Global Health ‘Actors’
and their programs
Thomas L. Hall, MD, DrPH
Elisabeth T. Gundersen, BA, RN
Trevor P. Jensen, MS, Medical Student
Univ. of California at San Francisco
Global Health Education Consortium
March 13, 2011
1
Module sections
1. Learning objectives
2. Brief history of international assistance
3. Issues and choices: Donors & Recipients
4. Types of global health ‘actors’
5. Evaluating effects of international assistance
6. A new approach: The Global Fund
7. Discussion questions
8. Summary
9. Quiz
10. Supplementary information
2
1
Learning objectives
• On module completion you should be able to…..
– List the issues & choices confronting aid donors and
recipients
– Describe the characteristics, strengths and limitations of
the major assistance organizations and institutions
– Understand how assistance priorities, methods and
efficacy have changed over time
Note: This module is long due to the large number and diverse variety of
organizations involved in global health programs. You can gain the big picture
reasonably quickly by staying with the slides. Those with special interests will find
additional information in the notes and references.
3
1
Pop quiz
• Rank the top three sources worldwide of funding for
health-related activities
• Rank the top three disease-specific recipients of
international assistance
• Name three major assistance organizations
– What types of organizations are they? For example, are
they private? Public? Non-governmental or intergovernmental?
Give these questions some thought as
you go through the module
4
2
Module sections
1. Learning objectives
2. Brief history of international assistance
3. Issues and choices: Donors & Recipients
4. Types of global health ‘actors’
5. Evaluating effects of international assistance
6. A new approach: The Global Fund
7. Discussion questions
8. Summary
9. Quiz
10. Supplementary information
5
2
Brief history of international assistance
• The motives behind international involvement in
health matters have been varied and complex over
the centuries, starting around the 1300s
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–
–
–
–
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Preventing plagues
Safeguarding global commerce & the slave trade
Protecting soldiers and colonists overseas
Protecting workers and improving colonial relations
Promoting ‘civilization’ in less developed regions
Religious, humanistic & social justice motivations
6
2
Pre-1800s
• Bubonic plague (mid-1300s,1630s), cholera,
smallpox & other mass afflictions
– Disease spread due to increasing global commerce
– Bubonic plague killed 20-50% of affected populations
– Quarantine first created in Venice in 1348 requiring
ships to wait 40 days before entering port
– Cordon sanitaire soon thereafter, establishing a land
barrier to people and goods around cities and regions
– No knowledge then of causative agents for bubonic
plague, smallpox, dysenteries, etc. (Bad airs, God, etc.)
– No nations during this period; actions were local or
regional
7
2
1800s to mid-1900s
• Industrial revolution further increased commerce
• Imperial conquests led to colonization & exploitation
– Invaders brought smallpox, measles, TB, etc., and in turn were felled
by malaria, dysenteries, sleeping sickness
– Slave trade became extensive with high mortality rates
– Efforts to protect health of colonists, workers, missionaries
• Internal and international migrations
• Rise of modern public health
– Sanitary reforms in many countries
– Health Office of the League of Nations
Image: http://www.nps.gov/archive/elro/images/nac_leaguenations_20920.jpg
8
2
1919-1944
•
•
League of Nations (1919-1920):
– Founded in 1919 out of the Treaty of Versailles, in the aftermath of WWI
• A multi-national, collective security organization with mission to prevent the
outbreak of another world war
– Despite American President Woodrow Wilson’s campaign for US’ entrance into the
League of Nations, the US never joined, crippling the organization
• The LoN was rendered powerless despite its few successful conflict resolutions
between member states
• Ceased to officially exist in 1945, with the establishment of the United Nations
Bretton Woods Agreement (1944)
– Developed at the UN Monetary and Financial Conference of 1944
• An agreement establishing guidelines international exchange rate management
– Currencies pegged to gold
• Established the International Monetary Fund (IMF) and the International
Bank for Reconstruction and Development (IBRD)
– IMF given the authority to intervene in discrepancies over exchange rates
9
2
Mid-1900s to late 1990s
• Rapid increase in the international, national and
NGO organizations providing health assistance
• International collaborations through WHO, World
Bank and others become the norm
• Much assistance is supply driven, i.e., what
donors have available and/or want to offer
• Aid increasingly focused on specific diseases
• With some notable exceptions (e.g., smallpox
eradication) most assistance has limited benefit
10
2
World Bank Group: 1945
•
Established after the international ratification of the 1944 Bretton Woods
Agreement:
– Comprised of five organizations:
• International Bank for Reconstruction and Development (IBRD)
• International Development Association (IDA)
• International Finance Corporation (IFC)
• Multilateral Investment Guarantee Agency (MIGA)
• International Centre for Settlement of Investment Disputes (ICSID)
– Mission:
• Assist poor countries in their human, economic, agricultural and “good
governance” development projects through leveraged loans.
