Investing In Health Again
We catch up with Dr. Sania Nishtar who was recently a panelist at the 2012 Annual Meetings of the IMF and World Bank in Tokyo, Japan.
AsianScientist (Nov. 19, 2012) - In October 2011, Asian Scientist Magazine featured Dr. Sania Nishtar, Pakistan’s first female cardiologist and founder of healthcare reform NGO, HeartFile. The focus then was on the launch of the Sania Nishtar Health Fund, which was set up to sustain HeartFile Health Financing.
Fast forward 12 months, we once again catch up with Dr. Nishtar who was recently a panelist at the 2012 Annual Meetings of the International Monetary Fund and the World Bank in Tokyo, Japan. In this issue, she shares with us updates from the seminars as well as her vision for investments in public healthcare. This interview includes some of Dr. Nishtar’s responses at the seminar.
You were recently a panelist at the program of Seminars of the IMF/World Bank Annual Meeting in Tokyo. We understand this is the first time health was featured prominently in the main program of seminars in this series of annual events. The title of the panel, "Investing in Health, Again," was rather interesting. Could you tell us about the significance of the word "again" in the title?
In 1993, the World Development Report, an annual report of the World Bank was published with the title Investing in Health. That publication was quite a landmark because it coined, perhaps for the first time, the notion that spending on health should not be viewed as expenditure but as an investment. The report marked the beginnings of a number of important transformations in the health sector.
In the years succeeding, a number of important institutions and funds were created. Health-related official development assistance (ODA) increased exponentially, although allocations to health sector as a percentage of ODA remained fairly constant; In absolute terms, aggregate increases were over 200 percent.
Around the same time, a number of normative frameworks were established and important landmark commissions were created such as the Macroeconomics Commission on Health and the Commission on the Social Determinants of Health.
Later in the year 2000, the Millennium Development Goals were agreed upon, in effect the world’s largest promise to date. All these factors lent an impetus to investments in health by stipulating time bound outcome-based targets. Goals 4, 5 and 6 in particular were dedicated to health. In summary therefore, normative frameworks, new funds, explicit targets and compelling evidence really gave a boost to investments in health. And of course that was a time when growth and fiscal space were not a problem at a global level.
But then came the financial crisis in 2008 and since then there has been stagnation in support for health and more broadly for development. Within this context, the word “again” in the title of the seminar was meant to indicate that we must spur investments again.
In any case, we have high expectations of the World Bank as far as health is concerned - after all its new President Jim Young Kim has a strong background in public health and understands exactly what needs to be done.
Is the financial crisis the only large event which has shaped the course of support for health internationally? What is the difference between 1993 and now?
The world, of course, is a very different place from what it was in 1993. Global interconnectedness has reached a level never seen before. Technological and scientific innovations have transformed the world; in particular in relation to connectivity and communications.
There are new global forces so the G20 matter as much as the G8. There are new global agendas of which environment and climate change is the most salient. Overall there is a much deeper understanding of the problems the world faces and also the solutions.
And of course the world has seen a lot of upheavals in terms of resource realities during this time frame. Terrorism is very much an overarching concern which nations face. So the world has dramatically changed since 1993.
What do you think would be the priorities for investments in health today?
We have witnessed many decades of investments in support of vertical disease specific targets, in particular malaria, tuberculosis, HIV and AIDS and certain rare infectious diseases are examples. Of course, significant strides have been made in terms of disease eradication, prevention, control and alleviation of suffering and disability.
But the recent increase in development assistance since the last decade and the aggressive pursuit of vertical targets has also taught us a lesson - that without attention to the core central systemic constraints at the systems level, we will not be able to achieve vertical targets completely. Therefore more recently there has been an emphasis on the systems that deliver vertical targets.
Consequently, the Global Fund and the Global Alliance on Vaccination Initiative have opened health system strengthening windows. The new health initiatives that have been created over the last ten years all have a systems focus and major global forces are increasingly according attention to the “pipes and plumbing” so to speak.
More recently however, there is even a more comprehensive rethink around systems and delivery policy in the shape of a renewed emphasis on Universal Health Coverage which has been termed by Richard Horton, editor of The Lancet, as “the 21st century equivalent of health for all.” The WHO has also placed a heavy emphasis on this as their key policy tool and from the way countries seem to be embracing this policy agenda, especially the emerging market countries where fiscal space is relatively less of an issue, it seems that Universal Health Coverage will fast become the new priority. Of course, we need to see what gets reflected in the Sustainable Development Goals post-2015, but from the way things stand Universal Health Coverage has become very important.
And then in terms of priorities we should not forget the new public health agenda of non-communicable diseases (NCDs). In 2011, there was a UN summit convened by the United Nations Secretary General to mobilize attention and commitment towards addressing the biggest global killers, i.e. non communicable diseases; a collective name given to cardiovascular disease, chronic lung conditions, diabetes and certain cancers. Of course, a whole new set of competencies are required at the public health level to address them, and these will certainly mark the landscape of priorities in health in the decade to come.
For example, Universal Coverage is not just about health but is more of a social policy agenda. Similarly, prevention and control of NCDs requires action outside of health. For these reasons the development sector is according much attention to the notion of the ‘whole of society approach’ and the ‘whole of government approach,’ which will also mark the prioritization as far as health sector and more broadly development is concerned.
The word "investment" by definition suggests that there should also be some kind of return associated with the given spending. How do you make a case for investments in health?
Investment in health is perhaps one of the smartest investments because it yields a triple bottom line return. First, a social return, not just in terms of better life expectancy, improved health conditions and well-being, but also a sense of satisfaction among citizens in a population.
Secondly, economic gains are a very important part of the returns on investment. We now know that health care costs are a very significant cost that nations have to bear. Better investments in prevention can help cut those costs. And not just that but also impact on lost productivity in a positive sense. And then of course what we at my organization are very passionate about is protecting people from catastrophic health expenditures which push them into poverty. Data from many developing countries show that health shocks constitute one of the most significant economic shocks faced by households. So, in essence there are many economic gains from investments in the health sector.
And thirdly there are political gains as well; the election in the United States is a case in point where ideological differences around healthcare are a salient aspect of the election debate.
Not everyone on your panel had the same view as you on investing in health. Could you share with us the discussion?
Yes, of course. The minister of finance of Uganda who was at the same panel was of the opinion that governments have to make choices vis-à-vis investments but my point was that you cannot see health in that way because health is a fundamental human right.
In fact, there are 119 countries in the world where health is fundamentally recognized as a right and many others where health is regarded as a right by virtue of an expansive interpretation of the right to life. So we need to view investments in heath from a ‘rights based’ lens.
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