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MILLENNIUM DEVELOPMENT GOALS: HEALTH Devi Sridhar, ASSOCIATE FELLOW, CENTRE ON GLOBAL HEALTH, CHATHAM HOUSE, FELLOW, ALL SOULS COLLEGE, OXFORD Lawrence Gosti

Carng About Health

Health is at the heart of the Millennium Development Goals, but has the world got its spending priorities right? Vast sums go to defence, bank bailouts, or even sport; health funding is much more scarce.
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n, PROFESSOR, GLOBAL HEALTH LAW, GEORGETOWN UNIVERSITY, FACULTY DIRECTOR, ONEILL INSTITUTE FOR NATIONAL AND GLOBAL HEALTH LAW

HE HEALTH COMMUNITY HAS BEEN

arguing over whether one health area is more deserving than another. Various initiatives have been competing for a limited pot of funds based on debates about how their cause will contribute to progress on the Millennium Development Goals (MDGs). We need to take a step back and start asking a different set of questions that look at priorities beyond health. Money is central to improving health. The World Health Organization estimates that basic health services cost around $40 per person per year, and about one third of the worlds people live in places with low national incomes where this cannot be provided, even with proper taxation. Until countries can finance their own efforts, the funds need to come from the international community as part of its responsibility for improving global health. How does health compare to other world priorities? While the estimated $22 billion devoted to international development assistance for health is extremely welcome, this level of funding is a small fraction of what high-income countries spend outside the health sector. For example, the international community allocates $1.5 trillion annually to military expenditure 2.43 percent of global gross domestic product (GDP) and $300 billion for agricultural subsides. High-income countries spent $11 trillion on bank bailouts, and over $1 trillion on the wars in Iraq and Afghanistan. South Africa, a transitional economy, devoted $1.7 billion to World Cup football. Global priorities are reflected at the national level. India is the largest recipient of external health funding, having received over $1.6 billion from the World Bank and another $500 million from the Global Fund. While this can be justified given the huge burden of death and disability, a closer look at the governments budget reveals that it spent over $40 billion on defence last year. A similar story can be told for China, the tenth largest recipient of external health funding which spends, officially, $80 billion on defence; and for Brazil, the fifteenth largest recipient, which allocates $20 billion to defence.

SUCCESS IS POSSIBLE
Critics allege that money makes little difference to improving health. Two countries identified as better performers in health are Rwanda and Mexico. What lies behind their success? Rwanda, despite being one of the poorest

countries in the world, has provided national health insurance for an estimated 92 percent of the population. The New York Times reports that the scheme, known as health mutuals, includes a premium of two dollars a year which includes basic healthcare and treatment for the major causes of morbidity and mortality: diarrhea, pneumonia, malaria, malnutrition and infected cuts. In addition, local health centers usually have all the medicines on the WHOs list of essential drugs and laboratories that can do routine blood and urine analyses, along with tuberculosis and malaria tests. Since introducing the national health insurance, life expectancy has risen despite HIV/AIDS and maternal and child mortality fallen. Who pays for the healthcare? The two-dollar premium does not cover the cost, which is around $10-20 per head. The Rwandan government has relied on external donors, primarily the US and the Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria, to cover 53 percent of health spending. When asked by the New York Times about the rationale for the scheme, Dr Agnes Binagwaho of the Ministry of Health said, Solidarity you cannot feel happy as a society if you dont organize yourself so that people wont die of poverty. Mexico, in contrast, has relied on a social protection scheme to improve health using a conditional cash transfer programme, initially called Progresa and now known as Oportunidades. Its main goal is to increase the basic capabilities of extremely poor people in rural areas. To do this, it provides monetary incentives direct to families to help overcome financial barriers to health service use and schooling. But this is conditional: mothers only receive the funds if their children attend health clinics and schools. The mastermind behind the programme, Santiago Levy, noted, Compared with giving a kilo of tortillas or a litre of milk as we used to in the past, Progresa delivers purchasing power. But even poor parents must invest in their childrens futures, thats why the strings are attached. Since it was introduced in 1997, the scheme has reduced morbidity and stunting and increased school enrollment. The Mexican government initially paid, but as it rolled-out to cover five million families, it has had to take loans to cover the budget which was around $1 billion in 2000. In 2008 costs reached $3.8 billion, or 0.2 percent of GDP and twenty percent of the federal budget. Of course, donors give health funding strategically, to influence governments by promoting democracy, or for geostrategic
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advantage, for example. But this raises questions regarding donor motivation behind providing foreign aid for health, despite altruistic rhetoric. For example, while the US government has launched the Presidents new Global Health Initiative (GHI) which provides $63 billion over six years focused around fifteen countries GHI-plus selected for good governance and results, the budget for the next financial year shows that only $100 million has been given to the GHI-plus countries, while Afghanistan, Pakistan and Iraq receive 64 percent of the foreign assistance budget, a total of $7.8 billion.

