PHA-Exchange> THE REPORT OF THE COMMISSION ON MACROECONOMICS AND HEALTH: A SUMMARY CRITICAL APPRAISAL

[Lynette Martin]

THE REPORT OF THE COMMISSION ON MACROECONOMICS AND HEALTH:  A SUMMARY CRITICAL APPRAISAL

Professor David Sanders
School of Public Health, University of the Western Cape, South Africa, 
Civil Society Member of SCN Steering Committee


"The world community has within its power the capacity to save the lives of millions of people every year and to bolster economic development in the world's poorest countries."  (CMH, p.21)

This is the stirring first sentence of the Report of the Commission on Macroeconomics and Health, sometimes referred to as "the CMH" or "the Sachs Report" - after its Chairperson, Professor Jeffrey D. Sachs of the Centre for International Development at Harvard University.  The opening passage continues:  "This Report describes a strategy for achieving these goals by expanding investments in the health of the world's poor.  Our conclusions are substantiated by extensive research and consultations undertaken during the past 2 years, especially by the work of six Working Groups, which in total produced 87 background studies and six synthesis monographs to be published by the World Health Organization". (CMH, p.21)

The Commission established six working groups on:  health, economic growth, and poverty reduction;  international public goods for health;  mobilization of domestic resources for health;  health and the international economy;  improving health outcomes of the poor;  development assistance and health. 

The Commission was set up by the Director-General of WHO to "assess the place of health in economic development".  

KEY FEATURES OF THE CMH
The central argument in the Report is that better population health will contribute to economic development.  The Report devotes significant space to analyzing the "channels of influence from disease to economic development".  In essence it argues strongly that better health creates economic growth which in turn creates health.  There is, indeed, significantly greater emphasis placed on the contribution of health to economic development than on the contribution of underdevelopment and poverty to ill-health.

The Report then demonstrates that the resources available for health care in low-income countries are insufficient to meet the challenges they face.  It is proposed that donor finance will be needed to bridge the financing gap.  Three mechanisms for raising these additional resources are proposed:  debt relief, through the Poverty Reduction Strategy Papers (PRSP) process, and through discount pricing of Pharmaceuticals. (Legge, p.1)

Other key features of the CMH are the identification of a particular set of disease priorities, especially communicable diseases, and a corresponding set of health interventions.  It also proposes a set of principles for health system development such as subsidized community-based financing, universal access and close-to-client (CTC) service strengthening, and categorical or vertical approaches to particular diseases.  

The CTC level, which is accorded highest priority, consists of "relatively simple hospitals", health centres, health posts and outreach services.  CTC services will be staffed predominantly by nurses and "paramedical" staff with supervision from doctors.  The health centre is identified as the key site for uncomplicated births, and for most             personal prevention, diagnosis and treatment of common priority diseases e.g. childhood infections, T.B., malaria, STI's and counseling and testing for HIV as well as administration of nevirapine to reduce the risk of mother-to-child transmission.

To circumvent the problems of "limited capacity within health systems" a "vertical" or categorical approach is proposed for HIV/AIDS, malaria, TB and "perhaps other specific conditions".  Such approaches, including childhood vaccination, are singled out for their past success and for "the concentration of expertise and commitment that drives (them)." (CMH Working Group 5, p.57)

NUTRITION IN THE CMH

Together with communicable diseases and tobacco-related disease, malnutrition is briefly mentioned as a "primary target" in the Sachs report.  However, in the Report of Working Group 5, "Improving Health Outcomes of the Poor", just over two pages are devoted to malnutrition which is identified as a key contributor to childhood mortality.  Breastfeeding, complementary feeding, improving micronutrient intake, treatment of malaria and intestinal worms and targeted supplementary feeding are identified as key interventions.

STRENGTHENING HEALTH SYSTEMS AND IMPROVING CAPACITY

The CMH acknowledges that "in some of the world's poorest countries, the coverage of many basic interventions is falling" (CMH, p.46), including attended deliveries and vaccination coverage.  It notes the urgency of "building new physical infrastructure, increasing the numbers and training of health sector personnel, and strengthening management systems and capacity" (p.64), with the highest priority accorded to the CTC level.

The report summarises in five categories constraints to increasing coverage.  At the health services delivery level "shortage and distribution of appropriately qualified staff, weak technical guidance, programme management and supervision"  (CMH, p.70) and inadequate supplies of drugs, equipment and infrastructure are all implicated.  The main report deals with capacity in a somewhat peremptory fashion, referring to "increasing the numbers and training of health-sector personnel, and strengthening management systems and capacity" (p.64) as well as to the need for strong community involvement and trust in the CTC system.  The Report of Working Group 5 goes into more detail, recognizing the need to both increase numbers of trained workers as well as skills.  It proposes that categorical programmes (e.g. vaccination, tuberculosis control) are often key sites for strong technical training, but acknowledges that such programmes can have a disruptive impact on the health system unless priority is given also to promoting social mobilization and inter-sectoral collaboration.  (CMH, Working Group 5 Report, p.66).  Management strengthening through training and mentored implementation and the improvement of information systems are noted to be important components of health system strengthening in the Report of Working Group 5.

