Meeting Report - WHO · Sweden’s Minister for International Development Cooperation Hillevi Engström invited a group of high-level colleagues engaged in global health and development

On October 31st 2013, the Swedish Minister of Development Cooperation, Ms Hillevi Engström, invited a group of high level colleagues engaged in global health and development for an informal discussion on the benefits and costs of investing in health and the post 2015 agenda.

This meeting report provides a summary of that conversation.

Meeting Report

Reinvesting in Health

A High-Level Policy Dialogue

31 October 2013 Stockholm, Sweden

Reinvesting in Health Meeting Report

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Reinvesting in Health A High-Level Policy Dialogue

31 October 2013

Stockholm, Sweden

Meeting Report

Key messages

The benefits of investing in health are clear: in addition to saving lives and

improving health and wellbeing, it makes for sound economic policy and

contributes to poverty reduction.

The additional investments required to increase life expectancy and maximize

health at all stages of life are substantial, but they are feasible and sustainable.

Success will require many low- and middle-income countries to allocate a greater

share of the government budget to health and social sectors; development

partners will need to increase technical and financial support, and to use their

collective resources more effectively.

New ways of working, more efficient partnerships for health, and a coherent

multi-sector policy approach are needed at national, regional, and global levels.

Alongside integrated high-impact medical interventions, prevention and health

promotion are increasingly important to improve population health.

Investing in health is not only about investing in nurses, doctors, and drugs. It is

also about addressing governance, management, and leadership.

Effective investments require ministries of finance and several other ministries

(education, environment, trade, etc) to be informed and engaged. The same

applies to parliamentarians, civil society, media and academia as they collectively

hold the government to account for its budgetary decisions and implementation.


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Introduction

Sweden’s Minister for International Development Cooperation Hillevi Engström

invited a group of high-level colleagues engaged in global health and development

for an informal discussion on the benefits and costs of investing in health, and the

role of health in the post-2015 agenda. Twenty-six high-level participants and their

advisors met on 31 October 2013 at the Ministry of Foreign Affairs in Stockholm. See

the annexes for the agenda and list of participants.

The objectives of the meeting were to discuss the links between health, poverty

reduction, and economic development, and draw conclusions on how available

evidence can be used to accelerate efforts to achieve the health MDGs and inform

on-going discussions on the post-2015 agenda.

Key questions included: What can be achieved by investing in health, especially in

reproductive, maternal, newborn, and child health (RMNCH)? What is the investment

case for health and to what extent does it lead to economic development and poverty

reduction? How much will this cost and who should pay in the post-2015 scenario?

What is the role of development cooperation for health up to and beyond 2015? What

type of global partnerships will be needed and what actions need to be taken to

shape a more appropriate global institutional landscape for health and development?

These are especially important questions to ask now as key decisions will be made

in the UN General Assembly over the next 24 months on the future development

agenda.

This report is a summary of the three presentations and two roundtable discussions.

Because at the time of the meeting the information in two of the presentations was

confidential and under embargo, this report was not made publicly available until

both were published in The Lancet on 3 December 2013.

An investment framework for women’s and children’s health

Marleen Temmerman from WHO presented findings of the Study Group for the

Global Investment Framework for Women’s and Children’s Health. Its report

estimates the effects of investing in RMNCH across the continuum of care, including

family planning and stillbirths; extends the time-frame to 2035; and analyzes the

economic and social returns on investment in addition to cost and impact. The focus

is on the 74 low- and middle-income countries (LICs and MICs) which together

account for more than 95% of all maternal and child deaths globally1 and 50 RMNCH

interventions for which health outcomes can be modelled.

The report emphasizes that the costs are affordable and the returns are high.

Between now and 2035 an additional US$ 5 per capita per year compared to current

1 These are the 75 Countdown to 2015 countries, excluding South Sudan due to data

limitations.


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investment levels would save close to 150 million children’s lives, prevent up to 32

million stillbirths, and prevent more than 5 million maternal deaths. By 2035 there

would be 110 million fewer children with stunting (low height-for-age) and 36 million

fewer children with wasting (low weight-for-height).

Compared with current total health expenditure per capita today, by 2035 this

investment is on average a 2% overall increase in health spending per person across

74 countries. Importantly, these investments could yield up to nine times that value in

economic and social benefits by 2035 (and up to 20 times or more by 2070),

including GDP growth from increased productivity, higher labour participation rates,

and increased savings. The figure below illustrates the costs and benefits relative to

GDP.

