Category Archives: Public Policy

Health as development?

The Guardian has a good article which makes the critical point that the vast majority of foreign aid flowing into Haiti since the devastating earthquake in Haiti (the fourth anniversary is this Sunday) has been directed almost exclusively to private, U.S.-based corporate development contractors.

See the data and the graph:

USAID spending in HaitiHaiti, in particular, ranks among the lowest in the percentage of USAID funding going to locally based NGOs or the Haitian government:

pecent USAID going to local orgs:govtUSAID claims that most Haitian NGOs and the government do not have sufficient internal financial controls to receive these contracts. They also cite that these data do not accurately account for less formal support to local organizations via subcontracting and local partnership and interactions. It is, however, impossible to know since the data on those subcontracts has yet to be published.

Despite a desire to reform from USAID administrator Rajiv Shah, major lobbying and entrenched interests exist to block reform.

Partners In Health, of course, is working to do things differently. Interested primarily in how we can best invest resources to build systems that can protect the human right to health, we know how vital it is to strengthen Haitian – particularly public – institutions. This has been the approach and rationale behind the major investment in the construction and operation of the University Hospital in Mirebalais, Haiti. Co-operated by the Haitian ministry of health and PIH, the hope is that through accompaniment, we can work to strengthen the capacity of the public institutions necessary for fulfillment of the right to health for Haitian citizens.

Beyond the rights-base requirement for the primacy of local, public institutions, the strategy also makes strong economic sense. New analysis by PIH and partners show that investment in health systems and necessary infrastructure like hospitals, can have a major economic multiplier in growing the Haitian economy. Using an input-output matrix, a well documented economic analytical tool, the team determined that for every $1.00 invested in the construction and operation of the University Hospital in Mirebalais, $1.82 was generated in revenue across many economic sectors in Haiti.

University Hospital Investment

These results are entirely consistent with the case laid out by the Global Health 2035 Commission regarding the economic gains to be made by sound investments in health care delivery. As the movement lines up behind UHC as a major focus for the post-2015 global development goals, perhaps more evidence like this will help us move beyond the primarily self-serving orientation of foreign aid and development assistance as reported by The Guardian.

The movement for UHC

The Center for Strategic and International Studies has a nice primer on the “movement” for universal health coverage. The report doesn’t go into very much depth, but it does provide a solid overview on where the players are, the major gains that have been made, the historical context of UHC, and the challenges that could prevent forward motion.

They describe the current moment as the early phases of a “movement”:

And so the movement is gaining steam. Across the globe, national, regional, and international initiatives are under way to address barriers and provide models and assistance for governments seeking to expand health coverage; universal health coverage is even being discussed as a possible goal for the United Nation’s post-2015 global development agenda (see appendix 1). As a result, millions more people globally now have better access to health services and countries are prioritizing health spending (see graph below).

per capita expenditures on health

Major points from the report:

  • As national incomes rise, citizens are demanding access to more and higher quality health services.
  • Increasingly, low and middle income countries are paving the way with new and innovative models of UHC: Rwanda and Mexico are case examples.
  • Advancing UHC is a complex process and is fundamentally political: the government must invest more resources in health care delivery.
  • One major tension exists between food, beverage, and alcohol companies and proponents of UHC. Margaret Chan of the WHO has likened them to the tobacco industry, who see potential regulation as a significant threat to their business.
  • Scaling up UHC will require more efficient and robust tax collection systems and public redistribution of wealth.

The report does not go so far as the Global Health 2035 commission and does not discuss the potential economic gains to be had through strategic investments in hight quality health delivery systems. But, once again, we see a big opportunity for large scale advocacy at local levels and international levels. As the Millennium Development Goals come to a close in 2015, what type of galvanizing advocacy movement can propel us towards investing in policies and systems that can further justice in health?

Improving Health while Preserving Wealth

The Center for Strategic and International Studies is hosting what could be a very interesting conference / webinar on advancing universal health coverage in emerging economies. The meeting will be chaired by Jim Kim and will have representatives from a wide range of institutions/governments including USAID, several universities, PAHO, and the WHO.

You can register for the webinar here, for free.

I’m particularly interested in seeing how the conversations and the outcomes from this meeting fit with the ideas laid out in the Global Health 2035 report.

Global Health 2035: a new roadmap for global health advocacy?


The World Development Report in 1993 focused on the economic value in focusing on a narrow set of health interventions.

The World Development Report in 1993 focused on the economic value in focusing on a narrow set of health interventions.

On the 20th anniversary of the highly influential 1993 World Development Report, titled ‘Investing in Health’, an independent commission convened by The Lancet has developed a potentially groundbreaking report (Global Health 2035: a world converging within a generation) summarizing the current research demonstrating the potential economic value of universal health coverage, and lays out an aggressive but fairly straightforward set of policy recommendations that could help ministers of health, civil society, and advocacy organizations push forward legislation and regulation necessary to secure the right to health.

I think that this report is very significant for a few reasons:

  1. The commission is a mix of the right players (Harvard academics and administrators, ministers of health, USAID, World Bank, IMF, etc).
  2. It is fairly critical of the failings of the 1993 WDR. And, it offers sound analysis and recommendations about how to build off of the successes, failures, and lessons gained during the tumultuous decades in global health and development since then.
  3. It seems to have Partners In Health’s strategy and logic all over it. From the almost explicit ‘preferential option for the poor’ language to the model of structure and function for emerging health systems, PIH has certainly influenced this important vision for the future.
  4. The report is coming at just the right moment. Twenty years after the ‘Investing In Health’ WDR and approaching the end of the era of the Millennium Development Goals, we sorely need a progressive, ambitious, and inspiring vision to guide us. As I’ve written previously and continue to witness/study, more students than ever are passionate about advancing the right to health. Our work with PIH | Engage shows that people of many ages and demographics are eager to participate as well.

