WHO’s Global Health Programs vs Independent Initiatives
By Jeremiah Norris
At Alma Ata, Kazakhstan, in 1977, WHO was charged with a new program initiative, “Health for All by the Year 2000” (HFA). Broadly, its aims were to “bring health within reach of everyone in a given country. By ‘health’, it is meant a personal state of well being, not just the availability of health services. [it implies] A state of health that enables a person to lead a socially and economically productive life.”
Subsequently, bilateral and multilateral agencies, as well as numerous non-governmental organizations, supported its goals and funded them extensively from that date through 2000 with billions of donor dollars. In 2001, WHO published “Macroeconomics and Health: Investing in Health for Economic Development” (MH). It was written by an impressive list of Commissioners, headed by Prof. Jeffery Sachs, then with HarvardUniversity, and funded at $2.5 million by WHO. The basic thrust of this new initiative is a formulaic expression: “expanding coverage for essential health services to the world’s poor through scaling up resources, poverty would be reduced, economic development accelerated, and global security advanced. This could save at least 8 million lives each year by the end of the decade, and assuming that each DALY saved “gives an economic benefit of 1 year’s per capita income of a projected $535 in 2015, the direct economic benefit … would be $186 billion per year, and plausibly several times more”.
A critical component of HFA was Multisectoral Planning, in which WHO would engage all line ministries in its global effort. It re-emerged in MH as a recommendation for the formation of National Macroeconomic Commissions, co-chaired by ministries of finance and health. There isn’t any public record of these Commissions having been formed. MH is completely absent of any references to HFA in the main text, in Appendix I listing the Commissioners; their Biographical Sketches; or Reports and Working Papers; or Appendix 2; or References; or even in the Glossary!
It calculated an economic benefit for the 8 million lives saved annually by essential health interventions. The Commissioners walked away from the downstream implications by making an assumption that those saved would go on to a life of suspended animation, free of noncommunicable diseases (NCD) and the costs associated with them. Once a child makes it beyond age 5, the unerring arrow of a costly NCD morbidity will strike somewhere along life’s path. Not much else in healthcare is certain. This is.
WHO never published a final report on HFA. This would have generated a wealth of ‘lessons learned’. Applied to the Commissioners 2001 work, this valuable resource could have substantially grounded its proposal in a legitimacy otherwise difficult to obtain.
Notwithstanding the lack of progress on these two initiatives, the 2005 World Health Assembly resolution and the 2012 UN General Assembly resolution supported the concept of Universal Health Coverage (UHC). Proponents of this concept believe that universal health coverage means “that people should have access to all the services they need, of good quality, without suffering financial hardship when paying for them”.
A key financial barrier to this coverage is co-payments by patients. At the 66th World Health Assembly in May 2013, the President of the World Bank said: “anyone who has provided health care to poor people knows that even tiny out-of-pocket charges can drastically reduce their use of needed services. This is both unjust and unnecessary”.
His statement was in contravention to the Bank’s report of 20 years ago, titled: “Investing in Health”. It proposed the implementation of user fees, a policy which was adopted by many Member States. It is also contrary to WHO’s ranking of Members on healthcare. In every category, “Singapore is either the very best in the world or near the very top. Its out-of-pocket healthcare costs are the highest in the world”.
The predominant form of health financing in most developing countries is in their private sectors. Out-of-pocket payments include co-payments for those covered by health insurance plans, government retirees under medical care through social security-type systems (it is 65% of total public health expenditures in Bolivia), and private health plans. Their removal under UHC would require approval from ministries of finance, causing them to impose additional sources of funding for public health via new taxes.
Alongside these two global initiatives, other programs were launched independent of direct WHO management. Two of the largest are PEPFAR (the President’s Emergency Plan for HIV/AIDS, TB and Malaria) launched in 2003 with a $15 billion grant from the U. S. It was renewed in 2008 with an additional grant of $53 billion. It works closely with the Global Fund to Fight HIV, TB and Malaria, “which in its recent replenishment was able to obtain $18.9 billion in new pledges”. Together, these two organizations expect to have 10 million AIDS patients under ARV treatment by the end of 2013. For the first time in the global fight against AIDS, the number of new infections has declined.
Rather than leading the way forward on global health, the two WHO initiatives followed past remedies: pour in money and stir. Money was used as a product for consumption when experience informed PEPFAR and the Global Fund that it needed to be used as a medium with a command power to create something of value between partners.