C R U CI A L C O M P O N E N TS
What are the five crucial components of success? The government, with major partners and international assistance, must ensure adequate resources; the public sector must assume leadership for providing and coordinating services; the host country, down to the local level, must be responsible for policies, programmes, and services; and health must be integrated across all sectors. Most importantly, success can be achieved only through an effective social contract within society that redistributes wealth from the richest to the poorest, as in Mexico, and provides health security for all, as in the case of Rwanda.

B AS IC R IG H TS
Ultimately, improving health and reaching the MDGs comes down to a social contract within countries, between the rich and the poor, and among nations. To mean something in practice, this contract needs to be institutionalised at the domestic level, through schemes such as universal health insurance or conditional cash transfers, and at the global level in a common agreement on roles and responsibilities in global health, such as a Framework Convention on Global Health. This is why governments legislate domestically and the WHO governs internationally. The global health system is currently organised in a fragmented, uncoordinated, and inefficient way with initiatives arranged around diseases. We need to move towards an integrated approach focused around basic rights, such as a Framework Convention on Global Health: http://ssrn.com/abstract= 1014082. This kind of agreement would empower Ministries of Health and guide

governments on how to improve health. It would focus on three areas: HEALTH SYSTEMS AND SERVICES The WHO sets out six essential building blocks of a well-functioning health system: health services; the health workforce; health information; medical products, vaccines, and technologies; a financing system that raises sufficient funds for health and ensures access; and leadership and governance. Health systems provide basic health care primary, emergency, specialised care for acute and chronic diseases and injuries and public health services look after surveillance, laboratories, and response for all citizens. ESSENTIAL DRUGS, VACCINES AND TECHNOLOGIES The WHOs Model List of Essential Medicines, includes the most efficacious, safe and cost-effective medicines for priority conditions. They are selected on the basis of current and estimated future public health relevance and potential for safe and cost effective treatment. Vaccines and medicines can be highly cost effective in treating common infections and chronic diseases. Other essential technologies, including medical devices and procedures, may also offer good value. BASIC SURVIVAL NEEDS Reframing the approach to global health requires a shift in national and international health funding and activities in the direction of basic survival needs, a traditional public health strategy essential to maintaining and restoring human capability and functioning. These needs include sanitation and sewage, pest control, clean air, potable water, diet and nutrition neither under- nor over-nutrition and tobacco and alcohol reduction. This type of agreement, similar to other international agreements would institutionalise the social contract, a type of global social health insurance in which all states work together towards a common goal. A treaty such as a Framework Convention on Global Health requires a broad global consensus. We are embarking on a Joint Learning Initiative for National and Global Responsibilities for Health to seek international consensus around broad health arrangements to meet the needs of the worlds least healthy people and close health gaps between rich and poor: http://www.acslaw.org/node/16479. It will lead to an overarching, coherent, framework for shared national and global responsibilities for health, and concrete strategies for global health beyond the MDGs.

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