Major concepts in GH2035:

There is a major economic payoff in investing in global health.

How does investing in health effect personal and national income?

How does investing in health effect personal and national income?

The report builds off of the work of the 1993 WDR in making the case that investing in health is not only a moral imperative – it is actually just that, an investment in the productive capacity and “full income” of a country. By solely using GDP growth (only accounts the market value of goods and services produced in one year) as the metric of development success, a lot of important value is missed and policy is built and evaluated in an incomplete way.

“On re-reading WDR 1993, admittedly with the benefit of hindsight after two decades, we believe that it had two major limitations. First, although WDR 1993 discussed the “instrumental value” of better health (eg, better health improves worker productivity), it did not attempt to quantify the “intrinsic value” of health (the value of good health in and of itself). Our report summarises research that quantifies the intrinsic value of mortality reduction— the findings should, we hope, lead to a notable reassesment of the priority of health in national and international investment portfolios. In particular, benefit-to-cost assessments and a strong implementation record point to the value of increased commitment to health.

Second, financial protection failed to receive sufficient attention in WDR 1993, although very few data were available in 1993 about out-of-pocket spending and catastrophic financial expenditures. Moreover, only a few analyses pointed to financial protection as an important goal of health systems. By contrast, the role of UHC in providing financial protection is a major feature of our report.”

The analysis that they have gathered shows that fully 24% of “full income” growth in low income and middle income countries can be attributable to the “value of additional life-years” which is linked to expanded investments in health.

What’s happened in global health over the past 20 years that has led to such success? Well, they’ve kindly summarized their finding in a handy table:

Global health over the past 20 years

A grand convergence of death rates from infectious disease, child, and maternal mortality between the high and low income countries.

With the right investments made by local governments, appropriate investment in health systems strengthening, renewed commitment to expanding development assistance for health from wealthy countries, we could see an incredible convergence of rates of infectious disease death, childhood death, and maternal mortality. The report builds the case that by 2035 we could see rich and poor countries alike experiencing very little unnecessary  deaths from these completely preventable sources.

What kinds of investment are necessary? Well, the price tag over the next twenty years is not small – an aggressive investment scenario calls for at least $500 billion to be invested between 2016 and 2035 in low income countries’ health systems.  Here’s the breakdown:

Costs associated with enhanced investment scenario

But what types of health outcomes could you conceivably see as a result of that type of aggressive investment in health? Perhaps as many as 7.5 million lives saved across low income countries during that time period:

Lives saved by investing in health.

Fiscal policies (taxation, regulation, etc) are a major lever in controlling non-communicable diseases.

The report advocates for aggressive use of fiscal policies as levers to combat what will be rapidly growing rates of chronic and non-communicable diseases, especially in low income countries. These polices include but aren’t limited to heavily taxing tobacco and other harmful substances as well as reducing subsidies on fossil fuels.

“Progressive universalism” is the most efficient way of achieving financial protection for health programs.

For me, the most striking focus of this report is the extraordinarily pro-poor focus on achieving universal health coverage through two potential pathways that they describe as “progressive universalism.” They conceptualize the process to move toward universal health coverage using the “universal health coverage cube – a way of understanding the trade-offs and choices policy makers must make along the way.

Pathways to universal coverage

The cube consists of three dimensions: the percentage of the population covered, the percentage of costs pre-paid at the point of service (the rest paid for out of pocket), and the percentage of interventions that are covered by prepaid schemes.

Essentially, if a system has no one covered, none of the real costs associated with clinical interventions are pre-paid, and no interventions are covered through pre-paid schemes, that’s bad and does not approach UHC. You’re in a system that is in the bottom, right, front corner of the cube. Conversely, if people within a health system have all of their costs pre-paid at the point of service, all possible services are covered within the pre-paid scheme, and everyone within a population is covered, then you’ve got universal health coverage.

The report outlines two ways of “moving through the cube.” The first, and ideal strategy, would be to create a publicly financed health insurance system that would cover essential health interventions for entire populations. Basically, using “x, y, and z” coordinates imposed on the cube above, it would mean a large x (population covered) and a large z value (percentage of costs prepaid vs out of pocket), but a relatively small y (percent of all interventions that are covered through the system).

The second feasible strategy would be to provide a larger benefit package, financed through a mix of public and personal resources, from which the poor would be exempt. Basically, a smaller x value, similar z value, and a larger y value.

Potential implications for advocacy strategy?

I’m personally most interested in this report because I think that it provides a viable “stake in the ground” around which nonprofit organizations, civil society, advocacy networks, and ministries of health can mobilize and direct collective effort. It presents an ambitious vision for what could be. It provides the beginnings of a roadmap for  how we could plausibly build upon the successes and challenges of the last 20 years in global health and actually make headway in recasting health expenditure from being considered sunk costs to be minimized, and moving towards a commitment of robust investment. And, just maybe, we can even move past the idea of investment and consider health a fundamental human right to be protected as a central component of modern citizenship.

This is, of course, where politics and advocacy come in. Some questions emerge:

  • What types of organizations and grassroots campaigns are necessary in high-income countries to create the political space necessary to create the necessary development assistance for health funding streams necessary to see a plan like this enacted?
  • What types of organizations and campaigns are necessary in low-income countries to hold their governments and elected officials accountable for adequate public sector investment in health?
  • What type of advocacy is necessary to bring the lessons and innovations from low income countries working to pioneer UHC to high income countries, in order to disrupt dysfunctional health systems with massive politically and economically entrenched interests?