Macroeconomics and health
BMJ 2002; 325 doi: https://doi.org/10.1136/bmj.325.7355.53 (Published 13 July 2002) Cite this as: BMJ 2002;325:53All rapid responses
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We wish to comment on two separate yet related issues raised in
editorials on international health1,2,3. Firstly, the scheme for
international fellowship is a welcome step towards building capability, it
is doubtful that this will help generate good quality actual data from the
low-income countries on effects of interventions, which is so desperately
required. We fear that the scheme of fellows chosen from national
ministries or regional leaders will create yet more health expert/
bureaucrats rather than researchers. We think that an equal immediate
emphasis needs to given to encouraging good quality research in the
context of low-income countries to inform policy rather than relying on
experts estimates.
The second issue relates to the need to understand the links between
international health and global security. Evidence from high-income
countries suggests that shame chronic anxiety and insecurity associated
with low status is related to violence, the very psychosocial factors that
have been implicated in ill health4. However, so far there is little
evidence that this is related to violence between. Little is know about
how these factors interact in low-income countries. These require
investigation in this context, first, to confirm these findings in low-
income country populations, and second, to examine their role in mediating
aggression between high and low-income populations of the world.
Dr Ilyas Mirza, Locum Consultant in Adult Psychiatry, The Royal
London Hospital (St Clement’s), 2 (a) Bow Road, London. E3 4LL.
Dr Amina Tareen, Specialist Registrar in Child and Adolescent
Psychiatry, Northgate Clinic, Edgware Community Hospital, Burnt Oak,
Edgware. HA8 0LD.
References:
1. Morrow R H. Macroeconomics and health. BMJ 2002; 325: 53-4.
2. Smith R. A time for global health. BMJ 2002: 325: 54-5.
3. Berwick D M. A learning world for the Global Fund. BMJ 2002; 325: 55-6.
4. Wilkinson R G. Health, hierarchy and social anxiety. Annals of N Y Acad
Med Sciences 1999; 48-63.
Competing interests: No competing interests
Editor –It is shocking to discover that Southern Norfolk primary care
trust (population 200,000 with a budget of £147 million)has a
Higher health spend than Uganda (per capita health spend US$ 8 for a
population of 22 million)1.
The report 2. does deserve support but I suspect it will not be
implemented due to lack of funds, I await the USA putting forward their
funds so the prime minister can follow the lead.
Having chaired a primary care group for three years and now the executive
committee of a primary care trust, I am very aware of the effects on a
health economy of centrally dictated targets with increased funding.
Professor Morrow questions whether least developed countries have truly
functional health systems. I wonder if we can claim to have a functional
health system ? We are increasingly investing for short term targets that
have little or no evidence base and questionable health gain. We are left
with no effective funds for local priorities that can empower
collaborative working with key stakeholders to deliver long term health
gain. So far there has been no shift in the balance of power.
Reading this report, written almost entirely by high flying academics and
economists (of 89 participants I could find one from sub Saharan Africa
who had worked at the coal face of health care) I am struck by the
similarities of target setting and centralised control over funding. I am
concerned that this will fail to empower the countries to deliver
sustainable health improvement so desperately needed. The pre set
conditions to be targeted might respond better to political and economic
reform in the gift of G8 nations, this would leave the least developed
nations the self determination to use the additional funds for long term
sustainable health improvement appropriate to the local need. Again I see
no shift in the balance of power.
1.Wendo C,Uganda hopes funds will bring long-term
progress.Lancet2002;360;66
2.World Health Organisation.Macroeconomics and health;Geneva;WHO,2001.
Dr John Sampson. General practitioner.
Heathgate surgery
Norfolk
NR14 7JT
woodton@easynet.co.uk
Competing interests: No competing interests
In two recent editorials, Morrow (1) and Smith (2) discuss the CMH
'Macroeconomics and Health' report. Morrow criticizes it for weak
technical underpinnings, but mis-interprets the derivation of some of the
evidence used. As the co-chairs of the CMH Working Group 5,which was
responsible for the analysis of interventions, constraints and costs, we
would like to comment on how the CMH conclusions were derived.
The report does not assume the existence of functional health
systems. The cost analysis took into account the considerable cost of
building up the necessary health system infrastructure to achieve high
coverage of a set of priority interventions. Moreover, the report of
Working Group 5 (3, 4)specifically addresses what can be done in countries
where health systems and government effectiveness are very weak. Although
the report agrees that the whole set of activities recommended cannot be
done in countries without a functional health infrastructure, it does not
take the pessimistic view that nothing can be done. Polio eradication is
just one example of an approach that can succeed even in highly
constrained environments.
Morrow suggests that in place of normative estimates, actual data
from poor countries on both effects and costs should be used. But the
identification of the priority interventions was based on extensive review
of the major causes of avoidable mortality between rich and poor
countries, and evidence on the effectiveness of interventions against
HIV/AIDS, tuberculosis, malaria, childhood diseases, malnutrition,
maternal conditions and tobacco use. The cost calculations were based as
far as possible on country specific estimates of target populations and
existing coverage levels. Unit costs were drawn from an exhaustive search
for unit cost data from 83 low-income and African countries. Methods used
were independent of those of the World Health Report 2000. Background
papers of the intervention reviews and methods were subject to peer
review, and are available at www.cmhealth.org/wg5.htm.
Smith’s editorial appropriately raises some of the tough questions
facing the global community in fighting disease and poverty. We fully
agree that there is uncertainty in estimating the impact of health on
economic returns (5). However, there is little doubt that poor health is
an important dimension of poverty (6). Global goals of poverty reduction
must include focused action against the relatively few causes of excess
mortality among the global poor.
