequality and inequity, together with broad support from
the international community and partners from all levels of society.
CMH Report p 91-101, Working Group 3 Report p 57-100, Working Group 6 Report p 35-43
12
1. In 1998 there were:
• 1.6 million deaths from measles, tetanus, and
diphtheria, all vaccine-preventable diseases
Under-60 deaths from infectious diseases and nutritional disorders, respiratory infections, and maternal
and perinatal conditions.
• 500 000 deaths among women during pregnancy
and childbirth, most of them in developing countries
• One million deaths from malaria and 2.4 billion
people living at risk of malaria
• 1.5 million deaths from TB and eight million new
cases of the disease.
2. In 1999, 5.3 million people died of acute lower
respiratory infections and diarrhoeal diseases, in
low- and middle-income countries, most of them
children under five.
3. In 2002 over 40 million people had died from
HIV/AIDS-relafed illnesses and 42 million were living
with HIV/AIDS.
4. Unless smoking patterns change, about 500 million
people are expected to die from tobacco-related
diseases over the next 50 years.y
WHO/WHR 2000 ond CMH Report 2001 p 103-105, Working Group 5
Scaling up interventions will save 8 million lives a
year by 2010
Report p 55-76
Avoidable deaths (all ages) and suffering A
from infectious diseases, maternal and
perinatal conditions, childhood diseases,
and nutritional deficiencies.
^Examples of essential interventions to combat major infectious diseases and malnutrition ]
TB
DOTS: Directly
Observed
Treatment
Short-course
• Treatment of
uncomplicated/
complicated malaria
• Safe blood transfusion for HIV/AIDS
• Intermittent treatment
for pregnant women
• Palliative care
• Indoor residual
spraying
• Epidemic planning
and response
• Social marketing of
insecticide-treated
bednets.
CHILDHOOD DISEASES
HIV/AIDS
MALARIA
• Prevention and clinical management of opportunistic
illnesses
• Family planning
• Cessation advice
• Emergency obstetric care
• Immunization
• Skilled birth attendance
• Specific immunization campaigns
• Antenatal and postnatal
care.
• Pharmacological
therapies to
prevent smoking.
• Peer education for vulnerable groups
• Policies to reduce indoor air pollution
• Needle exchange programmes for injecting drug users
• Food fortification with iodine, iron,
folate, zinc.
• School and youth programmes for HIV/AIDS.
13
SMOKING \
• Integrated Management of Childhood
Illness (IAACI)
• Antiretrovirals and breast-milk substitute for preventing • Treatment of severe anaemia
mofher-lo child-transmission (MTCT)
• IMCI for home management of fever
• HAART: Highly-Active Antiretroviral Therapy
• Micronutrients and de-worming
• Social marketing of condoms
MATERNAL/PERINATAL
C M H Report p 66-67, and Working Group 5
Report p 19-54
r
•••and generating at least US$ 360
billion annually by 2015-2020
330 million DALYs* worth around
The eight million lives that would be saved each year represent a far larger number of cumulative years of life
saved (so called Disability Adjusted Life Years or DALYs) as well as a higher quality of life for those involved.
US$ 180 billion in direct
One DALY is therefore a health gap measure, equating to one year of healthy life lost. The CMH Report argues
that 330 million DALYs would be saved for eight million deaths prevented each year — thereby accelerating
economic benefits, would be
economic growth and breaking the poverty cycle.
saved for every eight million
The Commission estimates that 330 million DALYs will be worth around US$ 1 80 billion per year in direct
deaths prevented each year and
another US$ 1 80 billion from
indirect economic benefits
economic savings by 2015; the world's poorest people would live longer, healthier lives and, as a result, would
be able to earn more. But the actual economic returns could be much higher than this if the benefits of improved
health help to spur economic growth.
Improvements in life expectancy and reduced disease burden would tend to stimulate growth through: lower
fertility rates, higher investments in human capital, increased household savings, increased foreign investment,
resulting from increased
and greater social and macroeconomic stability. The correlation between better health and higher economic
growth is derived from macroeconomic analyses suggesting that another US$ 1 80 billion per year by 2020 will
investment in health.
be generated as a consequence of indirect economic benefits. Taking into account the valuation of lives saved
and faster economic growth, the Commission estimates that the economic benefits would be around US$ 360
billion per year during 2015-2020, and possibly much more.
CMH Report p 12-13, p 23-24 and p 103-108
To achieve these huge gains in health and economic development, the Commission calls for a major increase in
the resources allocated to the health sector over the next few years. About half of the total increase would come
from international development assistance, with developing countries providing the other half by reprioritizing their
budgets. A few middle-income countries will also require assistance to meet the high costs of HIV/AIDS control.
*The term Disability Adjusted Life Years is a measure of both the
number of years of healthy life lost to premature death and the
years lived with varying degrees of disability. One DALY represents
one year of healthy life lost.
The total investment in health should focus on scaling up the specific interventions needed to control the major
life-threatening and disabling diseases and to strengthen health delivery systems to ensure they can reach all
people, particularly the poor. Interventions would be scaled up to target diseases and conditions including:
14
HIV/AIDS, malaria; TB; measles, tetanus, diphtheria, and other vaccine-preventable
The Cost of Essential Interventions
diseases, acute respiratory infections; diarrhoeal diseases; maternal and perinatal
conditions; malnutrition; and tobacco-related diseases.
The CMH Report estimates that the minimum expenditure for scaling up a
CMH Report p 35-38, and Working Group 5 Report p 19-76
set of essential interventions is on average US$ 34 (current USS) per
In addition, investment is needed in reproductive health, including family planning
person/year, including those needed to fight the AIDS pandemic. Among
and access to contraceptives, to complement investments in disease prevention and
the 48 least-developed countries, average total spending for health is about
control. The combination of disease control and reproductive health is likely to
US$ 11 per person/year of which US$ 6 comes from budgetary resources
translate into reduced fertility, greater investment in the health and education of each
(including donor assistance) and the rest from out-of-pocket expenditures
(1997). Current levels of donor support are very low, estimated at US$
child, and reduced population growth.
2.29 per person in the least developed countries in 1997-1999.
■ Donor funds
40-
Total
Spending
on Health
(per person,
1997, USS)
6
11
2.29
1,473
Other Low-Income
Countries
13
23
0.94
1,666
Lower-Middle- Income
51
93
0.61
1,300
Least-Developed
$34
Donor
Public
Spending
on Health
(per person,
1997,
USS)
Donor
Assistance
for Health
(per person,
average
annual
1997-1999)
□ Domestic funds
30-
Assistance
for Health
Annual
Average
(USS millions
1997-1999)
20-
Countries
0
Developing Countries
Upper-Middle- Income
125
241
1.08
610
1,356
1,907
0.00
2
0.85
5,052
Developing Countries
High-Income
Countries
All Countries
15
1997: Total spending on health
2007: Donors and governments
per person in least-developed
countries (of the $11, $6 are from
budget and the rest from out-ofpocket. The sum includes donor
assistance).
in low-income countries must
mobilize additional funds.
CMH Report p 11, p 56-57, and Working Group 5 Report p 166-168
CMH Report p 56 ,and Working Group 6 Report p 9-23
Domestic Spending and Donor
Assistance on Health (1997-1999)
The extra funding required is
unaffordable for poor countries
Current levels of investment by
A major increase in financial resources for health is needed to scale up health interventions and strengthen
developing countries are far less
low level of health spending in poor countries — due mainly to lack of resources and political commitment
than needed to address the
health challenges they face and
to scale up health interventions
and essential services. The
Commission envisages that lowincome countries would aim to
use their resources more efficiently
and increase budgetary spending
health delivery systems to ensure that these interventions are accessible, particularly for the poor. But the current
is
insufficient to address the health challenges they face. The Commission argues that most countries can mobilize
extra domestic resources for health and make cost-effective use of these resources. It says that public spending
should be targeted to the poor and used to support community financing schemes that protect households
against catastrophic health expenditures — pointing out that in some areas, up to 40 A of household revenues
may be spent on health care.
The Commission estimated the costs involved in expanding health coverage in sub-Saharan African countries
and all low-income developing countries. The Report states that national governments should be. at the centre of
efforts to raise domestic budgetary spending on health to US$ 35 billion per year for 2007 (an additional 1%
of their GNR) and to US$ 63 billion per year by 2015 (an additional 2% of GNP), though for some countries
a smaller amount would be sufficient to expand coverage.
CMH Report p 57-63 and Working Group 3 Report p 57-74
on health by an additional 1% of
These efforts will also require concerted actions to remove structural constraints and strengthen the capacity of
GNP by 2007 and 2% by 2015.
equity; and to work in partnership with other sectors. Ensuring government commitment, transparency, effective
However, it recognizes that even
these measures will be insufficient
national health systems: to deliver essential interventions; to set priorities in response to health needs; to ensure
governance, donor partnerships, and, above all, good stewardship in health and other sectors are key
recommendations of the Commission. Strengthening the delivery of essential services would require a properly
structured health delivery system that can reach the poor. The Commission states that creating a close-to-
client (CTC) system at health centres, health posts or through outreach facilities is one of the highest priorities
to generate the level of funding
needed in many poor countries
— especially those affected by
for scaling up essential interventions. The CTC system would operate locally, supported by nationwide
programmes for major infectious diseases and could involve a mix of state and non-state health services
providers with financing guaranteed by the state.
CMH Report p 64-73, and Working Group 5 Report p 50-54
the HIV/AIDS epidemic.
16
In addition, efforts will be needed to increase
community involvement and people's control of their
own health — through ensuring that people are
aware of and seek access to readily available health
Mobilising greater resources for health in
low-income countries
interventions and services. Donors and external
partners need to work closely with governments to
empower, assist, and enhance their capacity to lead
As a basic strategy for health-finance reform the Commission recommends six steps:
1 increase mobilization of general tax revenues for health — in the order of 1% of GNP by 2007 and
on macroeconomic and health priorities.
2% of GNP by 2015.
2.
To achieve these goals, poor countries will need to
increase domestic resources available for health if’
they are to convince donors of their commitment to
face the challenge. But even with more efficient
allocation of resources and greater resource
mobilization, the levels of funding necessary to cover
Increase donor support to finance the provision of public goods. Ensure access for the poor to essential
services.
3.
Convert out-of-pocket expenditures into prepayment schemes — including community finance programmes.
4.
A deepening of the HIPC initiative, in country coverage and extent of debt relief.
5.
Address inefficiencies in the way government resources are allocated and used.
6.
Reallocate public outlays from unproductive expenditures to social sector programmes focused on the poor.
CMH Report p 61 -62
essential services are far beyond the financial means
of many poor countries — particularly those for the
control of HIV/AIDS.
CMH Report p 57-91, and Working Group 3 Report p 75-100
Mobilising greater resources for health in
middle-income countries
As part of an economic development strategy the Commission recommends:
1.
Ensure universal access to essential interventions through public finance, with fiscal transfers to
poorer regions.
2.
3.
Provide incentives for informal sector workers to participate in risk-pooling insurance schemes.
Improve equity and efficiency through budgeting, payment contracting and cost-containment
measures (following the experience of OECD countries).
CMH Report p 63
17
Increased investment in health is
urgently needed
Donor finance will be needed to
More donor investment is urgently needed to close the financing gap in health in the poorest countries of
the world. Overall aid budgets have actually decreased over recent years and fall far short of even conservative
close the financing gap.
Assistance from developed
nations should increase from the
current levels of about
US$ 6 billion per year
to US$ 27 billion by 2007 and
US$ 38 billion by 2015.
estimates of what is currently needed to scale up action. In response, the donor community should not only
reverse the decline in overall development assistance but also increase it from present levels to sustain the
expanded coverage of essential health services and interventions. Further, they must support the scaling up of
research and development and other interventions which have global public health benefits ( so-called "global
public goods"). Although the level of donor funding required is high in absolute terms (US$ 27 billion per year
in 2007 and US$ 38 billion per year by 2015), the Commission maintains that additional assistance can be
mobilized. If all donors raised their Official Development Assistance (ODA) to reach the international
recommended standard of 0.7 % of OECD countries' GNP, the total 2007 ODA of US$ 200 billion would be
sufficient to accommodate health assistance (US$ 27 billion) as well as other significant increases in areas
related to poverty reduction and growth.
The Commission argues that a few middle-income countries will also require grant assistance, particularly to
meet the financial costs of expanded HIV/AIDS control. It also recommends that the World Bank and regional
increased aid for health must be
development banks should increase loans (non-concessional) to these countries for upgrading their health
systems; this should be balanced against the macroeconomic consequences of a debt increase.
additional to current aid flows.
Despite the apparent deficit in resources, the Commission reasoned that scaling up is feasible. Donor assistance
for health has increased over recent years (even though overall ODA has decreased) as donor governments
have become increasingly aware of the threat of infectious diseases to global security and of the spread of
infectious diseases and their vectors through international travel, trade, and migration. Another encouraging
development is that innovative ideas and resources are entering the health sector from private and corporate
philanthropy.
CMH Report p 91-97, and Working Group 6 Report p 9-23
18
The Commission proposes that WHO and the World
Bank, backed by a steering group of donor and
recipient countries, could be charged with the
coordination of the massive, multi-year scaling up of
Breakdown of recommended donor commitment
(incremental) US$ billions
donor assistance in health and the monitoring of
donor commitments and disbursements. Implementing
For the least-developed, low- and middle-income countries
this vision of greater expanded support for health
Other Global
Public Goods
requires donor support for build up of implementation
US$ in billions
(constant 2002 US$)
R&D
capacity and for addressing governance or other
2007 Estimates:
constraints.
Country-level
programmes :
R&D:
Other Global Public
Goods:
Key international forums (such as the IMF/World Bank
meetings, the World Health Assembly, and the UN
Conference on Development Finance) should provide
venues for specific commitments to scaling up of
donor assistance for health.
Country-level
Country-level
programmes in
middle-income
programmes
in least
developed
CMH Report p 91-103, and Working Group 5 Synthesis Paper
countries
Other Global
Public Goods
Country-level
I___
programmes in
low-income
A major increase in the current low level of
R&D
around US$ 6 billion must be mobilized. Donor
income. The CMH argues that total needs for
donor grants for country level programmes are
US$ 22 billion per year by 2007 and US$ 31
billion by 2015 for the least-developed, low- and
middle-income countries. Efforts will be needed to
improve donor administrative commitments, and
support should be readily forthcoming to help
USS in billions
(constant 2002 USS)
Country-level
2015 Estimates:
Country-level
programmes :
R&D:
Other Global Public
Goods:
programmes in
middle-income
countries
$3
Country-level
programmes in
low-income
Total:
countries
overcome country constraints.
19
E
E
□
countries
Official Development Assistance for health of
of their GNP— one cent for every US$ 10 of
Total:
countries
Recommended donor
commitments
countries can assist by contributing around 0.1%
$2
v>
The supply of global public goods in
poor countries
The impact of some health
interventions and activities — such
The impact of some health interventions and activities, such as the eradication of a disease or research and
development (R&D) in health extends beyond the country's borders to benefit the whole of mankind. These
scxalled global public goods are generally underfunded by governments in developing countries and require
global provision and financing. The Commission maintains that at least US$ 5 billion a year by 2007 and US$
as the eradication of a disease or
health research and development —
extends beyond a country's
7 billion a year by 2015 should be allocated to the development of global public goods targeted to the health
needs of the poor.
