A high level WHO commission has warned the rich world that unless there is a dramatic increase in development assistance for health the legitimacy and stability of the current regime of global economic governance may be seriously threatened.
The WHO Commission on Macroeconomics and Health (CMH) was established by the Director-General of WHO in January 2000. The Commission was chaired by Professor Jeffrey Sachs of Harvard. It members and helpers included former ministers of finance, people from the World Bank, the International Monetary Fund, the World Trade Organisation, the United Nations Development Program, the Economic Commission on Africa and the Organisation for Economic Cooperation and Development. The Commission was financially supported by the Bill and Melinda Gates Foundation, the Rockefeller Foundation and the UN Foundation and by the governments of the UK, Luxembourg, Ireland, Norway and Sweden. The CMH presented its final report to Dr Bruntland in December 2001.
The Commission set up six working groups, on: health, economic growth, and poverty reduction; international public goods for health; mobilisation of domestic resources for health; health and the international economy; improving health outcomes of the poor; development assistance and health.
WHO Director-General Dr Gro Harlem Brundtland welcomed the report of the WHO Commission on Macroeconomics and Health on December 20th 2001: "This report is a turning point," she said. "It will influence how development assistance is prioritized and coordinated in the years to come."
The Commission’s report is an important health policy statement. It may prove to be as significant as the 1993 World Bank Report, Investing in Health , in providing a ‘credible’ policy narrative proclaiming concern about the health of the poor while reconciling health development objectives with the continuing operation of a brutal and unfair global economic regime.
It is a difficult report to analyse. The argument is tortuous and selective in its use of evidence. For example, despite its commission about the relations between macro economics and health, there is no reference in the whole report to the population health progress of Cuba which has not been as closely integrated into the global economy as most developing countries (see Lobe, 2001). There is one reference only to Kerala where it is suggested that the excellent health outcomes achieved there may have been due to the adequacy of the water supply (page 122).
In places it stretches fact, logic and credulity to the point of combustion. More challenging is the task of interpreting the strategic purpose of the DG in commissioning the report and that of the members of the Commission in framing their presentation. It is clear that the report is meant to be read at several different levels.
It is a big report and is accompanied by dozens of working group reports. There is a lot of material to absorb and consider. This raises questions about how Third World governments, health activists, NGOs and academics might respond to the report.
This commentary is prepared as an initial contribution to (what I hope might develop as) a collaborative process of analysis involving health activists, practitioners and academics associated with the struggle for health in the Third World. We may not be able to match the resources available to the Commission but through an internet collaboration we can draw upon a wide range of expertise and experience in considering the Commission’s report and participating in the wider discussion which will unfold. (See accompanying notes about how this internet collaboration might operate.)
This commentary has three parts. In the first part I summarise the broad argument presented in the report. In the second part I discuss this argument exploring some of their assumptions of fact and movements of logic. Finally I explore the politics of the report; what is the subtext; what are the hidden messages; what were the strategic purposes and expectations of the DG and of the Commission?
This is a preliminary commentary, explicitly designed to stimulate a wider discussion and more broadly based analysis of the report. I am looking forward to hearing what other critics think about the report. I have not read all of the working papers and my judgements should be understood as tentative at this stage.
1. Editorial
2. Equity in Health
In an important step by the World Health Organization (WHO), the international health body is granting official WHO relations status to Infact, the US-based corporate accountability organization. In approving the admission of Infact and INGCAT (the International Non Governmental Coalition Against Tobacco), the WHO's governing board noted both organizations' advocacy work in support of the Framework Convention on Tobacco Control (FCTC). With a 25 year history of challenging life-threatening abuses of giant corporations, Infact will bring its corporate accountability expertise into its formalized relationship with WHO.
As if asbestos was not enough, 72-year old Gideon Mkhonto may soon find himself worrying about the financial health of the company that made him sick. Mkhonto is one of 7500 South African asbestos victims anxiously waiting for hard-won compensation from London-listed Cape Plc, which used to mine asbestos in Northern Province and Northern Cape. His problem is that Cape the company might not survive long enough to pay him the R55000 he is expecting.
