Macroeconomics and Health: an update - July 2003
Country achievements: a summary of progress
Alliance-building and maintenance
WHO is collaborating in interested countries with development partners to enable a national process for macroeconomics and health. In most cases, this will occur within the framework of the Poverty Reduction Strategy Paper (PRSP) and with the aim of achieving the health-related Millennium Development Goals (MDGs). The resulting dialogue builds local alliances, which in turn strengthen country ownership. The process of developing a MHS has coaxed partners into finding common platforms in Indonesia, sponsoring cross-sectoral research in Ghana and creating innovative long-term strategies in Sri Lanka.
MHS work is country-specific and uses existing WHO and country networks to foster strong alliances. Cambodia, for instance, has carefully sequenced the timing of partner and stakeholder engagement. Country work first linked senior Health Ministers with those in Finance and Planning, and then reached out to a broader audience of partners already committed to the PRSP. A different path was taken in Indonesia, which used the South East Asia Regional Parliamentarian's meeting as the vehicle to introduce health to a broad, multi-sectoral audience. Placing improved health and achievement of the MDGs alongside Indonesia's own developmental goals eventually led to the political consensus necessary to make health a priority within the national poverty agenda.
Analyses of country-specific issues and options
Once engaged, senior decision-makers want to know how to localise the Report's findings. Research stimulated by the CMH Report led Rwanda to see the value of placing health into long-term poverty reduction initiatives and thus to merge the MHS process within the PRSP. In Ghana, the National Macroeconomics and Health Commission produced several cross-sectoral technical reports in 2002 and 2003 examining various environmental factors adversely impacting the health of the poor. Research included evaluating access to clean water, analysing distribution of health services and the effect of waste management on health.
Regional Offices are providing support to aid country-level analysis. Recent examples include facilitating development of Regional concept papers in the three WHO Regional offices, supporting a common analytical framework for African member states instituting a MHS, and helping countries to share experiences within and between all Regions.
Marketing and advocacy of successful examples
In Ghana, an analysis completed by the National Commission on Macroeconomics and Health (NCMH) noted that increased investments in service delivery would be ineffective if human resources were not strengthened first. This has prompted new national policies to increase the capacity of human resources. Such country-based analysis of poverty and health relationships allows WHO to further the analytical and strategy development work of the CMH Report.
Methods to market and advocate for the MHS process remain effective, and the range of products has expanded to meet new needs. In China, translating the report and ensuring its wide dissemination and high level political visits succeeded in gaining senior government commitment. As a result, in April 2003 the Ministry of Health and the Chinese Health Economics Institute endorsed CMH follow-up activities and agreed to send senior ministers to the October global CMH meeting.
In Indonesia, the translated Report Summary impacted on the policy discussions within the Consultative Group on Indonesia chaired by the World Bank and the Coordinating Minister for Economic Affairs. A Working Group co-chaired by WHO resulted, creating: 1) a conceptual framework for including health in the development agenda, 2) a three year plan of activities and outcomes, and 3) a costed workplan for the year 2003.
Another important medium for information dissemination will be the upcoming WHO Regional CMH meetings, as well as the global CMH meeting in October. Resources and advocacy products, such as the new CMH booklet, “Investing in Health: A Summary of the Findings of the Commission,” will be shared, country experiences will be recorded, and Region-specific concept papers presented.
As more countries implement a Macroeconomics and Health Strategy, a collection of experiences and lessons are being compiled and posted on this web site.
The CMH Support Unit directly provides seed money and responds to countries' requests for technical support, easing country-specific impediments that constrain development of a MHS. In Ethiopia, placement of a CMH focal point was helpful to the country office, while the WHO Representative in Ghana sees support to rationalize data management within the WHO office as the first priority.
Countries are provided with a range of products and resources developed by the CMH Support Unit to respond to regional and country inputs. As countries move from Phase 1 to Phase 2, support shifts from help in setting up internal coordinating mechanisms to facilitating the development of a needs-based health investment plan. In addition, a pool of experienced technical staff and consultants is being steadily enlarged, ensuring the capacity of the Support Unit to meet future requests.
The Regional Offices of the Eastern Mediterranean, Africa, and South East Asia will contribute to supporting country follow-up activities by holding CMH workshops involving Ministers of Finance, Planning and Health. They, in turn, request and obtain support for efforts related to developing national health investment plans.
Country specific investment plans
On-going technical support is provided via various channels to help strengthen the process leading to a MHS in Phase 1 countries such as Pakistan and Cambodia. The added value of developing a MHS is its distinctive focus on pro-poor health investments. As a country enters Phase 2, a health investment plan will be designed that is capable of channelling new investments into key pro-poor health interventions. Health investment plans are already being developed in Phase 2 countries such as Sri Lanka and Indonesia. Regional Offices will collaborate closely with member states to help ensure that country plans and technical products spring from a thorough, country-led assessment of needs.
Outcomes are tracked on two levels.
Administratively, the CMH Support Unit responds to submitted country and regional requests with technical products and financial support. Overseeing implementation and monitoring achievements of funded submissions are core responsibilities. Budgets submitted for country and Regional CMH-related activities are carefully assessed to see that expenditures are linked to specific outcomes, and that these outcomes are clearly on the critical path to creating a national health investment plan.
At the country level, the Millennium Development Goals (MDGs) provide broad benchmarks to assess progress of poverty alleviation efforts. Three complementary approaches are used to help countries better track their progress. First, the CMH report is used to persuade senior decision-makers to adopt new and pro-poor health polices, which are then linked to achieving the health-related MDGs. Second, workshops, seminars and other mediums are used to foster collaboration between all partners working to implement MDG-related strategies. Third, through provision of resources and products, countries will be assisted in developing their own indicators for measuring progress in implementing the health investment plan as well as the achievement of health-based MDGs.
In the last case, to avoid duplication and unnecessary paperwork, the CMH Support Unit supports streamlined reporting processes, the use of existing information sources and working within each country's monitoring systems. This reflects the broader drive by WHO to secure better coordination and coherence of action among country partners.
Country support and preparations for Phase 3
During Phase 3, countries begin to implement their health investment plans. Decision-makers will need access to additional research as they near the end of Phase 2 so that they can make evidence-based decisions when finalizing the contents of a long-term health investment plan. To assist Phase 2 countries with these decisions, the CMH Support Unit is collaborating with WHO partners, Regions and countries to prioritize topics for research.
Ghana, Indonesia and other Phase 2 countries will provide input into the development of these drafts, sharing their experiences and providing insight into research needs. Each participating country will provide further updates and analysis of its own progress in lifting constraints, which the CMH Support Unit and Working Group will use to update and revise a portfolio of evidence-based courses of action. Country experiences show that development of a MHS is a flexible process adapted to local needs and dynamics. The resulting pro-poor health investment plan links current poverty reduction and development efforts with the health-based Millennium Development Goals.
One Cambodian expert described the relationship in this manner: "While the MDG targets for international development efforts over the next 15 or so years have been fixed, the CMH begins to construct the pathway to attaining these goals." This comment concisely and accurately describes the strategic vision of the CMH Support Unit.