A war against diseases requires not only cost-effective interventions, stronger health systems, political commitment
and resources, but also substantial investments in global public goods. One of the most important global public
borders to benefit the whole of
goods is research and development that is focused on the health needs of the poor. The Commission states that
mankind. These scxalled global
reproductive health. Also needed are effective microbicides, new pesticides to control vector-borne diseases, and
public goods are generally
new affordable and effective drugs and vaccines are required for HIV/AIDS, TB, malaria, childhood diseases, and
new drugs to tackle the increasing threat of drug resistance. However, rich country markets offer little incentive for
the R&D of new products to combat diseases that occur mainly in developing countries.
underfunded by governments in
In addition to R&D targeted to specific diseases and conditions, the collection and analysis of epidemiological
developing countries and require
global provision and financing. The
Commission maintains that at least
data and surveillance of infectious diseases at the international level must be improved. More support is needed
for data collection and analysis of global health trends, analysis and dissemination of best practices in disease
control and health systems management, and for technical assistance and training. These global public goods are
key forces in the scaling up process; their implementation and international diffusion is a central responsibility of
the World Health Organization, the World Bank, and other international institutions.
US$ 5 billion a year by 2007 and
To help channel the increased R&D investment, the Commission proposes the establishment of a new Global Health
US$ 7 billion a year by 2015 should
be allocated to the development of
global public goods targeted to the
Research Fund (GHRF) in addition to the existing major R&D channels (WHO, several public-private partnerships
for AIDS, TB and malaria, and the Global Forum for Health Research). A key goal of the GHRF would be to
support basic and applied biomedical and applied sciences research on the health problems affecting the poor
and on the health systems and policies needed to address them. The GHRF would build long-term research
capacity in the developing countries themselves.
health needs of the poor.
20
Finally, since the public sector does not have the means
to improve the supply of some global public goods, the
Commission says that incentives are needed to
encourage the private sector pharmaceutical industry to
The Commission calls for an increase in
research and development:
develop new and improved drugs, vaccines, and other
interventions for low-income countries. These include
extending 'orphan drug' legislation (drugs that treat
• US$ 1.5 billion per year for existing institutions involved in the research and development of new
vaccines and drugs. These include the Special Programme for Research and Training in Tropical Diseases
diseases which only affect a very small percentage of
(TDR), the WHO Initiative for Vaccine Research (IVR), the UNDP/UNFPA/WHO/World Bank Human
the population) to diseases that occur mainly in
Reproduction Programme (HRP), and the public-private partnerships for HIV/AIDS, TB, and malaria.
developing countries, as well as pre-commitments to
purchase priority new drugs and vaccines.
• US$ 1.5 billion per year through the proposed Global Fund for Health Research (GFHR) that would
support basic scientific research in health (including epidemiology, health economics, health systems, and
CMH Report p 8-9, p 76 -86, and Working Group 2
health policy) and would help build long-term research capacity in developing countries.
Report p 26-45
• Increased outlays for operational research at country level in conjunction with the scaling up of
health interventions equal to at least 5 % of national programme funding.
• Expanded availability of scientific information on the internet with efforts to increase
connectivity of universities and research sites in poor countries.
• Modification of the orphan drug legislation in the high-income countries to include diseases of
CMH Report p 79, and Working Group 6 Report p 42
the poor.
• Pre-commitments to purchase targeted technologies such as vaccines for HIV/AIDS, TB, and malaria
The 10/90 Gap
as a market-based incentive.
Many new technologies, such as genomics and
advances in diagnostics have been targeted to the
health needs of the industrialized countries rather
than the needs of developing countries. This
’
imbalance in research between the health
problems of the poor and those of the rich is
known as the 10/90 Gap. Less than 10% of
global health research funding is targeted at the
health problems that are of greatest concern to
people in developing countries and which account
for 90% of global disease burden.
21
Access to essential medicines
The international
pharmaceutical industry, together
Many people in low-income countries lack access to essential medicines - mainly because neither the poor nor
their governments can afford to purchase them. Meanwhile, shortages of doctors and health workers to select,
prescribe, and advise on the appropriate use of available medicines — aggravated by weak health systems
and poor community outreach services — have prevented a demand-led approach, and diverted benefits from
with low-income countries and
the poor. In many countries, access to essential medicines is held back through burdensome procurement
systems, domestic regulatory procedures, and high import duties and taxes.
WHO, should ensure that poor
countries have access to essential
medicines through
At the same time, pharmaceutical manufacturers tend to maintain high profit margins
especially in their rich
country markets — as a means of recouping their research and development costs. Yet access to drugs in poor
countries requires prices at or close to production costs since the poor cannot afford patent-protected prices.
Moreover, it is anticipated that in the near future an increasing number of essential medicines will be patented.
commitments to provide these at
The Commission considers differential pricing in low-income markets the best solution to this. Under differential
the lowest viable
for patented products, while poor countries would pay close to production costs. The Report also recommends
pricing, rich countries would bear the costs of research and development, through paying a relatively higher price
the licensing of the industry's technologies to producers of high-quality generics for use in low-income markets
commercial price in the
whenever the industry chooses not to supply these markets, or whenever the generic producers can demonstrate
that they can produce the drugs at high quality but at a markedly lower cost.
poorest settings.
The Commission calls for a new global framework for access to life-saving medicines that includes differential
pricing schemes in poorer markets as the operational norm, broader licensing of products to generics producers,
and bulk purchase agreements. It also recommends that WHO, low-income countries, and the pharmaceutical
industry should join forces and agree on guidelines for pricing and licensing the production of key technologies
in developing countries to ensure the uninterrupted supply of essential medicines. The guidelines would identify
a designated set of essential medicines for low-income countries, at markedly reduced prices
Throughout th,,, ,lfort,. th, phomoo.ufal Industry musl r.main „ key
'°dC lm°l™9 “““
Al th. ,am. „me, s„ong prolec,|o„ of in,e||ec,ual
property rights to preserve the pharmaceutical industry's incentives for the PAn
_i- •
ij
workable and effective solution.
® R&D °f neW medlcines could prove a
22
Finally, the corporate sector operating in developing
countries also has a critical role to play in ensuring
Responsibilities of the international community
that their own labour force has access to essential
medicines and services. For example, the mining
The donor community would guarantee adequate financing for the purchase, monitoring, and safe use of drugs.
companies of southern Africa, that are at the
epicentre of the HIV/AIDS epidemic, have a special
responsibility to help prevent transmission of the
disease and to ensure that their workforce has access
to essential medicines and care.
CMH Report p 86-91
The WHO, pharmaceutical industry, and low-income countries would agree jointly to guidelines for
pricing and licensing of production in low-income countries. This would be backed up by strong protection
of intellectual property rights in the higher-income markets to provide incentives for R&D of new drugs.
The World Trade Organization member governments would ensure adequate safeguards for the
developing countries and, in particular, the right of countries that do not produce key essential medicines
to invoke compulsory licensing for imports from developing country generic suppliers.
CMH Report p 88-91, and Working Group2 Report p 25-45
Responsibilities of lowincome countries
Responsibilities of the pharmaceutical industry
The pharmaceutical industry would cooperate with WHO and low-income countries to agree jointly to
Low-income countries would undertake to meet
guidelines. These guidelines would provide a transparent mechanism of differential pricing that would
their own obligations including:
target poor countries, and would identify a designated list of essential medicines for HIV/AIDS, TB,
• Prevention of the re-exportation of low-priced
malaria, respiratory infections, diarrhoeal diseases, and vaccine-preventable diseases, at the lowest viable
drugs to developed countries, either legally or
commercial prices.
via the black market.
The industry would agree to license their technologies to producers of high quality generic pharmaceuticals
• Removal of obstacles to market access such as
for supply to low-income countries when:
tariffs and quotas on the importation of essential
- they choose not to supply these markets themselves
medicines.
- the generic producers can demonstrate that they can produce high quality medicines at markedly lower costs.
• Regulation and cooperation with the donor
CMH Report p 89, and Working Group 4 Report p 25-45, and Working Group 2 Report p 39-44
community to ensure the effective use of
medicines in order to limit the onset of drug
resistance and other adverse effects that can
accompany poor administration of medicines.
• Ensure competitive tendering, bulk purchasing,
and transparency in pricing.
CMH Report p 89-90, and Working Group 4 Report p 33-35
23
New ways of investing in health for
development
To improve the health of the poor,
a global partnership involving
Finding new ways of tapping into additional resources is critical to improving health, reducing poverty, and
making significant progress towards the Millennium Development Goals. Since scaling up will require a major
increase in international financing, an effective partnership of donors and recipient countries, based on
mutual trust and performance, is essential. This partnership between rich and poor countries will help mobilize
both rich and poor nations is
investment in health, and scale up access to essential health services with a focus on specific interventions to
combat major diseases. Under the new partnership, financing of health would evolve in parallel with necessary
needed to scale up access to
essential health services. Efforts to
build on innovative funding
mechanisms and new frameworks
country reforms and improved mobilization of tax revenues for health. The mechanisms of donor financing
would evolve to include increased debt relief.
Efforts to deliver increased donor financing will require innovative funding mechanisms such as the
Global Fund to fight AIDS, TB and Malaria (GFATM), the Global Alliance for Vaccines and Immunization (GAVI),
and the establishment of a new Global Health Research Fund (GHRFj to help channel the increased R&D
expenditure. To support country-led poverty reduction initiatives, effective frameworks such as the Poverty
and to develop strong
Reduction Strategy Papers (PRSP) are promising approaches for addressing donor-recipient country relations. And
new modalities for delivering additional funding and health sector scaling up, such as the Sector-Wide Approach
intersectoral coalitions around
common goals would improve
health in low-income countries.
Creating a close-to-client system
would help expand coverage and
access to essential services.
(SWAp), can serve as a useful tool for donors and recipient countries for coordinating plans and action.
CMH Report p 97- 101
Evidence presented by the Commission also suggests that poverty reduction will be more effective if investment in
other sectors is increased as well. Complementary investments and intersectoral collaborations with education,
water, sanitation, and other sectors will have an impact on health. In addition, private sector involvement and
cooperation, particularly of the pharmaceutical industry, is key to ensuring access to the medicines that are critically
needed in low-income countries.
One of the Commission's highest priorities for scaling up efforts is the use of an innovative, well structured
close-to-client (CTC) system to help increase health coverage for the poor. However, the establishment of
an effective CTC system is no small task. It requires strong national leadership, coupled with local capacity and
accountability. This will require renewed'political commitment, increased organizational capacity, and greater
24
transparency in public services and budgeting —
backed up by an increase in funding and transparency,
Facilitating investment in health
including regular monitoring and evaluation. In
addition, the full and equal participation of the
The Poverty Reduction Strategy Paper (PRSP) framework facilitates donor financing mechanisms
community is critical. Without this, it will be impossible
and provides 1) deeper debt cancellation, 2) state leadership in the preparation of national strategies,
to scale up preventive care and treatment for the major
3) involvement of civil society at each step of the process, 4) a comprehensive approach to poverty
life-threatening and disabling diseases.
reduction, and 5) donor coordination in support of country goals.
CMH Report p 97- 101, and Working Group 5 Report p 50-54
A National Commission on Macroeconomics and Health (NCMH) can lead the task of scaling
up through: 1) assessing health priorities, 2) establishing a scaling up strategy, 3) working together with
other health-related sectors, 4) ensuring a sound macroeconomics framework, and 5) preparing an
epidemiological baseline, operational targets, and a financing plan, together with WHO and the World Bank.
Sector Wide Approaches (SWAps) can facilitate scaling up by providing donors and recipients with
an innovative coordination mechanism for delivering additional funding through: 1) joint planning
between country donors and national authorities, 2) agreeing on strategies for support, and 3) pooling
assistance for country-designed and country-led strategies.
The Global Fund to fight AIDS, TB and Malaria (GFATM) can support the scaling up process by
providing funds to country-level programmes. The Commission has proposed that US$ 8 billion per year
reach the GFATM by 2007 from the proposed overall US$ 22 billion donor assistance. The GFATM should
primarily: 1) target financial assistance to the poorest countries, 2) provide funding to countries with viable
strategies, 3) provide grants for proposal preparation, 4) encourage proposals to reflect a pan-national
dialogue on health, and 5) support demonstrated fiscal efforts.
CMH Report p 79-81 and Working Group 6 Report, p 36-43
A potential Global Health Research Fund (GHRF) suggested by the Commission can support basic,
biomedical, and applied sciences research on the health problems of the poor and on health policies and
systems required to address them. The Commission proposes that US$ 1.5 billion be dedicated to GHRF
work as part of the US$ 3 billion R & D donor commitment.
CMH Report p 81-86
25
Initiating macroeconomics and health
work at country level
The Report proposes a way
Because of the wide diversity of infrastructure and conditions in different countries, the CMH Report does not
provide a road map for transforming its recommendations into actions at the country level. Its aim is to invite
forward which, if vigorously
pursued at national and
international levels, would have
a major impact on the health
and wealth of nations and
each country to examine its health priorities and infrastructural and budgetary constraints. Countries are
encouraged to assess the current epidemiological situation, health status, and poverty determinants, in an effort
to develop a sound strategy for scaling up health interventions within a macroeconomics and health agenda.
Many countries have endorsed the findings and recommendations of the CMH Report as they review it in
relation to their country's health and economic needs. CMH follow-up work is intended to help governments
examine issues relating to health and macroeconomics and establish options for scaling up investment and
actions, while at the same time addressing the reforms needed to achieve more equitable and better health for
all. The CMH follow-up process in countries aims to :
their people.
• Support politicians, health and finance ministers, academic groups, senior figures from the private sector,
donor partners, and representatives of civil society as they examine the findings of the Report and its
implications for the economic and health challenges that lie ahead.
• Endorse sound macroeconomics and health analyses designed to re-evaluate policies for investing in health
and re-invigorate national plans for achieving the Millennium Development Goals.
• Help create channels for financial and technical assistance to governments and their partners, and lay the
groundwork for building stronger alliances within countries. This will catalyze the ability of governments to
plan and implement investment in order to improve the health of the poor more rapidly and in a
sustainable way.
Many countries have expressed interest in linking macroeconomics and health work to existing national structures,
policies, and capacities. This work begins through an interactive process that can involve health working groups of
the PRSP process, national steering committees or the National Health Council, where appropriate. Countries can
also set up a National Commission on Macroeconomics and Health (NCMH) or work through subregional groups
such as the Economic and Social Commission for Asia and the Pacific (ESCAP). Implementation of a plan of action
for increasing investment in health calls for strong political leadership and commitment at the highest level
consistency with the overall macroeconomics framework, and powerful intersectoral alliances.
26
A national body on macroeconomics and health or its
Important Macroeconomics and Health Activities
equivalent is expected to organize and lead the task of
scaling up national investment in health. This includes
working with WHO, the World Bank, and others to
analyse the national health situation and identify
priority areas for health interventions as well as the
financing strategies needed to address those
priorities. Other tasks include: designating a set of
Each country supporting Macroeconomics and Health work should develop a specific plan of action
appropriate to its situation, keeping in view the broad parameters of action outlined in the CMH Report.
Development of an action plan requires a number of key activities including :
1.
Advocacy on CMH findings and mobilization of additional political support
• communicate the CMH concept and messages and encourage debates on the Report's findings
essential interventions to be made universally available
• define the appropriate country-level response to CMH recommendations
to the population through public financing; initiating a
multi-year programme on health system strengthening
2.
Data analysis, development of strategies, and setting out a framework of macroeconomics and health action
• review relevance of CMH findings within a country context
focused on service delivery at the local level; and
• investigate system constraints to scaling up
establishing targets for reductions in the burden of
• ensure that information on coverage, equity, and cost effectiveness of priority services is available
disease. The use of integrated community development
• develop national health investment plans on how to reach people effectively
approaches, currently being developed by WHO
• consider approaches to retaining and training health care professionals across all levels of the health system
Regional Offices and other agencies, can amplify
• investigate how to incorporate health in the PRSP process
efforts to improve health and reduce poverty.
• incorporate increased health spending within national Medium-Term Expenditure frameworks
3.
Addressing the national burden of HIV/AIDS
• address the impact of HIV on poverty, economic growth, and health status
• establish policies and resources for increased access to prevention and care
4.
Estimating funding needs and mobilization of additional financial support from domestic and international sources
• improve information on the costs of health inaction
• ensure links between relevant ministries and insert health in HIPC
• build effective links with global funding initiatives
5.
