Slot-Machine Approach

Although it has been employed for a long time now, there is something grotesque about computing the economic and social cost of disease: that disease causes rapid turnover of the workforce, high absenteeism; reduces productivity; depresses tourism and blocks profitable investment; prevents the cultivation of arable land and the economic use of natural resources. Investment in public health under capitalism has classically come about only when the returns – in terms of labour productivity (as, for instance, in the prevention and elimination of certain kinds of occupations diseases, elimination of hookworm in plantations, or TB) or in resources available for profitable exploitation (as in the case of malaria eradication during the building of the Panama canal). After two years of work, the Commission on Macroeconomics and Health set up by the World Health Organisation at the instance of its director general Gro Harlem Brundtland which recently presented its report on investing in health for economic development does precisely this. The report of the commission comprising leading economists and health experts is an emphatic document showing how profitable it is to invest in health. One may not take issue with the argument that investing in health produces larger gains. It is however over the concepts that are used, the assumption made and the deafening silences that debate must occur.

To be fair the commission’s recommendations are so wonderfully right: after all who can quarrel with one of its key recommendations that “the world’s low and middle income countries, in partnership with high income countries should scale up the access of the world’s poor to essential health services, including a focus on specific interventions”. Or that lack of funds should not be a factor that limits poor countries’ capacity to provide health services to “the world’s poorest”. And even that each developing country establish a temporary National Commission on Macroeconomics and Health to organise and lead the task of scaling up of the health sector. What is missing in all this is the political reality of governments in place, working democracies and the vast and working, even if not efficiently, institutions and governance structures and the political and social dimensions of attempting any intervention in health and social sector. And that is a pity. Such prescriptions have been made in the past and because poor countries have not had the clout to resist pressures or have had few alternative ideas, they have attempted desultory implementation and failed miserably. WHO’s experience in health interventions in these countries, viewed objectively, should have yielded the understanding that brand remedies are no good, and that each country has to arrive at its own particular system for health care and eradication of disease. The commission’s failure to recognise that improvement in health status is a socio-political process and cannot be achieved by mechanistic solutions is unfortunate.