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Introduction
THE economic crisis facing several countries in Asia presents a great
challenge to the progress that these countries have made in many of their
indicators for health, including increases in life expectancy (e.g., from 45
years in 1967 to 63.9 years in 1997 in Indonesia and decreases in infant
mortality rates (e.g., from 145 per 1 000 live births in 1967 to 54 in
1996 in Indonesia.
The goal
of sustainable development cannot be achieved in a society if its peoples
suffer ill-health. However, healthy people can contribute to the achievement
of sustainable development. Therefore, health is a part of the goal of
sustainable development and, in turn, helps to achieve that goal. In this
sense, especially in a crisis, health is everybody’s business.
It is
fully understood that health is not isolated from other issues affected by an
economic crisis, including levels of poverty, transportation infrastructure,
water and sanitation. However, this paper focuses on the “sphere of
influence” that we have in the health sector and what role the World Health
Organization (WHO), in partnership with government, development and donor
allies in the health sector, plays to help alleviate the negative impacts on
health brought about by this economic crisis.
Roles of WHO in an Economic Crisis
WHO, as a specialized agency of
the United Nations (UN) system, has unique roles, to provide technical assistance. These roles become even more critical in a
time of economic crisis. Specific roles, and concrete examples of how these roles
have been implemented in Indonesia, include the following:
Advocacy for a social safety net, including health
In
January 1998, WHO convened a meeting of representatives of UN agencies in Jakarta to alert
the UN agencies of the threats to the health of the most vulnerable groups in
Indonesia
due to the economic crisis and to note that the UN agencies, working
together, could play a significant role in ameliorating the effects of the
crisis on health. This led to such innovative
approaches as the UNIDO effort to explore the potential of the Indonesian
fine chemical industry to manufacture the raw materials needed by Indonesian
pharmaceutical manufactures to continue to make essential drugs.
In
February, April, and July of 1998, WHO either chaired, or co-chaired, with
the Ministry of Health, informal donor meetings in the health sector on the
economic crisis and its impact on health. These meetings brought together
government agencies, UN agencies, development banks, bilateral development
assistance agencies, and nongovernmental organizations to discuss the impacts
of the crisis on health, the needs of the government to address these
impacts, and the willingness of donors to help meet these needs. Such
meetings helped to keep health high on the list of government and donor
priorities for inclusion in a “social safety net.”
Throughout
the crisis, WHO has met with numerous donors and potential donors to advocate
the important “link” that health should play in a “social safety net” in
Indonesia, including provision of information on: gaps developing for needed
raw materials for essential drugs; essential imported medical supplies (x-ray
films, sutures, IV kits and blood bags, test kits and reagents); and the
operational costs for providing services to the poor by village midwives (bidan di desa),
health centres (puskesmas) and first referral-level
hospitals (district hospitals).
In
addition, WHO, at the regional level, called a Meeting on the Economic Crisis
and its Impact on Health in Bangkok
in March 1998, and supported a Regional Meeting of Parliamentarians on the
same subject in Jakarta
in December 1998, to draw linear attention to the crisis, and for countries
to share their experiences in coping with the crises. At the global level,
WHO has been involved in advocacy for health under times of economic crisis. As recently as December 1998, WHO headquarters
called a special meeting in Geneva to review the experiences with structural
adjustments and their impacts on health and to recommend ways that WHO can be
even more proactive and effective at global, regional and country levels
during times of economic crises.