Managing implementation of plans and monitoring achievements
• build country capacity for stewardship, intersectoral action, and monitoring performance
• assess results, relate them to expenditure and track financial flows for health
6.
Securing better coordination and coherence of action
• document country experiences in intersectoral collaboration
• establish effective mechanisms for in-country coordination, coherence in regional and global action,
and to ensure that global initiatives respond to country needs.
National Responses Io the CMH Report Consultation, WHO, June 2002
27
How countries are moving forward
Since the global launch of the CMH
Many countries have already started to mobilize their knowledge, experiences, and resources to formulate long
Report, WHO and its Regional and
strategy — and are expressing interest in the CMH findings. Not all of these countries are planning to establish a
Country offices have worked
The international community, including WHO, will not urge countries to set up NCMH but will support promising
term programmes for scaling up essential health interventions — usually as part of a national poverty reduction
NCMH but nearly all are placing the CMH follow-up work in the context of their national development agendas.
closely with governments to promote
the Report's findings and to support
country efforts to bridge the gap
between national macroeconomic
and health policies. The CMH
national macroeconomics mechanisms in efforts to develop an approach to macroeconomics and health. WHOs
own approach will be refined and adapted to different country situations through a process of consultations with
countries and development agencies.
During 2002 and 2003, Regional and Country Offices have given priority to advocacy and the dissemination
of the Report's findings. The CMH Report has been translated from English into Arabic, Chinese, French,
German, Russian, and Spanish, and has been widely distributed. In some countries, CMH websites have been
constructed to publicize key CMH messages and disseminate local information on macroeconomics and health.
All WHO Regional Offices have distributed the Report and related documents widely in an effort to promote its
follow-up process in countries has
been providing opportunities to
national groups - from a range of
ministries to academic groups, civil
findings and sensitize senior policy makers on the relationship between health and economic growth, while
simultaneously providing guidance on how CMH recommendations could be taken forward in countries.
A number of meetings and conferences have been organized — from national workshops to high-level regional
events — to present the main findings of the Report to groups of politicians, academics, and researchers and to
debate how its recommendations could be applied to countries interested in the macroeconomics and health
approach. Most Regional Offices have also set up Macroeconomics and Health (or CMH) Task Forces to assess
groups, and the private sector
— to debate their vision of health
the relevance of the CMH findings, propose interventions and approaches tailored to the local situation, and to
coordinate and support CMH follow-up action at country level.
and to strategize on how to
Throughout the biennium, determined efforts by WHO Regional Offices to disseminate CMH findings have
incorporate health into national
and commitment have been mobilized in countries including: Federal Democratic Republic of Ethiopia, the
resulted in several successful events to publicize and debate the Report. As a result, high-level political interest
Republic of Ghana, the Republic of Kenya, the Republic of Mozambique, the Rwandese Republic, in Africa; the
development plans.
Association of Caribbean States and the United Mexican Stated in Americas; the Hashemite Kingdom of Jordan
28
and the Sultanate of Oman in the Eastern Mediterranean region; the Kingdom of
Nepal, Kingdom of Thailand, the People's Republic of Bangladesh, the Republic of
National responses to the CMH Report
India, the Republic of Indonesia, the Republic of Maldives, the Union of Myanmar
in South-East Asia; the Kingdom of Cambodia and the People's Republic of China
in the Western Pacific Region.
To identify future directions a "National responses to the CMH Report
Consultation was held at WHO Headquarters in June 2002. Ministers and
senior representatives from the ministries of health, finance and planning from
Missions to countries committed to CMH follow-up work continue to shape the
content of country macroeconomics and health support work in different ways. For
example, in countries undergoing reforms, decentralization, and poverty reduction
processes, the CMH follow-up work assists governments and the donor community
in accelerating existing health sector initiatives through providing technical expertise
and supporting capacity building. The Report's findings are also considered to be
of great value to the process of health reform — providing guidance to countries
or regions on priorities for health financing (including public-private partnerships
and the sharing of services) and an opportunity for integrating the work of diverse
19 countries came together with representatives from the World Bank, 12
bilateral agencies, the Bill and Melinda Gates Foundation, and WHO staff to
discuss how to translate the CMH recommendations into country actions. The
Consultation considered what could be done to dramatically increase investments
for achieving the Millennium Development Goals (MDG) in health, and the steps
countries need to take to accelerate national action.
Senior representatives from the following countries participated in the
Consultation:
partners. In other countries undergoing reforms, the provision of technical and
The African region
The Eastern Mediterranean region
financial assistance to support the analysis of epidemiological, budgetary, and
• Ghana
• Jordan
macroeconomic variables contributes towards the design of improved public policy
• Mozambique
• The Islamic Republic of Irasn
for health.
• Senegal
• Oman
• United Republic of
• Pakistan
In a growing number of countries, macroeconomics and health work is seen as a
Tanzania
powerful tool for enhancing external assistance for health from donors, for raising
• Uganda
additional domestic resources, and making more efficient use of existing resources.
In others, additional health-related risks such as under-nutrition, unsafe water, and
The Americas region
The South East Asian region
unhealthy environments are being integrated into the CMH follow-up action.
• The Caribbean States
• Bangladesh
• Guatemala
• India
• Santa Lucia and OECS
• Indonesia
Elsewhere, in some of the world's most populous countries that are poised for
further economic growth, governments are interested in pursuing and adapting the
countries
• Nepal
CMH recommendations. Because of their size, high disease burden, and great
• Sri Lanka
potential for improvements in health, there is a critical need to sustain the CMH
• Economic and Social Commission for
Asia and the Pacific (ESCAP)
recommendations as the means to economic growth. What happens in these
countries is vital for the rest of the world. It is inconceivable that any meaningful
progress can be made towards the Millennium Development Goals unless the
world's most populous countries are on board.
The European region
• Poland
Investing in Health Booklet
Concepl and Production
Agnes Leotsakos
Editor
Sheila Davey
Editorial and Technical Contributors
Amin Kebe, B.S. Lamba, Maria Paalman, Mubashar Riaz Sheikh, Ruben M. Suarez-Berenguela,
Dai Ellis, Silvia Ferazzi, Tom O'Connell, Ann Rosenberg, Josh Ruxin,
WHO CMH Support Unit, and Evidence for Health Policy Department
Executive Secretary CMH, Support Unit
Sergio Spinaci
Editorial Assistants
Zarita Khamkhoeva, Tashina Krishniah
Art and Design
James Elrington
World Health Organization,
CMH Support Unit,
20 Avenue Appia,
CH-1211 Geneva 27, Switzerland
www.who.int/macrohealth
INVESTING IN HEALTH
A Summary of the Findings of the Commission on Macroeconomics and Health
Please put me on your mailing lists.
I would like to receive CMH Support Unit publications as
What are your main areas of interest related to macroeconomics
and health:
they become available.
I would like additional copies of this document to share
with others Ref: ISBN 92 4 156241 2
NAME:
TITLE:
Feedback and comments:
ORGANIZATION:
STREET ADDRESS:
SECTOR, TOWN, CITY:
PROVINCE OR STATE:
COUNTRY:
POSTALCODE:
_
TEL (including country codes):
FAX (including country codes):
E-MAIL:
Please
place stamp
here
WORLD HEALTH ORGANIZATION
CMH SUPPORT UNIT
20 AVENUE APPIA
CH-1211 GENEVA 27
SWITZERLAND
Executive Summary
Macroeconomics and Health:
Investing in Health for
Economic Development
Report of the Commission on
Macroeconomics and Health
Presented by JEFFREY D. Sachs, Chair
to Gro Harlem Brundtland,
Director-General of the
World Health Organization
on zo December 2001
Executive Summary
Macroeconomics and Health:
Investing in Health for
Economic Development
Report of the Commission on Macroeconomics and Health
Chaired by JEFFREY D. SACHS
Presented to Gro Harlem Brundtland,
Director-General of the
World Health Organization,
on 2.0 December 2.001
World Health Organization
Geneva
WHO Library Cataloguing-in-Publication Data
Macroeconomics and health: Investing in health for economic development: executive
summary/report of the Commission on Macroeconomics and Health.
1.Financing, Health 2 Investments 3.Life expectancy 4.Economic development
5.Poverty 6.Developing countries 7.Developed countries I.WHO Commission on
Macroeconomics and Health
ISBN 92 4 154552 6 (NLM classification: WA 30)
The World Health Organization welcomes requests for permission to reproduce or translate
its publications, in part or in full. Applications and enquiries should be addressed to the
Office of Publications, World Health Organization, Geneva, Switzerland, which will be glad
to provide the latest information on any changes made to the text, plans for new editions,
and reprints and translations already available.
© World Health Organization 2001
Publications of the World Health Organization enjoy copyright protection in accordance
with the provisions of Protocol 2 of the Universal Copyright Convention.
All rights reserved.
The designations employed and the presentation of the material in this publication do not
imply the expression of any opinion whatsoever on the part of the Secretariat of the World
Health Organization concerning the legal status of any country', territory, city or area or of
its authorities, or concerning the delimitation of its frontiers or boundaries.
The mention of specific companies or of certain manufacturers’ products does not imply
that they are endorsed or recommended by the World Health Organization in preference to
others of a similar nature that are not mentioned. Errors and omissions excepted, the names
of proprietary products are distinguished by initial capital letters.
This report contains the collective views of the Commission on Macroeconomics and
Health and does not necessarily represent the decisions or the stated policies of the
World Health Organization.
Printed in USA
Macroeconomics and Health:
Investing in Health for
Economic Development
The Commission on Macroeconomics and Health (CMH) was established
by World Health Organization Director-General Gro Harlem Brundtland
in January 2000 to assess the place of health in global economic develop
ment. Although health is widely understood to be both a central goal and
an important outcome of development, the importance of investing in
health to promote economic development and poverty reduction has been
much less appreciated. We have found that extending the coverage of cru
cial health services, including a relatively small number of specific inter
ventions, to the world’s poor could save millions of lives each year, reduce
poverty, spur economic development, and promote global security.
This report offers a new strategy for investing in health for econom
ic development, especially in the world’s poorest countries, based upon a
new global partnership of the developing and developed countries. Timely
and bold action could save ar least 8 million lives each year by the end of
this decade, extending the life spans, productivity and economic well
being of the poor. Such an effort would require two important initiatives:
a significant scaling up of the resources currently spent in the health sec
tor by poor countries and donors alike; and tackling the non-financial
obstacles that have limited the capacity of poor countries to deliver health
services. We believe that the additional investments in health—requiring
of donors roughly one-tenth of one percent of their national income—
would be repaid many times over in millions of lives saved each year,
enhanced economic development, and strengthened global security.
Indeed, without such a concerted effort, the world’s commitments to
improving the lives of the poor embodied in the Millennium Development
Goals (MDGs) cannot be met.
In many respects, the magnitude of the scaled-up effort reflects the
extremely low levels of income in the countries concerned, the resulting
paltry current levels of spending on health in those countries, and the costs
required for even a minimally adequate level of spending on health.
Because such an ambitious effort cannot be undertaken in the health sec
tor alone, this Report underscores the importance of an expanded aid
effort to the world’s poorest countries more generally. This appears to us
of the greatest importance at this time, when there has been an enhanced
awareness of the need to address the strains and inequities of globaliza
tion.
We call upon the world community to take heed of the opportunities
for action during the coming year, by beginning the process of dramati
cally scaling up the access of the world’s poor to essential health services.
With bold decisions in 2002, the world could initiate a partnership of rich
and poor of unrivaled significance, offering the gift of life itself to millions
of the world’s dispossessed and proving to all doubters that globalization
can indeed work to the benefit of all humankind.
November 2001
Jeffrey D. Sachs, Chair
Isher Judge Ahluwalia
K. Y. Amoako
Eduardo Aninat
Daniel Cohen
Zephirin Diabre
Eduardo Doryan
Richard G. A. Feachem
Robert Fogel
Dean Jamison
Takatoshi Kato
Nora Lustig
Anne Mills
Thorvald Moe
Manmohan Singh
Supachai Panitchpakdi
Laura Tyson
Harold Varmus
Executive Summary of the Report
Technology and politics have thrust the world more closely together than
ever before. The benefits of globalization are potentially enormous, as a
result of the increased sharing of ideas, cultures, life-saving technologies,
and efficient production processes. Yet globalization is under trial, partly
because these benefits are not yet reaching hundreds of millions of the
world’s poor, and partly because globalization introduces new kinds of
international challenges as turmoil in one part of the world can spread
rapidly to others, through terrorism, armed conflict, environmental degra
dation, or disease, as demonstrated by the dramatic spread of AIDS
around the globe in a single generation.
The world’s political leaders have recognized this global interdepend
ence in solemn commitments to improve the lives of the world’s poor by
the year 2015. The Millennium Development Goals (MDGs), adopted at
the Millennium Summit of the United Nations in September 2000, call for
a dramatic reduction in poverty and marked improvements in the health
of the poor. Meeting these goals is feasible but far from automatic. Indeed,
on our current trajectory, those goals will not be met for a significant pro
portion of the world’s poor. Success in achieving the MDGs will require a
seriousness of purpose, a political resolve, and an adequate flow of
resources from high-income to low-income countries on a sustained and
well-targeted basis.
The importance of the MDGs in health is, in one sense, self-evident.
Improving the health and longevity of the poor is an end in itself, a fun
damental goal of economic development. But it is also a means to achiev
ing the other development goals relating to poverty reduction. The link
ages of health to poverty reduction and to long-term economic growth are
powerful, much stronger than is generally understood. The burden of dis
ease in some low-income regions, especially sub-Saharan Africa, stands as
a stark barrier to economic growth and therefore must be addressed
frontally and centrally in any comprehensive development strategy. The
AIDS pandemic represents a unique challenge of unprecedented urgency
and intensity. This single epidemic can undermine Africa’s development
over the next generation, and may cause tens of millions of deaths in
2
Table 1.
Macroeconomics and Health
Life Expectancy and Mortality’ Rates, by Country Development
Category, (1995-2000)
Development Category
Population
Annual
Life
(1999
Average
millions)
Income
Expectancy Mortality
at Birth
(deaths before
(US dollars)
(years)
Infant
Under Five
age 1 per 1,000
live births)
Mortality
(deaths before
age 5 per
1,000 live
births)
Least-Developed
Countries
643
296
51
100
159
Other Low-Income
Countries
1,777
538
59
so
120
Lower-MiddleIncome Countries
2,094
1,200
70
35
39
Upper-MiddleIncome Countries
573
4,900
71
26
35
High-Income Countries
891
25,730
78
6
6
Memo: sub-Saharan Africa
642
500
51
92
151
Source: Human Development Report 2001, Table 8, and CMH calculations using World
Development Indicators of the World Bank, 2001.
India, China, and other developing countries unless addressed by greatly
increased efforts.
Our Report focuses mainly on the low-income countries and on the
poor in middle-income countries.1 (See notes in the full report.) The lowincome countries, with 2.5 billion people—and especially the countries in
sub-Saharan Africa, with 650 million people—have far lower life
expectancies and far higher age-adjusted mortality rates than the rest of
the world, as shown in the accompanying Table 1. The same is true for the
poor in middle-income countries, such as China. To reduce these stagger
ingly high mortality rates, the control of communicable diseases and
improved maternal and child health remain the highest public health pri
orities. The main causes of avoidable deaths in the low-income countries
are HIV/AIDS, malaria, tuberculosis (TB), childhood infectious diseases,
maternal and perinatal conditions, micronutrient deficiencies, and tobac
co-related illnesses. If these conditions were controlled in conjunction with
enhanced programs of family planning, impoverished families could not
only enjoy lives that are longer, healthier, and more productive, but they
would also choose to have fewer children, secure in the knowledge that
their children would survive, and could thereby invest more in the educa
Executive Summary
3
tion and health of each child. Given the special burdens of some of these
conditions on women, the well-being of women would especially be
improved. The improvements in health would translate into higher
incomes, higher economic growth, and reduced population growth.
