Has the focus on AIDS and malaria blinded us to the need for better health systems?

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.

It is a big puzzle for me. As a democracy you would expect a big demand from the countryside for health services, but the countryside generally demands free electricity and free fertilizer, much more than it has demanded adequate health services. And I think NRHM in this sense is a great tool. I think it is creating a momentum that cannot be turned back.

Specifically, how is it building up a momentum for change?
What I see happening is that people are actually coming to the health services now. This is happening for a variety of reasons — for instance, the accredited social health activists (ASHA) in the NRHM are given an incentive to bring pregnant mothers for institutional delivery, and to my mind that’s an important development.

Now, when the mothers get to the delivery, the quality of the institution isn’t what it should be, but the idea is that this kicks in the next bit of pressure to upgrade the facility. You don’t get everything organised all in one completely logical lockstep. But I do think it is creating a momentum and a pressure for progress.
There is more creativity now about how to staff the rural health system, because the idea of the ASHA, which is an added post - with more than 600,000 young women hired for the purpose - gets to the idea that we need community-trained workers. Basically, while India has the reputation of having a massive public sector, the fact is that the health systems are understaffed. This isn’t surprising because how much can you pay from 1 per cent of the GNP? So I want many millions of people to be hired into the public health system. And we are seeing some progress in results. If India puts more money in the effort, it’s going to get even better results.

But how effectively will this money be used?
I think that there’s one major issue that is only now being addressed — the quality of health management at the local level, which is not good enough yet. There are lots of specific programmes and you have many local level workers in these essentially vertical programmes. These workers are responsible to different agencies - some for the family welfare systems, some for the ministry of health and so on. But you don’t have the health manager who makes the overall system work, someone who is able to oversee the whole local health team and hold it to account, and hold it to quantitative targets. This is one thing that would make the usage more effective.

There is always the idea that the money will just be stolen. But I don’t think that that’s the main issue. One of the things we are seeing is that some of the funds that are made available in the NRHM aren’t even taken up, because the local clinic or the manager doesn’t quite know what to do with it. So, rather than grabbing the money and doing whatever they want with it, there is not enough uptake, suggesting to me that there is care not to be blamed for misuse of the money.

Fingers are often pointed at the Indian government for pouring money into populist schemes which increase the fiscal deficit. How can we strike a balance between fiscal prudence and social schemes?
India’s overall fiscal problem is pretty well known. A tremendous amount of tax revenue which you’d love to use for productive things just goes to finance the payment of interest on existing debt.

Second, the social programmes that India has are not well designed. The fertiliser subsidy, the electricity subsidy, and the food distribution scheme are pretty poorly targeted. They are all understandable, given the politics, but they aren’t playing the role India really needs.

I always have a general recommendation that some states are kind of doing: If you are going to give a subsidy, don’t just subsidise the market price. Rather give a fixed allotment to every household or every farm, and if they want more than the fixed amount, they have to pay the market price. So, rather than saying electricity is free in rural areas, you say you get this many kilowatt hours, and use it for your pump or whatever, but if you want anything beyond that, then you pay.

I think the problem with India’s fiscal policy in general is that it’s stuck with large debt and inefficient subsidies. If it can turn the inefficient subsidies into more efficient subsidies, then there will be a big cost saving and you could spend more on education and health, where universal access is more the norm.

There are two overwhelmingly good pieces of news. The Indian economy is growing rapidly, which means government’s revenues are rising and there is scope for scaling up health systems and education. Second, India is using information technology to deliver services better, to monitor, to meter - I think there is a tremendous efficiency breakthrough on its way.

Why should countries which are better off support health care for the poor? Are there compelling economic reasons for being humanitarian?
First, I can’t really understand anybody’s ethical system that would leave millions of people to die when the cost of doing something about it is so tiny. We just need 1/10th of 1 per cent of the rich world’s income to fund the health systems of the poor countries. Because 1/10th of 1 per cent is about $40bn. That would fill the gap in Africa and most of the poorest countries in the world. Though it won’t fill India’s gap itself, it would help a lot. We are not saying break your economy to do this. I am suggesting doing something modest but meaningful, and it will have a huge effect.
Second, living in a world like we have right now, where everything is interconnected, expecting that some parts of the world can be diseased and impoverished while the rest of the world won’t mind strikes me as crazy.

The US, for example, keeps ending up in wars in poor countries. I don’t think they get it. Poor countries are unstable, and are much more likely to be unstable and harbour terrorists. Here we are in Afghanistan spending $100bn a year, and yet we said 10 years ago ‘Why should we help Afghanistan? What difference could that possibly make?’ And that’s a repeated pattern for the US. 
Third, what hits the poor hits everybody. The AIDS pandemic started in Africa but it spread to the whole world. If Africa had had a better health system we would have detected AIDS a decade earlier than it was caught. New diseases such as H1N1 or SARS or avian flu have been frightening but luckily did not become devastating pandemics. One of these days we are going to hit the bad luck. It’s going to be a new disease and it’s going to be easily transmitted and it is going to be lethal. And then we will realise that there are 1 or 2 billion people who have no health system.

And that they are spreading this disease. And every time we try to get it under control, something breaks. I hope it doesn’t happen, but I would then have to turn to these people and say, ‘What do you think? You waited for 20 years without helping the health system. Now you see the problem.’

What impact has the global economic crisis had on funding for health care for the poor?
Yes, budget deficits are tighter, and aid is harder to come by. But I have been doing this for 25 years and even in the big boom times, aid is hard to come by (laughs). The rich world has never been very interested in this. A few places such as Norway, Sweden, Denmark, and the Netherlands have displayed interest. But my country hasn’t been interested in this very much for 25 years. The US sometimes makes a breakthrough such as with AIDS and malaria, but it hasn’t made the real breakthrough. It spent $750bn this year on the military and under $30bn on development. That’s a serious misallocation of funds. So I am still counting on the US breakthrough to happen.