Achievements through September 2004
In countries in which the process has moved past initial requests for information, a synopsis is provided of how the Macroeconomics and Health process is catalysing some notable efforts to strengthen cross-sectoral networks linking donors and national leaders.
African Region (AFRO)
There is growing interest among WHO African Regional Office (AFRO) member states to implement the CMH recommendations. For example, Ghana and Ethiopia are in the process of developing investment plans for strengthening "close-to-client", or primary health care, systems and extending coverage of essential health interventions. Angola, Botswana, Republic of Congo, Ethiopia, Ghana, Kenya, Malawi, Mozambique, Nigeria, Rwanda, Senegal, Swaziland, Tanzania and Uganda requested support to engage in a cross-sectoral process leading to multi-year Health Investment Plans.
To augment human resource capacity at the regional level, a regional CMH officer has been recruited. The officer is working collaboratively with other regional CMH contacts and the CMH Secretariat at WHO Headquarters to support local adaptation and ownership of the Macroeconomics and Health process. AFRO has produced a wealth of practical guides and background documents to help countries implement the Macroeconomics and Health (MH) process. Exchanging similar documents between regions has broadened the range of products and resources available for all participating countries.
Fourteen countries attended a WHO AFRO workshop on 4-8 August 2003 in Addis Ababa, Ethiopia. The workshop objective was to support countries in developing a process that will lead to investment plans for expanding coverage of essential public health and health-related interventions that address the most important causes of avoidable morbidity and mortality. Participants from each of the participating countries included: (a) Director of Planning, Ministry of Health; (b) Director of Planning, Ministry of Finance; and (c) WHO Country Office health economist (or National Management Professional). The role of the latter is to ensure follow-up at the country level. The workshop has led to the development of draft Plans of Work for 12 countries, and clearly outlined the steps necessary to advance the CMH follow-up in these countries. By the end of the workshop consensus was established on the importance of Macroeconomics and Health to the countries. Countries developed draft Plans of Action to take the process forward.
A regional concept paper and country guidelines for incorporating MH into poverty reduction efforts have been developed. The current focus of activities at regional level is on human resources and technical support to countries. A critical milestone for regional advocacy efforts was the 53rd Regional Committee (RC) meeting of ministers of health from the 46 countries, which took place 1-5 September 2003 in Johannesburg, South Africa. During the RC meeting, the Ministers of Health and the Regional Director endorsed the recommendations of the Report of the Commission on Macroeconomics and Health (CMH), attaching great importance to the Report's findings. They also commended the AFRO CMH strategy paper “Macroeconomics and Health: The way forward in the African Region” and the resolutions contained within. On the last day of the meeting, the ministers adopted the resolution and paper on Macroeconomics and Health.
Macroeconomics and Health: the way forward in the African Region
- 53rd session, WHO Regional Committee for Africa - September 2003
- Inter-country workshop for developing plans of action for taking forward CMH-related work - August 2003
- The OAU/AU Conference of African Ministers of Health - April 2003
The MH process is generating awareness of the important links between health and economic development among essential target audiences. The authorities welcomed a MH approach and the opportunity to establish a Technical Working Group under the Ministry of Health and the country's Central Joint Steering Committee of the Health Sector Development Programme.
A Macroeconomics and Health Country Co-ordinator (MHCC) was recruited in December 2003 to assist the Technical Working Group. The MHCC and Technical Working Group, under the guidance of the Health Minister, will direct research to evaluate the current health care frameworks and the costs of increased health care expenditures. The MH Plan of Action received final approval and endorsement by the Ministry of Health in May 2003. The Technical Working Group has started to assess how the MH process can integrate into the established PRSP. An MH workshop was completed during the Annual Review Meeting of the Health Sector Development Programme II (HSDP) in April 2003.
Ethiopia hosted the Intercountry workshop for CMH for AFRO states in August 2003, giving the government an international platform to share its experiences, whilst exchanging ideas on developing a country-led MH process with other countries. In addition, visits by the Columbia University team and by WHO occurred several times throughout 2003. International experts from Columbia University provided technical expertise in economic and technical analysis to support Ethiopian efforts to carry out needed research and build an effective evidence base for policy development.
A high-profile launch of the Ghana Macroeconomics and Health Initiative (GMHI) was held in Accra in November 2002. The Ghana Commission on Macroeconomics and Health (GCMH) is carrying forward the GMHI, analysing the Ghanaian Poverty Reduction Strategy in light of the CMH Report's findings. Six technical papers sponsored by the GCMH were reviewed, investigating cross-sectoral factors affecting health (published in February 2003). Ghana is focusing on three main issues: health insurance, access to water and sanitation, and human resources capacity at village level. A Technical Working Group has investigated performance and outcome gaps in every area of the Ghana PRSP implementation, identifying cross-sectoral causes of health system deficiencies. In one notable outcome of the MH process, analysis has prompted new policies and strategies that aim to increase the capacity of human resources within the health sector.
