Jeffrey D Sachs is Professor of Economics at Columbia University and Special Adviser to the United Nations Secretary-General on the Millennium Development Goals. He is a co-author of the recently published book, Improving Access and Efficiency in Public Health Services: Mid-term Evaluation of India’s National Rural Health Mission. He was in Mumbai recently for the launch of a Columbia University Global Center. In an exclusive, wide-ranging interview with DNA, Sachs spoke about the difficulty in getting the rich world to fund primary health systems which don’t catch the headlines like AIDS, TB and malaria do. As for India, he finds it surprising that so much money is poured into subsidies for electricity and fertiliser and so little into health and education. He hopes the National Rural Health Mission can be a catalyst for change. Excerpts from the interview:
The UN’s global health fund has specific targets like malaria, TB and AIDS. As a result, a majority of poor people, especially women and children, who suffer for lack of basic health services, are left out. How can this be rectified?
For a number of years I have been recommending that the global fund to fight TB, AIDS and malaria - which I recommended at the beginning - should be expanded to become a global health fund for exactly the reasons you are saying. There has been a long discussion on vertical and horizontal programmes. Vertical programmes mean those directed at specific diseases like AIDS. Horizontal programmes mean building the basic health system. There is a lot of evidence - despite tremendous debate about one versus the other - that we need both.
The problem is that globally it’s easier to mobilise money for vertical programmes. The donors can see what the programmes need. It can reach the headlines. But they aren’t so eager to fund the primary health systems.
This year is kind of a test for this. The Obama administration has said that it is interested in health systems. Several other countries in Europe like Norway, the UK and France have also said they are interested. But now we are enmeshed in a typical struggle because some of those in favour of health systems want to cut the funding for the specific disease programme, rather than add to the funding.
You said you earlier recommended vertical programmes, but now also advocate funding for horizontal programmes. What prompted this change?
It wasn’t really a change for me because I chaired a commission for the World Health Organisation in 2000-01 called the Commission of Macroeconomic Health. We recommended a significant increase in financing for the primary health system as well as to fight specific diseases. We said the rich countries should raise their spending from $3bn a year to $27bn.
The report had a big effect. It led to an increase of aid from $3bn to about $14bn today. Most of that came through the vertical programmes. There was no shortage of interest in health systems, but there was no funding. Our report, however, was clear: to do both.
Why are the donor countries now expressing an interest in funding the horizontal programmes?
What happened was that donor agencies - who are very slow in general, not very scientific, not very goal-oriented — came to realise that there wasn’t enough progress in the more general areas like neonatal survival or maternal survival. They saw the lag in indicators. And they said, ‘Oh, this isn’t working’. And I said, ‘How could it work, there is no funding there’. We went back and forth and since then there have been a couple of important initiatives, led by the governments of Norway and the UK, to scale up funding.
Then the Obama administration said that they wanted health systems, but they haven’t put any more money into it. And this is my big concern. That one of the top people in the US government is making it seem like an either-or proposition (vertical or horizontal). And that can’t work because we already have people dying of AIDS as there isn’t enough funding for the basics of AIDS control. We don’t want to kill more people by taking money out of the AIDS treatment.
There is scepticism about how much of the resources for government-run schemes like India’s National Rural Health Mission (NRHM) actually reach the beneficiaries, due to leakages in the system. But you seem positive about the efficacy of NRHM. What is the basis for your optimism?
I like the idea that after decades of neglect the public health system is coming back to life in this country. I think it is fair to say that the rural health system was almost moribund five years ago. Many people would say, why should we care about the public system when almost everybody spends out of their pocket for private health? Well, that’s true. If you don’t have a public health system, that’s the only thing you can do. That doesn’t mean we give up on the public health system.
The amount of spending in India [on health] has been shockingly low and it remains remarkably low till today. The spending is only a little more than 1 per cent of the Gross National Product, and if you compare what India spends with that of other developing countries with a similar income level, India is half or one-third of what other countries are doing.
Comments