Figure 1 Costs and benefits from investing in RMNCH relative to GDP in 74 high burden countries

Source: Stenberg et al., Lancet 2013

The investment framework is intended to help countries optimize RMNCH

investments over the next two decades, as part of sector-wide health plans. WHO

and partners will provide technical support to countries, including on use of the joint

UN OneHealth Tool to link national health plans to impact estimates, a resource

envelope, and a budget.

Health as an investment for poverty reduction and economic

development

Dean Jamison from the University of Washington presented selected highlights of the

Lancet Commission on Investing in Health (CIH) report, a follow-up report to the

World Bank's influential Investing in Health report, published 20 years ago.


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Health gains and economic progress since the early 1990s have been extraordinary.

Life expectancy in countries like China, Ethiopia, and India has almost doubled, and

children born in Mexico today can expect to live almost as long as children born in

the USA (see figure 2).

Figure 2 Increasing life expectancy, 1950-2010

Source: Jamison et al, Lancet 2013

In 1990 3.1 billion people (57.8% of the world’s population) lived in LICs; by 2011

that number had fallen to 820 million (11.7%) (see figure 3). More than half of the

world’s avertable deaths are now in lower-middle income countries (LMICs); with a

quarter to a third in LICs.

Figure 3 Movement of populations from low income to higher income, 1990 – 2011

Source: Jamison et al, Lancet 2013


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Global Health 2035 estimates the incremental costs and impacts of scaled up

investments to achieve a “grand convergence” in global health by 2035—a reduction

in deaths from infections and RMNCH conditions in most LICs and LMICs down to

levels currently seen today in the best-performing MICs (e.g. Chile, China, Costa

Rica, and Cuba). The report defines convergence as achieving “16–8–4”: an under-5

mortality rate of 16 per 1000 live births, an annual AIDS death rate of 8 per 100 000

population, and an annual tuberculosis death rate of 4 per 100 000 population.

For LICs, the incremental costs of convergence would be an additional $23 billion per

year from 2016–2025 and an additional $27 billion per year from 2026–2035; such

convergence would avert about 4.5 million deaths in 2035 relative to a scenario of

stagnant investments.

For LMICs, convergence would avert about 5.8 million deaths in 2035 relative to a

scenario of stagnant investments; the incremental costs would be about $38 billion

per year from 2016–2025 and an additional $53 billion per year from 2026–2035.

Overall, across LICs and LMICs, benefits would exceed costs by a factor of about 9–

20 across the time period 2016–2035.

Countries need to follow a progressive pathway to universal health coverage (UHC),

ensuring the poor are protected from the outset. The global health community can

best support countries achieve this convergence by funding the development and

delivery of new health technologies and managing externalities. The CIH calls for a

doubling of funding for R&D targeted at diseases disproportionately affecting LICs

and LMICs from current levels of US$3 billion to US$6 billion per year by 2020.

In a video link Larry Summers of Harvard University reiterated three messages from

the CIH. First, for the first time in human history most countries have the opportunity

to achieve high life expectancy and low infant mortality. Global Health 2035 lays out

a constructive agenda to realize this world of far greater equality. Second, the full

impact of investing in health goes beyond GDP to the value of being alive: when this

is taken into consideration the return on health investments is magnified several

times over. Third, with most of the disease burden now in LMICs there is more scope

for national efforts to support the provision of treatment and basic prevention

measures and for development assistance to focus more on disseminating

information and providing global public goods.

Summary of first roundtable discussion

Joy Phumaphi, co-Chair of the independent Expert Review Group moderated the first

roundtable discussion. Participants were asked to take as a given the need for and

the benefits of investing in health (especially RMNCH), and to focus their comments

on how to make it happen, the roles of countries and development partners, and the

implications for development cooperation. As the following examples illustrate, the

interventions were wide ranging.


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How to make it happen

Leaders outside the health sector need to be engaged. As one participant said: “The

best Minister of health is the President or Prime Minister.” Both countries and

development partners need to find more effective ways to communicate their health

messages to non-health audiences. Many MICs need to invest more in health. How

can this best be encouraged?

For countries, investment cases can be useful but they should be investment cases

for health. Issue- or disease-specific investment cases and multiple frameworks can

fragment the debate and distract political attention. The many global initiatives for

health, including several under the Every Woman Every Child campaign, create

disturbance at country level and are very challenging for poor and small countries to

manage. The solution is for countries to have their own plans and for partners to

align with these.

To help push the health agenda in cabinet and parliament, ministries of health need

high-quality presentations and reports similar to those used to make the case

globally for the central role of health in development. For example, to mobilize

domestic resources for health global costing tools need to be adapted to suit

individual countries.

