Achievements through September 2004
The Eastern Mediterranean Region (EMRO)
In WHO's Eastern Mediterranean Region, the Commission on Macroeconomics & Health (CMH) Report was discussed at the 18th Meeting of the Regional Director with WHO Representatives and Regional Office staff in October 2002, with the participation of the CMH Secretariat. Further, EMRO's 26th Regional Consultative Committee (RCC 2002) commissioned work to assess the "impact of economic trends on health care delivery with special emphasis on deprived populations." The 27th RCC meeting (July 2003) noted that an EMRO task force on Macroeconomics and Health was formed and discussions with Headquarters colleagues culminated in a proposal and a plan of action to support poor countries in the region. Moreover, they placed on the 28th RCC agenda (July 2004) another issue relevant to macroeconomics and health: mechanism for prioritization of public health problems in the region and health research priorities.
On 9 June 2003, representatives of the CMH Secretariat participated in an "Experts Consultation to Discuss the Regional Strategy on Sustainable Health Development and Poverty Reduction" in Fez, Morocco. Along with World Bank representatives and other partners, CMH joined a roundtable discussion on strengthening the mechanisms for collaborative vision and integrated work within and outside WHO.
Linked to the Expert's Consultation, the WHO/HQ and EMRO hosted a Meeting to Facilitate the Implementation of CMH in the Eastern Mediterranean Region, 13 - 14 June 2003 in Fez. Themes from the Expert's Consultation fed into the CMH workshop, particularly the drive to build upon Community-Based Initiatives (CBI) and incorporate lessons learnt following the World Bank Development Report (1993) into current efforts for long-term investments in health. Country, Regional and the CMH Support Unit staff came together to draft CMH national plans and a regional MH strategy.
Main themes from workshop discussions stressed that operationalizing MH work requires a solid government commitment to reallocate national budgets and seek additional internal resources for health. The success of Health Investment Plans will also rely on clear outcome tracking, strong supervision and addressing known constraints realistically by offering practical steps to remove barriers. EMRO supports country strategies that link MH work to WHO initiatives (e.g. Community Based Initiatives, "3 by 5"), as well as with existing national mechanisms such as PRSPs and Sector Wide Approaches (SWAps). Finally, participants agreed that investment plans should show a coherent path towards achievement of the MDGs.
The Regional Concept paper on sustainable development was presented at the Regional Committee (RC) for the Eastern Mediterranean (29 September - 2 October 2003, Cairo). Ministers of Health, other RC delegates and the Regional Secretariat approved the paper, entitled "Investing in Health of the Poor: Regional Strategy for Sustainable Health Development and Poverty Reduction".
In March 2004, a joint WHO mission from CMH and the MDG/PRSP team met with EMRO focal points for sustainable development, Basic Development Needs (BDN) and CMH follow-up. EMRO staff requested that WHO/HQ work with them to develop a more coherent range of analytical and technical tools, which could be made available to WHO country offices. Such tools would help national ministers and WHO representatives (WRs) clarify the strategic linkages needed among various initiatives (such as PRSP, Heavily Indebted Poor Countries (HIPC) Initiative, Global Alliance for Vaccines and Immunizations (GAVI), Global Fund for AIDS, TB and Malaria (GFATM), etc.) and national policies.
- Meeting to facilitate CMH implementation in the Eastern Mediterranean Region - June 2003
Investing in health of the poor: Regional Strategy for Sustainable Health Development and Poverty Reduction
The Minister of Health gave a presentation at the 2nd Consultation on Macroeconomics and Health, "Increasing Investments in Health Outcomes for the Poor", 28-30 October 2003. Describing efforts to implement a Macroeconomics and Health strategy, he noted that Djibouti has a poor physical and human resource base. Furthermore, Djibouti has some of the highest rates of poverty, illiteracy, morbidity, and maternal and infant mortality in the world. As the Ministry of Health's allocation has dropped from 5.7% to 4.2% of the total government budget, the Minister places a priority on raising awareness among senior government leaders of the centrality of health to developmental strategies. The country has just commenced the first stage of a multi-year programme to reduce poverty, improve health and other social sector outcomes and spur economic growth and development. The World Bank and USAID have recently agreed to fund health and educational interventions in Djibouti with a total of approximately US$ 50 million over the next three years.