In Ghana, the MH strategy is positioned to heighten commitment of important ministries that influence the allocation of resources through the national planning process. In addition, Regional Ministers, a potent political force, are being sensitized to the necessity of reassessing current health investments. Moreover, such downstream political support is necessary to develop the capacity of district managers to design and implement realistic district plans. The predicted increase in the capacity to deliver essential health interventions ties in well with Ghana's establishment of sector-wide insurance schemes. Additionally, MH work supports MDG achievement.
The GMHI has completed several early objectives. This is embodied in three groups of reports: 1) the technical reports commissioned by the GCMH, 2) the consultant's report “Investments in Health to Reduce Poverty and Stimulate Economic Development in Ghana: Findings and Recommendations of the Consultant, December 2002”, and 3) the report “Scaling –up Health Investments for Better Health, Economic Growth and Accelerated Poverty Reduction, June 2003”.
The Ghana Macroeconomics and Health Initiative (GMHI) is endeavoring to target and scale up health services for the poor. The Initiative was launched in November 2002 and is currently finalizing a health investment plan. Ghana is focusing on a pro-poor approach to expand essential health services and close to client facilities. The investment plan is established on collection and analysis of data on disease burden, interventions, non-financial constraints, health expenditure and poverty at the district level.
The Government sees the GMHI’s health investment plan as a step towards operationalising the health and health related MDGs. The plan is a key input into the revised Ghana Poverty Reduction Strategy, in which the MDGs will be integrated as development targets, and the Ministry of Health programme of work for 2007-2011.
Report of the Ghana Macroeconomics and Health Initiative - October 2005
- President Kufuor launches Ghana Macroeconomics and Health Initiative (GMHI) in Accra - November 2002
In March 2003, the Columbia team met with the newly appointed Minister of Health, the head of the National AIDS Control Council (NACC) and donor organizations in Nairobi to discuss the potential value of implementing a cross-sectoral plan for increased health investments. The Minister of Health, the NACC and donor groups requested technical assistance to evaluate the financial needs for scaling up health expenditures in Kenya. The President is keenly interested in expanding health prevention and interventions in the country, making this is a pertinent time to engage in a MH process. In July 2003, a Columbia team met with senior health and finance policy makers to discuss options for commencing the MH process and potential linkages between existing health frameworks and PRSPs.
Since the CMH workshop in Addis Ababa, the team led by Ministry of Health 's health economists has focused on consensus building among stakeholders. Toward this objective, briefings have been carried out for: 1) The Permanent Secretary and Director of Medical Services in Ministry of Health, 2) Permanent Secretary Ministry of Planning and Development, 3) the Minister for Health, and 4) Chief Executive for National Hospital Insurance fund and senior management of the Ministry of Health.
The team has also finalized the Plan of Action for Phase 1 for the next 6 months. It aims to link the MH process and subsequent health investments to: 1) the Economic Recovery Strategy (ERS) investment programme; 2) the next National Development Plan (2006-15); 3) the national budgetary process; and 4) and UN Development Assistance Framework Group (UNDAF) workplan.
The Republic of Malawi
Political and socio-economic development is constrained since Malawi is a landlocked, single cash crop agricultural economy with concentrated ownership of assets, limited foreign and domestic investment and a high population growth and density. Malawi participated in the CMH workshops in Addis Ababa, but is still in the preliminary stages of deciding how best to use the findings of the CMH Report. As a Heavily Indebted Poor Countries (HIPC)-I country, the delegation felt that a possible CMH entry point was the reallocation of funds, previously tied to servicing external debt, into the PRSP-defined poverty reduction objectives. The MH process will be located in Ministry of Economic Planning & Development (MOEPD). The MOEPD holds cross-sectoral meetings once a month on development programmes and projects. The other opportunity is that the MOEPD coordinates the activities of the PRSP jointly with Ministry of Finance.
An expert from CMH Geneva is working with the country office to explore the feasibility and receptivity to the macroeconomics and health approach, in close coordination with the ongoing WHO work. The expert is collecting data on health and poverty from different sources, with a focus on health systems, poverty reduction strategies and sustainable financing and preparing a situational analysis making recommendations on options to further assist the process in the country.
Nigeria accounts for 13% of sub-Saharan Africa's GDP and 55% of West Africa's GDP, so an enhancement of Nigerian socio-economic progress could have tremendous spill-over effects for the continent. Oil and gas account for 20% of GDP, 95% of foreign exchange earnings and up to two thirds of government revenue. A significant window of opportunity currently presents itself to initiate a multi-sectoral process that will generate development of a Health Investment Plan integral to poverty reduction mechanisms. It is important to note that Nigeria is a heavily indebted poor country with severe debt-servicing constraints, even with the non-concessional rescheduling of Paris Club debts (December 2000). Access to bilateral credits is virtually non-existent, while commercial credit exists only at market rates.
Nigeria's Minister of Health chaired an important session which closed the 2nd Consultation on Macroeconomics and Health, "Increasing Investments in Health Outcomes for the Poor" (28-30 October 2003), synthesizing the various themes of the meeting and helping push forward the draft Declaration from the Consultation. Following this Consultation, the Minister of Finance from Nigeria chaired part of the recently-completed High-level Forum on the Health MDGs, co-sponsored by WHO and the World Bank. Nigeria also chaired a number of sessions at the 53rd Regional Committee which took place in September 2003 in South Africa. Present were 45 ministers of health from the AFRO region who unanimously endorsed the CMH agenda and requested WHO to provide technical support to countries.
