Interview

With Jeffrey Sachs, Director of the Earth Institute, Columbia University and Special Advisor to the UN Secretary General.

How important is maternal and newborn health (MNH) to the realisation of the Millennium Development Goals (MDGs)?

The MDGs put a special focus on mother and child health. MDG 4 is to reduce child mortality by two-thirds by the year 2015, and MDG5 is to reduce maternal mortality by three-fourths by 2015, both against the 1990 baselines. Part of MDG 1 is to fight hunger and undernutrition, of special significance for mothers and children. So when the MDGs were established, mother and child health was paramount in the objectives of the world leaders.

The health of the population, including child survival and maternal health, is both a fundamental end in itself and also a crucial input for economic development. The MDGs really embody this dual importance of health.

 

Can we quantify the damage inadequate MNH does to the global economy?

It is possible to estimate the effects of disease burden on overall economic development. I chaired WHO’s Commission on Macroeconomics and Health in 2000-1, and found that populations suffering an excessive disease burden pay not only the obvious human price, but the economic price as well. Economic growth and productivity is reduced. Children who have childhood illnesses and miss school may be impaired for a lifetime. Even younger children, ages 0-2 can see their lifetime potential permanently impaired by a few years of poor health and undernourishment.

Nutrition plays a fundamental role in brain development and therefore in allowing individuals to reach their potential. If a child is malnourished, they may carry physiological burdens for their entire lives. The economic consequences of infant illness, poor nutrition and, of course, the tragedies of orphan-hood for the whole family are well established.

Historical experience shows that when health improves so too does economic performance.

 

Is money a problem, an excuse or an inconsequential factor for the achievement of MNH targets?

Money is key for a proper health system, and this includes not only formal medical care, but also related systems of safe drinking water and sanitation, food storage, family planning, nutrition, proper ventilation within kitchens, and so on. So the challenges of mother and child healthcare require investments of several kinds, some within the household, and many at the national level (especially in the public health system).

Such costs are beyond what very poor families can muster on their own. It does not work anywhere in the world to simply leave healthcare to ‘out-of-pocket’ payments of households themselves. This happens in the US and tens of millions of people fall through the cracks. In India, out-of-pocket expenditure on health can be as much as 80-85 per cent of total household spending, but this is only because public spending on health is so little. Public finance must therefore fill the gaps the poor themselves cannot cover. It would be normal for public spending to account for 80 per cent of the total (as in most of Europe), rather than for private spending to account for this share.

When I led the Commission on Macroeconomics and Health, we calculated the cost of a basic medical system and preventative health system, and found it took as little as US $34 per person per year of public spending, measured in 2000-2001 prices. Today that would be around US $50 per capita.

The Indian government is not yet investing enough in health, and until the Indian government can reach the level of US $50 per capita, many deep public health problems will not be resolved. India could be aiming for around $25 per capita within the next few years, and plan to build up to $50 or higher after that in line with economic growth and rising budget revenues.

I wish that the world would give India more aid funds for public health now. The problem is that India is so big that donors are afraid even to start down that road. (If India were 28 smaller countries, rather than 28 states, each of those ‘countries’ would be getting a lot more foreign aid, as do countries around the world with India’s per capita income but much smaller populations).

Of course money alone is never sufficient – because if the systems are disorganized, the money will go waste. Is it money, is it systems or is it household awareness that is important? The answer, of course, is all of them. When you have a system, many things have to be in place. Money is one of them.

 

Looking back at history, are there lessons to be drawn from the developed world and its successes in MNH? At which point in western society’s evolution, did MNH stop being a problem and start being an asset?

There are many lessons that can be drawn, both positive lessons as well as warnings. The main causes of maternal and newborn mortality in India are traditionally infection, undernourishment, and unsafe childbirth. The positive lesson is that all three areas can easily be addressed by modern public health, by investing in control of infectious diseases, preventing acute and chronic undernourishment, and ensuring safe childbirth for the mother and the newborn. Lessons from many other countries show that it is possible to drive down death rates very sharply and rapidly if these priority areas are targeted and properly resourced.

The second lesson is that it takes systems to bring this about, not just market forces. It requires an organised publicly financed system of disease surveillance, proper training, proper staffing and supervision, monitoring disease burden, enforcement of protocols by supervisors. This is an organizational challenge, not simply a demand-supply question. For example, immunization coverage does not tend to happen because individuals want immunization. It happens because it is decided at the societal level that there should be mass immunization and then efforts are made to ensure that immunization reaches all those in need.

The third lesson is that public finance is central. Out-of-pocket expenditure and even community-based insurance cannot cover the cost. This is because the poor simply cannot afford basic healthcare on their own. They therefore need fiscal transfers, often in the form of state-supplied clinical services, or in some cases, reimbursement by the government to private providers, who may be lower cost and more efficient than directly provided government services.

In rich countries, the best working systems delivering the best healthcare at the lowest cost with the most equity are publicly financed systems that typically enforce universal or near universal coverage. The US is an exception because it has a half-private, half-public spending scattered across a large private sector delivery system. The result is that a large part of the poor population has fallen outside coverage. This is distressing. The system is not equitable because of the broad variation in coverage between the well-to-do and the poor. It is also a very expensive system. The well-to-do can afford high-quality medical care but the poor are left out of the system.

Successes like in Sweden, Norway, Denmark, the Netherlands, and the United Kingdom have a more systematic, affordable and effective approach towards healthcare. They are all based on public financing, with some mix of public provision and private provision (reimbursed by public finance).