Technical assistance to government in
assessing the likely impacts of the crisis on health and developing
interventions to ameliorate those impacts
WHO prepared materials, in collaboration with
government counterparts, on the likely early effects of the economic crisis
on health, including availability of essential drugs and vaccines, declining
health status of the poor and near poor population, increase in the
utilization of government health services, and decrease in the demand for
private sector health services. Short-term interventions recommended to address
these likely impacts included: issuing Ministry of Finance letters of credit
to immediately import at least a six-month supply of critical consumables
(e.g., x-ray films and laboratory reagents) and the raw materials to make
essential drugs; halting of non-essential new civil works, construction and
equipment purchases; reprogramming donor-assisted projects to the highest
priority needs; targeting scarce resources to the priorities of maternal and
child health care in areas of greatest need; maintaining the distribution of
doctors and village midwives in the poorest rural areas; paying subsidies to
support operational costs of health centres and hospitals in areas with a
high proportion of poor; rapidly developing the kartu
sehat (health card for the poor) system to correct
its deficiencies; and establishing a sensitive monitoring system for the
health effects of the crisis. Intermediate and longer term recommended
actions included: encouraging increased use of generic drugs and promoting
health insurance with cross-subsidies for the poor.
As the crisis unfolded, WHO continued its
dialogue with the Ministry of Health and the central planning bureau
(BAPPENAS) to identify additional areas of impact of the crisis on health and
to refine cost-effective recommendations on interventions.
Such work is based upon the technical expertise of in-country WHO
international and national staff as well as selected visits of technical
experts from its Regional Office and headquarters (e.g., a consultation by
the headquarters’ Drug Action Programme on the issues of rational drug use,
drug dispensing policies, and drug registration procedures).
Technical assistance to the government in developing monitoring systems
WHO provided technical assistance to the Government
in developing monitoring systems (with recommended outcome health indicators,
such as levels of malnutrition in children, and process indicators, such as
essential drug prices and availability). Such
monitoring, although still at an early stage, will ultimately help to
determine the actual impacts of the crisis on the health status and delivery
of health services, target interventions to the areas of greatest need, and
assess the effects of interventions. For example, WHO is working with the
Ministry of Health to improve the collection and analysis of information
about drug supplies at the district level. In
addition, support is being given for a rapid assessment of drug supplies and
prices at all administrative levels. In Indonesia, the Ministry of Health has created a crisis centre
to be a focal point for this monitoring activity and WHO provides the
services of international and national staff in supporting this activity.
It is a challenge to
balance the needs of a streamlined, timely, complete and focused monitoring
system at a time of crisis versus the routine reporting systems for health
data. In addition, more needs to be done to link information with
interventions and to provide data useful to decision-makers. Ideally, the
monitoring systems in the crisis can be a stimulus to a more effective
routine data collection system that will remain in place after the crisis –
rather than a parallel system that is only temporarily established and then
dismantled after the crisis has passed.
Supporting coordination
efforts of the government
WHO works
to support the government’s efforts in coordinating inputs by the
international community (UN agencies, development banks, bilateral
development assistance agencies, and nongovernmental organizations) to avoid
duplication of efforts and reduce gaps in critical areas.
Such support ranges from helping to organize informal donor meetings of all
donors in the health sector, to providing the services of in-country WHO
international and national staff to work, together with Ministry of Health
counterparts, on a one-to-one basis with donors to develop and refine their
individual project or sector loans and grants.
Technical assistance to others in the international community
WHO also
provides technical assistance to others in the international community, both
on request and through proactively offering, regarding their project or
health sector loans or grants to help maximize the impacts of these loans or
grants on improving health. In Indonesia, examples
have included: consultations with UN agencies (such as UNICEF, UNFPA, and
UNIDO), development banks (such as World Bank and the Asian Development
Bank), bilateral development assistance agencies (such as US Agency for
International Development , Japanese International Cooperation Agency, and
the Australian Agency for International Development), and nongovernmental
organizations (such as PATH and UPLIFT International).
Limited Funds
Although WHO is primarily a technical assistance
agency, it sometimes provides limited funds for critical shortfalls where
other donors may not be able to mobilize funds quickly. In Indonesia,
examples have included: providing $100 000 for an emergency purchase of
HIV test kits to ensure continuity of testing for blood safety while other
donor funds were being mobilized to assure a longer term supply of the test kits,
helping to support the establishment of a Health Development Reform Task
Force, and assisting in the formation of a crisis centre within the Ministry
of Health.