Nigeria's MH process is to be directed in the Department of Health Planning and Research of Federal Ministry of Health. This department has a government mandate to coordinate the implementation of the health components of ongoing initiatives such as NEPAD, PRSP, MDG, etc. Social mobilization will be embarked upon concurrently, in partnership with other sectors such as Women Affairs, Water resources, Environment, Agriculture and Education. Various partners (e.g. NGOs, civil society, donors, etc) will be targeted for a comprehensive briefing on the relevance of CMH findings and recommendations to Nigeria. This will spur national ownership of the process and garner the support required to the implement the CMH action agenda.
The Phase 1 objectives comprise two main prongs: 1) to build consensus on the relevance of the findings of and recommendations of the CMH Report at federal, state and local levels, and 2) to set up an appropriate institutional mechanism for moving forward the MH agenda in Nigeria. The latter includes defining linkages to the PRSP efforts and support for establishing National Health Accounts to track the sources and flows of funds to and within the health sector. This includes economic research studies, analysis of intervention options and assessment of financing mechanisms. Once funding is secured, the government will inaugurate a national mechanism to drive the MH process, create a concept paper on MH in Nigeria, and develop the specific operational strategy to integrate relevant CMH findings into long-term health investment strategies.
In March 2003, a team from Columbia University visited Rwanda at the invitation of the President of Rwanda, the Minister of State for HIV/AIDS, and the Executive Secretary of the National AIDS Commission (CNLS). The purpose was to identify how the MH process could be adopted. A PRSP was completed in June 2002, with a priority on rural development and agricultural transformation. The aim was to realize a real annualised GDP growth rate of 6-7% and to reduce poverty from 60% in 2001 to 30% by 2015. The Minister of Finance and Economic Planning and the Minister of Health both worked with WHO to develop a Macroeconomics and Health Strategy. Initially, the plan will focus on four areas for analysis and research:
- The potential contribution of community health insurance schemes (‘health mutuels’) to finance health service delivery and improve access to healthcare in Rwanda;
- Strategies for enhancing the salary, professional development, and incentive packages of health professionals in the public sector to enable the scale-up and sustainability of public health programmes;
- An evaluation of spending on major health interventions, and the need to prioritize health care expenditures;
- The macroeconomic impact of healthcare spending in Rwanda.
Focal points are the Director of PRSP Planning and Monitoring in the Finance Ministry and the Director of Planning for the Ministry of Health. Columbia University has placed an in-country adviser to support these individuals as well as the Secretariat for the National Task Force.
On 28 April 2003, the International Monetary Fund (IMF) approved a new 3-year agreement under the Poverty Reduction and Growth Facility (PRGF) mechanism to support Senegal's economic reform program for 2003 to 2005, totalling about US$ 33 million. This is closely articulated with the Senegalese I-PRSP framework and is heavily reliant on wide-ranging structural reforms. At this critical juncture, Senegal wishes to ensure the centrality of essential health interventions, and that macroeconomic analysis carefully looks at health outcomes when deciding upon the shape and nature of proposed structural reforms.
The Ministry of Finance has primary responsibility for defining a global public expenditure control policy. As Senegal moves to full implementation of a MTEF through a PTIP (programme triennial d'investissement public), capital budgetary expenditures will become more scrutinised, especially since they will be linked with the performance based budgeting (PBB), introduced in 2002 to the health and education sectors. Of note, Senegal has identified a reduction in HIV/AIDS growth as a high priority. This implies a substantial public health component to ensure achievement of this objective.
The MH process can provide a strong analytical and evidence-based argument for significantly increased health investments. Phase 1 objectives for Senegal revolved around two main thrusts: wide dissemination of key messages from the CMH Report, and the development of a national and high profile mechanism to manage and sustain the MH process. The country wishes to support the creation of an evidence base showing the impact of various health investment scenarios upon health outcomes, especially for the poor.
Several entry points for commencing a MH process were identified by Uganda's participants to the CMH workshop in Addis Ababa. Core on-going processes, for which the mechanism to manage the MH process can be linked, include:
- Revision of the PRSP (PEAP)
- Developing Health Sector Strategic Plan II
- Studies to generate evidence for Health Sector Strategic Plan (HSSP) II, e.g. burden of disease studies
- National Health Accounts
- Health systems performance assessment and the Benefit Incidence Analysis
- Inter-ministerial efforts to improve health and level of funding
- Health sector working group
The principle outcome sought for the first six months is the forging of a consensus on carrying forward the work on MH at the country level. The objectives are:
- Define the framework and structure for articulating health and development.
- Outline the advocacy package for investing in health.
The MH process will be located in the Prime Minister's (PM's) office, as the PM's mandate will be to coordinate inter-ministerial health financing. The comprehensive approach to health and economic development will be discussed during the upcoming scheduled PRSP review. This will also delineate linkages and potential synergies with the revision of the Poverty Eradication Action Plan (PEAP) and the Health Sector Strategic Plan (HSSP) II development process.