Even though we focus mainly on communicable diseases and mater
nal and perinatal health, noncommunicable diseases (NCDs) are also of
great significance for all developing countries; for many middle-income
countries the mortality from communicable diseases has already been sig
nificantly reduced so that the NCDs tend to be the highest priority. Many
of the noncommunicable diseases, including cardiovascular disease, dia
betes, mental illnesses, and cancers, can be effectively addressed by rela
tively low-cost interventions, especially using preventative actions relating
to diet, smoking, and lifestyle.2 Our global perspective on priorities needs
to be complemented by each country analyzing its own health priorities
based on detailed and continually updated epidemiological evidence. Our
argument for outcome-oriented health systems also implies substantial
capacity to deal with a range of conditions not detailed here, such as lowcost case-management of mental illness, diabetes and heart attacks. The
evidence also suggests that approaches required to scale up the health sys
tem to provide interventions for communicable diseases and reproductive
health will also improve care for the NCDs.3
The feasibility of meeting the MDGs in the low-income countries is
widely misjudged. On the one side of the debate are those optimists who
believe that the health goals will take care of themselves, as a fairly auto
matic byproduct of economic growth. With the mortality rates of children
under 5 in the least-developed countries standing at 159 per 1,000 births,
compared with 6 per 1,000 births in the high-income countries,4 these
blithe optimists assume that it’s just a matter of time before the mortality
rates in the low-income world will converge with those of the rich coun
tries. This is false for two reasons. First, the disease burden itself will slow
the economic growth that is presumed to solve the health problems; sec
ond, economic growth is indeed important, but is very far from enough.
Health indicators vary widely for the same income level. The evidence sug
gests that 73 countries are far behind in meeting the MDGs for infant
mortality, and 66 are far behind for meeting the MDGs for child mortali
ty.5 The disease burden can be brought down in line with the MDGs only
if there is a concerted, global strategy of increasing the access of the
world’s poor to essential health services.
4
Macroeconomics and Health
On rhe other side of the debate are the pessimists, who underestimate
the considerable progress that has been made in health (with the notable
exception of HIV/AIDS) by most low-income countries and believe that
their remaining high disease burden is a byproduct of corrupt and broken
health systems beyond repair in poorly governed low-income countries.
This alternative view is also filled with misunderstanding and exaggera
tion. The epidemiological evidence conveys a crucial message: the vast
majority of the excess disease burden is the result of a relatively small
number of identifiable conditions, each with a set of existing health inter
ventions that can dramatically improve health and reduce the deaths asso
ciated with these conditions. The problem is that these interventions don’t
reach the world’s poor. Some of the reasons for this are corruption, mis
management, and a weak public sector, but in the vast majority of coun
tries, there is a more basic and remediable problem. The poor lack the
financial resources to obtain coverage of these essential interventions, as
do their governments. In many cases, public health programs have not
been modified to focus on the conditions and interventions emphasized
here.
The key recommendation of the Commission is that the world’s lowand middle-income countries, in partnership with high-income countries,
should scale up the access of the world’s poor to essential health services,
including a focus on specific interventions. The low- and middle-income
countries would commit additional domestic financial resources, political
leadership, transparency, and systems for community involvement and
accountability, to ensure that adequately financed health systems can
operate effectively and are dedicated to the key health problems. The highincome countries would simultaneously commit vastly increased financial
assistance, in the form of grants, especially to the countries that need help
most urgently, which are concentrated in sub-Saharan Africa. They would
resolve that lack of donor funds should not be the factor that limits the
capacity to provide health services to the world’s poorest peoples.
The partnership would need to proceed step by step, with actions in
the low-income countries creating the conditions for donor financing,
while ample donor financing creates the financial reality for a greatly
scaled-up, more effective health system, with the shared program subject
to frequent review, evaluation, verification, and mid-course corrections.
The chicken-and-egg problem of deciding whether reform or donor
financing must come first would be put aside with both donors and recip
ients frankly acknowledging that both finance and reform are needed at
Executive Summary
5
each stage, and that both must be sustained by an intensive partnership.
For lower-middle-income countries with large concentrations of poor, a
prime task of national governments would be to mobilize additional
resources to finance priority interventions that assure coverage of the poor
within those societies.
The commitment of massive additional financial resources for health,
domestic and international, may be a necessary condition for scaling up
health interventions, but the Commission recognizes that such a commit
ment will not be sufficient. Past experience shows compellingly that polit
ical and administrative commitments on the part of both donors and
countries are key to success. Building health systems that are responsive to
client needs, particularly for poor and hard-to-reach populations, requires
politically difficult and administratively demanding choices. Some issues,
such as relative commitments to the health needs of rich and poor, relate
to the health sector. Others, such as whether the public sector budget and
procurement systems work or whether there is effective supervision and
local accountability of public service delivery, are public management
issues. Underlying these issues are broader questions of governance, con
flict, and the relative importance of development and poverty reduction in
national priorities.
The Commission recognizes the importance of these and other con
straints and treats them in depth in several places in this Report. Success
will require strong political leadership and commitment on the part of
countries that can afford to contribute resources as well as from develop
ing countries—in the private and public sectors and in civil society as well.
It requires the evolution of an atmosphere of honesty, trust, and respect in
donor-recipient interactions. Success requires special efforts precisely in
those settings in which health conditions are most troubling and where
public sectors are weak. Donor support should be readily forthcoming to
help overcome these constraints. Where countries are not willing to make
a serious effort, though, or where funding is misused, prudence and cred
ibility require that large-scale funding should not be provided. Even here,
though, the record shows that donor assistance can do much to help, by
building local capacity and through the involvement of civil society and
NGOs. This is a daunting challenge, yet one that is more than ever a
strategically relevant objective. Governments and leaders who help stimu
late and nurture these actions will be providing a specific antidote to the
despair and hatred that poverty can breed.
6
Macroeconomics and Health
The Commission worked hard to examine whether the low-income
countries could afford to fund the health systems out of their own
resources if they were to eliminate existing wasteful spending in health
and other areas. Our findings are clear: poverty itself imposes a basic
financial constraint, though waste does exist and needs to be addressed.
The poor countries should certainly improve health-sector management,
review the current balance among health-sector programs, and raise
domestic resources for health within their limited means. We believe that
it is feasible, on average, for low- and middle-income countries to increase
budgetary outlays for health by 1 percent of GNP by 2007 and 2 percent
of GNP by 2015 compared with current levels, though this may be opti
mistic given intense competing demands for scarce public resources. Lowand middle-income countries could also do more to make the current
spending, public and private, more equitable and effective. Public spend
ing should be better targeted to the poor, with priorities set on the basis of
epidemiological and economic evidence. There is scope for private out-ofpocket spending in some cases being replaced with prepaid community
financing schemes. Yet for the low-income countries, we still find a gap
between financial means and financial needs, which can be filled only by
the donor world if there is to be any hope of success in meeting the MDGs.
In most middle-income countries, average health spending per person
is already adequate to ensure universal coverage for essential interven
tions. Yet such coverage does not reach many of the poor. Exclusion is
often concentrated by region (e.g., rural western China and rural north
east Brazil), or among ethnic and racial minorities. For whatever reason,
public-sector spending on health does not attend sufficiently to the needs
of the poor. Moreover, since many middle-income countries provide inad
equate financial protection for large portions of their population, cata
strophic medical expenses impoverish many households. In view of the
adverse consequences of ill health on overall economic development and
poverty reduction, we strongly urge the middle-income countries to under
take fiscal and organizational reforms to ensure universal coverage for pri
ority health interventions.6 We also believe that the World Bank and the
regional development banks, through nonconcessional financing, can help
these countries to make a multi-year transition to universal coverage for
essential health services.
The Commission examined the evidence relating to organizational
requirements for scaling up and some of the key constraints that will have
to be overcome. Fortunately, the essential interventions highlighted here
Executive Summary
7
are generally not technically exacting. Few require hospitals. Most can be
delivered at health centers, at smaller facilities that we refer to as health
posts, or through outreach services from these facilities. We call these col
lectively the close-to-client (CTC) system, and this system should be given
priority to make these interventions widely accessible. Producing an effec
tive CTC system is no small task. National leadership, coupled with
capacity and accountability at the local level, is vital. This will require new
political commitments, increased organizational and supervisory capacity
at both local and higher levels, and greater transparency in public servic
es and budgeting—all backed by more funding. These, in turn, must be
built on a foundation of strong community-level oversight and action, in
order to be responsive to the poor, in order to build accountability of local
services, and in order to help ensure that families take full advantage of
the services provided.
Some recent global initiatives for disease control, including those for
TB, leprosy, guinea-worm disease, and Chagas disease, have proved high
ly successful in delivering quality interventions and, in some cases, chang
ing attitudes and behaviors in some very difficult situations over large geo
graphical areas. An important feature of these initiatives is the inclusion
of rigorous systems of monitoring, evaluation, reporting, and financial
control as mechanisms for ensuring that objectives are met, problems arc
detected and corrected, and resources are fully accountable. The result is
a growing body of evidence concerning both the degree of progress
achieved and the operational and managerial strategies that contribute to
success. Lessons from these experiences can provide useful operational
guidance, especially for the delivery of interventions at the close-to-client
level.
In most countries, the CTC system would involve a mix of state and
nonstate health service providers, with financing guaranteed by the state.
The government may directly own and operate service units, or may con
tract for services with for-profit and not-for-profit providers. Since public
health systems in poor countries have been so weak and underfinanced in
recent years, a considerable nongovernmental health sector has arisen that
is built upon private practice, religiously affiliated providers, and non
governmental organizations. This variety of providers is useful in order to
provide competition and a safety valve in case of failure of the public sys
tem. It is also a fait accompli in almost all poor countries.
A sound global strategy for health will also invest in new knowledge.
One critical area of knowledge investment is operational research regard
8
Macroeconomics and Health
ing treatment protocols in low-income countries.7 There is still much to be
learned about what actually works, and why or why not, in many lowincome settings, especially where interventions have not been used or doc
umented to date. Even when the basic technologies of disease control are
clear and universally applicable, each local setting poses special problems
of logistics, adherence, dosage, delivery, and drug formulation that must
be uncovered through operational research at the local level. We recom
mend that as a normal matter, country-specific projects should allocate at
least 5 percent of all resources to project-related operational research in
order to examine efficacy, the optimization of treatment protocols, the
economics of alternative interventions, and delivery modes and population/patient preferences.
There is also an urgent need for investments in new and improved
technologies to fight the killer diseases. Recent advances in genomics, for
example, bring us much closer to the long-sought vaccines for malaria and
HIV/AIDS, and lifetime protection against TB. The science remains com
plex, however, and the outcomes unsure. The evidence suggests high social
returns to investments in research that are far beyond current levels.
Whether or not effective vaccines are produced, new drugs will certainly
be needed, given the relentless increase of drug-resistant strains of disease
agents. The Commission therefore calls for a significant scaling up of
financing for global R&D on the heavy disease burdens of the poor. We
draw particular attention to the diseases overwhelmingly concentrated in
poor countries. For these diseases, the rich-country markets offer little
incentive for R&D to cover the relatively few cases that occur in these rich
countries.8 We also stress the need for research into reproductive health—
for example, new microbicides that could block the transmission of
HIV/AIDS and improved management of life-threatening obstetric condi
tions.
We need increased investments in other areas of knowledge as well.
Basic and applied scientific research in the biomedical and health sciences
in the low-income countries needs to be augmented, in conjunction with
increased R&D aimed at specific diseases. The state of epidemiological
knowledge—who suffers and dies and of which diseases—must be greatly
enhanced, through improved surveillance and reporting systems.9 In pub
lic health, such knowledge is among the most important tools available to
successful disease control. Surveillance is also critically needed in the case
of many NCDs, including mental health, the impact of violence and acci
dents, and the rapid rise of tobacco and diet/nutrition-related diseases.
Executive Summary
9
Finally, we need a greatly enhanced system of advising and training
throughout the low-income countries, so that the lessons of experience in
one country can be mobilized elsewhere. The international diffusion of
new knowledge and “best practices” is one of the key forces of scaling up,
a central responsibility of organizations such as the World Health
Organization and the World Bank, and a goal now more readily achieved
through low-cost methods available through the internet.
A war against disease requires not only financial resources, sufficient
technology, and political commitment, but also a strategy, operational
lines of responsibility, and the capacity to learn along the way. The
Commission therefore devoted substantial effort to analyzing the organi
zational practicalities of a massive, donor-supported scaling up of health
interventions in the low-income world. We started by noting the changes
that will be needed on the ground within the countries themselves. After
all, essential health interventions are delivered in the communities where
poor people live. Scaling up must therefore start with the organization of
the CTC delivery system at the local level. The role of community
involvement, and more generally of mobilization of a broad partnership
of public and private sectors and civil society, is crucial here. The CTC sys
tem should also be supported by nationwide programs for some major dis
eases, such as malaria, HIV/AIDS, and TB. Such focused programs have
important advantages when properly integrated with community health
delivery, by mobilizing communities of expertise not available at the com
munity level, public attention and financing, political energies, and public
accountability for specified results.
Since scaling up will require a significant increase in international
financing, an effective partnership of donors and recipient countries,
based on mutual trust and performance, is essential. In this context, the
mechanisms of donor financing must change, a point that has been recog
nized in the international system in the past 3 years by the creative intro
duction of a new framework for poverty reduction, often termed the
Poverty Reduction Strategy Paper (PRSP) framework.10'The early results
of the PRSP process to date are promising, and the Commission endorses
this new process.11 A concerted attack on disease along the lines that we
recommend will help to ensure success of this emerging approach to
donor-recipient relations. The strengths of the PRSP include: (1) deeper
debt cancellation, (2) country leadership in the preparation of the nation
al strategy, (3) explicit incorporation of civil society at each step of the
process, (4) a comprehensive approach to poverty reduction, and (5) more
IO
Macroeconomics and Health
donor coordination in support of country goals. All of these are applica
ble—indeed vital—to the success of the health initiative proposed here. To
achieve the potential benefits of the PRSP framework, donor and recipient
countries must specify a sustainable financing scheme and investment plan
for the health sector as an integral part of the PRSP scheme for health.
Though we advocate a greatly increased investment in the health sec
tor itself, we stress the need for complementary additional investments in
areas with an important impact on poverty alleviation (including effects
on health). These include education, water and sanitation, and agricultur
al improvement. For example, education is a key determinant of health
status, as health is of education status. Investments in these various sectors
work best when made in combination, a point highlighted by the PRSP
process. We did not, however, make cost estimates outside of the health
sector.12
Within the context of the PRSP, the Commission recommends that
each developing country establish a temporary National Commission on
Macroeconomics and Health (NCMH), or its equivalent, chaired jointly
by the Ministers of Health and Finance and incorporating key representa
tives of civil society, to organize and lead the task of scaling up.13 Each
NCMH would assess* national health priorities, establish a multi-year
strategy to extend coverage of essential health services, take account of
synergies with other key health producing sectors, and ensure consistency
with a sound macroeconomic policy framework. The plan would be pred
icated upon greatly expanded international grant assistance. The National
Commissions would work together with the WHO and World Bank to
prepare an epidemiological baseline, quantified operational targets, and a
medium-term financing plan. Each Commission should complete its work
within two years, by the end of 2003.
We recommend that each country will need to define an overall pro
gram of “essential interventions” to be guaranteed universal coverage
through public (plus donor) financing. We suggest four main criteria in
choosing these essential interventions: (1) they should be technically effi
cacious and can be delivered successfully; (2) the targeted diseases should
impose a heavy burden on society, taking into account individual illness as
well as social spillovers (such as epidemics and adverse economic effects);
(3) social benefits should exceed costs of the interventions (with benefits
including life-years saved and spillovers such as fewer orphans or faster
economic growth); and (4) the needs of the poor should be stressed.
