Richard Smith on why the private sector is needed to achieve the Millennium Development Goals

Richard Smith On Monday I was at a meeting with Bill Clinton and Ban Ki-moon, illustrating my global significance. I’d better make clear, however, that 500 other people were also present, and neither Bill nor Ban would have had any idea that I was there.

Held at the United Nations building in New York, the meeting was intended to encourage philanthropists to continue to contribute to achieving the Millennium Development Goals, particularly those related to reducing maternal mortality and the harm from neglected tropical diseases. These two MDGs are not on track to be achieved.

Half a million women die in childbirth every year, 99% of them in developing countries. A woman in Niger has a one in seven chance of dying in childbirth, whereas a woman in Ireland (the safest country in which to give birth) has a one in 48 000 chance of dying. Fifty million women a year give birth without a skilled attendant being present.

Maternal mortality could be cut substantially by a triad of having a skilled attendant present at every birth, providing access to emergency obstetric care, and giving access to family planning. Improving the human rights of women and girls is also important. Yet a 2008 review showed that few developing countries are making progress in reducing maternal mortality.

One billion people are affected by the 13 major parasitic and bacterial infections that constitute the neglected tropical diseases, and 500 000 people die from them each year. But they debilitate, deform, and blind more than they kill, and they account for more DALYs than either TB or malaria. Neglected tropical diseases are controllable and possibly eradicable by treatments already available. Yet little has been done about them, largely because of lack of awareness of their impact.

As Bill Clinton said, the big question for the 21st century is “how.” For all of his political life, he said, he’d been concerned with two questions: what to do and how to pay for it? But the how is more important.

Part of the how is partnership, one of the great themes of the meeting. The meeting was organized by the Economic and Social Council (ECOSOC), which is charged with implementing the MDGs. It discharges this responsibility primarily through its Annual Ministerial Review each July, and the New York meeting was preparation for the review. It was only the second time that ECOSOC had held a meeting with global philanthropists.

Sylvie Lucas, the president of ECOSOC, said: “Partnerships are the cornerstone for advancing the MDGs, and there is no doubt that these will not be reached by 2015 if we do not work together for their realization…I am encouraged by the presence of representatives of the philanthropic community and by their willingness to engage more actively in the work of the Council. This kind of collaborative response has become a new paradigm of international cooperation in tackling global challenges, including public health.” Ban Ki-moon said: “We need the innovative spirit of the private sector.”

This may all sound a bit odd in Britain, which is possibly the country in the world where there is the most suspicion of profit and private companies. I find it strange that Brits, who invented the industrial revolution and grew rich through trade across the world, should be so suspicious, and, as I’ve written and said before, I blame the Romantic poets (whom I much admire) and snobbishness: “I hear that his father was in trade.”

A second major theme was whether philanthropy would collapse in the financial crisis. Clinton pointed out that 30 trillion dollars (twice the US GDP and around half of world GDP) has disappeared. But, he argued, philanthropy must continue because there is no investment that gives a better return than investing in the health of people in poor countries. It is also essential to make every dollar count. We should redouble our efforts not walk away from our commitment. Working in poor countries is the least expensive thing we can do to fulfill our obligations.

But innovative ways of financing are needed, and there was much talk of GAVI (Global Alliance for Vaccines and Immunisation), which has developed at least two innovative financial instruments. With the International Finance Facility for Immunisation governments make legally binding 10-20 year commitments to funding. GAVI can then borrow from capital markets against these commitments. Another innovation is the Advanced Market Commitment, whereby countries commit money to guarantee the price of vaccines once they are developed. Gordon Brown is currently co-chairing the High Level Task Force on Innovative Financing for Health Systems.

Clinton also referred to innovative financing and thought that the future might be—as with recent political campaigns in the US – small amounts of money coming from the many rather than large amounts from the few.

The need for strong health systems was another major theme of the conference — because without them nothing. Bill Clinton urged investment in building out health networks, and, he argued, once a network has been built to test for and treat HIV it can be extended to treat other problems. Nobody is dying now simply because they can’t get drugs, but they are, he said, dying because they can’t engage with any health system.

A final theme of the meeting was the need for global coalitions to reduce maternal deaths and promote treatment of neglected tropical diseases — along the lines of the Global Fund for AIDS, TB, and Malaria. We now have what is needed for effective global coalitions in these areas: clear targets, evidence on policies that will work, high level political commitment, and a communication and marketing strategy.

Perhaps it was the influence of New York but the mood of the meeting was optimistic and can do rather than depressed and defeatist. Klaus Leisinger, president and CEO of the Novartis Foundation for Sustainable Development, emphasized in his keynote address that for the first time in history we have the skills, knowledge, resources, and technology to solve these global health problems. We must now make it happen.