Initial MH efforts aim to insert a strong health component into the World Bank and USAID programmes for restructuring and reform, which accompany the national development plan. Currently, the national macroeconomics steering committee and CMH technical group are being put in place, to be directed by the Health Ministry. As over 50% of the health budget is funded externally, Djibouti finds its national priorities dictated by external donors. Cooperation between the Ministries of Health and Finance is increasing, but the health sector is allotted a very small portion of internally-generated resources.
In October 2003, a member of the Secretariat spent nine days in discussions with the Secretary General for the Ministry of Health and the Director of Budgets for the Ministry of Financing and Planning. This led to revision of the Djibouti work plan and a preliminary situation analysis in which epidemiological and economic data was collected and collated. Additionally, Djibouti was assisted in preparing for their participation at the 2nd Consultation on Macroeconomics and Health in Geneva (28-30 October 2003), where they gave a well-received country presentation on their perceptions of the MH process.
A follow-up visit by a member of the CMH Secretariat as well as by a consultant health economist from EMRO took place in January 2004. The objective was development of a concrete plan of work to draw up a national Health Investment Plan by October 2004.
The Islamic Republic of Iran
The highest levels of the Ministries of Health, Planning and Budget have debated the CMH recommendations. The Deputy Minister for Social Affairs felt that the provision of technical support to analyse existing data, which could then be used to develop an evidence base for pro-poor policies, would be critical for success.
Medical education is integrated under the Ministry of Health, with provincial health ministers also filling the role of medical school deans. Iran is building upon the success of recent poverty alleviation initiatives to increase community involvement in health. One important gap they have identified is the weakness of current information management systems, which are inadequate for generating an analysis useful to decision-makers. WHO is being requested to aid in identifying IT tools, and the Regional Office and HQ will work with Iran to explore various options to remove this constraint to progress.
In assessing the macroeconomic and political constraints to increasing pro-poor health services, the Deputy Minister for Social Affairs noted that Iran and many other countries are facing opposing inputs: on one side are "neo-classical inputs pushing privatisation and downsizing of public sector services" while on the other side are calls for "increasing investments in health services to the poor, which can only be delivered by the public sector". The resolution of this "political question" needs the involvement of WHO in its role as global advocate for equitable health services.
In June 2003 Iran sent a team to the EMRO CMH meeting that included the Deputy Minister for Social Affairs. Iran notes that a 5-year health and development plan is being finalized now, creating a window of opportunity for ensuring the centrality of health to poverty reduction and sustainable development strategies. The country feels that the basis of such multi-sectoral planning should be reliance on Iran's internal resources, with reallocation based on evidence. These comprise two prime objectives of Iran's Phase 1 work plan for Macroeconomics and Health.
The government of Jordan is embarking on a social and economic transformation program of which health is a prominent component. Intersectoral collaboration is also evident in the establishment of the National Committee on CMH with representatives from the Ministry of Planning, Ministry of Finance, and other concerned parties. Health problems such as malnutrition, diarrhoea, infant and maternal mortality, clean water and sanitation and access to a functional referral system and quality care are considered to be impacting the poor disproportionately. Basic essential interventions that have greatest impact on the poor are needed, and this requires a planned intersectoral effort (clean water, adequate sanitation, primary education) with appropriate policies and mobilization of resources to respond adequately and equitably to the health needs of the poor.
The government of Jordan is highly committed to advancing the CMH model by expanding evidence-based essential interventions to all people, including the poor and disadvantaged. Therefore, in December 2002, the Prime Minister has established a high-level National Committee to respond to the CMH initiative, chaired by the Health Minister and including the Minister of Planning and the Secretary General of the High Health Council. A technical committee has emerged and is charged with developing a strategy and plan for health services consistent with the CMH model.
