Recently, I participated in a well-attended panel discussion on the challenge of global population growth, sponsored by a consortium of academic global health programs in the San Francisco Bay Area. The discussion ranged from the pressing problems of inadequate and diminishing access to water and food to the megatrend of unremitting urbanization and the need to shift development dollars to where people are and will be.
As the session moved to audience questions, one participant asked, “If you had $100 million and were not allowed to divide it between priorities, how would you spend it?”
A hundred million dollars may seem like a large sum of money, yet it really is not when you consider the range and size of needs in global health; in 2012, the World Health Organization (WHO) reported that global spending on health exceeded $6 trillion annually. Thus, considering what the top priority should be if we had only $100 million to spend is an important exercise in triage because, sad to say, resources will always have limits.
Certainly, the possibilities are overwhelming. Some point to the need for research and development of vaccines and enhancing the availability of existing medications and treatments. Others focus on social determinants of health, which include water, sanitation and transportation infrastructure; or on the promise of shared governance, such as expanding the Latin American model of participatory budgeting, which has led to improvements in infant mortality and life expectancy. Still others propose investing more in the WHO’s urban health observatory, which carefully monitors populations and evaluates programs and policies in areas where most people live around the world; this could be extended to more countries where city growth is rapid, especially in the slums.
Another area with the potential for a large return on investment is primary education that consciously includes women. The case for this is especially strong in low- and middle-income countries, because education builds human capital, and the inclusion of women enables countries to mobilize the entirety of their human resources.
Perhaps it’s not surprising, though, that I would argue another important direction for progress in global health is investing in the education of nurses. Doing so complements existing structures and resources such as medical schools and tertiary care hospitals for specialty care. Expanding the nursing workforce in community and public health supports essential population health initiatives in prevention, surveillance, primary care delivery and referral. More nursing education also is the fastest way to bring skilled health care workers to the front lines of all forms of health promotion, primary care and midwifery. And more nurses creates a larger workforce of community-level clinicians and leadership-trained community health workers, thus raising the collective knowledge of health and increasing the presence of quality health services for a greater proportion of any country’s population. That would be a pretty good return on a $100 million investment.