World Health Organization's Commission On Macroeconomics And Health: A Short Critique
Jawaharlal Nehru University
B-43 Panchsheel Enclave, New Delhi 110017 India
The World Health Organization (WHO) has been able to interest some of the top economists of the world to join the Child and Maternal Health (CMH) to study macroeconomics of health services for the poor people of the world, who account for more than two-thirds of the population (1). The approach followed by the CMH is disturbing. They have been politically motivated, theoretical and not of much benefit (2). They have not succeeded in making contributions from the discipline of economics to enrich the interdisciplinary method of health service development to ensure optimal use of the very scarce resources. On the contrary, they have added further to the already existing confusion in the field of international health. They have adopted a selective approach to conform to a preconceived ideology. They have ignored the earlier work done in this field. They have pointedly ignored such major developments in the health services as the Alma Ata Declaration (3) and failure of the Universal Programme of Immunization (4). They have made frequent references to the relevance of what they call "operational research", but they made different interpretations of this approach in different parts of the Report.
The experience of application of this method in other countries from as early as 1951 (5, 6, 7) were simply ignored. This is attitude of developing massive blind spots in their vision has brought the quality scholastic work to almost the rock-bottom level. It is not surprising that the CMH has developed a tube vision in making recommendations on such an important subject as what they call Close to Client (CTC) institutions, a 100- bed hospitals with a single doctor and some paramedical staff, undertaking a wide range of responsibilities to attend to the requirements of the patients, putting in place organizational and management superstructure to lend support to the CTC Hospital complex, are the major recommendations for action. The lack of understanding in conceptualizing such a plan of action is startling. Even more starling is the emphatic assertion by the CMH to perpetuate vertical or categorical programs against major communicable diseases like Tuberculosis, AIDS and Malaria. That the CMH justifies such already discredited approaches on the grounds that vertical programmes have proved to be convenient in a number of ways to the "donors" let out the real motivations for undertaking such an almost openly ideological driven agenda. This is a serious danger signal for scholars of the world who would like to have a scientific attitude towards program formulations for the poor to get the maximum returns from the limited resources.
The concept of DALYs is brisling with gross infirmities. DALY means Disability -Adjusted Life Years averted. International organizations and their hangers on in the countries, including India, use it extensively. I have strong objection to the method on its conceptual grounds. Then, there is the ultimate question of reliability and validity of the data that are fed to calculate DALY. How can we have data for the misconceived tool when, we, in India do not have civil registration of even births and deaths?
The WHO generated data used for DALY calculation and convert them into dollars terms are patently invalid, unreliable and not comparable between and even within countries. The figures churned out from the patently defective models and mathematical discourses are obviously meaningless. There appears to be a nexus between WHO and the type of scholars represented in the CMH. A hint of this link up emerged when the WHO was impelled to ask for consultative advice to examine the managerial process through which the organization has planned and monitored its performance (8). The consultants revealed a shocking state of affairs within the organization. "Cruelty and inflexibility of senior managers and policymakers" and "a range of high-profile actions and interventions that are clearly not sustainable" and "short-term results are justifiable at any cost to satisfy external stakeholders", are some the indictments made by the consultants. These indictments also apply to the CMH.
Alma-Ata showed the route to effective resource allocations for health:
In the early 1990s, apparently at the instance of the rich countries that contribute to the bulk its budget, WHO had been asked to look up to. The donor funding has become the centerpiece of an international debate on national resource allocation is chilling evidence on the steep decline and fall of public health practice over the past two decades. The word "donor" has patronizing connotations of condescension and even denigration for the poor countries of the world. Donors setting up health agendas for the poor countries are the very antithesis of the repeated, strong commitments to integration of health and health services made by WHO and its Member States in 1965, at Alma-Ata in 1978, and in the "new public health" of 1995. Donor funding ought to be mere ancillary to the funds mobilized by poor countries to develop their health services in an integrated, inter-sectoral manner, yet donor-driven programs have become pandemic. Identification of allocations that yield the greatest health benefits is a problem for health systems research; it is these findings that ought to determine the allocation of donor funding, if it is available without strings and on a long-term basis.
The Universal Immunization Program offers an astonishing instance of an ill-conceived, scientifically inept and administratively unsustainable donor-funded program. Because of these failing, in India the program fell far short of its self-proclaimed goal of attaining a global coverage of 85%. Hundreds of millions of US $ were wasted and national governments suffered even greater losses, apart from enormous damage to the infrastructure of the their health service system, because the funding agencies demanded and got top priority for the program. The debacle was quietly forgotten. Significantly, while it was still being implemented, another global initiative launched by donors further damaged the infrastructure of countries health systems - eradication of poliomyelitis from the world by 2000. This too, failed to meet its objectives. Beyond costing over US $ 9 billion, it has been tottering on the brink of collapse and causing extreme anxiety to its promoters. There appears to something beyond mere altruism in the minds of donors; perhaps economics, politics and even the generation of employment for their people.
The bold writing on the wall finally found their place in India's National Policy of 2004. India squarely distances itself from plunging into vertical programs in the future, because they are far from being cost-effective, they are not sustainable and they cause immense damage to the infrastructure of its health services. Incidentally, the WHO Commission on Macroeconomics and Health still refuses to read the writings on the wall. Instead of chasing the mirage that donor-driven programs will lead to better resource allocation, the time is long overdue to follow the road map drawn up at the Alma-Ata Conference on Primary Health Care (9).