On December 18 the first report was presented from a new study of the prevalence of drug-resistant HIV in U.S. patients in early 1999.1 This study found that somewhere between 50 and 78 percent of these patients (depending on how you count patients whose viral resistance could not be measured) had some degree of reduced susceptibility to at least one antiretroviral. White, gay, middle class, insured patients had the most resistance, on the average, while those with less access to care had less. The national press eagerly picked up that story; and when we got home from the ICAAC conference in Chicago where the preliminary report was presented, we found that people all over the country had heard it -- and little else from the conference. A closer look shows that while the study results are valid (though not as surprising as they might appear), the central messages that carried the press story appear to be misinterpretations -- ones that could have future consequences for society's political will to deal with the HIV epidemic, both in the U.S. and abroad.
The provincial health department has appealed to communities to take particular care against contracting cholera as another 260 new cases of the disease were reported. KwaZulu-Natal has battled a cholera outbreak since August 2000, with 108687 confirmed cases reported and 235 deaths related to the disease recorded.
Report from the chair of the Commission, Professor Jeffrey D. Sachs, to Dr Gro Harlem Brundtland, Director-General of the World Health Organization.
A drastic scaling up of investments in health for the world’s poor will not only save millions of lives but also produce enormous economic gains, say experts in a landmark Report presented to the World Health Organization (WHO). A group of leading economists and health experts maintain that, by 2015–2020, increased health investments of $66 billion per year above current spending will generate at least $360 billion annually. About half of this will be as a result of direct economic benefits: the world’s poorest people will live longer, have many more days of good health and, as a result, will be able to earn more. The other half will be as a consequence of the indirect economic benefits from this greater individual productivity.
At a recent landmark conference in South Africa, 50 prominent health care providers, public health researchers, policymakers and representatives of technical agencies from around the world issued a call to action in support of advancing the role of midlevel health care providers in menstrual regulation and safe abortion care.
KwaZulu-Natal premier Lionel Mtshali on Thursday remained resolute that the anti-retoriviral drug Nevirapine would be made available to HIV-positive pregnant mothers in the province's state hospitals.
The Commission on Macroeconomics and Health is a collaborative effort led by eighteen of the world’s leading economists and policymakers from academia, governments, and international agencies to assess the place of health in global economic development and offer a new strategy for investing in health for economic development, especially in the world’s poorest countries. The Commission is a crucial part of the World Health Organization’s (WHO) strategy to meet the challenge of assembling and analyzing the evidence linking health status and poverty reduction. In this regard the Commission is a source of advice and analysis for WHO and the broader development community on the relationship between health, economics, and poverty reduction and will communicate its findings to policy makers in national governments and in development agencies. This document provides an overview of the CMH purpose, composition, and activities during the period January 2000 to October 2001.
POVERTY cannot be reduced in the current environment where HIV/AIDS prevalence is high, a Ministry of Finance report to the World Bank has stated.
THE Central Board of Health (CBoH) has placed North-Western and Western provinces on alert following an outbreak of a wild polio virus among refugees entering Zambia.
3. Human Resources
G. Goldstein, R. Helmer, M. Fingerhut
WHO, African Newsletter on Occupational Health and Safety, Volume 11, December 2001.
Conditions at work, and especially occupational health and safety have improved substantially during the past few decades in many parts of the world. But the overall global situation remains poor. Working conditions for the majority of workers do not meet the minimum standards and guidelines set by the International Labour Organisation (ILO) and the World Health Organization for occupational health, safety and social protection. As an example the majority of the world’s workforce is still not served by competent occupational health services. As a result the global burden of occupational disease and injury remains unacceptably high, on a par with the burden from malaria. Yet occupational health programmes receive only a tiny fraction of the resources devoted to combating malaria.
Zimbabwe's unemployment rate is set to reach an unprecedented 70% in 2002 due to company closures, labour economists said this week. The economic analysts said that it was imminent that failure by the economic stakeholders labour, business and government in creating opportunities to stimulate industrial expansion would lead to increases in unemployment.
4. Public-Private Mix
Governments and donor agencies increasingly recognise the need to provide protection for the poor against income fluctuations or livelihood shocks. In this context, ‘social protection’ is an umbrella term covering a range of interventions, from formal social security systems to ad hoc emergency interventions to project food aid (e.g. school feeding, public works). This paper synthesises current thinking and evidence on a number of issues around the design and impact of social protection programmes, including: the case for and against targeting resource transfers; alternative approaches to targeting; what form resource transfers should take (cash, food, agricultural inputs); the ‘crowding out’ debate; cost-efficiency of transfer programmes; whether these programmes meet the real and articulated needs of their ‘beneficiaries’; impacts on poverty and vulnerability, and fiscal and political sustainability.