How resources are spent is as important as what resources are spent on.

Participants pointed out the Mexican experience as an example to build on.

Participants also noted that misallocation is often more common than lack of

allocation especially lower middle countries.

How can citizens be empowered to demand action from their political leaders?

Accountability mechanisms at every level should be in place to respond to the

demands.

Countries need reliable and timely data and evidence-based information from many

sectors (health, environment, education, energy, transportation, nutrition, water,

sanitation, etc) so that they can make their own informed policy decisions to address

the unmet health needs of their citizens. Development partners need good data to

make good allocations. High-quality data is critical to improve accountability at all

levels and among all stakeholders.

Multi-sector policy coherence is essential to maximize health impact. For example,

policies to improve road safety should go hand-in-hand with trauma centres; malaria

and environmental factors are interrelated.

The future role of development cooperation

Several interventions during this roundtable discussion related to the future role of

development cooperation in general and of ODA in particular. Given that so much of

unmet need is in MICs, should development partners focus on poor people or on

poor countries?


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Domestic resources are the mainstay of public health spending. Health spending

from external resources is increasingly marginal in most countries, especially in

countries transitioning to middle income status.

Many participants expressed the view that the future of international development

cooperation is to focus on a few countries (including fragile states) and on strategic

financial and technical support related to social protection and strengthening national

health systems. Over time, ODA could potentially shift to R&D and global public

goods, which are underinvested and therefore this is an important direction to take.

The architecture of global collaboration is changing. The global health community

needs to learn how to best collaborate with the private sector and with emerging

development partners such as China and Brazil to create an incentive structure to

catalyse action around common goals, and to look for opportunities to improve health

in an increasingly interconnected world.

Overall, global health and development should not be confused with ODA: global

health involves all countries, not only those that receive ODA. For this reason a

universal agenda for development is important and it sets the tone for our global

conversation.

Health in the post-2015 framework

Anders Nordström of Sweden’s Ministry of Foreign Affairs presented a brief summary

of the impressive health achievements under the MDGs and a framework for health

in the post-2015 agenda.

Two strategic questions were highlighted. Should we see health as a means or as an

end to development, or both? Can health lead the way — again?

Health is both a contributor to and beneficiary of development in sectors other than

health. It emphasizes the social determinants of health and the need to make links

with many other sectors in order to improve health outcomes.

“Maximizing healthy lives” could be the specific health goal, in which the health

sector would play a larger but far from exclusive role. This goal should include:

accelerating progress on the health MDG agenda; reducing the burden of NCDs; and

ensuring universal health coverage and access. Achieving better health at all stages

of life (including crucial phases such as the neonatal stage and adolescence) is a

goal that is relevant for every country. Interventions from all sectors of society will be

required.

Efforts to accelerate progress on the health MDG agenda should build on national

and global efforts that have already resulted in significant progress in reducing child

and maternal deaths and controlling HIV, tuberculosis, malaria, and neglected

tropical diseases. Rather than pulling back from these goals the new agenda should

be even more ambitious, and reaffirm the targets of ongoing initiatives such as:


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ending preventable maternal and child deaths; eliminating chronic malnutrition and

malaria; providing universal access to sexual and reproductive health services,

including family planning; increasing immunization coverage; and realizing the vision

of an AIDS- and tuberculosis-free generation.

Reducing the burden of major NCDs could focus on cardiovascular diseases,

cancers, chronic respiratory disease, and diabetes (the four NCDs causing the most

deaths), and mental health. Some targets could be based on the World Health

Assembly resolution of a 25% reduction of deaths due to these four NCDs by 2025.

Other targets could be aimed at reducing morbidity and disability from NCDs at all

ages, including reducing the prevalence of risk factors.

Providing all people with access to affordable, comprehensive, and high-quality

services that address basic health requirements and country health priorities is a

means to achieve better health outcomes. It is also a desirable goal in its own right

because people value the assurance of access to a health system that prevents and

treats illness effectively and affordably within their homes and their communities, with

referral to clinics and hospitals when required.

Summary of second roundtable discussion

Anarfi Asamoa-Baah, WHO’s Deputy Director-General, moderated the second

roundtable discussion. Participants commented on the place of health in the post-

2015 agenda, the importance of health as a broad development agenda as opposed

or complementary to a health-sector goal, and how UHC could fit in this agenda.

Health should lead in the post-2015 agenda

Several reasons were given for why health should lead in the post-2015 era (as it

has in the MDGs). For example, health is ahead of other sectors in realizing the

interactive nature of different sectors. Health has been at the leading edge of

strengthening systems and capacity for accountability, real-time tracking, and

monitoring — these will be essential post-2015 in terms of innovative financing

options and engagement with the private sector, civil society, the media, and the

judiciary.