• To “eradicate” poverty
www.worldbankgroup.org
11
2
1948-present
•
•
•
World Health Organization, 1948
– An arm of the United Nations dedicated solely to health
– Established in 1948 on the first official ‘World Health Day’ to coordinate international health
activities and assist governments in improving health services for their citizens
• Activities range from providing best practice guidelines to addressing international pandemics
and disease outbreaks
International Cooperation Agency (ICA), 1955
– First coordinating agency for US foreign aid
– Provided economic and technical assistance operations to poor nations
United States Agency for International Development (USAID), 1961
–
–
Established as a result of the 1961 Congressional Foreign Assistance Act to unify the US’ foreign aid projects and
goals
Intended to be free of influence from the military
• Combined and unified under the common goal “long range economic and social assistance
development efforts” the technical assistance provided by the ICA;
• the loan activities of the Development Loan Fund;
• the local currency functions of the Export-Import Bank
• and the agricultural surplus distribution activities of the Food for Peace program of the Department of
Agriculture
12
2
Brief history of international assistance
• Increased attention to specific
diseases, successful eradication of
smallpox, primary health care
(PHC) and ‘special PHC’, with its
emphasis on those diseases most
easily prevented or treated
• International agreement on setting
8 “Millennium Development Goals”
(2000), to be attained by 2015
13
2
Late 1990s to present
• New approaches to international assistance
–
–
–
–
–
–
–
More use of partnerships (international, public-private)
Increased funding (governments, banks, philanthropy)
More emphasis humanitarian motives
Greater recognition of the global nature of disease
Greater recognition of infrastructure & workforce needs
Greater attention to priorities of recipient countries
Greater emphasis on transparency and accountability
See: Textbook of International Health: Global Health in a Dynamic World, 3rd Edition, by
Birn, Pillay and Holtz. Oxford Univ. Press, 2009, Chapter 2, pp. 17-60, for an excellent
review of global health history.
14
2
Some milestones on path to global health
•
•
•
•
•
•
•
•
•
•
•
•
•
•
1796, Jenner discovers way to prevent smallpox
1851, International Sanitary Conference, Paris
1854, Discovery of cause of cholera
1863, International Committee of the Red Cross
1902, Pan American Sanitary Bureau, later PAHO
1913, Rockefeller Foundation (hookworm, yellow fever, others)
1914, Panama Canal completed (overcoming Yellow Fever )
1920, League of Nations Health Organization
1945, World Bank Group founded
1946, U.N. Infant and Child Emergency Fund, UNICEF
1948, World Health Organization founded
1977, Eradication of smallpox
2002, Global Fund to Fight AIDS, Tuberculosis and Malaria
2005, Millennium Development Goals established
MDGs are briefly considered in next slides as important and
broad sweeping health targets for the coming years
15
2
Where is international assistance headed?
U.N. Millennium Development Goals, 2015
• A multi-sectoral approach: Education, gender, environment
and international cooperation are key issues
• Calls for sustainable development requiring improvements in
health, education, environment, water & sanitation, and not
on quick fixes.
• Uses a political process designed to mobilize resources,
maintain visibility, monitor results and strengthen global
health governance
• Provides guidance for WHO, World Bank, World Trade
Organization, OECD countries, U.N. Development Program
See supplemental information
16
2
UN Millennium Development Goals
•
Eight goals for 2015 -- Goals set in 2005 at
World Summit of UN General Assembly (three
are primarily health-sector related)
1.
Eradicate extreme poverty & hunger
- Reduce by half those living on <$1/day
- Reduce by half % suffering from hunger
2.
3.
4.
5.
6.
7.
8.
Achieve universal primary education
Promote gender equality and empower women
Reduce by 2/3rds child mortality for < fives
Reduce by 3/4ths maternal mortality ratio
Combat HIV/AIDS, malaria & other diseases
Ensure environmental sustainability
Develop a global partnership for development
17
2
In 2005 there were 7 goals broken up into 16 targets (lower right). Progress data for
these targets, as of 2005, are represented on the map below:
1)
1 2 3 4
5 6 7 8
9 10 11 12
13 14 15 16
2)
3)
4)
5)
6)
7)
8)
9)
10)
11)
12)
13)
14)
15)
16)
The 16 targets represented by the 4*4 squares are detailed further in the following link
http://unstats.un.org/unsd/mi/pdf/MDG%20Chart%20No%20Text.pdf
Reduce extreme poverty by
half
Reduce hunder by half
Universal primary schooling
Equal girls’ enrolment in
primary school
Women’s share of paid
employment
Women’s equal representation
in national parliaments
Reduce mortality of under-fiveyear-olds by two thirds
Measles immunization
Reduce maternal mortality by
three quarters
Halt and reverse spread of
HIV/AIDS
Halt and reverse spread of
malaria
Halt and reverse spread of
tuberculosis
Reverse loss of forests
Halve proportion without
improved drinking water
Halve proportion without
sanitation
Imprve the lives of slumdwellers
18
3
Module sections
1. Learning objectives
2. Brief history of international assistance
3. Issues and choices: Donors & Recipients
4. Types of global health ‘actors’
5. Evaluating effects of international assistance
6. A new approach: The Global Fund
7. Discussion questions
8. Summary
9. Quiz
10. Supplementary information
19
3
Issues and choices: Donors
• Thought exercise: Imagine you are working in a
donor institution and an applicant organization has
requested your support. Write down in one minute
the words, eg, priorities, budget, that characterize
the areas about which you would want to obtain
information before agreeing to provide support.