5. Resource allocation and health financing
Ellen Verheul, Wemos, the Netherlands <ellen.verheul@wemos.nl>
Mike Rowson, Medact, UK <mikerowson@medact.org>
Only 11% of the global health budget is spent in the low- and middle- income countries, where 84% of the global population lives. 1,1 billion people do not have access to clean water. 2,4 billion people lack access to sanitation. One third of deaths in developing countries are due to preventable and/or treatable conditions.
The purpose of this report is to consider the legitimacy of the assumption that communities or societies with more unequal income distributions have poorer health outcomes. The report presents a critical review of the existing international literature on the relationship between income, income inequality and health, in terms of conceptual approaches, research methods and the policy implications drawn from it. The report also offers some guidance for judging between policy priorities based on the relative importance of income inequality versus other potential causal factors in determining population levels of health. An overview of the potential relationship between income, income inequality and health is set out, followed by a discussion of the methodological and technical issues required to explore these links.
Joseph S. Coyne, DrPH, PhD, Health Policy and Administration Program, Washington State University, Spokane.
Peter Hilsenrath, Department of Health Management and Policy, School of Public Health, University of North Texas Health Science Center, Fort Worth.
Comparative studies have been part of health services research literature for decades. The benefits of these analyses include documenting how the more successful practices can be adapted in another country. Such has been the case in France, where many US health care delivery practices have been adopted in market reforms.
The World Health Organization (WHO) studied the health systems of 191 countries for its World Health Report 2000. The study is provocative and has stimulated significant analysis of the structure and performance of health systems. We examine the variables and methodology used by the WHO to measure efficiency and performance of health systems.
Vicente Navarro, MD, PhD, DrPH
Director of the Public Policy Program jointly sponsored by the School of Public Health of The Johns Hopkins University
The major criticisms that can be made of the WHO report are conceptual and methodological in nature and can be made for each of the components (effectiveness, responsiveness, and fairness) of the single indicator of performance used in the report. Regarding effectiveness of health care, for example, the WHO report assumes erroneously that health care is the primary force responsible for the decline of mortality and morbidity in both developed and developing countries. That assumption is evident in statements such as "[If] Sweden enjoys better health than Uganda—life expectancy is almost exactly twice as long—it is in large part because it spends exactly 35 times as much in its health systems." Not surprisingly, the report concludes that what is needed to eradicate disease in less-developed countries is a greater investment in health care: "with investment in health care of $12 per person, one third of the disease burden in the world in 1990 would have been averted." Such statements reveal a medicalization of the concept of health that is worrisome and surprising, coming as it does from the major international health agency of the United Nations.
6. Governance and participation in health
Community Working Group on Health and TARSC. Editors: M. McCartney and R. Loewenson. November 2001
The story of the first years of the Community Working Group on Health in Zimbabwe, describing how the CWGH surveyed and met with over 20 membership-based community groups across Zimbabwe in 1997, to identify the major community concerns about health, and to devise effective strategies for dealing with them. Providing a concise and comprehensive overview of the issues facing the health sector in Zimbabwe, problems associated with community participation, and a discussion of the best strategies for community based advocacy and action.
We are organizing a People's Summit, the G6B Conference to be held just prior to the G8 meeting in June, 2002 in Calgary, Canada. The People's Summit will address issues of global importance. In researching HIV in Africa for the People's Summit, we are requesting information regarding the following:
* What are the areas of interest for your organization?
* Can you provide us with specific information in the areas of your work regarding HIV in Africa?
* Are you interested in collaborating with the People's Summit Conference?
* Can your organization join the Conference? Are you able to fund the participation of a delegate to the Conference? We are looking for experts in this area to join a Health Committee Panel during the Conference. Do you know of any such persons who would be suitable for this?
More information on the G6B Conference can be found at the website.
7. Monitoring equity and research policy
COHRED, Geneva, 2001
This learning brief is based on a paper which reviews the literature assessing how research impacts on policy, and how policy draws on research. The paper provides insight into the various modes of advocacy that researchers can adopt, methods of communication and dissemination they can use, and a number of new lessons about knowledge utilisation.