STRENGTHS OF THE REPORT.  
The key strength of the Sachs report is the clear message it gives of the health crisis facing poor countries.  It emphasizes the widening gap in health experience between rich and poor countries, the rapidly increasing and intolerable burden of ill-health affecting the poor, especially in Sub-Saharan Africa with deepening poverty and the devastating HIV/AIDS epidemic.  

The key recommendation of the CMH Report is that "the world's low and middle-income countries, in partnership with high-income countries, should scale up the access of the world's poor to essential health services, including a focus on specific interventions."  (CMH, p.4)

WEAKNESSES OF THE REPORT
As David Legge has observed:  "The Commission relates its findings and recommendations to the crisis of legitimacy of the prevailing regime of global economic governance."  He notes that on page 15 the Report states:  "With globalisation on trial as never before, the world must succeed in achieving its solemn commitments to reduce poverty and improve health."

Legge notes that "the message for the governors of the World Bank, the leaders of the G8 and the members of the Paris Club is simple:

·	The health situation in many developing countries is insufferable;
·	These countries do not have the resources to provide basic health care;
·	Poverty and ill-health contribute to social and global instability;
·	Globalisation is on trial (indicted on the grounds of poverty and health and under threat through social/global instability);
·	Increased funding for health care in low income countries must be found through debt relief and increased aid."  (Legge, p.3)

Yet, notwithstanding the Commission's recognition of the mutually reinforcing strong links between ill-health, poverty and poor health services and the context of globalisation, there is no attempt to critically analyse the current regime of global economic governance and regulation.  It is striking - and disappointing - that the Commission carefully avoids any explicit interrogation of currently dominant macroeconomic policies or of the structures and mechanisms which entrench developing country disadvantage, ill-health and deteriorating services.  For health and the health sector, these include the WTO - dominated by the rich and powerful countries - and its conventions regulating trade in both commodities and intellectual property, the latter being exploited as patent rights by the transnational pharmaceutical corporations and placing many essential drugs beyond the economic reach of many poor countries.  Similarly, the new GATS (Global Agreement on Trade in Services) convention, which threatens privatization of public services, including health, is not mentioned.  Thus, while the CMH concludes that the current global economic dispensation is not generating sufficient resources for poor countries to address their basic health needs, it avoids any analysis of or suggested response to such systemic discrimination against the world's poor.  Instead, it notes the recent declines in official development assistance (ODA) and concludes that the rich governments, the banks and pharmaceutical corporations must provide the necessary ODA, ensure debt relief and provide discounts on pharmaceuticals so that basic health services can be funded.  To use a medical metaphor, the CMH focuses on palliative care rather than on primary prevention or active treatment of global inequity and its effects.  

PRSPs are recommended by the CMH as the main mechanism through which ODA is directed to strengthen health systems.  Yet PRSPs are an integral component of the current regime of global economic governance and include such reforms as reduced public spending on social services, including health!

Another weakness of the Report is the limited recognition it accords to social factors in shaping population health.  This leads to an overwhelming focus on health sector interventions and, within those, vertical programmes.  For nutrition this is of concern, given the increasing recognition that nutrition programmes require for their success efficacious technical inputs embedded in broader social processes involving communities and other sectors.

CONCLUSIONS

The Report of the CMH is likely to be influential given the high profile of the Commissioners, the weighty composition of its Working Groups and its endorsement by WHO.  Its description of the global health situation and of health systems in poor countries, as well as its key recommendations are strongly reminiscent of the central thrust of the World Bank's influential 1993 Report, "Investing in Health", which also emphasized the point that health is a major input to economic growth, but also studiously avoided any critical engagement with the global macroeconomic architecture which continues to generate economic growth accompanied by deepening inequalities.

A decade has elapsed since that influential global health policy document was published and promoted.  Yet in poor countries, particularly Africa, poverty has deepened and the health situation has further deteriorated, and health systems and their capacity have declined.  It is difficult to avoid asking the question:  "Why should things be different this time?"






BIBLIOGRAPHY

·	Commission on Macroeconomics and Health (2001).  Macroeconomics and Health:  Investing in Health for Economic Development.  Geneva, WHO

·	Commission on Macroeconomics and Health (2002).  Improving Health Outcomes of the Poor, Report of Working Group 5, Geneva, WHO

·	Legge, David, Globalisation on trial:  World Health warning, preliminary comment, 13 June 2002, School of Public Health, La Trobe University, Australia.




Prof David Sanders/Lynette Martin
School of Public Health
University of the Western Cape
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Bellville, 7535
Cape, South Africa

Tel: 27-21-959 2132/2402
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Cell: 082 202 3316