Then check your terms against those on the next
slide.
20
3
Key issues for Donors
•Priorities: How were they set, by whom and based on what evidence?
•Objectives: Are they clear, quantitative, realistic?
•Budget: How realistic and specific; salaries, supplies, equipment?
•Recipient: Who receives & manages the funds; what is their track record?
•Fund structuring: Grant, loan, tranches, performance conditions, etc?
•Organizational capacity: Numbers & competencies of personnel; administrative
capacity; past performance; risks of corruption, etc.
•Monitoring & evaluation: Provision for data collection and analysis
•Country context: How does project or program relate to other activities? Compete,
complement, synergistic, no relationship, etc?
•Capacity-building: Aside from specific objectives will assistance strengthen overall
institutional capacity?
•Sustainability: Will project require continuation funding and/or complementary
funding, and if so, for how long?
21
3
Issues and choices: Recipients
• Thought exercise: Now imagine you are seeking
major funding for a program in your low income
country. Write down in one minute the words that
characterize your concerns as you prepare your
proposal. Then check your terms against those on
the following slide.
Image: http://www.publicdomainpictures.net/pictures/8000/nahled/twenties-banknotes-11277482616NMgQ.jpg
22
3
Key issues for Recipients
•Priorities: Are they locally derived or in response to donor priorities?
•Local buy-in: Is there good local support for the proposed activity?
•Flexibility: Can funding allocations and activities be modified as experience
dictates or is the budget tightly fixed?
•Constraints: What limitations will be imposed, e.g., equipment purchases only
from donor country, ‘gag order’ for abortion services?
•Monitoring and accounting: Frequency and complexity of reporting
requirements? Compatibility or not with existing data systems?
•Intrusiveness: Are foreign consultants and/or evaluators required and if so, who
recruits, pays, directs, monitors and terminates them?
•Compatibility: Does program complement, complicate or compete with work in
other areas, e.g., taking personnel away from other programs, complicating
administrative relationships, etc?
•Political implications: Will donor support have potentially positive or negative
repercussions?
23
4
Module sections
1. Learning objectives
2. Brief history of international assistance
3. Issues and choices: Donors & Recipients
4. Types of global health actors
5. Evaluating effects of international assistance
6. A new approach: The Global Fund
7. Discussion questions
8. Summary
9. Quiz
10. Supplementary information
24
4.1
Three major types of global health actors
1. Multinational organizations
A. Organizations within the UN system relevant to health
B. Organizations outside of the UN system relevant to
health
2. Bilateral -- government-to-government or to
sub-government levels
3. Non-governmental organizations (NGOs)
Click for supplemental material
25
4.1
1. Multinational organizations
•
Overview
– Most created since World War II
– Number of countries participating and organizations
involved has increased rapidly
– All or most of the ~195 countries are members, most have
votes and have input to policies and priorities
– Countries contribute according to economic abilities
– Multinational staff, in part selected to attain a good
geographic representation
– Multinationals may have regional & country level offices
26
4.1
1. Multinational
• Organizations within UN system relevant to health
• WHO (World Health Organization, 1948)
• UNICEF (U.N. Infant & Children’s Emergency
Fund,1946)
• UNFPA (Population Fund, 1967)
• UNDP (U.N. Development Programme, 1965)
• FAO (Food & Agricultural Organization, 1943)
• UNESCO (U.N. Educational, Scientific and Cultural
Organization, 1945)
• UNHCR (U.N. Refugee Agency, 1950)
• WFP (World Food Programme, 1962)
• UNODC (U.N. Office on Drugs & Crime, 1997)
27
4.1
WHO: Organizational overview
•
•
•
•
•
Director General: Margaret Chan (from Hong Kong) elected by
World Health Assembly, May 2007
193 member states; Executive Board with 34 rotating members
Biennial budget 2008-2009: $4.23 billion (up 15.2%)
– Regular assessments and income: $959 million
– Other contributions for specific programs: $3.3 billion
– “Zero Nominal Growth” (Helms-Biden)*
Organized in three levels: Geneva headquarters; 6 regional offices
(PAHO, WPRO, AMRO, AFRO, SEARO, EURO), and in most
countries, WHO country representatives (WRs)
Major areas of Work (www.who.int/en/): malaria, HIV, tobacco,
nutrition, mental health, immunizations, etc.