Competing interest: Richard Smith directs the UnitedHealth Chronic Disease Initiative, which is funding and partnering with centres in low and middle income countries to counter chronic disease. The company paid his expenses in attending the meeting. He travelled economy and stayed in one of New York’s cheaper hotels but did have an excellent steak at Peter Luger’s Brooklyn steakhouse and got to see the Pierre Bonnard late paintings of interiors, which were a revelation of colour and light, at the Metropolitan.

  • Dr John Corish

    Richard Smith has clearly fallen for the much hyped Clinton charisma: in a relatively short text he refers to Clinton five times. But how well qualified is the former American President to pontificate on these global health problems?

    And a few of us who still have reservations about the morality of Clinton’s tenure would even question the appropriateness of having him as a keynote speaker at a conference such as this. Here’s one view of the Clinton legacy that I find hard to refute:

  • I agree, of course, with your goals, illustrated in perfect way. I’d like to state, once again, something regarding ” As Bill Clinton said, the big question for the 21st century is “how.” For all of his political life, he said, he’d been concerned with two questions: what to do and how to pay for it? But the how is more important”. Well! Beside the maternal mortality,neglected tropical diseases, a.s.o., there are distressing epidemias all around the world, especially in western countries: CAD, diabetes, cancer, among them.
    The best of all therapy of such epidemias is NOT the screening, at all, but their Primary Prevention, which can be realized nowadays in rational manner, starting from the BIRTH of every individual, bedside recognized positive for a well-defined constitution “and” related INHERITED Real Risk as illustrated in a large literature (Ask

  • Dr Rajiv Sharan

    Respecd Sir,
    Importance of Post natal Care a neglected cause of maternal Mortality ratio.
    It is important to take innovative steps to reduce maternal mortality and these steps should be of practical importance and acceptable to the cultural practices of the society.Evidences show that more than 50% of maternal deaths occur after delivery. The first 48 hours followed by first 7 days is most .
    crucial period for health and survival of mother and born. • Most complications like bleeding, infection and fits occur during the first 48 hours and take a substantial toll on mothers during the first seven days.
    • Post Natal Care deaths are preventable and easy to manage in a health facility. Evidences suggest that majority of the newborns of mothers who became victim of maternal mortality also die.
    • Poor service delivery system (lack of services, infrastructure, inadequate skills, transportation, attitude of service providers etc.)
    • Lack of awareness and ignorance (cultural believes, low education etc.)
    Most of the deaths among women and neonates can be prevented by adopting simple measures. These include –
    • Sensitize service providers for proper post natal care

  • Sir

    It was good to learn from Richard Smith that he is applying his talents at the United Health Chronic Disease Initiative and shared with us his impressions of the Conference in New York on the Millennium Developmental Goals. (MDGs)

    Most of the MDGs relate to children – the goals are useful in as much they have focused on the problems but by isolating as ‘targets’ interrelated problems they are unlikely to solve the basic issues and thereby create a culture of failure.

    There is no one solution but we need to work up from families and communities and encourage the ‘will’ of all the national leaders for them to realize they have the solution in their own hands.

    The current global financial problems provide an opportunity to reflect on how money can be invested for the future . The significant ‘correction’ over the last year has slashed more than a third off the reserves of many institutions. The widening gap between the rich and poor nations increases this global instability Most fund managers have previously focused on short term gains to get a quick fix for their quarter quotas without taking the long term view. But what we really need to do is to take a wider view and reflect on where the value of investment lie. It is in people.

    The most dramatic illustration of this is the difference between the number of children dying under the age of five for each 1000 births between the countries of the world. This under five mortality rate is a sensitive index on the value placed by nations on their children. A few years ago Sweden was top of the international table with an under five mortality rate of 3 per thousand love births. Bottom of UNICEF’s ‘league’ table was Sierra Leone with a rate of 314 children dying under the age of five. – nearly one third of their children ! What a devastating impact this is having on the future of that country.

    Children are a country’s future. Healthy children attend school, become healthy and productive adults and improve the economic wellbeing of their country
    . They also lead a healthier old age

    Poverty breeds disease and disease causes poverty. Disease in just one family member may have disastrous effects on the children through loss of care and reduced family income causing older children to leave school to support the family. The tragedy of the AIDS orphans is all too apparent in Africa.