Yours sincerely
Anne Mills, Professor of Health Economics and Policy, London School
of Hygiene and Tropical Medicine, Keppel St, London WC1E 7HT
Prabhat Jha, Canada Research Chair of Health and Development
University of Toronto, Toronto, Ontario, Canada, M5B 1W8
References:
1. Morrow RH. Macroeconomics and health BMJ 2002; 325: 53-54.
2. Smith R. A time for global health BMJ 2002; 325: 54-55.
3. Jha P, Mills A Improving Health of the Global Poor, The Report of
Working Group 5 of the Commission on Macroeconomics and Health, Geneva and
London, London School of Hygiene and Tropical Medicine, 2002 (available
at http://www3.who.int/whosis/cmh/cmh_papers/e/pdf/wg5_summary.pdf)
4. Jha P, Mills A, Hanson K, Kumaranayake L, Conteh L, Kurowski C, Nguyen
SN, Cruz VO, Ranson K, Vaz LM, Yu S, Morton O, Sachs JD. Improving the
health of the global poor. Science. 2002 Mar 15;295(5562):2036-9.
5. Alleyne GAO, Cohen D Health, Economic Growth and Poverty Reduction.
The Report of Working Group 1 of the Commission on Macroeconomics and
Health, Geneva, WHO, 2002 (available at
http://www3.who.int/whosis/cmh/cmh_papers/e/pdf/wg1_summary.pdf
6. World Bank “Voices of the Poor”, Washington DC: Oxford University
Press for the World Bank, 2001
Competing interests: No competing interests
There has been an incredible explosion in population in the Transkei
and Zululand as I have observed having visited and worked there
intemittently since I first left the country forty years ago. I did not
see any evidence to support the common view of AIDS, and my visit included
seeing every adult and paediatric patient in the Charles Johnson Memorial
Hospital in the shadows of Isandalwana. The poverty is as far as I could
see a consequence of the birth abd illegitimacy rates exceeding the job
growth rate.
Providing food for famine relief in Malawi and Zimbabwe and investing
in healthcare in Southern Africa will compound the problem unless bith
rate is not just contained but reduced relative to the economic growth
rate. The equation, therefore, is far more complex that you would have us
believe. Is not investment in education the priority in conditions where
the only hope that people who survive have is for their childrens' future?
Competing interests: No competing interests
Increased funding for health in the developing countries is important and necessary.
It is heartening that poor health has been endorsed as a major
contributor to poverty demanding an increase in the funding for health in
the poor / developing countries by the World Health Organisation(WHO) and
there is support for this(1). This is especially important in view of the
current definite trend towards budget cutting and privatisation in the
developed as well as in the developing countries(2,3). Cost cutting rather
than provision of adequate health services has been the emphasis in most
countries despite the recognition that good health is necesssary for
economic development. Taking cue from the developed nations (which have
different needs and aspirations)or sometimes due to international
pressure(as in the case of Structural Adjustment Procedurtes, SAPS)many
developing countries have embarked on privatisation reforms(2). The
returns from these reforms in the developing countries(that have different
health, social and economic environment) has been qeustionable. As high as
40 to 55 percent of the population in the developing countries live in
absolute poverty(less than a dollar a day)(4). Housing, water suply,
sanitation, living and literacy standards are low for the vast majotrity
and populations are faced with a dual load of communicable and non-
communicable diseases.
Under these circumstances, where populations may be
unable to pay, it is not surprising that people (despite having a true
need for health care) "delay treatment, borrow money, make less use and
eventually suffer more and pay up more" even if thay have to pay for much
subsidised "user fees"(5). Though efforts have been made in some instances
to guard the poor and exclude essential health services in privatisation
reforms, more often than not, these sections have been affected leading to
worsening in the health situation, productivity and the economic
development in the developing countries(2).The WHO recommendation for
scaling up of "essential services for all" is appropriate and necessary
and is going to cost much. The amount of spending on health in the
developing countries (average 1.1 percent Gross Domestic Product GDP in
South East Asia and 1.7 percent GDP in Africa)(4)is grossly inadequate.
The limited economy in the developing countries makes it even harder for
these countries to increase allocations (though a way has to be found).
International aid has helped and is helping developing countries to
improve their health situation. As identified(1), though developing
countries may not have as much skills in managing large increases in
funding, better strategies for fund utilisation and monitoring are being
developed(6), and are likely to improve with experience, and
this(inadequate skills) should not be a deterrent to the developed nations
from funding health care in the developing countries.
References:
1.Morrow RH. Macroeconomics and health BMJ 2002;325:53-54.
2.World Health Organisaton(WHO). Evaluation of recent changes in the
financing of health services. Report of a WHO study group.(Technical
Report Series No.329) Geneva, WHO,1993.
3.Zwi BA, Brugha R, Smith E. Private health care in developing countries:
If it is to work it must start from what users need BMJ 2001;323:463-464.
4.World Health Organasation(WHO). World Health Report 1999:Making a
dirfference WHO, Geneva,1999:90-119.
5.Ensor T, Sau BP. Access and payment for health care:The poor in Vietnam.
Int J of Health Planning and Management 1996;2:69-83.
6.Deptartment of Health and family Welfare, Government of West Bengal(HFW
GOWB). Referal manual, West Bengal Health Sector Development Program. HFW
GOWB kolkata.1997.
Competing interests: No competing interests