Dr. Margaret Chan
*Legislation in 1999 and since renewed that provides for partial payment of U.S. dues, always in arrears,
in return for reducing U.S. maximum assessment from 25% to 22% of the UN’s budget, and achieving
certain administrative reform benchmarks
28
4.1
WHO: Functional overview: What does it do?
•
•
•
•
•
•
•
Provides technical assistance, training
& fellowships
Formulates & disseminates advice,
standards, guidelines
Convenes Expert and Technical
Advisory Committees; commissions
consultant reports
Develops & disseminates International
Classification of Disease (ICD-X) codes
Publishes monographs and manuals
Assists & organizes projects on specific
problems and/or target groups per
priorities set by World Health Assembly
Visit for an overview of WHO projects
and partnerships
“1945, The United Nations Conference in San Francisco,
USA, unanimously approves the establishment of a new,
autonomous international health organization.”
29
4.1
WHO Priorities
• Reducing maternal and child mortality
by aiming at universal access to, and
coverage with effective interventions
and health services
• Addressing epidemic of chronic noncommunicable diseases, with an
emphasis on reduced risk factors such
as tobacco, poor diet, and physical
inactivity
2008 WHO
Annual Report
Primary Health
Care
2009 WHO Annual Report
Health System Financing
• Improving health systems, focusing on
human resources, financing, health
information and primary health care
30
4.1
WHO Priorities
• Implementing International Health
Regulations to respond rapidly to outbreaks
of known and new diseases and
emergencies, building on poliomyelitis
eradication to develop effective surveillance
and response infrastructure
• Improving performance of WHO through
more efficient ways of working, and building
and managing partnerships to achieve the
best results in countries
“2001, The Measles Initiative is launched in
partnership with the American Red Cross,
UNICEF, the United Nations Foundation and
the US Centers for Disease Control and
Prevention. As of October 2007, overall
global measles deaths have fallen by 68%.”
See Supplemental information
31
4.1
Program example: Poliomyelitis eradication: 1988-2008
1988
350,000 cases
125 countries
Almost there, but a
few very resistant
pockets (internal
conflict, religious
opposition, etc.) of
transmission
2008
1625 cases
17 countries
32
4.1
What are WHO’s strengths?
Take one minute to write down words that describe
potential strengths of a multinational
institution like WHO.
Then go to next slide
33
4.1
WHO - Strengths
• Legitimacy, by virtue of near universal membership & support
• Representation, at central, regional and country levels
• Expertise drawn from around the world
– Establishes international goals and standards
– Recommends ‘best practices’
• Cross-national statistics that are collected, compared, analyzed
and disseminated
• Collaborations, organized, sponsored, facilitated
• Publications on important topics and in multiple languages
• Training via fellowship and intern programs
34
4.1
What critiques could be made of an
organization like WHO?
Take one minute to write down words that
come to mind regarding possible critiques of a
multinational institution like WHO.
Then go to next slide
35
4.1
WHO – Possible critiques
• One country, one vote (tiny countries have disproportionate impact,
especially in WHO elections)
• Over-extension, by trying to address needs of all countries since all
countries participate and contribute
• Expensive organizational structure with
Geneva HQ, six regional offices and at
times, cumbersome bureaucracy
– Alleged administrative inefficiencies; USA
(Helms-Biden amendments) link funding to
improvements
• Weak constituency. Ministries of health
are among the weaker ministries in many
governments
“1966, The new headquarters building of the World Health
Organization in Geneva is inaugurated.”
36
4.1
WHO – Possible critiques (continued)
• Political pressures that effect programs, e.g.,
–
–
–
–
Global North vs. Global South
Cold War blocks (USSR, China, West)
Middle East conflict, Israel, Palestine
Population growth policies & reproductive health
• Staff profile (but also a strength)
– Too many doctors, too few other disciplines
– Requirements for geographical diversity
• Fellowship allocations
– Country level decisions may respond more to internal political and
personal pressures than to country needs
37
4.1
WHO – Possible critiques (continued)
• Funding constraints
– Core budget barely exceeds that of a large U.S. hospital
– Many countries (especially USA) don’t pay on time
– Large extra-organizational, ear-marked funding for specific
diseases and programs can distort overall program
• Hard to evaluate accomplishments
– WHO has been described as a procedural organization, where
you can observe what it does but not what it produces. In
fairness, however, this critique can be made of very many
domestic and international organizations. WHO doesn’t
provide direct services to populations.