    Poor families compensate for children’s deaths by having a large number of children with the expectation that sufficient will survive to care for the parents in their old age. Large families simply cannot afford education and health care for each child. Conversely reduction in mortality can be a spur to reducing fertility rates. The evidence linking fertility levels to infants under the age of 1 yr and child mortality under 5 is powerful. Countries who have an infant mortality rates of les than 20 have an average total fertility rate of 1.7 children. In countries where the infant mortality rates of over 100 have an average total fertility rate of 6.2. children. This confirms the studies undertaken 25 years ago in nine different countries on the Value of Children. When children are valued in their own right rather than for utilitarian purposes, family size is smaller.
    The mothers education is clearly another important factor but one which is also associated with the family’s increased earning capacity. The clear message is that looking after children means less and not more mouths to feed, better education , healthier adults and improved economic progress

    The main cause of children worldwide dying under age the age five years are malnutrition, malaria measles, diarrhea, respiratory illness and AIDS. All are preventable. All are treatable. The impact of controlling these diseases in Sub Saharan Africa would be dramatic Historically the virtual elimination of malaria in several subtropical regions in the 1940s and 1950s had a ‘galvanizing’ effect on economic growth spurring massive tourism and foreign investment. Such gains would greatly exceed the direct costs of the disease as would have been measured in a ‘cost of illness’ study .

    The risks to commercial enterprises of AIDS in sub Saharan Africa seems to be taking an enormous toll on investments in the region. With the massive turnover resulting from AIDS, firms are constantly facing the breaking up of work groups and the heavy cost of re-training workers. Indeed some more enlightened companies are finding it cost effective to provide the appropriate treatment for their workers Something that would also apply to Governments !

    When a significant number of people become ill in a community, the whole community suffers. An money available is often shifted to care for the ill reducing the amount available for preventative and supportive health social services. The level of trust within the community may fall especially if the disease is interpreted as a curse as frequently reported in parts of Africa in response to AIDS. Skilled workers may flee leaving the community leaderless without the necessary drive and technical expertise.

    The high burden of disease disrupts national budgets in the same way as the family budget . The health care systems are overwhelmed and require more resources. Tax revenues collected by governments are reduced as the economic activity is diminished with the decline in tourism and new business development. This combination of reduced budget revenues with increased budget demands tends to lead to budget deficits that in turn can destabilize the macro-economy with further adverse effects on the economy of the poor countries

    Well targeted investment in Heath care has resulted in significant improvements. Over the past three decades, various immunization campaigns and child health initiatives have increased by millions the number of children protected against common childhood infections. But the burden of preventable disease in poor countries remains unacceptably high. Measles is still a major killer -800,000 deaths in 1998. It has been estimated that by 2010 around 8 million lives per year could be saved by essential interventions against infectious diseases and nutritional deficiencies.

    The Poverty reduction Strategy Framework is a good start as it provides a comprehensive approach explicitly incorporating local civil societies at each step with more door co-ordination in support of the country’s goals. The Commission on Macroeconomics and Health reporting to the World Heath Organization suggested that each country should define an overall programme of ‘essential interventions’ to be guaranteed universal coverage through public and door funding. Four main criteria were suggested. The interventions should be 1. Technically effective and deliverable. 2 Involve diseases causing the greatest burden of illness 3 the social benefits should exceed the cost of the interventions 4 the needs of the poor be stressed.. The Commission estimated the cost of these essential interventions on a per capita basis to be #34 per person per year. A modest sum especially when compared with the average per capita health spending in high income countries of more than $2,000 per year. The least developed poor countries can mobilize around $15 per person per year. The gap is $19 per person per year ! With the 750 million people in the poor countries in 2007 that adds up to $14 billion. Not much more than tobacco companies extract from their cigarette smokers each year to advertise their death dealing products globally !

    In Africa, many households spend significant sums of money on traditional forms of ‘therapy’ often with disastrous result. Others pay for good treatment at private and faith based facilities. Public expenditure can also be misdirected and wasteful especially when too much funding goes to prestige high tech curative services for the ‘urban elite’ in the nations capital cities.

    There are well trodden paths to progress. The increased resources required must come from a combination of government funding, private domestic expenditure, faith based organizations, other non governmental initiatives, external official development assistance from the rich nations and industry especially the pharmaceutical companies..
    Pharmaceutical companies need to build on their commitment to provide essential medicines in the low income countries at the lowest viable commercial price.

    The rich nations need to invest more in official development assistance. The total Gross National Product of the ‘donor’ nations is around $525 trillion per year (2001). The total development assistance is around $53 billlion, or 0.2% of gross national product of the donor nations. The International ‘standard’ recently endorsed by the International Monetary Fund and The World Bank is 0.7 % of GNP. Only five donor countries subscribe at that rate. In 1999 the UK subscribed 0.23% and the United States 0.1%. Ireland and the United Kingdom are committed to invest the recommended 0.7% in the future. If others followed with this investment and it was targeted at the most needy children our future economic health and social wellbeing will be safeguarded

    James Appleyard