We need to take the accountability issue further, evaluate the current mechanism,

and recommend a robust one that can be used for the whole post-2015 development

agenda. We also need to develop a mechanism for engaging the private sector —

we don’t have one at the present time.

Those who will agree on the goals are not us. The post-2015 negotiations will be

conducted by the permanent representatives in New York — what will get us there?

Will healthy life expectancy and wellbeing work, or are these concepts too abstract?

Health is a broad development goal

Health goes far beyond health-care services and the health sector: it is a broad

development goal. For example, the number one killer in some age groups is injuries,


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making road safety a major health issue. For older age groups urban planning may

be more important for improving health outcomes than some health interventions.

The goal should be maximizing healthy lives at all stages of life and not just life

expectancy.

Significant improvements in health can result from the attainment of other

development goals (e.g. clean cook stoves, the Abuja target, building roads, better

nutrition, and sustainable electricity for all). We have to be supportive of all the goals

because in the long run they will have an impact on health.

How can other sectors be held to account for harmful impacts on health (e.g. tobacco

and fast-food industries). Should this be done through parliament or other means?

Should we try to influence policies in other sectors or do we take a more defensive

stance?

Inequalities and inequities in countries need addressing; equity must be built into

each goal. Assessments of health outcomes and health impacts need to go to the

community level and not just to the district level.

UHC is essential for poverty alleviation: in some countries paying for health care is

the number one cause of poverty. Financial protection is as important as health

gains. UHC means access to high-quality health services regardless of income (i.e.

financial protection), prevention, health promotion, rehabilitation, and palliation.

Some argued that UHC is inspiring because it is rooted in the right to health and the

principles of universality.

In many countries investing in the health workforce and creating centres of

excellence are urgent priorities.

Currently countries are formulating their positions on the post-2015 agenda. We

should as a matter of urgency develop a tool to share among countries to show how

health links to other development goals. This piece was missing with the MDGs. We

should emphasize the social determinants of NCDs and the MDGs, quickly

strengthen the evidence showing how policies in other sectors impact on health, and

develop health outcome indicators for relevant policies delivered by other sectors.

Summation and closing remarks

In his summation Richard Horton of The Lancet focused on the why, what, and how

of reinvesting in health.

We have reaffirmed why we should reinvest in health. Larry Summers puts it best:

“We have a great sense of the unique possibility of our generation”. It matters

because too many deaths are preventable, because it leads to broad economic and

societal gains, and because it provides financial and social protection. Investing in

health is an instrument of political stability; and it also means investing in something


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that we value but cannot necessarily measure (as with environmental valuations).

How do we take these arguments to the post-2015 Open Working Group?

What to invest in depends on who is doing the investing. Governments in the 74

high-burden countries need to invest in strengthening health systems and moving

towards UHC. Many countries need to allocate a higher percentage of the

government budget to health. External development assistance for health needs to

better respond to the changing nature of ODA and the calls from countries for an end

to fragmentation of efforts and the proliferation of initiatives. Countries want more

support for their national health plans (including health promotion and disease

prevention) and their efforts to ensure financial protection and improve access to

high-quality health services. Overall, through the various consultations for the post-

2015 agenda, a framework for health and its links to sustainable development is

taking shape, with an overarching goal that seeks to maximize health at all stages of

life, and with universal health coverage and access as a key means to its

achievement.

We need to do a better job on the “how” of investing in health. Instead of talking

among ourselves we need to reach beyond our “health group”. There is no single

blueprint because each country’s context must be taken into account. Health does

not exist on its own; it needs to be part of a broader development agenda. How can

we make health a higher priority and ensure that spending on health does not decline

as fiscal space grows? There are important roles for the private sector and civil

society organizations to overcome this challenge.

There are also two major gaps in the conversation to date. First, do we have the right

institutions to ensure reinvestments in health work well globally and nationally? To

achieve better health outcomes we need to have institutions for the following six

functions: information and data, oversight and democratic governance (parliaments,

CSOs, judiciary etc), financing, stewardship (for better service delivery), normative

understanding, and accountability. Second, have we fully understood what we mean

by a new era of sustainable development? It is fundamentally different from poverty

reduction: it is about all of us not some of us; it is about planetary health and well as

people’s health and wellbeing; it is about creating resilient people and systems.