Executive Summary
II
We estimate that by 2010 around 8 million lives per year, in princi
ple, could be saved—mainly in the low-income countries—by the essential
interventions against infectious diseases and nutritional deficiencies rec
ommended here.14 The CMH estimated the costs of this expanded cover
age,15 including related general costs of system expansion and supervision,
for all countries with 1999 GNP per capita below $1,200, plus the
remaining handful of countries in sub-Saharan Africa with incomes above
$1,200 (see Table A2.B in the full report for the list of countries).16Total
annual health outlays for this group of countries would rise by $57 billion
by 2007 and by $94 billion by 2015 (Table A2.3 in the full report). The
countries in the aggregate would commit an additional $35 billion per
year by 2007 and $63 billion per year by 2015.17 The donors, on their
part, would contribute grant financing of an additional $22 billion per
year by 2007 and $31 billion per year by 2015 (Table A2.6 in the full
report).18 Current official development assistance (ODA) is on the order
of $6 billion.19 Total donor spending, including both country-level pro
grams and the supply of global public goods, would be $27 billion in 2007
and $38 billion in 2015. The increased donor financing for health would
be additional to overall current aid flows, since aid should be increased in
many areas outside of the health sector as well.
Most of the donor assistance would be directed at the least-developed
countries, which need the most grant assistance to extend the coverage of
health services. For those countries, total annual health outlays would rise
by $17 billion by 2007 and $29 billion by 2015, above the level of 2002.
Given the extremely low incomes in these countries, domestic resource
mobilization would fall far short of need, however, rising by $4 billion by
2007 and $9 billion by 2015. The gap would be filled by donors, with
grant assistance equal to $14 billion per year in 2007 and $21 billion per
year in 2015. We also note that, on a regional basis, Africa would receive
the largest proportion of donor assistance, a reflection both of Africa’s
poverty and its high disease prevalence. AIDS prevention and care would
account for around half of the total cost of scaling up.20
To understand these sums, it is instructive to consider the costs of the
health interventions on a per capita basis. We find that, on average, the set
of essential interventions costs around $34 per person per year, a very
modest sum indeed, especially compared with average per capita health
spending in the high-income countries of more than $2,000 per year. The
least developed countries can mobilize around $15 per person per year by
2007 (almost 5 percent of per capita income). The gap is therefore $19 per
IO
Macroeconomics and Health
donor coordination in support of country goals. All of these are applica
ble—indeed vital—to the success of the health initiative proposed here. To
achieve the potential benefits of the PRSP framework, donor and recipient
countries must specify a sustainable financing scheme and investment plan
for the health sector as an integral part of the PRSP scheme for health.
Though we advocate a greatly increased investment in the health sec
tor itself, we stress the need for complementary additional investments in
areas with an important impact on poverty alleviation (including effects
on health). These include education, water and sanitation, and agricultur
al improvement. For example, education is a key determinant of health
status, as health is of education status. Investments in these various sectors
work best when made in combination, a point highlighted by the PRSP
process. We did not, however, make cost estimates outside of the health
sector.12
Within the context of the PRSP, the Commission recommends that
each developing country establish a temporary National Commission on
Macroeconomics and Health (NCMH), or its equivalent, chaired jointly
by the Ministers of Health and Finance and incorporating key representa
tives of civil society, to organize and lead the task of scaling up.13 Each
NCMH would assess* national health priorities, establish a multi-year
strategy to extend coverage of essential health services, take account of
synergies with other key health producing sectors, and ensure consistency
with a sound macroeconomic policy framework. The plan would be pred
icated upon greatly expanded international grant assistance. The National
Commissions would work together with the WHO and World Bank to
prepare an epidemiological baseline, quantified operational targets, and a
medium-term financing plan. Each Commission should complete its work
within two years, by the end of 2003.
We recommend that each country will need to define an overall pro
gram of “essential interventions” to be guaranteed universal coverage
through public (plus donor) financing. We suggest four main criteria in
choosing these essential interventions: (1) they should be technically effi
cacious and can be delivered successfully; (2) the targeted diseases should
impose a heavy burden on society, taking into account individual illness as
well as social spillovers (such as epidemics and adverse economic effects);
(3) social benefits should exceed costs of the interventions (with benefits
including life-years saved and spillovers such as fewer orphans or faster
economic growth); and (4) the needs of the poor should be stressed.
Executive Summary
II
We estimate that by 2010 around 8 million lives per year, in princi
ple, could be saved—mainly in the low-income countries—by the essential
interventions against infectious diseases and nutritional deficiencies rec
ommended here.14 The CMH estimated the costs of this expanded cover
age,15 including related general costs of system expansion and supervision,
for all countries with 1999 GNP per capita below $1,200, plus rhe
remaining handful of countries in sub-Saharan Africa with incomes above
$1,200 (see Table A2.B in the full report for the list of countries).16 Total
annual health outlays for this group of countries would rise by $57 billion
by 2007 and by $94 billion by 2015 (Table A2.3 in the full report). The
countries in the aggregate would commit an additional $35 billion per
year by 2007 and $63 billion per year by 2015.17 The donors, on their
part, would contribute grant financing of an additional $22 billion per
year by 2007 and $31 billion per year by 2015 (Table A2.6 in the full
report).18 Current official development assistance (ODA) is on the order
of $6 billion.19 Total donor spending, including both country-level pro
grams and the supply of global public goods, would be $27 billion in 2007
and $38 billion in 2015. The increased donor financing for health would
be additional to overall current aid flows, since aid should be increased in
many areas outside of the health sector as well.
Most of the donor assistance would be directed at the least-developed
countries, which need the most grant assistance to extend the coverage of
health services. For those countries, total annual health outlays would rise
by $17 billion by 2007 and $29 billion by 2015, above the level of 2002.
Given the extremely low incomes in these countries, domestic resource
mobilization would fall far short of need, however, rising by $4 billion by
2007 and $9 billion by 2015. The gap would be filled by donors, with
grant assistance equal to $14 billion per year in 2007 and $21 billion per
year in 2015. We also note that, on a regional basis, Africa would receive
the largest proportion of donor assistance, a reflection both of Africa’s
poverty and its high disease prevalence. AIDS prevention and care would
account for around half of the total cost of scaling up.20
To understand these sums, it is instructive to consider the costs of the
health interventions on a per capita basis. We find that, on average, the set
of essential interventions costs around $34 per person per year, a very
modest sum indeed, especially compared with average per capita health
spending in the high-income countries of more than $2,000 per year. The
least developed countries can mobilize around $ 15 per person per year by
2007 (almost 5 percent of per capita income). The gap is therefore $19 per
IX
Macroeconomics and Health
person per year. With 750 million people in the least-developed countries
in 2007, that comes to around $14 billion. The other low-income coun
tries can mobilize around $32 per person on average (again roughly 5 per
cent of per capita income). Some of these countries will need donor aid to
reach the $34 per person requirement, and others will not. The other lowincome countries will have a combined population of around 2 billion in
2007, and when calculated on a country-by-country basis will need rough
ly $3 per capita on average to close the financing gap, therefore requiring
a total level of donor aid of approximately $6 billion. The low-middleincome countries will need an additional $1.5 billion, mainly to cover the
high costs of AIDS.
It is important to put the total donor assistance into perspective.
Although the required assistance is large relative to current donor assis
tance in health, it would be only around 0.1 percent of donor GNP, and
would leave ample room for significant increases in other areas of donor
assistance as needed. We stress that the increased aid for health must be
additional to current aid flows, since indeed increased aid will be needed
not only in health but also in education, sanitation, water supply, and
other areas. Also, although the donor flows look large in relation to cur
rent health spending, particularly in the poorest countries, this reflects
how little they spend, which in turn reflects their low incomes. This
expansion of aid to the health sector needs to be phased over time to
ensure that resources are used effectively and honestly, which led us to the
time path of increasing coverage shown in Table 7 of the full report, which
shows the basis of our costing. Note that the donor assistance will be
required for a sustained period of time, perhaps 20 years, but will eventu
ally phase out as countries achieve higher per capita incomes and are
thereby increasingly able to cover essential health services out of their own
resources.
This program would yield economic benefits vastly greater than its
costs. Eight million lives saved from infectious diseases and nutritional
deficiencies would translate into a far larger number of years of life saved
for those affected, as well as a higher quality of life. Economists talk of
disability-adjusted life years (DALYs) saved,21 which add together the
increased years of life and the reduced years of living with disabilities. We
estimate that approximately 330 million DALYs would be saved for each
8 million deaths prevented. Assuming, conservatively, that each DALY
saved gives an economic benefit of 1 year’s per capita income of a pro
jected $563 in 2015, the direct economic benefit of saving 330 million
Executive Summary
13
DALYs would be $186 billion per year, and plausibly several times
that.22 Economic growth would also accelerate, and thereby the saved
DALYs would help to break the poverty trap that has blocked economic
growth in high-mortality low-income countries. This would add tens or
hundreds of billions of dollars more per year through increased per capi
ta incomes.
The $27 billion of total grant assistance in 2007 would be devoted to
three goals: (1) assistance to low-income countries (and to a few middle
income countries for HIV/AIDS-related expenditures) to help pay for the
scaling up of essential interventions and health system development ($22
billion, detailed in Appendix 2); (2) investments in research and develop
ment (R&D) devoted to the diseases of the poor ($3 billion); and (3)
increased delivery of global public goods by the international institutions
charged with coordinating the global effort, including the World Health
Organization, the World Bank, and other specialized United Nations
agencies ($2 billion). There would also be additional nonconcessional loan
assistance for middle-income countries.23 We believe that if well managed
and phased in along the timetable that we recommend, these requisite
flows could be absorbed by the developing countries without undue
macroeconomic or sectoral destabilization.
These financial targets are a vision of what should be done, rather
than a prediction of what will happen. We are all too aware of donor
countries that neglect their international obligations despite vast wealth,
and of recipient countries that abjure the governance needed to save their
own people. Maybe little increased funding will take place; donors might
give millions when billions are needed, and impoverished countries will
fight wars against people rather than disease, making it impossible for the
world community to help. We are not naive: it is no accident that millions
of people—voiceless, powerless, unnoticed by rhe media—die unnecessar
ily every year.24
The delivery of such large donor financing will require a new modus
operandi. The Commission strongly supports the establishment of the
Global Fund to Fight AIDS, Tuberculosis, and Malaria (GFATM), which
initially will focus on the global response to AIDS, malaria, and TB. We
recommend that the GFATM be scaled up to around $8 billion per year
by 2007 as part of the overall $22 billion of donor aid to country pro
grams. Given the unique challenge posed by AIDS and its capacity to over
turn economic development in Africa and other regions for decades, we
believe that the GFATM should support a bold and aggressive program
T4
Macroeconomics and Health
that focuses on prevention of new infections together with treatment for
those already infected. Prevention efforts would aim at achieving a high
coverage of prevention programs for highly vulnerable groups including
commercial sex workers and injection drug users, and achieving wide
spread access to treatment of sexually transmitted infections (STIs), vol
untary counseling and testing (VCT), and interventions to interrupt mother-to-child transmission. Given the costs and challenges of scaling up treat
ment, especially using antiretroviral therapy (ART) effectively and without
promoting viral resistance to the drugs, scaling up should be carefully
monitored, science-based, and subject to intensive operational research.
We endorse the estimates of UNAIDS and WHO’s ART program that 5
million people can be brought under antiretroviral treatment in lowincome settings by the end of 2006.25
To help channel the increased R&D outlays, we endorse the estab
lishment of a new Global Health Research Fund (GHRF), with disburse
ments of around $1.5 billion per year. This fund would support basic and
applied biomedical and health sciences research on the health problems
affecting the world’s poor and on the health systems and policies needed
to address them. Another $1.5 billion per year of R&D support should be
funded through existing channels. These include the Special Programme
for Research and Training in Tropical Diseases (TDR), the Initiative for
Vaccine Research (IVR), the Special Programme of Research, Develop
ment and Research Training in Human Reproduction (HRP) (all housed
at WHO) and the public-private partnerships for AIDS, TB, malaria, and
other disease control programs that have recently been established. In
both cases, the predictability of increased funding would be vital, as the
necessary R&D undertakings are long-term ventures. The existing Global
Forum for Health Research could play an important role in the effective
allocation of this overall assistance. To support this increased research and
development, we strongly advocate the free internet-based dissemination
of leading scientific journals, thereby increasing the access of scientists in
the low-income countries to a vital scientific research tool.
The public sector cannot bear this burden on its own. The pharma
ceutical industry must be a partner in this effort. The corporate principles
that have spurred recent and highly laudable programs of drug donations
and price discounts need to be generalized to support the scaling up of
health interventions in the poor countries. The pharmaceutical industry
needs to ensure that low-income countries (and the donors on their behalf)
have access to essential medicines at near-production cost (sometimes
Executive Summary
15
termed the lowest viable commercial price) rather than the much higher
prices that are typical of high-income markets. Industry is ready, in our
estimation, for such a commitment, enabling access of the poor to essen
tial medicines, both through differential pricing and licensing their prod
ucts to generics producers.26 If industry cooperation is not enough or not
forthcoming on a general and reliable basis, the rules of international
trade involving access to essential medicines should be applied in a man
ner that ensures the same results. At the same time, it is vital to ensure that
increased access for the poor does not undermine the stimulus to future
innovation that derives from the system of intellectual property rights.
Private industry outside of the pharmaceutical sector also has a role to
play, including by ensuring that their own labor force—the heart of a
firm’s productivity—has access to the knowledge and medical services that
ensure their survival and health. For example, the mining companies of
southern Africa, at the epicenter of HIV/AIDS, have a special responsibil
ity to help prevent transmission and to work with government and donors
to ensure that their workers have access to care. The main findings of the
Commission regarding the links of health and development are summa
rized in Table 2. An action agenda is summarized in Table 3. Our specific
recommendations on increased international donor assistance and domes
tic financing are summarized in Table 4.
With globalization on trial as never before, the world must succeed in
achieving its solemn commitments to reduce poverty and improve health.
The resources—human, scientific, and financial—exist to succeed, but
now must be mobilized. As the world embarks on a heightened struggle
against the evils of terrorism, it is all the more important that the world
simultaneously commit itself to sustaining millions of lives through peace
ful means as well, using the best of our modern science and technology
and the enormous wealth of the rich countries. This would be an effort
that would inspire and unite peoples all over the world. We call upon the
leaders of the international community—in donor and recipient nations,
in international institutions such as the World Bank, the World Health
Organization, the World Trade Organization, the Organisation for
Economic Co-operation and Development, and the International
Monetary Fund, in private enterprise, and in civil society'—to seize the
opportunities identified in this report. Now, united, the world can initiate
and facilitate the global investments in health that can transform the lives
and livelihoods of the world’s poor.
Macroeconomics and Health
16
Table 2.
Key Findings on the Linkages of Health and Development
1.
Health is a priority goal in its own right, as well as a central input into economic
development and poverty reduction. The importance of investing in health has been
greatly underestimated, not only by analysts but also by developing-country govern
ments and the international donor community. Increased investments in health as out
lined in this Report would translate into hundreds of billions of dollars per year of
increased income in the low-income countries. There are large social benefits to ensur
ing high levels of health coverage of the poor, including spillovers to wealthier mem
bers of rhe society.
2.
A few health conditions are responsible for a high proportion of the health deficit:
HIV/AIDS, malaria, TB, childhood infectious diseases (many of which are preventable
by vaccination), maternal and perinatal conditions, tobacco-related illnesses, and
micronutrient deficiencies. Effective interventions exist to prevent and treat these con
ditions. Around 8 million deaths per year from these conditions could be averted by
the end of the decade in a well-focused program.
3.
The HIV/A1DS pandemic is a distinct and unparalleled catastrophe in its human
dimension and its implications for economic development. It therefore requires special
consideration. Tried and tested interventions within the health sector are available to
address most of the causes of the health deficit, including HIV/AIDS.