Currently, the High Health Council (HHC) is leading the effort to develop a pro-poor Health Investment Plan in cooperation with a local consultant and the Technical Committee on CMH. The HHC's efforts are directed at the policy and strategy level and aim to improve health system performance and to achieve effectiveness, efficiency and equity in health services in Jordan. A Jordanian team from the HHC, Ministry of Health, Ministry of Planning, and Ministry of Finance, attended all the regional and international meetings on CMH organized by the WHO.
There are plans to establish a country-wide health information system. This will facilitate decision-making and foster cooperation between the different health sub-sectors. The Healthy Villages Program is considered to be one of the successful experiences that can be built upon, because it can effectively meet the needs of the poor in Jordan. Expansion of this program to include more villages is under consideration. The Healthy Village Program is an example of what an intersectoral approach can achieve.
Human resources development is one of the top priorities in Jordan. Two studies to assess the dental and nursing workforce situation in Jordan are underway. These studies are being conducted by the High Health Council in cooperation with consultants from local universities. Another response to the health needs of the poor is development of a universal health insurance program, a topic currently under study in Jordan.
Next steps to implement a National Health Plan:
- The CMH concepts are rarely disagreed upon and therefore advocacy in this regard is not difficult. However, a national body with a full mandate is needed to maintain momentum and enthusiasm for the MH process.
- Effort is needed to identify the poor so as to reach them with well-targeted interventions.
- In order to reach a consensus on a list of essential evidence-based, feasible interventions, technical assistance will be needed during the process.
Pakistan has a multi-pronged approach to reducing poverty, based on the Poverty Reduction Strategy Paper (PRSP) and incorporating 1) acceleration of economic growth, 2) governance reforms, 3) expanding social safety nets, and 4) investing in human resources. Health sector investments are viewed as part of the Poverty Reduction Plan, with attention shifting to the provision of primary care and community-based initiatives. The foundation of the current health sector reform process is felt to be improved governance. As the PRSP is already finalized, the objective for Pakistan will be to disseminate the major findings of the CMH Report, translate them into the local macroeconomic context, and use them to define research to construct an evidence base for integrating health into the PRSP. While reaching the MDGs is a high priority, the pressing need is to reach the 45% of the population that currently does not have access to essential health services.
At the EMRO CMH workshop, the WHO Representative (WR) stressed that technical support was more urgently needed than financial support and that increasing local institutional capacity was critical. He felt the entry point for implementing CMH-related findings will be the augmentation of the capacity of countries to carry out strategic thinking and policy analysis that can support a multi-partner, multi-sectoral strategy for health and poverty reduction.
The Secretary of the Ministry of Health made the case that the MH process provides an opportunity to re-examine health strategies from a macroeconomic perspective. He strongly suggested to EMRO colleagues that each health ministry form a distinct "policy development" unit that has high political clout, adequate resources to "conduct macroeconomic analysis for strategic planning", and includes at least one health economist and one political strategist. This will aid in devising policies and strategies that will win support from the most senior levels of government. He also stressed that the chair be the prime minister or president, someone who could break down sectoral walls and foster bold initiatives to strengthen all the determinants of health. The NCMH should also have technical working groups dealing with research, analysis, policy development and implementation. These would be chaired by influential political leaders, respected for their technical ability, and able to take concrete steps to achieve desired outcomes.
Sudan is a large country of nearly 32 million inhabitants that must cope with almost 1 million internally displaced people and a rural population of about 10 million. Within the context of severe civil strife and a large trans-national migrant population, long-term strategic health planning must rely on coordinating a diverse network of internal and external partners, aid agencies and other agents. Since the push for primary health care, there has been a marked inability to foster intersectoral collaboration or achieve coordination of various plans even within one public sector. The PRSP is merely one of many UN initiatives, and the government feels some integrated framework to rationalize all these initiatives is needed. They expressed the hope that the CMH focus on building up existing networks and strengthening partner networks will lead to a real cross-sectoral dialogue and participation in poverty reduction efforts.