38
4.1
1. Multinational
• Organizations outside the UN relevant to health
• U.N. Affiliated Programs
– Banks: Global Fund to Fight AIDS, TB and Malaria, 2002
– UNAIDS (Joint U.N. Programme on HIV/AIDS, 1994)
– And many others
• World Bank Group, International Monetary Fund (IMF)
• Others: World Trade Organization
39
4.1
UN Affiliated Programs
The Global Fund to Fight AIDS, TB and Malaria
(GFATM)
– US$ 19.3 billion since 2002 for >572 programs in 144 countries
(GFATM case study later in this module)
– GFATM accounts for 1/4th of all international financing for AIDS,
2/3rds for tuberculosis and 3/4ths for malaria
40
4.1
UN Affiliated Programs
UNAIDS
• UNAIDS Secretariat plus 10 co-sponsors & contributors.
• These Include UNICEF, WFP, UNDP, UNFPA, UNDCP,
UNHCR, ILO, UNESCO, WHO, World Bank)
– Functions include surveillance, policy, advocacy, standards &
coordinated funding, including country resources, of $2.6 B for 201011 biennium
41
4.1
Other UN affiliated Multinational
Initiatives
• Five other examples of recent initiatives and partnerships
designed to address priority problems
– Roll Back Malaria (1998) -- http://www.rollbackmalaria.org/
– STOP Tuberculosis (2001) -- www.stoptb.org/
– International AIDS Vaccine Initiative (1996)
www.iavi.org/Pages/home.aspx
– Global Alliance for Vaccines & Immunizations (2000) -www.gavialliance.org/
– Global Health Workforce Alliance (2006) -- www.ghwa.org/
See supplemental information
42
4.1
World Bank Group: Overview
• Five interrelated banking organizations (1944). Two
main WB Group components with health relevance are:
1: International Bank for Reconstruction and Development (IBRD)
– Loans at market rates to low and middle income countries
– Regional banks for Africa, Asia, Latin America
2: International Development Association (IDA; created 1960)
– Low or no interest loans, long payouts, grants to 81 poorest
countries (<$1000 p.c.), and ‘Heavily Indebted Poor Countries’.
Over a 3-year period IDA typically gives ~$33 billions
– HIPC Initiative (1996), a joint IMF/WB program of debt reduction that
by 2010 provided ~$51B in debt service relief to 35 countries
http://www.worldbank.org/
http://www.imf.org/external/np/exr/facts/hipc.htm
43
4.1
World Bank Group: Overview
• Five interrelated organizations (continued –
these have little
or no relevance to health field)
3: International Finance Corporation
– Finances and advises private sector ventures and
projects in developing countries
4: Multilateral Investment Guarantee Agency
– Provides insurance for foreign investors against losses
caused by noncommercial risks, e.g., expropriation,
currency inconvertibility, war
5: International Center for Settlement of Investment Disputes
– Provides arbitration of investment disputes
44
4.1
World Bank Group: Overview*
•
•
•
•
Board of Governors, 186 member states
Executive Committee, 24 members
President, normally American
Annual Bank loans = $18-20 billions
– Health, Nutrition and Population: ~27,200 projects and
~$23 B in loans and grants for HNP since 1970
– Annual HNP project lending = ~$1 B
– HNP projects are ~5% of total WB lending
*The World Bank website provides >2000 development indicators. Annual listings for 420 indicators
covering the period 1960-2009 are provided for 209 countries. The site has much more information of
potential interest. http://www.worldbank.org/
45
4.1
World Bank Group: Operation
• Overall priorities are poverty reduction, country
assistance and financial / markets stabilization
– View WB Country Profiles and 1200 World Development Indicators
– Powerful resources for WB country data
• World Development Indicators & Global Development Finance
• Global Economic Monitor
• Besides funding WB does much analytic work
– Papers describe and assess macroeconomic, development, social,
HIV/AIDS, tobacco, and structural issues
– Program evaluations, especially regarding programs affecting HIPCs
(“Heavily Indebted Poor Countries”) and Millennium Development
Goals
– Many loans are preceded by extensive technical inputs by external
and national consultants
46
4.1
Programmatic distribution of World Bank funds in 2007
47
4.1
Other International Financial Institutions
• International Monetary Fund (1944) (www.imf.org/external/)
– 186 countries, works to foster monetary cooperation, secure financial
stability, facilitate trade, promote employment and sustainable
economic growth, and reduce poverty.
• Regional banks are independent of World Bank but have
coordinated programs and provide health-related loans
– African Development Bank (1964)
• Bank owners are 53 African countries and 24 others
– Asian Development Bank (1966)
• Bank owners are 48 Asian countries and 19 others
– Inter-American Development Bank (1959)
• Bank owners are 48 Latin American & Caribbean countries
48
Before we consider one last multinational
organization (the World Trade Org.) can you think of
any potential strengths and critiques of large
multinational financial institutions (banks) like the
World Bank and IMF?
Once you are done advance to the next three slides.