4.
Investments in reproductive health, including family planning and access to contracep
tives, are crucial accompaniments of investments in disease control. The combination
of disease control and reproductive health is likely to translate into reduced fertility,
greater investments in the health and education of each child, and reduced population
growth.
5.
The level of health spending in the low-income countries is insufficient to address the
health challenges they face. We estimate that minimum financing needs to be around
$30 to $40 per person per year to cover essential interventions, including those need
ed to fight the AIDS pandemic, with much of that sum requiring budgetary rather
than private-sector financing. Actual health spending is considerably lower. The leastdeveloped countries average approximately $13 per person per year in total health
expenditures, of which budgetary outlays are just $7. The other low-income countries
average approximately $24 per capita per year, of which budgetary outlays are $13.
6.
Poor countries can increase the domestic resources that they mobilize for the health
sector and use those resources more efficiently. Even with more efficient allocation
and greater resource mobilization, the levels of funding necessary to cover essential
services are far beyond the financial means of many low-income countries, as well as
a few middle-income countries with high prevalence of HIV/AIDS.
7.
Donor finance will be needed to close the financing gap, in conjunction with best
efforts by the recipient countries themselves. We estimate that a worldwide scaling up
of health investments for the low-income countries to provide the essential interven
tions of $30 to 40 per person will require approximately $27 billion per year in donor
grants by 2007, compared with around $6 billion per year that is currently provided.
This funding should be additional to other donor financing, since increased aid is also
needed in other related areas such as education, water, and sanitation.
Executive Summary
17
8.
Increased health coverage of the poor would require greater financial investments in
specific health sector interventions, as well as a properly structured health delivery
system that can reach the poor. The highest priority is to create a service delivery sys
tem at the local (“close-to-client”) level, complemented by nationwide programs for
some major diseases. Successful implementation of such a program requires political
and administrative commitment, strengthening of country technical and administrative
expertise, substantial strengthening of public management systems, and creation of
systems of community accountability. It also requires new approaches to donor/recipient relations.
9.
An effective assault on diseases of the poor will also require substantial investments in
global public goods, including increased collection and analysis of epidemiological
data, surveillance of infectious diseases, and research and development into diseases
that are concentrated in poor countries (often, though not exclusively, tropical dis
eases).
10 Coordinated actions by the pharmaceutical industry, governments of low-income
countries, donors, and international agencies are needed to ensure that the world’s
low-income countries have reliable access to essential medicines.
Macroeconomics and Health
18
Table 3.
An Action Agenda for Investing in Health for
Economic Development
1.
Each low- and middle-income country should establish a temporary National
Commission on Macroeconomics and Health (NCMH), or its equivalent, to formulate
a long-term program for scaling up essential health interventions as part of their over
all framework in their Poverty Reduction Strategy Paper (PRSP). The WHO and the
World Bank should assist national Commissions to establish epidemiological base
lines, operational targets, and a framework for long-term donor financing. The
NCMHs should complete their work by the end of 2003.
2.
The financing strategy should envisage an increase of domestic budgetary resources
for health of 1 percent of GNP by 2007 and 2 percent of GNP by 2015 (or less, if a
smaller increase is sufficient to cover the costs of scaling up, as may be true in some
middle-income countries). For low-income countries, this entails an additional budget
ary’ outlay of $23 billion by 2007 and $40 billion by 2015, of which the least-devel
oped countries account for $4 billion by 2007 and $9 billion by 2015 themselves, and
the other low-income countries the balance. Countries should also take steps to
enhance the efficiency of domestic resource spending, including a better prioritization
of health services and the encouragement of community-financing schemes to ensure
improved risk pooling for poor households.
3.
The international donor community' should commit adequate grant resources for lowincome countries to ensure universal coverage of essential interventions as well as
scaled-up R&D and other public goods. A few middle-income countries will also
require grant assistance to meet the financial costs of expanded HIV/AIDS control.
According to our estimates, total needs for donor grants will be $27 billion per year
in 2007 and $38 billion per year in 2015. In addition, the World Bank and the region
al development banks should offer increased nonconcessional loans to middle-income
countries aiming to upgrade their health systems. The allocation of donor commit
ments would be roughly as follows:
2007
2015
Country-level programs
$22 billion
$31 billion
R&D for diseases of the poor
$3 billion
$4 billion
Provision of other Global Public Goods
$2 billion
$3 billion
Total
$27 billion
$38 billion
The WHO and the World Bank, with a steering committee of donor and recipient
countries, should be charged with coordinating and monitoring the resource mobiliza
tion process. Implementing this vision of greatly expanded support for health requires
donor support for build-up of implementation capacity and for addressing governance
or other constraints. Where funds are nor used appropriately, however, credibility
requires that funding be cut back and used to support capacity building and NGO
programs.
Executive Summary
J9
4.
The international community should establish two new funding mechanisms, with the
following approximate scale of annual outlays by 2007: The Global Fund to Fight
AIDS, Tuberculosis, and Malaria (GFATM), $8 billion; and the Global Health
Research Fund (GHRF), $1.5 billion. Additional R&D outlays of $1.5 billion per year
should be channeled through existing institutions such as TDR, IVR, and HRP ar
WHO, as well as the Globa! Forum for Health Research and various public-private
partnerships that are currently aiming toward new drug and vaccine development.
Country programs should also direct at least 5 percent of outlays to operational
research.
5.
The supply of other Global Public Goods (GPGs) should be bolstered through addi
tional financing of relevant international agencies such as the World Health
Organization and World Bank by $1 billion per year as of 2007 and $2 billion per
year as of 2015. These GPGs include disease surveillance at the international level,
data collection and analysis of global health trends (such as burden of disease), analy
sis and dissemination of international best practices in disease control and health sys
tems, and technical assistance and training.
6.
To support private-sector incentives for late-stage drug development, existing “orphan
drug legislation” in the high-income countries should be modified to cover diseases of
the poor such as the tropical vector-borne diseases. In addition, the GFATM and other
donor purchasing entities should establish pre-commitments to purchase new targeted
products at commercially viable prices.
7.
The international pharmaceutical industry, in cooperation with low-income countries
and the WHO, should ensure access of the low-income countries to essential medi
cines through commitments to provide essential medicines at rhe lowest viable com
mercial price in the low-income countries, and to license the production of essential
medicines to generics producers as warranted by cost and/or supply conditions, as dis
cussed in detail in the Report.
8.
The WTO member governments should ensure sufficient safeguards for the develop
ing countries, and in particular the right of countries that do not produce the relevant
pharmaceutical products to invoke compulsory licensing for imports from third-coun
try generics suppliers.
9.
The International Monetary Fund and World Bank should work with recipient coun
tries to incorporate the scaling up of health and other poverty-reduction programs
into a viable macroeconomic framework.
20
Table 4.
Macroeconomics and Health
Recommended Donor and Country Commitments
(billions of constant 2002 US dollars)
2001 (CMH estimates)
2007
2015
Donor Commitments
Country-level programs:
Least-Developed Countries
$1.5
$14
$21
Other-Low-Income Countries
$2.0
$6
$8
Middle-Income Countries
$1.5 ODA
0.5 Nonconcessional
$2
$2
$0
$8
$12
R&D
of which: Global Health
Research Fund
(<) $0.5
$3
$4
0
$1.5
$2.5
International Agencies
$1
$2
$3
Total Donor Commitments
$7
$27
$38
Least-Developed Countries
$7
$11
$16
Other Low-Income Countries
$43
$62
$74
$93
$119
of which: Global Fund to Fight
AIDS, Tuberculosis, and Malaria
Global Public Goods
Domestic Resources for Health
Country-Level Programs in Low-Income Countries
Donor Commitments plus
Domestic Resources
$53.5
Note: Recommendations are for annual commitments in a global scaled up program. As
stressed throughout the Report, actual disbursements will depend on policy performance
within recipient countries.
World Health
Organization
Geneva
C o oh H -7- .
A Rejoinder to The Report of th®
Sachs Commission on
Macroeconomics & Health
- An Alternative Perspective
N. H. Antia
N. F. Mistry
Foundation for Research in Community Health
Pune
Foundation for Medical Research
Mumbai
December 2002
CONTENTS
Background
3
Poverty the root cause of diseases
6
The role of market forces
9
A brief appraisal of the economic
aspects of Sachs Report
11
Alternatives for Health
13
Tuberculosis
17
HIV-AIDS
21
Malaria
23
Conclusion
25
Selected Readings
28
Background
The Sachs Report compiled by macroeconomists is based on a firm
conviction that all human problems are essentially economic in nature.
Hence their solution lies in the realm of Western economics theory and
consequently of macroeconomists when it comes to solving them on a
world wide scale. Also that the solution, even in a highly personalized and
intensely human field like health can only be solved by the use of Western
f'nedical science. This argument is advanced, regardless of the entirely
different social, cultural, economic conditions and the concepts and
practices evolved by olderand advanced civilizations based on a fardeeper
understanding of human beings and health rather than its failure. This is in
keeping with the arrogance of the West provided by its newly discovered
science which has given it the power to dominate and exploit the rest of the
world to satisfy insatiable material needs and greed. This domination was
achieved through imperialism in the past and now by enforcing a new
economic order under the guise of globalization, liberalization and
privatization evolved at Bretton Woods in 1944 which is equally devoid of
the morals and ethics of civilized society.
Almost three decades earlier, Ivan lllich had foreseen that Western
medicine with its eventual extensions into areas like 'food fads’ and 'body
Linage’ parading under the guise of health, would itself become a new
hazard to human health while providing a lucrative avenue for the
unregulated and uncontrolled market forces of globalized capitalism in an
area where consumer resistance is at its lowest. The demand created for
the most expensive and lucrative aspects of illness care based on fear of
pain and death, or for gratification of sheer vanity is now being assiduously
promoted with the help of the new mass media. This has converted illness,
underthe guise of'health1, into the fastest growing business and industry in
the world today, while ignoring the more important and humane but non-
3
profitable preventive, promotive and basic curative aspects.
In a globalized market place dictated by the sole aim of maximizing profit,
the prime targets are the affluent societies of the West followed by the coopted 'Westoxicated' neo-elite of the newly independent countries who
have become equally affluent by exploiting their own poor. Though small in
proportion, they nevertheless offer a substantial market forthe international
’health' industry. This is regardless of the distortions it causes to the local
health scene with its traditional values, practices and health systems whicl^~
have sustained the majority of the inhabitants of this planet over the
millennia. The last concern is for the poor and their health and well being,
which is conveniently relegated to the level of Primary Health Care.
The Sachs Committee has involved the WHO to provide international
credibility to a highly Westernized medical and technological approach to
what is considered a ’health' report. A WHO which has strayed, under the
increasing pressure of its western donors, from its original Alma Ata
declaration for providing basic health care to all citizens of this world. This
holistic concept of'Health for AH' was enunciated by WHO in 1978 under the
directorship of Dr. Halfdan Mahler(13) who knew the actual problems of
health of the poor in different parts of the world from extensive personal
experience.
Hence it is the original Alma Ata Report with its integrated social, political,
technical and economic understanding of health that should have provided
the guidelines to the Sachs Committee rather than the over-westernized
techno-managerial approach of the present WHO which better suits their
requirements. WHO is an ’international' organization whose senior staff
and experts are chiefly from the West. They are supported by equally
westernized health professionals, bureaucrats and economists from the
’need based' countries in order to provide the necessary international es
4
flavour to this document. Lured by lucrative emoluments they profess to
represent the problems and interests of their countries, including that of the
poverty stricken masses from whom they are both physically distanced and
culturally alienated.
The major flaw of this Report lies in its blatant 'Westcentricity'which denies
all other approaches to the world's health problems. Even worse is its
^dvocacy of a blanket economic and techno-managerial solution restricted
To only three select diseases of their choice. It fails to address the vast
problems of health as a whole, with no concern for the entirely different
social, cultural, political, epidemiologic and economic conditions in different
parts of the world which vary between and even within each country. Yet it is
these factors with the underlying worldwide poverty, with its social problems
and diseases, which have been created by the globalization process which
will ultimately determine success or failure even in the implementation of a
world wide blanket westernized solution devised in Washington and
Geneva restricted to three diseases. Paying mere lip sympathy to these
fundamental socio-political factors has no relevance.
Diseases by and large fall into two categories:
(T.
Communicable diseases chiefly affecting the younger age group as a
result of poverty-a socio-political cause.
b.
Diseases of affluence which affect the aged rich, eg. the degenerative
diseases affecting the physical body and the mental problems affecting
all ages.
Western science with its Cartesian bio-mechanical concept of life fails to
understand the complexity of the human mind and its interaction with the
physical body; leave aside spiritualism with its higher values. And yet this is
5
the essence of most other systems of health such as ayurveda and yoga
which to the West consist merely of an alternative source of non- synthetic
remedies ora form of physiotherapy, both of which can also be marketed as
another 'health' related commodity. The theory and practice of economics
divorced from this complex reality of life can hardly be expected to solve
what are essentially self-created human and social problems.
The attempt to further narrow the vision of health to western technological
solutions for three diseases viz malaria, tuberculosis and AIDS [arid 4_.
course the inevitable family planning for the developing (read 'need
based1) countries] can hardly be expected to have any major impact on
these problems. This has been demonstrated by the failure of population
control programmes even after 50 years of imposing a western techno
managerial solution for an intensely human problem. This only further
disturbs the integrated and holistic approach to health and medical care, an
approach which is inherent in all other cultures and their health systems as
was recognized even by WHO at Alma Ata. This holistic concept of health
was soon converted into a series of Specific Primary Health Care
programmes for individual diseases based on western medical technology
as also for population control under the guise of Family Planning. The
Sachs Report utilizing an even narrower approach of the existing WHO,
advocates additional inputs of money to help provide a mask of concern to
hide the ugly and ruthless face of capitalist greed.
2.
Poverty the root cause of diseases
The failure of health as well as medical care is a part of the overall distortion
of the process of development of the 'need based1 countries not only during
imperialism but even after their gaining independence. The root cause lies
pnmanly in the realm of poverty created as a result of continued systematic
exploitation of the remaining natural resources ofthese countries, even
6"
after the demise of imperialism, by capitalism guided now by the missile of
economics. The report ignores, nay refuses to address itself to this primary
question of poverty and its perpetuation under its economic compulsions.
It only provides lip sympathy to poverty which is of their own creation.
The Sachs Report takes for granted that the poverty of these countries is
now an established phenomenon which should not and cannot be
questioned and must be left to the tender mercies of the 'trickle down'
f eory. Nor does it explain why countries endowed with the greatest natural
and human resources which produced the great civilizations of the world
have also been reduced to poverty. The role of western imperialism, now
perpetuated underthe banner of economic globalization with its ancillaries
of liberalization and privatization is conveniently ignored in this Report as
this would open a Pandora's box.
The strategy for cultural and economic recolonization of the world was
devised at Bretton Woods in 1944 even before the end of the internecine
war fought by the Western powers for each others' colonies. It was for this
thatthetwins, the World Bank the international usurer and The International
Monetary Fund (IMF), the enforcers of conditionalities' after inveigling
these countries into debt, were conceived. This strategy for redomination
of the world and its resources was based on the crudest aspects of human
TOture namely selfishness and greed, the credo of capitalism. Following the
destruction of the USSR (its ally during the war and a country which was
able to provide a remarkable health service to all its people even during the
subsequent cold war), it was realized that this strategy based on cultural
and economic domination would be cheaper and more effective for
exploiting the world's resources than crude military imperialism of the past
which was to be reserved forthe ’non- cooperating' nations.
Trading on the pliability ofthe neo-elite leadership of the newly
7
independent countries has played a cardinal role in this strategy. Won over
by covert and overt bribes and opiated with an affluent western life style,
they have reopened the doors of their countries for exploitation by the West.
