Towards a single health goal
In the global conversation around sustainable development goals (SDGs), there is consensus that the United Nations Millennium Development Goals (MDGs), which expire in 2015, need to be incorporated as that is not a closed chapter—the maternal and child health targets and infectious disease control have only been partially met. Despite major progress in fighting infectious diseases such as HIV/AIDS and tuberculosis (TB) and reducing infant mortality, huge disparities exist between richer and poorer nations. These need to be reflected in the new goals. At the same time, it has been clearly recognized by the UN and the World Health Assemble that non-communicable diseases (NCDs) are the dominant public health challenge of the 21st century. We need concerted global efforts with substantial national commitment and these need to be incorporated in the new goals. Meanwhile, universal health coverage (UHC) has become an important aspiration by countries.
In order to accommodate all of these—MDGs, NCDs and UHC—in a single health goal, one has to take a life course approach to health rather than segmenting it into stages of life and fragmenting the health system into approaching these diseases through vertical programmes. The wording of these goals is still being debated across the world and it will take another 18 months before the actual goals are adopted by the United Nations.
Commission on Investing in Health (CIH) was agnostic about the ongoing debate concerning SDGs. Nevertheless, the commission’s work substantially overlaps with the debate on SDGs and covers the same elements. The commission has argued that a “grand convergence” entails the reduction of infectious, child and maternal mortality rates to universally low levels by 2035. The concept of grand convergence is about the tangible opportunity—with strategic investment in health and utilization of present knowledge—to achieve MDG targets of maternal and child health indicators to levels that are currently seen in high income countries by 2035. These will also yield huge return on investments. Of course, as people survive infectious diseases, they are more likely to be more vulnerable to non-communicable diseases. Both these agendas—NCDs and MDGs—will have to be combined within the UHC approach. Also, the commission argues that an increased expenditure on public health is an “ambitious but feasible” way to achieve these targets. Economic growth will allow low and lower-middle income countries to pay for the bulk of health improvements themselves and gradually, high income countries will see a shift in their role as a donor to that of a stakeholder providing scientific research and policy guidance.
Additionally, even hardheaded economists in this commission agree that the value attached to life gain has to go beyond productivity that is reflected in the gross domestic product (GDP). Existing macroeconomic studies measure the impact of health improvements on GDP, they do not capture the intrinsic value people place on their own improved health. Imagine two countries that have an identical GDP per person, but that have stark differences in their health status. The people of one country live longer than the second. Using GDP does not capture the reduced mortality risk in country A in national income accounts. This is a huge omission which the “full income accounting” seeks to address. The full income approach combines growth in national income with the value people place on increased life expectancy—that is, the value of their additional life years (VLYs). One VLY is the value in a particular country or region of a one-year increase in life expectancy. Global Health 2035 estimates that, on average, across low-income and middle-income countries, one VLY is about 2.3 times the per-person income.
These are arbitrary figures but they extend the valuation of health beyond mere economic productivity and GDP to increase the value gained by extending life.
We do recognize that resources in low and middle income countries do not permit them to undertake universal healthcare in all its dimensions overnight. What we call “progressive universalism” is a path prescribed for it. The commission believes that infectious diseases, maternal and child health—which constitute the grand convergence—together with some key elements of non-communicable diseases must constitute the bare essential package that every country must invest in. As resources progressively increase, they can expand the benefit package. The preferred pathway is a public financed programme of universal healthcare without levying user fee. This is going to be pro-poor, not because they target the poor but because these conditions affect the poor the maximum.
Reddy is president of Public Health Foundation of India and member of the Commission on Investing in Health. As told to Vidya Krishnan