Macroeconomics and global heath: ten years past and future
At the turn of the millennium, a Commission established by the World Health Organization (WHO) concluded that health is a creator and pre-requisite of development. With spending on global health rising from $6 billion to $30 billion in the last 10 years, Jimmy Whitworth examines progress over the last decade, and future directions for global health and research.
The Commission on Macroeconomics and Health was established to assess the contribution of health to global economic development. The central theme of its highly influential report [PDF 546 KB], presented to the WHO in December 2001, was for increased global spending for health: universal coverage for priority interventions, national state guarantees for increased health spending, and the scaling up of funding for global health research and development to tackle the diseases of the poor.
The Commission made a strong business case for health financing showing that improved health is a means to economic growth. The report showed that increased resources for health could save 8 million lives a year by 2010 at a cost of US$27 billion a year – and that the resulting increased productivity would yield US$186 billion a year. Put simply, they argued that extending the coverage of health services and a number of critical interventions to the world’s poor could save millions of lives, reduce poverty, spur economic development, and promote global security.
Under the recommendations made in the report, richer governments were to commit to allocate 0.7 per cent of their gross national income to development assistance and poorer governments were to spend $34 per person on health. Few of either group have actually done this, but over the last 10 years spending on global health has increased from around $6 billion to $30 billion. Is this due to the Commission or to other new institutions and initiatives – including the Millennium Development Goals, the Bill and Melinda Gates Foundation, the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR), and the Global Fund to Fight HIV, Tuberculosis and Malaria? This is a matter of some debate, but it is undeniable that the Commission has made a substantial contribution.
The Commission focused particularly on communicable diseases, for which there is more scope for low-cost and high impact interventions, on developing public–private partnerships for health, and for private financing. In the future, we will need to grapple more with the prevention and treatment of chronic diseases (which requires a greater focus on effective health systems); streamlining the plethora of narrowly focused public-private partnerships and increasing their funding base; and ensuring the central role of public financing of health, with private and third sector agencies playing a supporting and collaborative role – history tells us that all the major triumphs in global public health have been driven by public services.
The Commission did not really tackle the social determinants of health (e.g. education, water and sanitation) and yet the majority of global health problems stem from a combination of poor social and economic policies, unequal global trade policies, and inequity between and within countries. They also did not look at international trade, external aid or the need for pro-poor policies. There is also the need to look at economic growth through an environmental lens – is such growth sustainable, and what are the impacts on climate change and nutritional resources? For the future, there is a need to widen the focus to take all these different factors into account. This includes a greater emphasis on prevention and response to natural emergencies and humanitarian disasters.
In light of the economic downturn we currently find ourselves in, what are the prospects for the future? Apart from the broader macroeconomic and health agenda outlined above, there will also be need for greater scrutiny of priorities, greater efficiency in the use of resources and in health systems.
The shortfall in funding for the Global Fund to Fight AIDS, Tuberculosis and Malaria in 2011 is salutary. The Fund is essentially the brainchild of the Commission and the largest international funder of programmes to treat tuberculosis and malaria, and second to PEPFAR for the treatment of HIV. Under $12 billion has been pledged, well short of the $20 billion required, or even the $13 billion needed to continue existing programmes. The shortfall in funding has meant that the Fund has cancelled all new projects until 2014 and will need to curtail some existing programmes. This threatens the tremendous gains made in recent years – rates of tuberculosis, malaria and HIV are coming down around the world. It also threatens the lives of millions of people in endemic countries. While reforms are needed at the Global Fund – they have promised new risk-management approaches, better internal governance, new grant-approval processes, strengthened decision-making, a results-driven approach and a transition from emergency to sustainable platforms – this shortfall of funding should be a source of shame to the world’s richer governments.
In Africa, there are specific issues. There is a disproportionate burden of mortality and morbidity, poverty and malnutrition on this continent. Yet there has been huge change in the past 10 years, with a surge in democracy (17 national elections in 2011), and in economic growth (over 10 per cent in Ghana and Ethiopia in 2011). This increase in economic growth, while developed countries’ economies shrink and external aid is falling, means that they will probably need to become more self-sufficient, which is a good thing. There is also the advantage of a great increase in connectivity, which could revolutionise health service delivery using e-health and mobile-health innovations.
Improving health systems is going to be key to improved health in the coming decade and the increased attention to this is gratifying. In 1985, an influential book, Good Health at Low Cost looked at successful health systems in China, Costa Rica, Kerala and Sri Lanka. The authors identified three key things needed to improve population health: equitable access to health care, universally accessible education and adequate nutrition. A new book, Global Health at Low Cost: 25 Years On [PDF 5.6MB], was published this year. In the new edition, the authors focused on the key determinants of successful health systems in Bangladesh, Ethiopia, Krygystan, Tamil Nadu and Thailand. They concluded that successful health systems need a strong foundation of political commitment, leadership, effective and stable bureaucracy, and a degree of economic development allowing for infrastructure, economic growth, information technology and resources for the system (in other words, the link between health and wealth is bidirectional). They found that successful systems were equitable, pro-poor and with a focus on quality and acceptability of services. There also needs to be resilience in the system to cope with shocks and threats through the flexible use of resources, including health workers, and by embracing and testing innovation. They also emphasised the importance of collaboration between different sectors (not just health), active linking of public, private and third sectors, and wider social development and female empowerment.
So what is the Wellcome Trust’s stance on all this? We welcome the increased focus on global health, having supported research on tropical diseases for 100 years (since Henry Wellcome himself first ventured to Khartoum, Sudan). But we are concerned that the fruits of the research that we fund are not translating into interventions and saved lives, and that this may get worse with the current economic downturn. We need to work ever more closely with other institutions, such as the MRC and DFID, to develop effective initiatives for research funding. We will need to focus more strongly on supporting research into health policy and systems in the future to ensure increasingly effective use of scarce resources. And we need to ensure that our focus extends beyond the traditional communicable diseases, into chronic diseases, as well as climate change, nutrition and the environment, as enshrined in our 2010–20 Strategic Plan.
Dr Jimmy Whitworth is Head of International Activities at the Wellcome Trust.