Lessons Learned
The
economic crisis provides an opportunity to learn what approaches work and
don’t work that may be useful as the crisis continues and may have
applicability to other countries experiencing a similar crisis. Some of these
lessons learned in Indonesia,
to date, include the following:
Crisis as opportunity
At first, the crisis seems overwhelming in its
nature. From the WHO side, we appreciate that, in a crisis situation, it is
often difficult to look ahead from the immediate crisis at hand to the
looming crises yet to come. However, the crisis forces a “new look” at
virtually all policies, strategies and programmes due to the threats of
contracting funds. Often the problems existed before and are only exacerbated
by the crisis. In this way, the crisis can also be seen as an opportunity to
solve key problems and make significant improvements in both government and
donor programmes and interactions.
In the health sector, this means that we also need to view the crisis
as an opportunity for change and to improve
efficiency. In Indonesia, such opportunities include: (a) developing
timely and comprehensive monitoring systems to look at utilization rates of
health centres and hospitals, availability and
costs of essential drugs, and increases in diseases (especially those
associated with poverty) to assess trends and the effects of interventions;
(b) increasing the proportion of government budgets to the social and health
sectors (real increases as compared to increases due only to the donor
projects being valued at a higher rate of exchange due to their dollar-based
funding); and (c) Improving the procurement of raw materials, finished
products and medical equipment being imported for the health sector.
Importance of priority setting
In a situation of scare resources, decisions must be
made on funding priorities. For example, is it better to use public funds for
the medicines needed to keep 1 000 terminally-ill cancer patients alive
for a few months longer, or to use these funds to provide the antibiotics
needed for treating pneumonia in 100 000 children? In an ideal world,
all medical care needed for all peoples would be available. We do not live in
that ideal world in any country and, in Indonesia, some of these choices may have to be made. In the absence of
consensus on such issues, conflicts over the use of funds will arise and
often the most vocal, rather than the most needy,
will win. The government should focus its resources on subsidizing public
goods and cost-effective interventions. On the other hand, such insurance
schemes should be established as would enable all people to have access to
treatments for more costly diseases, such as cancer and renal failure.
Potential to lose priority setting pressures in the face
of additional funds
The
pressures brought by an economic crisis to prioritize, may, however, be deferred as additional funds are provided by the donor
community. There is a balance between providing a safety net whereby
extremely difficult choices (such as whether or not to use the funds to save
100 000 children from pneumonia or 100 000 children from diarrhoeal
diseases) do not have to be made, and between providing a surplus of funds
that allows cost-inefficient programmes to easily continue (including
non-competitive procurement of medical equipment and imported raw materials
for the manufacture of essential drugs, practices of corruption, and
non-rational drug prescribing practices).
Donor driven or inappropriate consumer
driven programmes
A crisis may result in donors with good intentions
providing materials that may not be in the best interests of the country. A
good example is the donation of medical supplies and pharmaceuticals. In Indonesia, for example, dialysis supplies have been sent by
donors without first checking to see if they are compatible with the dialysis
equipment used in the country. Pharmaceuticals have been donated that were
short-dated or not in the drug formularies of the country.
Consumers, too, can put pressure on the government
to supply items that may, in fact, worsen the situation. An example in Indonesia has been the concerns expressed by some mothers
about the prices of infant formula. Importation and distribution, by the
government and donors, of infant formula may create the impression that
infant formula is preferable to exclusive breast-feeding for the first 4-6
months of life. Rather than the protective
effect of exclusive breast-feeding (and the fact that breast milk is free),
infants will potentially be weaned to an infant formula that may be overly
diluted (because of its expense, even if subsidized) and prepared with
contaminated water (because of the difficulty and expense of boiling or using
bottled water for proper formula preparation) in situations with unsafe water
supplies.