They have participated in imposing a capital intensive export- oriented
uroan industrialization mode of development in what have traditionally been
self sustaining and labour intensive agro-industrial economies; all this in
return for a slice of the exported cake. This has also helped to polarize these
societies in the capitalist mode.
ij
There is no better example of this than in the field of health. Bribery and
corruption are integral elements ofthis over-Westernized, over-centralized,
over-bureaucratized, over-privatized and over-medicalized strategy. This
has also facilitated the penetration of multinational corporations in search of
profit, devoid of moral or ethical restraints. Having co-opted the medical
profession, the pharmaceutical and medical instrumentation industries,
which comprise the new medico-industrial complex, is now playing havoc
not only in the 'need based' countries but have increased the cost of
medical care even in the most affluent country like the US to an
unsustainable level. Health insurance, a new entrant in this industry has
further increased the cost of such services under the guise of controlling
cos'ts.
The amoral and unabashed profit oriented western medical system based
on providing curative medicine forthe rich is now being thrust on the need
based
countries as a purchasable commodity ■ regardless of its
appropriateness or relevance. This is not oniy affecting the affluent class
9 adually percolating to the middle class and now even to the poor to
extract even their 'last drop of blood'. The symbiosis between capitalism
P
rty
under imperialism and now under globalization which has
the entire world is too well documented to require reiteration.
8
3.
The role of market forces
The effect of this cannibalistic form of 'development' is at its worst when
such unregulated market forces using mass media have converted human
suffering into a major international business and industry regardless of the
consequences even on the poor who are now being enticed to spend
almost 20% of their meager household expenditure^) on what may be
jmnecessary and even dangerous drugs, injections and doctors. In this
mefarious trade in human suffering, the rich are dangerously over
investigated, over-medicated and over-surgicalized, the middle class
pauperized in imitating their role model, the rich, while the poorest are
sought to be decimated either by a new form of population control based on
western techno-managerial 'fixes' or through affliction with the severest
forms of diseases where affordability for cures is impossible. Examples
from a state like Kerala which has demonstrated the achievment of good
health care through education of its women at far lower cost are almost
always ignored orunderstated.
A human facade is now sought to be provided by the Sachs Committee to
this unwholesome strategy after giving full rein to their multinationals as
also to the public and private health sectors of these countries. A sum of
L’SD 27 billion is now being sought to be raised from the affluent Western
countries for the control of these three diseases of poverty. A hypothetical
and questionable economic cost of saving a human life based on disability
adjusted life years (DALYS), a solely economic concept of life, is utilized to
encourage this form of philanthropy' and charity'. Equally hypothetical
projections are made upto 2025 under the assumption that there will be no
changes and alternative to the present self created grim scenario.
Even worse is the stipulation that funds will have to be raised by the local
governments themselves, by charging fees for services even from those
9
who have already been pauperized by an exploitative private sector under
duress of pain and suffering when all alternatives are denied them. And yet
even the richest countries like the US, are not willing to part with even 0.2%
leave aside 0.7% of its GDP to gain such 'merit'
The Global Health Fund is also proposed to be utilized for research for
producing vaccines and 'enticing' the pharmaceutical multinationals to
produce drugs for these three diseases. Also for employing highly paid
western experts as advisors and monitors forthese programmes. This will"
ensure that a substantial part of this 'generosity' will be recycled to the
donor countries. The political vaccine against poverty which can control if
not eradicate these and many other diseases and social problems is not on
their agenda.
The people all over the world have lived for millennia in reasonable
harmony with each other and with nature in a self sustaining form of
economy by evolving social norms for enabling a stable civilized existence
by curbing innate human greed and violence. This has been the preaching
of all prophets and the wise throughout the ages, which has been
propagated by the word; not by the sword. The present problems that face
the human race, and its very survival, lie not in economics but in the loss of
these well established age old values.
I,
Western science divorced itself from these values when those like Galileo
and Copernicus mistook papal dogma and persecution for Christianity not
understanding the true values as preached by Christ. This science has
therefore alienated itself from its very onset from social and moral values.
Macroeconomics based on the values of this science therefore can only
pander to selfishness and greed and hence cannot provide solutions to
what are basically human and social problems and their associated values.
10
4.
A brie. appraisal of the economic aspects of Sachs Report
The Commission talks about the assurance of funds from recipient
countries for scaling up health interventions. It examines how budgetary
resources can be mobilized for health in low-income countries where
income is least transferable to tax collection leave aside savings for a rainy
day. The Report assumes firstly that on an average the low income
countries must now increase their budgetary outlays on health by 1% GNP
(^and by 2% of GNP by 2005. It further projects that quality health services
can be purchased at USD30-45 per person. These estimates refer to a
rather minimal health system and service that can attend to the major
communicable diseases and maternal and perinatal conditions that
account for a significant proportion of the avoidable deaths in low-income
countries because it indirectly supports their priority of population control.
Nevertheless a recent study undertaken by the IMF suggests that effective
health coverage would require 12% of GNP ofthe low-income countries for
reduction in only infant mortality (4).
Donor support from the G-7 nations is only one ofthe strategies put forward
for health finance reform though most advertised. More insidious is the pre
payment community financing programs supported by charging for
services hitherto provided free by the public health sector in both urban
"hospitals and rural PHCs forthose reduced to poverty. This is presumably
based on the assumption that because of inefficiency together with further
charges by the public sector, the public will be willingly driven into the amis
of the private sector well known for its profit oriented motive. The term
prepaid community financing' is an allegorical reference to the introduction
of private insurance schemes in the health sector, encouraged by the
incentive of a 1:1 augmentation of this scheme by the national government.
Introduction of external insurance will, as experience amply shows, only
drive up the cost of health care which will invariably in the current scenario
11
be both inappropriate and unnecessarily excessive. These are part of the
Bretton Woods strategy of capitalism for globalizing, liberalization and
privatization for the motive of profit regardless of the consequences to the
poorof the world.
A far superior, humane and more cost-effective strategy as utilized by all
socialist countries would be the development of local community-based
self-sustaining health services utilizing local human and financial resources
effectively and augmented by the existing expenditure in the public health I
sector without need for either an exploitative private sector or health
insurance. The cause would be best served if such a community based
health system is firmly in place at the grass roots which can cater to a
majority of health and illness problems as was in China after its
independence. Such a system needs to be supported by inputs in
information, education, encouragement, support and guidance of the
community, which is unfortunately anathema to capitalist thought.
The Report talks about the costs of essential services, but is silent as to who
decides the nature of these services or the guidelines in computing these
costs. The Report’s contents reflect a self-imposed isolation within the
confines of a "Western curative approach" (even neglecting the preventive
and promotive aspects) and not utilizing community resources and
extensive utilization of their traditional practices and advanced systems of
medicine and health care. This needs to be strongly deprecated since it will
render entirely inaccurate any computing of the real cost. There is ample
evidence that good health and medical care is remarkably cheap if divorced
fromthe profit motive and devoid of unnecessary frills.
A countrywise case study is required not only to see the applicability of the
Report's recommendations, but also to define the nature and cost of the
essential interventions that are required to suit their own conditions. The
12
experience of people-based alternatives already documented within many
countries needs study as well as their financial and logistic requirements.
This is also ignored by this Report.
In order to even embark on some of the above mentioned economic
analyses, two factors are as always, incumbent the political will of the
country's rulers and the culture of the country's medical establishment both
indigenous and of foreign origin.
e
5.
Alternatives for Health
In the field of health, as in most areas of human endeavour, it is far easier
and betterto start at the micro end of the scale, for ail life whether fauna or
flora is composed of an aggregate of individual cells which, though
specialized interact, coordinate and cooperate to form the ultimate
structure of all living matter, including homo sapiens. This is the law of
nature.
Health and medical care chiefly concerns the individual, the family and the
local community. Nature has also provided all life with a remarkable immune
system for self protection as also the means for the healing of wounds. This
has ensured our survival long before the advent of modern medicine and
^surgery. Most societies have also established the need of a healthy diet
utilizing locally available foods as also remedies based on locally available
herbs and other natural substances. This has been achieved through
prolonged observation, experimentation and usage. These have evolved
into well established practices and formalized medical systems which by
their very nature are also readily accessible at low cost and in harmony with
nature. Western science has only added to this incrementally.
While each system has its inherent advantages and strengths, it is
13
unfortunate that they invariably fail to integrate for the common good.
Western medicine is no exception. Unfortunately being the system of the
foreign rulers who sought to glorify it as 'superior, it was employed not only
for their expatriates but also imposed
adhoc on the people they ruled.
Unfortunately this also led to ignoring and even denigration of the local
practises and systems, most of which had a more holistic understanding of
life and health, than merely of disease. A philosophy in keeping with the age
old concept oflife and living.
(
Even after India gained Independence, this domination of allopathy with its
high profile formalized structure consisting of medical colleges and
hospitals has continued to dominate the local health scene. The major
reason for its increasing domination has been the result of changing the
human mindset including that of the local elite who have been enamoured
by its glamorous high-tech and high cost curative aspects while ignoring the
farmore useful and cost-effective, preventive and promotive and many of its
curative aspects. It is this dominant local elite who dictate their country's
health policy to suit their beliefs and their newly created western life style
and needs and adopt adhoc policies recommended by agencies like the
World Bank and WHO especially when accompanied by sweetening grants
and funds.
<
While the excessive promotion of western curative medicine of the wrong
type for profit has exponentially increased the cost of medical care, an
appropriate integrated use of the best aspects of all systems (including that
of allopathy) and even of home remedies, diet, life style, health culture,
mental health, traditional practices and spirituality can provide a very
effective promotive, preventive as well as curative health care both physical
and mental at remarkably low cost in a decentralized manner to all citizens
of this world. An integrated approach is becoming increasingly difficult due
to increasingly narrow specialization,in contrast to that of the poor majority
14
for whom it is necessarily so. This has become a part of their age-old
culture.
The Rockefeller Report
Good Health at Low Cost' of 1985 (2) has
documented this for China, Costa Rica, Sri Lanka and Kerala. This report
demonstrates that the prime requirement for achieving Health for All is the
political will as also shown by socialist countries like the USSR, China,
^puba, Nicaragua, Vietnam and Chile (under Dr. Allende). Each of them
have developed in their own way an affordable cost-effective and humane
health care system accessible to all without the need for voluntary
agencies, loans or charity. The commonality of the leadership of all such
countries is the desire to provide health for all rather than wealth for a few.
The Sachs Reports does not even mention the Rockefeller Report as also
the predominance of the political system and its will in achieving real Health
for All as demonstrated by the socialist counties.
While the policy decisions on the type and mode of functioning of health and
medical services are generally centralized in most political systems, their
forms are dependent on the sectorthrough which they are implemented viz.
the public, private, voluntary or the peoples sector. In the socialist countries
the provision of health and medical care is chiefly through the public sector
through in countries like China and Cuba the peoples' sector has played the
dominant role.
In the older and more advanced European capitalist countries, the majority
of health care is still chiefly through the public sector as also in the fields of
education and social welfare. The private sector caters only to a small
population of the elite while the voluntary sector plays only a marginal role.
This is the result of pressure of an educated public. And yet in the most
affluent market oriented capitalist society of the US where the expenditure
on health is over 14.5% of its GDP, 15% of its population finds it difficult to
15
access even basic health and medical care. The majority of their population
has to meet its needs for curative medicine through an excessively profit
oriented private sector.
Unfortunately in the newly independent countries that have chosen to adopt
the US model, under the guise of the representative type of democracy,
over80% of medical care, not only in quantity but even more so in quality, is
monopolized by 15% of the population living in affluent urban enclaves by
depriving 85% of its population that lives in rural areas or urban slums dj
even elementary health and medical care. This is in stark contrast to the
less affluent socialist economics where appropriate health and medical
care are provided to all as a matterof right, not charity.
"n
All this demonstrates that good health and medical care is nowhere as
expensive as made out by profit oriented capitalist societies. And yet it is the
Report of the Joint Indian Councils of Social Science and Medical Science
Research (ICSSR-ICMR) Report of 1981
Health for All : An Alternative
Strategy(3) that clearly defines the social, cultural economic and political
factors that play the dominant role in determining the health of the entire
population in an appropriate and cost effective manner. That this can be
best achieved by the people themselves with their own locally trained
community health workers with graded support by their own trained
functionaries together with a small supportive 'Health Centre’ providing
professional, public health and medical and surgical facilities upto the broad
based specialist level.
This has been demonstrated even in various parts of India as well as other
newly independent countries like Bangladesh, besides that of China and
Cuba on a countrywide scale. This has the inherent advantages of self
interest, ready accessibility and accountability, all at low cost in a highly
labour intensive field which no distant, unaccountable public sector or profit
16
oriented private sector can ever hope to achieve. Its most useful
components are the preventive and promotive aspects which vary not only
from region to region but often from village to village. Such a system has
many other advantages like empowering women while providing
opportunity for large scale employment within the villages at low cost
Though reflected in the WHO Health Forum(13), it is significantly missing in
this Report.
(0ie advent of Panchayati Raj as a constitutionally decentralized form of
governance in India now provides both administrative as well as financial
authority to local communities to devise and operate various rural
development programmes including that of health (8).
The provision of large loans by the Sachs Report for Primary Health Care
through an impersonal, over centralized and over bureaucratized public
health sector with conditionalities that 40% of the loans be used for
constructions, 30% for equipment and 15% for foreign training jaunts to
senior doctors can only further corrupt the public sector with its lack of
accountability to the people and drive even the poor into the arms of the
private sector while increasing their country's indebtedness.
Let us examine how all the three diseases focussed in the Report can lend
memselves to such a people based and people operated system if
integrated with all other social and economic development activities of the
Peoples Sector.
6.
Tuberculosis
Tuberculosis has been one of the largest killing and disabling disease in the
world
for centuries.
It's root cause lies in
poverty. While the
immunocompromised individual suffering from diseases like HIV/AIDS
17
offers it a ready host, far more people die of tuberculosis today than without
HIV/AIDS. Tuberculosis started disappearing from Europe even before the
causative organism was identified and it declined/disappeared even before
drugs and vaccines were available for its prevention and/or cure (7). This
was a result of modest reduction in the alleviation of poverty due to the
'trickle down' effect of wealth extracted from their colon ies.
Resurgence of the disease during the 1939-45 'internecine' war in Europe
for each other’s colonies and its disappearance within a decade of it
termination demonstrates the intimate relationship of this disease with
poverty. Cornia et al in 1988 (1) provided compelling evidence of a direct
association between reduction in health expenditure and health status in 10
countries where World Bank guided financial refonns had been initiated.
Significantly higher morbidities were reported for infectious diseases such
as diarrhoea, pneumonia and tuberculosis. The Amsterdam Declaration of
1999 recognizes that TB is linked more strongly with poverty and rapid
social change than any other major disease. Ninety eight per cent of annual
deaths from TB and 95% of new cases are in the developing countries
facing a dual onslaught of HiV-infection and multi-drug resistant
tuberculosis (MDR-TB). Rising poverty and the ensuing nutritional
deprivation ensures that the action of drugs is less potent and that the
disease may well progress to a drug non-responder state. It is worth noting
than no great interest was shown in this greatest killer disease till HIV/AIDS
came on the scene.
Its present worldwide resurgence in the former colonies is also related to
the increase in poverty as a result of the policy of globalization, liberalization
and privatization which has not only polarized the world at large but also
within each country. It is futile for the World Bank to attempt to control
tuberculosis by refusing to address the root cause which is of their own
making. The promoting of Direct Observed Therapy Stratgey (DOTS) and
18
attempts to produce a vaccine is another western techno-managerial
approach to a problem (as in family planning) when the solution lies in the
social domain namely poverty and lack of education, it is hence bound to fail
and only diverts attention of the people from addressing the root cause
while providing a facade of concern forthe poor.