49
4.1
Multinational Financial Institutions:
Strengths
• Substantial funding
• Bank imposed ‘conditionalities’
– Extensive pre-project planning usually required, often with help of
external consultants
– Funds ‘conditioned’ on negotiated reforms and conditions, i.e., if you
do “X” by “Y” year you will get “Z” funds
– Funds released in ‘tranches’ according to attainment of pre-specified
accomplishments
• Loans are increasingly coordinated with bilateral (national
government assistance) agencies
50
4.1
Multinational Financial Institutions:
Potential critiques
• They may undermine role of state and national sovereignty
– Poor countries may be obliged to adopt potentially harmful policies,
e.g., “structural adjustment programs”
•
•
•
•
Economic considerations may dominate decisions
Largest stakeholders (donors) dominate votes
Challenge of corruption in recipient countries
Correlates of program success may not be present
– Country characteristics favoring good loan performance include good
administration, stable currency, established legal system, sustained
policies over time, lack of social strife, and low corruption. Countries
that most need help lack many of these characteristics.
51
4.1
Multinational Financial Institutions:
Potential critiques
• WB banks & IMF primarily focused on infrastructure
– 1950s-70s: primary focus on macroeconomic issues with
‘conditionalities’ set regarding performance & payments
– Latter 1970s, Structural Adjustment Policies (SAPs) introduced linking
loans to export promotion, open trade, reduced government
employment and subsidies, and privatization of many enterprises
– Critics argued that SAPs exacerbated poverty for poorest segments of
the population and kept poor countries dependent on rich countries
Click here to view a five-minute YouTube clip contextualizing SAPs and famine in Niger
http://www.youtube.com/watch?v=Iw9OARpp-KI
Click here to view a seven-minute YouTube clip of a BBC inquiry into WB policies
http://news.bbc.co.uk/nolavconsole/ukfs_news/hi/newsid_5150000/newsid_5150500/bb_rm_5150592.stm
52
4.1
World Trade Organization (1995)
• WTO (153 members), deals with trade rules between nations
– WTO’s Agreement on Trade-Related Aspects of Intellectual Property
Rights (TRIPS) attempts to balance between long term objective of
providing incentives for inventions, and short term objective of
allowing poor countries to use life-saving inventions and creations.
– Patent protection of certain essential drugs has meant that the high
cost of these drugs prevented their use in resource poor countries
– After much conflict a compromise was reached on TRIPS* that allows
importation or production of essential pharmaceutical products under
a compulsory license by the least developed countries.
*URL provides extensive information on this issue. See also other GHEC modules on TRIPS
and patent conflicts over drug production and importation.
http://www.wto.org/english/tratop_e/trips_e/factsheet_pharm00_e.htm
53
4.2
Types of global health ‘actors’
1. Multinational / inter-governmental
organizations
A. Organizations within the UN system relevant to health
B. Organizations outside of the UN system relevant to
health
2. Bilateral -- government-to-government or to
sub-government levels
3. Non-governmental organizations (NGOs)
54
4.2
Types of global health ‘actors’
2. Bilateral aid agencies*
• Many of the “rich” 34 OECD countries have official,
government owned or controlled aid agencies, e.g.,
–
–
–
–
–
–
–
USAID (U.S. Agency for International Development)
DFID (U.K.)
SIDA (Sweden)
CIDA and IDRC (Canada)
DANIDA (Denmark)
JICA (Japan)
And many others
*”Bilateral” nominally refers to aid assistance provided by one government to another government. In
practice a donor government may provide funding to NGOs within its own borders, and these then
provide assistance to organizations within the recipient countries. Governments can also provide
assistance directly to NGOs and other entities in the recipient countries. For example, USAID provides
large contracts to US NGOs to provide capacity-building services and tools to recipient countries.
55
4.2
Types of global health ‘actors’
2. Bilateral aid agencies
– US Government: Agencies with Global Health Activities
• Dept. of Health & Human
Services (DHHS)
– Centers for Disease Control &
Prevention
– National Institutes of Health
– Health Resources and Services
Administration
– Food & Drug Administration
• Dept. of Defense
• Department of State
– USAID
– PEPFAR
– Peace Corps
• Millennium Challenge
Corporation
• President’s Malaria Initiative
• Dept. of Homeland Security
• Dept. of Agriculture
• US Trade Representative
56
4.2
DHHS Office of Global Health Affairs
• Office represents DHHS to other governments, other
Federal Departments and agencies, international
organizations, and to the private sector on international and
refugee health issues
– Develops health-related policy and strategy positions
– Provides policy guidance and coordination on refugee health policy
issues
• DHHS is a domestic agency but Health, Education, and Labor
appropriations includes $754 million for Global AIDS
Source: http://www.globalhealth.gov/office/index.html
57
4.2
Centers for Disease Control (CDC)
• Advocates and supports global health promotion, protection
and “diplomacy” (~$1B, including ~$600M for
AIDS/PEPFAR, $150M for polio / measles elimination, $70M
for influenza, $30M for disease detection). Overall CDC
budget has remained relatively flat
• Promotion: Infectious & non-infectious disease, MCH, injury
• Protection: Preparedness, detection and response, bioterrorism
• Diplomacy: Sustainable systems, natural disasters, refugees,
internally displaced, complex emergencies
• Other international work
• Outbreak investigations
• Contributions to multinationals
• Training (Field Epidemiology Training Program)
58
4.2
National Institutes of Health (NIH)
• Overall NIH budget increased by $500M/year since
2006, currently ~$31B (2010). Global health
related funds are relatively small and spread
among many different fields
– Fogarty International Center (1968). FIC’s research, training, and
capacity-building activities are in 100+ countries and involve ~5,000
scientists in U.S. and abroad with a budget of ~$69M
– Pre- and post-doctoral FIC global fellowships are available
– Multi-institute global health projects: tobacco, HIV/AIDS, bioethics,
etc. Each Institute has international focal point and funding
depends on institute priority
59
4.2
Health Resources & Services Admin. (HRSA)
• In partnership with PEPFAR, HRSA is investing $130 million
over five years to transform African medical education and
dramatically increase the number of health care workers.
