Scaling up investment in health -
Country responses to the Commission on Macroeconomics and Health report
Briefing to Country Delegations and NGOs WHA, 21 May 2003
Chair: Carole Presern, Permanent Mission of the UK to the UN Office and other International Organizations in Geneva.
Speakers: Andrew Cassels, Strategy Unit, Director-General Office; Sergio Spinaci, Coordination of Macroeconomics and Health, Sustainable Development and Healthy Environments Cluster; Bhupinder Singh Lamba, Sustainable Health Policy, WHO Regional Office for South-East Asia; Sarah Barber, WHO Indonesia Office.
Sergio Spinaci reviewed the main implications of the macroeconomics and health strategy, in the light of the increasing attention on health in the context of poverty reduction and economic development debate. Three crucial components of the strategy were highlighted: the focus on the poor, advocacy for more money for health and assistance to countries in removing non-financial constraints to increase health investments for poverty reduction. Bhupinder Singh Lamba and Sarah Barber complemented this briefing with a focus on activities and plans in the south-east Asia region and in Indonesia. During the following discussion, participants, including from countries implementing macroeconomics and health activities, reflected on how the commitment of interested actors had developed and could be further strengthened.
According to the Minister of Health of Bhutan, country specificity and sustainability are key issues. The Bhutanese experience with the Health Trust Fund, mobilizing the majority of resources from internal sources, was mentioned as an example of how a relevant effort to generate internal confidence and alleviate poverty through health should be more consistently supported by donors.
An official of the Ministry of Health of Senegal highlighted the close link between health and economics in poor countries. Thanks to the focus on that link, the Ministry of Health in Senegal have been able to better place health in poverty reduction strategies and its dialogue with the Ministry of Finance. Focus must remain on outcomes: while financial flows are improving, it must also be understood what can be done with limited resources. As also shown in the WHO briefing on health and poverty in the morning [the Bolivia case], more studies should be done on poor countries that significantly succeeded in improving health for the poor without substantial inflow of external funding.
The representative from the Ministry of Health, Sri Lanka, agreed on the importance of looking at sustainability. Based on the beginning of the experience of the Sri Lanka national commission on macroeconomics and health, the following needs emerge at country level: 1) clarity on funding sources for investments in health; 2) awareness of interlinked effects of macro/micro factors on health and poverty; 3) better integration of other players, particularly the World Bank, into the macroeconomics and health framework.
David Woodward, development economist, said that the two-way linkages between health and economic development were well known, but that the CMH report focused disproportionately on the link from health to development. The linkages from the macroeconomy to health were also critically important, as indicated in the presentation on Indonesia; and WHO had done some important and groundbreaking work on this area in the early 1990s, although this appeared to have been discontinued. He asked what work WHO envisaged on the link from economic policies to health, both at the country and the global level.
The World Bank highlighted that external support is only a fraction of overall resources for health and the importance of: 1) a framework that ensure sustainability by integrating external and internal funding sources; 2) reform of health systems as a way to make pro-poor interventions sustainable; 3) better data, including costing studies.
The People Health Movement, Tanzania, referring to the Indonesia presentation, asked for clarification on the ongoing “structural reforms” [reply by the presenter: system changes, ex. financial decentralization], because in many countries structural adjustment has shown to rather have a negative impact on health and poverty, among others by increasing unemployment and taxes.
The Royal Tropical Institute, Amsterdam, highlighted that action for health cannot be externally driven and that countries play a central role in harmonizing the various competing demands and initiatives on health and poverty.
The remarks of the Ghana Minister of Health focused on the impact of the macroeconomics and health approach on the country’s policies for health, which had switched from “doing good” to recognizing the “economic imperative” of investing in public health. Thanks to this approach the Ministry of Health was in a position to agree with the Ministry of Finance upon a substantial increase in budget for health (for 7 to 12%).
In her concluding remarks, the Chair recognized that the debate was clearly highlighting, among others, the need for donor discipline in approaching health for economic development.
Andrew Cassels summarized the main messages from the debate in a few points:
- high value of the CMH report as a political and advocacy tool, aimed at raising the interest of decision makers, at global and country level, in the need for health investments for the poor;
- the macroeconomics and health agendas put forward by countries were broadening, and issues related to constraints and health systems were becoming central;
- sustainability and, related, “predictability” were key issues;
- poverty reduction strategies did not seem to suffice to effectively integrate health in poverty reduction mechanisms, a more articulated and framed approach to health and poverty was needed;
- the macroeconomics and health strategy was not acting as an additional initiative among others, but rather using existing mechanisms, to be put together at country level, for a better focus on health for the poor;
- consideration still needed to be paid, in a broader picture, to the effects of the macroeconomics environment on health and poverty.