Equality, Equity and Policy: Critical Analysis Of Investment In Health Improvement and the Part Played By Economic Development And Global Organisations
Investment in health improvement can take two forms:
- Investment in health care - including health facilities, staff, prevention programmes, public health and health care management.
- Investment in wider determinants of health - (see Figure 1 in section 10: Inequalities in Health) such as poverty, living and working conditions, housing, education, etc.
In the UK, recent investments in health care have focused on building partnerships (between the NHS and local councils, social services, the private sector, charities, academia, and community organisations), improving facilities, improving performance, staff education and training, improving patient care, and disease prevention (NHS, 2000). The impact of investments in healthcare on health improvement can be assessed through health care evaluation (see module 1c: Health Care Evaluation and Health Needs Assessment).
UK investments in the wider determinants of health have recently included urban regeneration policies. These are often delivered through area-based programmes which seek to incorporate initiatives to improve the physical, social, and economic environment. In fact, the potential for health improvement is often used to justify government investment in urban renewal. However, there is virtually no evidence that area-based urban renewal programmes lead to health impacts, either directly or indirectly, through influencing some of the wider determinants of health (Thomson, 2008).
In developing countries a number of global organisations invest in both health care and the wider determinants of health (see Table 1).
Table 1: Examples of actors in health improvement.
Some economic development organisations and government agencies place ideological and structural restrictions on funding which may restrict health improvement (see Box 1). Health improvement projects of other global organisations have received criticism for unrealistic targets, insufficient funding, and poor programme implementation. For example, the WHO 3 by 5 initiative experienced all of these criticisms (see Box 2).
Box 1: Ideological and structural restrictions on funding.
The World Bank’s mission statement is "to reduce poverty, and improve living standards by promoting sustainable growth and investment in people." The World Bank sets up, funds, and implements economic policies in many developing countries throughout the world. Poverty reduction and better living conditions should lead to better health outcomes in developing countries. However, the World Bank’s economic policies, and their potential influence on health, are a source of debate among the economists and the public health community (Stott, 1999). Some claim that the World Bank’s restrictions (including strict controls on programme implementation, monitoring and evaluation) have prevented some health resources from being allocated (Bretton Woods Project, 2008).
The effect of International Monetary Fund (IMF) programmes on health is also controversial. An article in the Public Library of Science linked IMF loans to increased incidence, prevalence, and mortality rates from tuberculosis in post-communist Eastern European and former Soviet countries. The authors hypothesised that countries with IMF programmes spent less on public health and therefore experienced worse outcomes (Stuckler et al, 2008). Similarly, The Centre for Global Development has claimed that the IMF has unduly constrained countries’ policy choices, limiting health spending options.
In the past, the conservative leadership in the US affected the ideology of USAID, and therefore any USAID-funded reproductive health programmes. Under President Bush’s leadership, USAID ceased to support agencies involved in abortion related activities (the so called ‘global gag order’), while increasing funding for abstinence related programmes. Hwang and Stuart (2004) claim that “ideological concerns appear to trump evidence-based decision-making” in USAID policy. The implications of this ideological shift on health are largely unknown as yet. However, President Obama lifted the ban on US funding for international organisations that offer advice on, or perform, abortions in January 2009.
Box 2: Unrealistic targets, insufficient funding, and poor programme implementation.
In 2003, the WHO and UNAIDS introduced the “3 by 5” initiative to address the global emergency of AIDS. The 3 by 5 target aimed to provide antiretroviral treatment to three million people living with AIDS in developing countries and countries in transition, by the end of 2005. The target was widely criticised as unrealistic given the short time period. Bate (2007) further criticises both the financing and implementation of the 3 by 5 initiative. He states that the initiative was rescued largely by a commitment from the Canadian International Development Agency and argues that the initiative put undue pressure on poorly funded local health systems. “Several countries, particularly in Africa, were encouraged to make commitments they could not afford and undertook revisions of existing treatment targets in line with 3 by 5 on the ‘expectation of substantially increased financial support which did not materialise’. Some of these revisions involved redirecting funds from other primary health-care initiatives, such as maternal and child health.” The WHO was unable to meet the 3 by 5 target and publicly admitted that its strategy had failed. However, Adelman (2006) states “the failed campaign did not prevent WHO from quickly announcing a new ‘10 by 10’ AIDS treatment program - with the goal of treating 10 million people by 2010. The effort calls for $28 billion a year for treatment starting in 2008, even though there are no modifications to WHO's strategy.”
- Adelman C. (2006). “Let's learn from global health failures: WHO and AIDS”. International Herald Tribune, May 23, 2006.
- Bate R (2007). “Unchecked Idealism: WHO’s epidemic?”. Health Policy Outlook. No. 7. American Enterprise Institute for Public Policy Research.
- Bretton Woods Project (2008). World Bank and IMF get a dose of health criticism. Update 62.
- Hwang AC, Stuart FH (2004). “Family planning in the balance”. American Journal of Public Health, 94(1): 15-8.
- NHS (2000). The NHS plan: a plan for investment, and plan for reform. London: The Stationary Office.
- Stott R (1999). “The World Bank”. BMJ 318;822-823.
- Stuckler D, King LP, Basu S (2008). “International Monetary Fund Programs and Tuberculosis Outcomes in Post-Communist Countries”. PLoS Medicine 5(7): e143
- Thomson H (2008). A dose of realism for health urban policy: lessons from area-based initiatives in the UK. Journal of Epidemiology and Community Health, 62: 932-6.
- World Bank (1998). Q and A. Facts and Figures about the world bank group. Washington, DC: World Bank,1998 Spring 1.
- UN Population Fund
- World Bank
- Food and Agriculture Organisation
- Japan Health and Development Initiative
- Canadian International Development Agency
- Global Fund to Fight HIV/AIDS, Tuberculosis and Malaria
- The Global Alliance for Vaccines and Immunisation
- Bill and Melinda Gates Foundation
- Open Society Institute/ National Soros Foundations
- Instituto Carso de la Salud
- Doris Duke
- World Food Programme
- International Committee of the Red Cross/Crescent
- Medecins Sans Frontieres
© Rebecca Steinbach 2009, Margaret Eni-Olotu 2016