WHO and response of the rich to the Alma- Ata Declaration:
The World Health Assembly resolution on Primary Health Care of 1977 and the Alma Ata Declaration of 1978 mark a watershed in the practice of public health. The concept of primary health care had turned the prevailing practice of public health "up-side down". The prime consideration was given to the people, rather than to "mobilizing" them by motivationally manipulating them to accept prepackaged, techno-centric programs that are thrust on them to conform to political and commercial interests of the rich class.
These programs have been extensively critiqued elsewhere. Significantly, WHO and the other powerful organizations and countries which supported these initiatives, did not take the elementary step to make even an internal evaluation of these programs, using well established scientific methods. Instead it carried out highly suspect "program reviews", to learn lessons for the future. It is not surprising that almost each of these programs suffered from similar types of infirmities. Four of them will be mentioned below:
1. Even if the "verticality" of the programs is taken as given, there have been serious flaws at the levels of policy formulation, program designs and in implementation and evaluation of these global programs.
2. Each of the programs failed to attain even the performance objectives that were set for them
3. They were extremely expensive when measured by any criterion of cost-effectiveness. The ratio become much worse when one includes contributions in kind made by the recipient countries and the damage they have inflicted on their health services. Incidentally, cost-effectiveness was projected as the cornerstone of the concept of Selective Primary Health Care (SPHC).
4. These programs have caused extensive damage to the capacity of the health service systems to deal with other much more pressing community health problems.
WHO, which earned the trust and confidence of poor of the world through its long advocacy for the philosophy of primary health care, had to pay a heavy price for deviating from it. Its credibility has been seriously eroded because of its betrayal of the trust of the poor by advocating imposition on them ill-conceived, scientifically suspect, poorly implemented, expensive and prefabricated vertical programs. Referring to India, Dreze, J. has wryly commented "in large parts of India there are no public health facilities worth the name except female sterilization and polio immunization".
In its National Health Policy document, the government India (2002) has finally come out with a forthright "confession" of the degree to which the health service system of the country has suffered for agreeing to the donor driven vertical programs (including UIP, GPEP, Tuberculosis and AIDS). It now says: "Over the last decade or so, the Government has relied upon a "vertical" implementation (sic) structure for the major disease control programs. Through this, the system has been able to make a substantial dent in reducing the burden of specific diseases. However, such an organizational structure, which requires independent manpower for each disease program, is extremely expensive and difficult to sustain. Over a long time range, "vertical" structures may only be affordable for those diseases, which offer a reasonable possibility.
It goes on to state: "It is a widespread perception that over the last decade and a half, the rural health staff has become a vertical structure exclusively for the implementation of the family welfare activities. As a result where there is no separate vertical structure, there is no identifiable service delivery system at all. The Policy will address this distortion in the public health system" (10).
The line of action for those few who still attach a high value to intellectual and moral integrity, and prepared to pay the price to fight this fascistic trend is clear. Public health workers in China and India, two of the world's most populous countries, who also have had a rich experience of in developing their health services, have to take the responsibility to set the tone for building an alternative, people-oriented health services for the long-exploited deprived people of the world.
When donors earmark funds for a developing country, it does not necessarily follow that the amount of money allocated to programs that yield the best health benefits will increase in the country concerned. Does donor pledge inspire domestic investment in health? Earmarking can distort resource allocation in unintended ways. Earmarked funds rarely cover the whole cost of an activity. Typically, it is assumed that a network of staff and health facilities already exists, whereas earmarked funds are designated for items such as drugs, vaccines and transport.
For continued government support, the earmarked activity must be viewed as affordable and a top priority among many competing demands. There are many health interventions that yield great health benefits. Some of them are highly cost-effective, but nevertheless unaffordable to some countries. Ministries of health in developing countries face a cacophony of demands to regard particular interventions as a high priority. We are grateful to Professor Emeritus Debabar Banerji for sharing his thoughts and experience in India with us.
- Commission on Macroeconomics and Health: Investing in Health For Economic Development - Report, Geneva, World Health Organization, 2001.
- Banerji, D. Report of the WHO Commission on Macroeconomic and Health: A Critique, Int. J. Health Serv., Vol. 32, pp. 733-54, 2002.
- World Health Organization: Primary Health Care: Report on the International Conference on Primary Health Care, Alma- Ata, USSR, September 6-17, 1978, Geneva, WHO, 1978.
- Banerji, D. People and Health Services Development in India: A Brief Overview, Int. J. Health Serv. Vol.34, pp. 123-42, 2004
- Mahalonobis, P. C.: An Approach of Operational Research to Planning in India, Sankhya, vol.24, pp. 5-90, 1951..
- Churchman, C W., et al: Introduction to Operations Research, New York, John Wiley, 1957.
- Andersen, S :Operations Research in Public Health, Public Health Reports, 79: .4, April, 1964.
- Lerer, L. and R. Matzopoulos : "The Worst of Both Worlds" : The Management Reform of the World Health Organization, International Journal of Health Services, vol.31, pp.415-437, 2001.
- Banreji, D. Alma-Ata Showed the route to effective resource allocation for health. Bulletin of the World Health Organization, Vol 82, No. 9, pp. 707-8; September 2004.
- Government of India: National Health Policy 2002, New Delhi, Ministry of Health and Family Welfare 2002
Women's Health and Education Center (WHEC)