Even DOTS was designed as a techno-managerial solution based on a tew
teolated experiences with large medical and financial inputs. This can
nardly be expected to succeed when implemented through the same public
and private and voluntary health sectors which have failed to achieve
results in most vertical programmes. These programmes like Family
Planning (population control) can only further corrupt and distort both these
sectors who will be ultimately blamed and further large loans provided to
increase the country's indebtedness. Mere biomedical technical inputs
such as early diagnosis, or drug sensitivity testing or identification of
contacts cannot by themselves affect transmission of diseases precipitated
by socio-economic malaise. Sensitivity of diagnostic tests in India is less
than about 25% both in the public and private sectors and claims indicate
that 30% of patients (probably comprising of problematic cases) are turned
away from treatment centers by virtue of their place of residence or disease
complications or previous history of refractoriness to anti-TB drugs (5). In
|my event such patients will shop for alternative treatment, face several
episodes of disease and eventually die. Even if on the other hand second
line treatment is provided for refractory patients, its efficacy will not exceed
50%, all this at a cost of Rs.2,00,000/- per patient besides additional loss of
time and wages(11). Mismanagement in use of anti-microbials in India
through self prescribing over-counter sales and medical malpractice will
further ensure that primary resistance to even second line drugs will
inevitably occur. The multinational pharmaceutical industry under the
umbrella of the West- are the major culprits for such unethical drug
promotion.
19
Even worse is the evolving of a world economic culture which polarizes the
newly independent countries, increases poverty on one hand and denies
appropriate treatment to those afflicted by its consequences, (eg. second
line treatment for MDR-TB).
The present approach is based on the presumption that people have no
interest in themselves and cannot be trusted to implement such
programmes fortheir own welfare. Yet local village health workers (women
catering to their own neighbourhood as an extended family), have--
repeatedly demonstrated far better results for most health and medical as'
well as social problems. Eady suspicion based on the cardinal symptoms,
especially when they know the local index case, can help them to get the
disease confirmed by sputum examination at their own Community Health
Centre. This would also assure regularity of treatment far betterthan more
highly paid formal government and private sector functionaries.
Local
concern for fellow beings which also protects their own family is a far better
incentive at much lower cost than a distant government paramedic or
primary health care or a profit oriented private doctor. Such a part time
locally resident functionary can simultaneously undertake several other
health and also non health functions if encouraged and supported.
The decision for such a decentralized people based system cannot be
conceived by western experts of WHO orthe World Bank nor by centralized
public or the private sectors of countries who have vested interest in,
maintaining the status quo.
This can only be achieved by the people themselves who seek an order
which serves their own interest. The prevention and control of such
diseases and problems has been demonstrated repeatedly by almost all
socialist regimes (before they too get bureaucratized and centralized) as
also on a smaller scale even in countries like India. Education, awareness
and eternal vigilance is the price for self improvement and safety which can
be best achieved under decentralized people based Panchayati Raj.
20
7.
HIV-AIDS
The acquired immuno deficiency syndrome (AIDS) a condition of
progressive ill health, is the end stage of infection in the human
immunodeficiency vims (HIV). Occupying the centre stage as a significant
i
global public health problem, its original presence in healthy homosexual
men in Los Angeles & New York in 1981 belies the much proclaimed
scientific claim of the African Green Monkey as the origin of HI V. Rather its
appearance is coincidental with the scientific era of the development of
(primitive, ill understood and poorly regulated genomics in the West.
The diversity of HIV spread throughout populations and countries is striking
with prevalences ranging from 10% (Sub-Saharan Africa to less than 1%
(India - 0.8%). Even in the low prevalence countries, the infection
insidiously creeps from high risk groups into the normal population. The
Sub-Saharan Africa region may display spread through high sexual
promiscuity but it is also a region where wars, famines and poverty have
taken a heavy toll in the last fifty years. The perceived value of life in regions
such as these (representative of many areas that exist even in India) is so
cheap that sanctimonious efforts at control such as limiting sexual partners
or use of condoms are poorly valued. Several studies demonstrate that
where death is no stranger and sometimes even a welcome guest, one
harbinger is as good as another(6).
^,'he engendering of such fatalistic viewpoints are favourable when
accession to cure or even simply care is severely limited. The current 'cure'
]
expenditure per day of single and now multidrug therapy ranges from $40 -
$300, a sum whose even minimal limit is out of bounds for a great majority of
the AIDS sufferers.
The accessibility to drugs (or vaccines) however
advanced or effective will remain an insurmountable problem unless issues
of affordability and accessibility are also simultaneously addressed. Whilstexaggerated expectations and the inherently difficult process of developing
and testing a vaccine in poorer countries renders this approach almost
impractical,
the
concerted
rush
by private
(and
public)
industries/organizations of the richer nations to test out several vaccine
21
candidates in various parts of the world represents an intrinsic dangerto the
people of several countries where ethical norms of testing are often non
existent orflaunted.
Accepting the increasing gravity of the spread of AIDS does not preclude
the questioning of the orchestrated hysteria whipped up by governments,
mass media, World Bank, WHO and the technology business complex. In
countries where weak surveillance systems exist, the overall prevalence of
HIV infections is often computed from extremely limited sample surveys by
national agencies. The recent challenge to national prevalence figuresof 4
million in India by The Central Intelligence Agency of the USA (quoting 8
million) is surprising on two counts.
Firstly, the Agency claims to have
obtained its figures from Indian NGOs - a fact hitherto unknown
and
secondly the keen interest of a foreign (covert) security agency in the
disease profile of another country nowand in the distant future.
The increasing projections of AIDS cases in India by 2015 (25 million) and
elsewhere ignores recent findings of a) the reversibility of HIV positivity b)
the increasing proportion of long-term non-progressors (from HIV positivity
to AIDS) for over 25 years. Both of these are indicators of the development
of herd immunity which invariably develops in the natural course of history
of most infections.
The race to produce ever increasing amounts of drugs, vaccines and even
condoms are fatal attractions in the presence of the megabucks that are'
being pledged to AIDS control.
More so because they prevent the
questioning of an insane form of foisted development that renders vast
masses of people, nomads -- be they refugees, unemployed youth turned
drug pushers, truck drivers or migrant labour far away from their own
homes.
The containing of the HIV/AIDS epidemic in the country of its origin, through
education and awareness institutes should be a sobering lesson.
Why
have not conditionalities been imposed by financial organizations on
recipient countriesto promote Education for All and resources (not loans)
22
provided for a subject that not only deserves attention on its own merit but
also confers benefits to many other fields which would also ensure selfsustaining economics for all.
The spread of this disease in the countries forced into urban
industrialization to produce goods forthe globalized elite is a major cause of
the spread of AIDS by destroying their traditional small-scale village based
agro industrial form of development sustained overthe millennia.
P.
Malaria
As stated previously there is no better example of the control of this disease
on a countrywide scale by mobilizing the local population with their inherent
self interest, social skills and local knowledge as was demonstrated on a
country wide scale in India after gaining independence. The clinical
suspicion and even diagnosis of this disease is remarkably simple, as also
its treatment after confirmation by simple microscopic examination of a
finger prick smear of blood and medication with chloroquine followed by
primaquine. All this can be undertaken by training health workers from
within the local community.
Even more important is their ability to mobilize the local community to
control mosquito breeding and spraying of the houses with insecticide. The
role of the medical profession is to train, mobilize and support the local
population; and not converting it into a distant bureaucratic vertical
governmental exercise. All this under the guidance and support of the local
community and its non political leaders.
The malaria control programme in India using such a grassroots approach
had remarkable success with morbidity figures in 1965 touching 0.1 million
cases and no deaths. Thereafterthe incidence started rising and reached a
record figure of6.4 million cases in 1976. Subsequent to the introduction of
a modified plan of control the figure came down to 2 million cases since
when the incidence has been static. While the failure to eradicate the
disease is linked to chloroquine resistance and increase of the falciparum
23
type of infection, the severity of the disease is also clearly linked to
immunocompromised populations and vulnerable groups such as children
and pregnant women (10). Ironically in 1992 a massive 40% reduction in the
national malaria programme was inflicted as a part of the Structural
Adjustment Programme of the World Bank (12).
Furthermore malaria control is intrinsically linked with overall social,
economic and political development. No amount of external financial inputs
into the same vertical government programme which has failed to delive^
the goods and take cognizance of the potential of local community action'
can ever hope to succeed on its own. Nor can scientific inputs like vaccines
or bed nets be sole remedies for a disease which lends itself best to the local
community's own effort. Even these technologies can to a major extent be
utilized by the local community.
Scientific and financial inputs can help to a limited extent if they can reach
the local community; not through a leaky pipe line controlled by vested
interests at every level.
Two larger issues also need consideration - the
rapid emergence of drug resistance of malarial parasites both to pyrethroid
impregnation of bed nets and to newer drugs such as mefloquine to whom
resistance has been seen to develop within one year of its use as in
Thailand.
As a precedent, the international vaccine initiative has proportioned only'
17% for strengthening health systems whereas 83% has been for research'
and production of vaccines. In view of the problem of drug resistance, new
drugs and vaccines will also place new demands on weak health systems.
Seemingly minor changes such as transition of anti malarial first line
treatment from chloroquine to sulphadoxine can take years to achieve or
extensive replanning and evaluation may be required. High value products
in the hands of unethical health workers of the public sector are also likely to
leak into uncontrolled private sector channels.
24
9.
Conclusion
A brief glance through the Reference Section of the Sachs Report reveals
no or minimal documentation by researchers from those parts of the world
which the Report intends to serve. It is therefore no surprise that the basic
premise of the Report stems from a purely occidental viewpoint of diseases
driving the wheel of poverty. The report fails right at the onset in identifying
poverty as the driving force for all disease. It extends its failure further by
assuming that an imposed economic solution on the poor nations of the
^orld will singly wish away disease and ill health without realizing that most
aspects of illness and health care are chiefly the concern of individuals, their
families and the local community who to a defined limit can be given the
appropriate knowledge and skills for their own action in an appropriate
social and political milieu. Traditionally too the poorer countries mostly
representing the ancient civilizations, perceive strong linkages between
nature and health and recognize the strong body-mind relationships which
can be bonded better through spiritual and moral values. These little
traditions therefore have strong abilities to modulate a blind acceptance or
conformism to scientific and technological solutions that are thrust on them.
The Report is undoubtedly a part of the hegemony of a monoculture being
imposed on the world. Its ancestry is derived from the Breeton Woods (of
which the WHO is also a part) credo of a global capture of markets. Its
agenda of health is a part of the monoculture since an excess of science
jnd technology has rendered it market-driven and vulnerable to
exploitation since therein consumer resistance is also at its lowest. The
Report does make a fleeting reference to the common problems of
corruption, nepotism and the struggle between the haves and have nots in
the poorer countries. Yet it hardly draws these severe difficulties into its
analyses. The USD 27 billion which the Report pledges for health can
therefore in the existing scenario only create corruption in the leadership
and distortion of priorities and resources in the poorer countries. By
relegating essential health services to a vague definition and by stressing
on pre-paid community financing, (? a pseudonym for insurance) for
accessing the same, it encourages the relinquishing of responsibility of
25
nat.onal governments and the assuming of a dominant role Of the orivm
sector. Whilst the voluntary sector is a part of the publ- ^e
partnerships, no role has been assigned fora decentralized people's sector
which has the potential for dealing with 70% of preventive, promotive and
curative aspects of health and illness care at the grassroots level (2,8).
The health structure envisaged in the Report, coming as it is from a
neoliberal economic background differs strikingly from the health care
systems of the former socialist bloc and even the United Kingdom where
governments took direct responsibility for all aspects of peoples' health anf
human welfare. The need for a voluntary sector, was obviated, the private
sector, if any, well-regulated and self monitored and health (along with
education) perceived as an inherent right. The expansion of the
pharmaceutical, medical instrumentation and vaccine industries even in
such politically committed countries has driven the cost of health care
exceedingly high and substantially weakened their economies as well as
the quality of their health care. The sole emphasis on commodity-based
control measures of drugs, vaccines, condoms etc as a scientific fiat on
diseases focussed on in this Report will undoubtedly benefit the
pharmaceutical industry and the research centres of the West.
The WHO who should have been the chief guiding light of this Report has
lost its independence and become an appendage of the multinational
pharmaceutical and health industry. It has shelved the original concept of
integrated health as stated in its Alma Ata declaration and now marches to £
different tune. Starved of funds by the affluent countries, it can only raise
USD 1.4 billion from government contributions towards a partial fulfillment
of its annual budget of USD2.3 billion (3a). How it meets the rest of its
requirements is a prudent question.
There is ample evidence which shows that good health care using all
systems of medicine and devoid of the profit motive and frills is
extraordinarily cost-effective. The Report excludes the mention and the
analysis of these examples perhaps since they may pose strong °PP0S 1
to the Report's aims. Almost all countries can provide health care with
26
their existing finances and budgets without need for external loans and
exploitation and disruption provided in the guise of support. Choosing a
health system and embarking on a biomedical research agenda that suits
best its own local conditions and culture is the sovereign right of all national
governments and more so their peoples' -- but do the people even know of
howthese rights areinfringed and by whom.
Compassion is a far more suitable alternative to good health care than is
economics. Nevertheless in the neoliberal era, economics and com
passion make ill bed fellows.
27
SELECTED READINGS
1.
Comia G.A. et al (1988). "Adjustment with a human face. Vol. 1. Protecting the
vulnerable and promoting growth". Country case studies, Oxford Clarendon Press.
t2.
Good Health at Low Cost - Ed. S. Halstead, J. Walsh and K. Wen Conference Report The Rockefeller Foundation, Bellagio, Italy, 1985,
3.
Health for All: An Alternative Strategy Report of a study group set up by jointly by Indian
Council of Social Science Research and Indian Council of Medical Research, 1981.
3a.
Horton, R (1992). WHO's mandate : a damaging reinterpretation is taking place
Commentary. Lancet 360:960.
4.
IMF (2001a) Heavily Indebted Poor Countries Initiative : Status of Implementation
http://www.lmf.org/
5.
Kaul, S. (1998). An Observational study ofRNTCP and DOTS strategy in three districts
(Jan - March, 1998) Voluntary Health Association of India, N. Delhi.
6.
Maun. J. and Tarantola, D., eds. AIDS In the World II: Global Dimensions, Social Roots
and Responses. Oxford, University Press, 1996:616.
7.
McKeown T. 'The role of Medicine : Dream, Mirage or Nemesis'
Nuffield Hospitals
Provincial Trust, London, 1976
8.
People's Health in People's Hands A model forPanchayati Raj Ed. By N.H. Antia and
K. Bhatia FRCH publication, 1993.
9.
Rao, S„ Ramana, G.N., Murthy, H.V. (1997) Draft-Report on Financing of Primary
Health Care In Andhra Pradesh - A Policy Perspective. Prepared by Centre for Social
Services, Hyderabad with support from WHO.
10.
White, N.J. Plorde, J. In: Wilson, J.D. et al (Eds). Harlson's principles of Internal
medicine. New York: McGraw Hill, 1991:782.
11.
WHO Report on Proceedings of 199b. Meetings and Protocol Recommendations. Basis
for the development of an evidance-based case - management strategy for MDR - TB
within the WHOS DOTS strategy. Espinal M. (Ed.) Communicable Diseases. World
Health Organization.
12.
World Bank (1992) India: Health Sector Financing, Washington, DC.
13.
World Health Forum. Health For All by 2000, Vol.2(1 ):3.
28
Foundation for Research in Community Health
3-4, Trimiti-B Apartments, 85, Anand Park, Aundh, Pune - 411007.
Phone : 91-020 588 7020
Fax : 91-020 588 1308
Email: frchpune@giaspnO1.vsnl.net.in
Foundation for Medical Research
84-A, R. G. Thadani Marg, Worli, Mumbai - 400 018.
Phone : 91-22-2493 4989
Fax : 91-22-2493 2876
Email: frchbom@bom2.vsnl.net.in
- Media
EXECUTIVE SUMMARY 2.pdf
Position: 6091 (1 views)