– Via Medical Education Partnership Initiative (MEPI), grants are
awarded directly to African institutions in 12 countries, working in
partnership with U.S. medical schools. The initiative will form a
network including about 30 regional partners, country health and
education ministries, and more than 20 U.S. collaborators.
• The program is designed to support PEPFAR goals to train and retain
140,000 new health care workers and improve the capacity of partner
countries to deliver primary health care.
Source: www.fic.nih.gov/news/press_releases/2010-mepi.htm
60
4.2
Food and Drug Administration (FDA)
• FDA actions are closely watched by other countries and their
decisions can have significant effects. The FDA…..
– Has regulatory authority for food and drugs and must balance
between safety and getting drugs to market
– Gets involved in controversies with family planning, AIDS, certification
of imported drugs (e.g., generics, drugs from Canada)
– Experiences tension on food safety with USDA (e.g., use of antibiotics
and hormones in animal feed, pesticides)
– Has no tobacco regulatory role
– Does not regulate additives and food supplements
61
4.2
Department of State (DOS)
• U.S. Agency for International Development (USAID)
– Modest technical capacity; primarily operates through contracts to
other domestic and foreign organizations
– FY 2009 total expenditure of $11.0B ($1.7B to health, $0.8B to
education, $0.5B to vulnerable populations per budget report):
– 75% of USAID staff is in the field
– Programs can be subject to substantial political considerations, e.g.,
support to Egypt, Israel, El Salvador and Honduras during the
‘Contras’ war
• Next few slides are examples of recent and long-standing
US government global health initiatives
Source on expenditures: www.usaid.gov/policy/afr09/FY2009AFR11-16-09.pdf)
62
4.2
PEPFAR
President’s Emergency Plan for AIDS Relief
• Up to $48 B over 5 years (2003-2008) including previously committed
MTCT funds (maternal-to- child-transmission) programs; $1B for Global
Fund for AIDS, TB, Malaria
• Focus on 15 countries: Botswana, Côte d’Ivoire, Ethiopia, Guyana, Haiti,
Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa,
Tanzania, Uganda, Vietnam and Zambia
• In 2009 President Obama announced reauthorization of PEPFAR. The
second round expands fund usage somewhat to address major health
system and health worker bottlenecks
• PEPFAR Documentary
See supplemental information
63
4.2
Peace Corps
• Peace Corps, founded in 1961, is an independent agency
with a budget of ~$319M
– Since start, ~195,000 volunteers to 139 countries (77 at present)
– Current Volunteers and Trainees = 7,617
Average age, 28; 94% single; 60% female;
– Minorities: 16% of Peace Corps Volunteers
– Volunteers over 50: 5% (oldest is 84)
– Education: 89% have at least an undergraduate degree, 11% have
graduate studies or degrees
– Four main sectors in which they work
• Education, 35%; health, 22%; business & development, 15%;
environment, 14%
64
4.2
Peace Corps
Orange: Countries the Peace Corp currently works in
Purple: Countries the Peace Corp has worked previously
Source: http://www.peacecorps.gov/index.cfm?shell=about.fastfacts
65
4.2
Millennium Challenge Corporation
• U.S. Government corporation established in 2004 that gives
~$5B/year to promote economic growth and reduce poverty.
Distinctive features include:
– Competitive selection: 17 indicators are used to assess country
commitments to good governance, economic freedom, and
investment in people (especially women and children)
• Sample Country Scorecards
– Country-led solutions: Countries must identify their priorities for
achieving sustainable economic growth and poverty reduction.
Proposals are developed in broad societal consultation.
– Country-led implementation: Recipient countries set up their own
accountable entity to manage and oversee implementation. Fund
monitoring is rigorous and transparent, often via independent agents.
Source: http://www.mcc.gov/pages/about
66
4.2
President’s Malaria Initiative (PMI)
• Launched in 2005, led by USAID, and implemented together with CDC.