Disbursement of funds
without clear guidelines
In the good-intentioned effort to disburse funds
quickly to create a social safety net, there must first be a well thought-out
guideline as to how to use the funds. For example, in Indonesia, a social safety net programme disbursed funds
(10 000 rupiah per poor family) to district levels to support health
services for the poor by village midwives and health centres. However, many
midwives and health centres delayed drawing on these funds because of their
initial concerns that there was not sufficient guidance on exactly what the
funds could be used for. They feared that if they used the funds without
detailed guidelines, they might later be subject to an audit that could
accuse them of not properly using the funds.
Paucity of data for decision making
Of great concern to many donors, and to the
government as well, is the difficulty of activating the routine information systems
to rapidly report, in a timely and complete manner, essential indicators by
which to measure trends in health status and the provision of health
services, to target the vulnerable populations in greatest need, and to
determine the effect of intervention programmes. In Indonesia, these concerns have led, in some cases, to the
development of parallel information systems that may duplicate the work of
the routine system, or overlap with the work of other parallel information
systems being set up by different units within the government, funded by
different donors. In addition, there is a tendency to set up an elaborate,
centralized reporting system. Interventions are conducted locally and useful
information is most needed at these levels to guide local efforts. The
establishment of a crisis centre, with a mandate to oversee all data
collection efforts to monitor the crisis, may help to stimulate the routine
system and maximize the benefits of specialized reporting systems. This will
ensure that the data for decision-making are readily available and will also
provide donors with the confidence that their contributions are accounted for
and making an impact on ameliorating the effects of the crisis.
The effects
of other sectors on health
There are many other sectors
whose activities have direct or indirect impacts on health. Transportation
affects the distribution of food, medicines and referral medical care.
Agriculture and the availability of agricultural products affect the
nutritional status of the population. Education levels affect basic health
knowledge and literacy has been demonstrated as a factor in improved health.
Family planning limits the too many, too often, too young and too old
pregnancies that lead to high maternal mortality rates and a cycle of
poverty. Industry and employment affects the levels of poverty. Environment
and public works affect the availability of safe water and adequate
sanitation. It is a challenge during a crisis to see how to maximize the
positive impact of the different sectors on health and, in turn, how good
health can lead to positive impacts in the other sectors (e.g., a healthy
worker is a more productive worker in industry or agriculture).
Conclusion
It is clear that the Government of Indonesia and its
Ministry of Health are very concerned about the implications of the economic
crisis on the health of the Indonesian people. It is also recognized that, in
addition to health, there are great concerns regarding the entire social
sector and the need to establish a “social safety net” to protect the most
vulnerable segments of society.
The development and donor
community in Indonesia, including WHO, is also very
concerned about the health implications of the economic crisis and is showing
an unprecedented degree of flexibility of approach to ensure that loan and
grant projects are suitably adapted to the new realities.
Is the common goal to achieve
sustainable development of the Indonesian people threatened by the potential
of this economic crisis to take back many of the hard-won development gains,
including those in health, such as decreases in infant and childhood
mortality rates, increases in life expectancy, and decreases in fertility
rates?
No one person or agency has all
the answers; and no one, alone, can solve all of the problems. But, working
together, creative and innovative ways can be found to help ensure that the
most vulnerable groups will continue to have access to primary health care
services. After the process of overcoming this crisis, it may be possible to
ultimately look back at some future time and realize that such a crisis has
provided the impetus that was needed for improving efficiencies in the health
system; strengthening competition in such areas as pharmaceuticals, medical
equipment and vaccines in the era of globalization; and establishing reforms
for health financing to protect the poorest of the poor.
WHO’s role is to advocate and provide technical assistance
to those working on structural adjustment policies, to encourage placing “a
human face” on such adjustments and to put into place the “social safety net”
that prevents the most vulnerable segments of our society from plunging into
a cycle of poverty and ill-health – each conspiring to create an inescapable
spiral of needless suffering, disability and even death.
* This is an updated version of the paper presented at the
Regional Meeting of Parliamentarians on Economic Crisis and its Impact on
Health, held in Jakarta, 7-9 December 1998
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