As part of the lead up to the October 2000 International Conference on Health Research for Development in Bangkok, the Council on Health Research for Development (COHRED) called upon its associates around the world to reflect on achievements and setbacks in the 1990s. This book is the result of those reflections. In Forging Links for Health Research, a team of international experts record the important lessons of the past decade and suggest what must be done in the research arena to ensure a healthy future for all. It follows up on the landmark publication Health Research: Essential Link to Equity in Development (Oxford University Press, 1990) and is unique in its combination of evocative human stories and expert insight from international health researchers. Forging Links for Health Research will be of interest to academics, researchers, students, and policymakers in public health, epidemiology, health sciences, international health, development studies, and international affairs; professionals in donor organizations, development organizations, and NGOs worldwide; and concerned citizens, particularly health-care workers, interested in international affairs and Third World development.
Research into Action is COHRED's quarterly Newsletter. Some of the articles included in this issue are:
* Bali meeting confirms establishment of the Asian and Pacific Forum for Health Research
* Latest steps towards the establishment of the African Health Research Forum
* Prioritised health research in support of health systems development in Mali
* Global health studies based on local realities.
8. Useful Resources
The EQUITY Project is a joint Project between the Government of the Republic of South Africa and the United States Agency for International Development (USAID)/South Africa. The mission of the EQUITY Project is one of collegial empowerment building capacity in the Eastern Cape Department of Health that assures a dynamic, responsive, sustainable and equitable health system with full participation of all people of Eastern Cape based on the global principles of primary health care. Copies of the following documents are available free of charge from the EQUITY Project by phoning Cathy or Melissa on (040) 635 1310 or writing to: Management Sciences for Health, P O Box 214, Bisho, 5605. Many of the publications can also be downloaded in PDF format from the website.
ISEqH will launch the International Journal for Equity in Health by Spring 2002. This will be a peer-reviewed, electronic journal under the auspices of BiomedCentral (www.biomedcentral.com). Articles published in the journal will be cited in PubMed. The purpose of the journal will be to further the state of knowledge about equity in health, defined as systematic and potentially remediable differences in health across populations and population groups defined socially, economically, demographically, or geographically.
This 12-page booklet provides a general description of Ipas and its worldwide activities in training, research, advocacy, distribution of reproductive health technologies, and information dissemination. It includes highlights of Ipas programs in Africa, Latin America and the Caribbean, Asia, North America and Europe, and at the global level. The brochure also articulates Ipas's vision of, and leadership in, a global initiative to mobilize commitment and resources at all levels to improve the quality and accessibility of abortion care in the context of comprehensive reproductive health care, to ensure sustainable access to reproductive health technologies, and to create social and policy environments that support women's reproductive health and rights. Hard copies are available free of charge.
A new website dedicated to science, technology, and development was launched in London, UK on
Dec. 3, 2001. Called SciDev.Net, the site aims to be both a source of information and a forum for the exchange of ideas of relevance to the developing world. Two prestigious journals, Nature and Science, are backing the initiative and will give free access to selected articles each week. In addition, a network of correspondents will bring news about scientific and technological developments in the South to a global audience. Its broad objective is to help empower individuals, communities and decision-makers in developing countries, in particular by increasing their ability to ensure the effective contribution of science and technology to public health and economic well-being in an environmentally sustainable way. An integral part of the website will be a series of 'dossiers'. These will bring together various types of material - ranging from short news items and opinion articles to authoritative 'policy briefs' - on key topics at the interface between science, technology and society, with a particular focus on the relevance of these topics to developing countries.
The TB Information Guide, Version 2.0 CD-ROM is now available with updated content and improved usability. The CD-ROM provides ready access to education and training materials, major CDC TB guidelines, Morbidity & Mortality Weekly Reports, surveillance reports, slide sets, and publications ordering information.
9. Jobs and Announcements
International Society for Equity in Health (ISEqH) would like to remind everyone that the due date for abstract submission for the ISEqH international meeting is JANUARY 28, 2002 Instructions and other information about the meeting, including applications for financial assistance, and about the Society are on the website. The Conference theme is Equity: Research in the Service of Policy and Advocacy for Health and Health Services. June 14-16, 2002 - Toronto, Canada.
The Lancet is looking for experienced journalists to write for their news pages. They are particularly interested in hearing from health policy writers with a biomedical background and 5-10 years experience on a national newspaper or newswire service. They are only interested in hearing from writers from Africa. Contact Haroon Ashraf with a CV and four recent examples of your work including news and features.