In his concluding remarks Anders Nordström made a plea for positive thinking,

pointing out that we, as the global health community, have the opportunity to broaden

the impact on health by supporting and embracing investments in education, water,

climate change, and other sectors, and making efforts to ensure that their impacts on

health are systematically monitored and evaluated.


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References:

Jamison DT, Summers LH, Alleyne G, et al. Global health 2035: a world converging

within a generation. Lancet 2013. published online Dec 3.

http://dx.doi.org/10.1016/S0140-6736(13)62105-4

Stenberg K, Axelson H, Sheehan P, on behalf of the Study Group for the Global

Investment Framework for Women's and Children's Health. Advancing social and

economic development by investing in women's and children's health: a new Global

Investment Framework. Lancet 2013. published online Nov 19.

http://dx.doi.org/10.1016/S0140-6736(13)62231-X

http://dx.doi.org/10.1016/S0140-6736(13)62105-4

http://dx.doi.org/10.1016/S0140-6736(13)62231-X


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Annex 1

Reinvesting in Health Stockholm, 31 October 2013

Agenda

10.00 Welcome and introductions Minister Hillevi Engström

10.10 Introductory remarks to the presentations Dr Richard Horton

10.15 Presentation 1: An investment framework for women and children

Preliminary findings of the new Global Investment Framework for Women’s and Children’s Health which looks at cost and impact of investing in RMNCH in 74 countries

Dr Marleen Temmerman

10.30 Presentation 2: Health as an investment for poverty reduction and economic development

Preliminary findings of The Lancet Commission on Investing in Health report

Prof. Dean Jamison

10.45 Moderated roundtable discussion

a) What are the benefits of investing in health, and especially in reproductive, maternal and child health?

b) What are the investment needs? Who pays – the role of ODA and domestic resources?

c) What conclusions can we draw on the role of development cooperation?

Ms Joy Phumaphi

12.00 Lunch

13.30 Presentation 3: Health in the post 2015 framework Dr Anders Nordström

13.45

Moderated roundtable discussion

a) What is the role of health in the post 2015 agenda and can we say that there is a renewed agenda for global health?

b) What type of global partnerships will be needed post 2015? What actions need to be taken to shape the global institutional landscape?

Dr Anarfi Asamoa-Baah

14.45 Summation Dr Richard Horton

15.00 Closing


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Annex 2

List of participants

Participants

Canada Ms Jennifer Goosen Director of Maternal, Newborn, and Child Health Programming, Department of Foreign Affairs, Trade, and Development

Denmark Mr Carsten Staur Ambassador, Permanent Representative to the UN in Geneva

Germany Ms Ursula Müller Director General, Federal Ministry for Economic Cooperation and Development

Ghana H.E. Hanny-Sherry Ayittey Minister of Health Norway Hans Brattskar State Secretary for International

Development Cooperation Myanmar H.E. Dr. Pe Thet Khin Minister of Health The Netherlands Mr Lambert Grijns Special Ambassador for SRHR and

HIV/AIDS Senegal H.E. Awa Coll-Seck Minister of Health UAE H.E. Sheikha Lubna Al Qasimi Minister of International Cooperation and

Development UK Mr Nick Dyer Director General, Policy & Global

Programmes , UK Department for International Development

USAID Mr Ariel Pablos-Mendes Assistant Administrator East African Community

Ms. Jane Mashingia Senior Health Officer of Medicines and Food Safety

Bill and Melinda Gates Foundation

Dr Chris Elias President of the Global Development Program

GAVI Dr Seth Berkley CEO PMNCH Dr Carole Presern Director of The Partnership for Maternal,

Newborn & Child Health UN Foundation Ambassador (Rt.), John E

Lange Senior Fellow, Global Health Diplomacy

WHO Dr Anarfi Asamoa-Baah Deputy Director General WHO Dr Marleen Temmerman Director, Department of Reproductive

Health and Research ALMA Ms Joy Phumaphi Executive Secretary of the ALMA and co-

chair of the IeRG CHESTRAD Dr Lola Dare CEO The Lancet Dr Richard Horton Editor and co-chair of the iERG Public Health Foundation India

Prof Ramanan Laxminarayan Vice President Research and Policy

Save the Children International

Mr Simon Wright Head of Child Survival

University of Washington

Dr Dean Jamison Professor of Global Health & co-chair of Commission on Investing in Health

Sweden (host) Ms Hillevi Engström Minister for International Development Cooperation

Sweden Dr Anders Nordström Ambassador for Global Health

Documents

Meeting Report - WHO · Sweden’s Minister for International Development Cooperation Hillevi Engström invited a group of high-level colleagues engaged in global health and development