Finally, nobody has solved all of the challenges of outlays and public health. Healthcare systems all around the world are stretched for funds. It is a difficult sector because people want high-quality care at very low cost and sometimes the two can’t coexist.

In the Indian context, there has been a chronic under-investment in primary health services since Independence. Until now, the level of spending has been amazingly low. The government is spending around one per cent of GNP on health in the public sector. In the US, which is a much more private sector oriented economy, public spending is around six or seven per cent of GDP (and private spending is also around nine per cent of GDP). In Europe, public spending is around nine or ten per cent.

 

Talking of India, this country is proud of its demographic dividend, of being the major economy with the largest number of young people in the first half of the 21st century. Can poor MNH indices negate this dividend?

India has many challenges with regard to this demographic dividend. It has achieved a reduction in the total fertility rate (TFR) but, at an estimated 2.7, this remains far above the replacement rate of 2.1. It is important for India to reach the replacement rate quickly and voluntarily.

India has a population of 1.1 billion people. It is extremely crowded, and faces major environmental, water, food, and farmlands area stresses. This is going to get worse. On current projections, India’s population could easily rise to around 1.6 billion people in a few decades, by 2050.

Effective family planning would be one major component to achieve the demographic dividend. This means enabling women, especially in rural areas and in disadvantaged households to gain access to family planning services that they need, including free contraceptives, and empowerment to make the choices they want to make.

More generally, India faces many health challenges. The H1N1 virus shows our health systems have to be up to par in order to face what will be a continuing set of new challenges and emerging diseases. HIV/AIDS, of course, is one disease that absolutely requires a public response.

India is experiencing other new epidemics as well. Perhaps the most traumatic of these new epidemics relate to diabetes and a number of cardiovascular diseases. India is in this special situation that is called the ‘double-disease burden’. Not only does it have to grapple with the three traditional challenges of infections, nutrition, and unsafe childbirth, but India also has to grapple with new epidemics and chronic diseases associated with changes in lifestyle and these also require a public health approach.

The US is also deep in this diabetes and obesity epidemic and we have an inadequate public health approach to deal with it. We have food companies selling things that are not safe. Many of them know they need to change, and that’s the good news. But because we lack a public health system, the epidemic of obesity, for example, remains out of control.

This should not happen in India. It would be frustrating if many in the population were to become ill at a young age from a quick transition to unhealthy diets and lifestyles. Obviously then the gains from the economy would not be realised.

 

You’re working with the Indian government and advising it on health issues. How seriously is the government taking MNH?

The National Rural Health Mission (NRHM) is the first major initiative I have seen in India that really aims to get primary healthcare to the poor on a mass basis, especially in the larger states. It tries to address the notorious North-South divide in health service quality and outcomes. The government is spending more money and looking at systems in a very serious way. It is unveiling new health management information systems and is using ASHA (accredited social health activist, a kind of community health worker) to connect poor households with formal facilities. This has resulted in a huge increase in institutional deliveries by mothers who would traditionally have given birth at home in unsafe and unhygienic conditions. Now the JSY (Janani Suraksha Yojana) and ASHA schemes are offering incentives for institutional delivery.

However, many things need to work in a system, to make the process deliver. So while pregnant women may come to the facility to deliver, the facility is often understaffed, lacks cleanliness, running water, maybe even a doctor or anaesthetist, or somebody to help organize an ambulance.

The NRHM is making positive changes but it is exposing other weaknesses along the way. I am suggesting more financing to close the gaps and more managers who will link all these so-called vertical programmes – ASHAs and ANMs (Auxiliary Nurse Midwives), anganwadi workers, and others – into an effective integrated system. We need to have a health systems manager who helps put all these pieces together at the village level, and the block level, not only at the district level.

We also observe that the manager in the system today is a medical doctor. This is generally a misplaced assignment because India does not have enough medical doctors and this takes them away from their patients, especially in rural areas. Moreover, doctors are not necessarily good managers. I would like to see a properly trained health systems manager in place, freeing up the medical officer to do medicine.

I am suggesting more financing, more systems management and more data flow. There is already a positive change under way and you can see it, especially the increase in institutional deliveries. This is starting to show in declines of maternal mortality rates (MMR) in some places. One thing I think could be quickly ramped up is data collection. The time lag in this country for collecting MMR and other data is often three years. We need much faster feedback to improve systems management and upgrading.

These are numbers that can and should be collected monthly. It makes no sense to wait three years, because we need those numbers not just for reports but also as management tools, for the local manager to see how many women have died in his district at childbirth in the past month. The manager then has the information to go and find out what’s wrong. Such information needs to be used to make the system operational. This is still a missing component.

 

Is there anything else you’d like to add that may be of importance in terms of MNH?

One thing I keep stressing is that it is paramount to have systems work properly. In the US and India right now, the government wants to do more but implementation can be very weak. This is not only a matter of political will or interest at the central/federal level, but also effective systems right down to the communities. We are looking at a lot of the detailed wiring right now. Who reports to whom? Are there ways to simplify the management structure? Are there ways to link information flows more productively?

Many countries’ demonstration projects show new approaches to service delivery. When those new approaches function successfully, the government comes in and has a look at the changes, and then spreads those changes to other parts of the country. In India, it would be a good idea to look at local working models – those that have been proven to drive down maternal and child mortality rates – then take the lessons from these, and argue for system reforms at a large scale.

This is where I will certainly put a lot of my own effort in the next few years. I am trying to translate positive policy intentions into actual results on the ground.

 

* Interview conducted by Rashmi Pachauri Rajan and Ashok Malik on 10 August 2009 in Delhi, India.