The WR has pointed out that there is a window of opportunity presented by HIPC funds since the International Monetary Fund has agreed that 100% of these released obligations will be applied to the PRSP. The National Plan for Health Investments will aim to take advantage of this. Senior Ministry officials in delegation (Finance, Health, Social Welfare) discussed and revised the MH workplan.
A joint WHO CMH/PRSP mission visited Sudan in March 2004. Based on feedback from the Ministries of Health and Finance, the team suggested that the government use the momentum provided by the MH process to build upon increased inter-ministerial dialogue and seize the opportunity for more holistic approaches for health sector planning. Furthermore, it could employ a health systems framework to restate key health policy issues, allowing strategic options to be addressed effectively, while reconciling immediate post-conflict activities with broader, more comprehensive development of the health sector.
Yemen's Coordinator for the Macroeconomics and Health Program (MHP) attended the EMRO CMH workshop accompanied by the Assistant Deputy Minister for Foreign Affairs from the Finance Ministry and the Director General of Projects from the Ministry of Planning. The team identified the following priority areas for work: 1) the determination of burden of disease of the poor and vulnerable, 2) advocacy, and 3) the creation of a consensus among stakeholders. The health sector reform initiative was identified as an entry point for the MH process. The PRSP process will be the vehicle for operationalizing the MH process, with the Yemen MHP Coordinator maintaining momentum and developing buy-in from influential stakeholders.
The Coordinator of the MHP is located within the Ministry of Public Health and Population. The Ministry has set up an inter-sectoral National Commission on Macroeconomics and Health to adapt the CMH Report to its national strategic priorities.
At the request of the Ministry of Health of Yemen and the WHO Resident Representative of Yemen, a joint PRSP and CMH mission from WHO Geneva visited Sana’a from 9 to 12 March. The objectives of the mission were to assist the Ministry of Health in strengthening its health sector strategy, which will then feed into the PRSP, and to assess the role of the Macroeconomics and Health initiative in supporting this process, as well as identifying areas in which WHO-HQ could provide further support.
The main findings of the mission were that the Health Investment Strategy being developed by the MH process can be an effective tool in linking goals, health systems function strategies and health expenditure plans as well as a tool for advocacy. The team recommended that the MH work focus on:
- Analysis: Using the three themes of the CMH Report to assess the evolving health sector strategy.
- Pro-poor strategies: assess if current and proposed strategies specifically target interventions to improve the health status of the poor (e.g. primary health care (PHC) over tertiary care, and preventive over curative interventions, etc.). Then, assess if the implementation strategy includes a data collection strategy that allows monitoring and evaluation of outcomes and impact on the poor (e.g. are epidemiological data, household health spending surveys and assessment of health facility usage being disaggregated by household income quintiles, etc.)
- Greater financing for health. Assessment of the financing gap to look at both options for internal reallocations of funds to health and how external funds can predictably fill gaps. Includes commission of studies to develop a localised impact analysis of the socio-economic benefits of significantly greater investments in health, especially PHC and improving access to essential health interventions among the poor and rural populations.
- Removal of system barriers to access by the poor. The primary focus is to stimulate a dialogue on how the various health and health-related sectoral strategies (e.g. education, water, and sanitation strategies) can be harmonized, how local evidence can be used to set priorities, and how the various strategies can be correctly sequenced to sustain achievements. Strategies should explicitly consider how to progressively build up institutional and human resource capacity, using progress towards the MDGs as one way of tracking success.
- Planning: The MH process works within the Ministry of Health to assess the quality of the evidence base, commission research to fill gaps (two papers are being completed to address these first two points), cost various health strategies, and then determine priorities and sequencing of strategies. This well-costed and evidence-based strategy will be the basis for requests for increased internal allocations and donor support.
- Implementation: The national CMH team has drafted a Terms of Reference for a coordinating body that can provide input into health sector strategy, advocate for greater public expenditure on health and track the impact over time of the pro-poor elements of health plans. Two short-term objectives, incorporated in the PRSP, are to:
- Support National Policy on Essential Drugs and Logistics, including the review and approval of the Essential Drug List and National Treatment Guidelines
- Encourage NGOs to participate in provision of health services (e.g. Yemen Family Health Association).