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And here I thought it was poverty which led to poor health... - SM

http://bmj.com/cgi/content/full/325/7355/53

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Collections under which this article appears: Medicine in Developing Countries International health

BMJ 2002;325:53-54 ( 13 July )

Editorials

Macroeconomics and health

Despite shortcomings the plans in this report deserve strong support

Macroeconomics and Health, a provocative report from the World Health Organization, is a dramatic call for action from both rich countries and poor countries.¹ The report emphasises the linkage of avoidable disease to poverty and argues that investments in health are fundamental to and perhaps a prerequisite for economic development. The report proposes a massive increase in funding for health in the poor countries, with a fivefold increase in support from wealthy countries and at least a doubling from the poor countries themselves.

The key recommendation is for the world's poor countries to work in partnership with high income countries to scale up their health systems to provide access for all to a limited number of essential health interventions. Although emphasising the partnership of the poor with the rich, the report is primarily an advocacy document addressed to the donor nations. It requests the high income countries to resolve "that lack of donor funds should not be the factor that limits the capacity to provide health services to the world's poorest people."

The argument that poor health in and of itself is a major contributor to poverty and that relatively small investments in health could lead to dramatic improvements in health and development, though hardly new, is coherently and eloquently expressed. It should not be cynically dismissed as an unrealistic and ineffective giveaway.

The arguments are well articulated, but the technical underpinnings are weakalthough six working groups developed 91 background reports over 24 months. The technical components of the report include the role of poor health in the production of poverty, the strategy of scaling up essential interventions to all (particularly for infectious disease controlHIV and AIDS, malaria, and tuberculosisnutrition, and maternal health) largely through what is termed "close to the client" services (basically what had been called primary health care in the Alma Ata declaration), the costs to scale up the interventions, the health gains to be expected from these, and the economic development and income returns from these health gains.

The evidence linking poor health to poverty or, more positively, better health to economic growth, is strong. But the report itself points out that further research is needed to establish a causal role for improved health.

The estimated incremental costs for the poor countries to scale up the essential interventions to all, and the estimated resulting gains in healthy lives, would seem reasonable if applied to ongoing, truly functional health systemsbut these are rarely found among the least developed countries. To overcome the constraints faced by the majority of least developed countrieswell outlined in a paper²will require enormous political and social reforms before meaningful investment in the health system and the complementary infrastructure for education, transport, and communication can take place. The unlikely feasibility of any useful investment in countries without a functional health infrastructure is not discussed.

The numbers used are based on expert estimates about what should be able to be accomplished and draw heavily from estimates assembled by WHO's global burden of disease group. Scepticism about such numbers in the aftermath of the WHO Report 2000 are inevitable.³ The use of such normative estimates points to the need for actual data from the poor countries both on effects of interventions and on their costs.

The economic development and the income gains from effective implementation of the essential interventions in the poor countries are asserted without any obvious empirical basis. The basis for the statement that a disability adjusted life year (DALY) gained is worth at least an average annual income per head is not at all evident. Economists normally count the marginal wage in less developed countries as zero since rampant unemployment and underemployment are the norm.

Although the estimated fivefold increase in funding from donors required to support the scale up is only 0.1% of the gross national product of donors, it will be a major political challenge in most wealthy countries, especially the United States, to obtain a fraction of this amount. But the real problems lie with the poor countries, most of which lack the capacity to carry out the planning and management that such a large increase in resources would entail. The report acknowledges that the poor countries must provide strong political leadership, initiative, mobilisation, and organisation with appropriate community governance and accountability mechanisms. To obtain funds each country must establish a national commission to develop a comprehensive and realistic blueprint for the use of increased funds, and the report outlines a series of tasks that must be carried out for this to happen. But a major weakness is that criteria, standards, and mechanisms for judging the blueprints and for monitoring their implementation are not discussed. Presumably these will be established soon; donors should require them before committing funds.

Despite the technical shortcomings of the report, the plans laid out for a partnership of the rich and poor countries to provide the resources greatly to scale up essential health interventions to all deserve strong support and immediate action from us all.

Richard H Morrow, professor of international health. 

Department of International Health, Johns Hopkins University, Bloomberg School of Public Health, 515 N Wolfe St, Baltimore, MD 21205 USA

© BMJ 2002
 

PDF of this article Email this article to a friend Respond to this article Read responses to this article See related This week in BMJ item Other related articles in BMJ PubMed citation Related articles in PubMed Download to Citation Manager Search Medline for articles by: Morrow, R. H Alert me when: New articles cite this article

Collections under which this article appears: Medicine in Developing Countries International health

This article has been cited by other articles:

• Smith, R. (2002). A time for global health. BMJ 325: 54-55 [Full text]  

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