Works in partnership with Global Fund, WHO, Roll Back Malaria,
UNICEF, NGOs, etc.
• Initial five-year commitment of $1.2 billion; rapid increase in
expenditures with $500M allocated for FY 2010
• PMI goal: 50% malaria reduction in 15 focus countries, attained by
reaching 85% of most vulnerable groups – children <5 and pregnant
women – with effective prevention and treatment measures. PMI
supports four key areas – indoor spraying of homes, insecticide-treated
mosquito nets, anti-malarial drugs, and treatment to prevent malaria in
pregnant women.
• Program targets15 worst hit countries in Africa
Source: http://www.fightingmalaria.gov/about/index.html
67
4.2
PMI Focus Countries and Malaria
Distribution in Africa
Major malaria regions in
Africa and the targeted
countries – darker colors
indicate more malaria
http://www.fightingmalaria.gov/about/index.html
68
4.2
Bilateral organizations
Strengths
• Substantial resources from governments
• Generally have qualified, long-term staff
– Subcontractors also tend to develop substantial expertise
• Moderately flexible, responding to changing conditions
• In U.S., increasing use of long-term commitments and very
large ($20-100 millions), multi-project and country contracts
• Can coordinate activities with other bilateral and NGO
programs
69
4.2
Bilateral organizations
Potential critiques
•
•
•
•
•
Political factors may drive assistance (‘Cold War’ period)
Programs may require purchases of drugs, equipment,
etc., in donor country, thus increasing costs & decreasing
recipient flexibility to find best/cheapest products
Programs may be more oriented toward donor’s priorities,
industries, programs and capabilities than recipient’s
priorities
Aid may be poorly coordinated or even competing with
other, especially non-governmental, programs
Programs may siphon off best host country health workers
with higher salaries, better administration, etc.
70
4.2
Bilateral organizations
Potential critiques
•
Foreign aid is politically vulnerable due to a small
constituency (e.g., equipment makers, contractors)
•
The US public supports global health aid, though with
misconceptions. A 2009 Kaiser Family Foundation poll
found that:
–
–
–
–
23% favor decreased aid, 39% same aid, and 26% increased aid
Support increases when specific types of health spending are
mentioned
52% say U.S. spends too much on “foreign aid,” but only 23% say
this about efforts to improve health or fight HIV/AIDS (16%)
But, 45% incorrectly choose foreign aid as one of the largest areas
of spending by the government, more than choose Medicare or
Social Security (33% each) – programs that dwarf foreign aid
Source: http://www.kff.org/kaiserpolls/upload/7894.pdf
71
4.2
Net “overseas
development aid” from
24 donor countries. Aid
includes government
and major NGOs. Of
the total, top 10 U.S.
recipients get 41%, and
health, education &
nutrition get ~27%. Iraq,
Afghanistan & Sudan
get ~22% of that aid.
Development assistances, 24 DAC countries, 2008
For more detail on U.S.
aid, go to:
http://www.oecd.org/dataoe
cd/42/30/44285539.gif
Source: http://www.oecd.org/document/9/0,3343,en_2649_34447_1893129_1_1_1_1,00.html
72
4.3
Types of global health ‘actors’
1. Multinational / inter-governmental
organizations
A. Organizations within the UN system relevant to health
B. Organizations outside the UN system relevant to health
2. Bilateral -- government-to-government or to
sub-government levels
3. Non-governmental organizations (NGOs)
73
4.3
3. Non-governmental organizations (NGOs)
•
NGOs defined by their extraordinary diversity
–
–
–
–
–
–
–
–
–
–
Non-profit and profit-based
Religious and secular
Narrow and broad scope programs
Wealthy and shoe-string operations
• Big NGOs are called BINGOs
Well paid, marginally paid and volunteer staff
Long- and short-term commitments
Single-country, multi-country and regional focus
Single problem and multi-problem focus
Single sector and multi-sector focus
Emergency relief and development focus
74
4.3
3. Non-governmental organizations (NGOs)
Charitable (secular) organizations
•
•
•
•
•
•
•
•
•
•
•
Oxfam
CARE
Save the Children/UK (& US)
International Red Cross
Doctors without Borders
Project Hope
International Rescue Committee
CARE
Freedom from Hunger
Child Family Health International
Doctors for Global Health
See supplemental information
75
4.3
3. Non-governmental organizations (NGOs)
Faith-based organizations (FBOs)
•
•
•
•
Catholic Relief Services
Christian Aid
Lutheran World Relief
Unitarian Universalist Service Society
76
4.3
3. Non-governmental organizations (NGOs)
Philanthropic foundations
•
•
•
•
•
•
•
•
•
•
•
Bill & Melinda Gates
Atlantic Philanthropies
Carnegie
Rockefeller
Clinton Global Initiative
Carlos Slim
Josiah Macy, Jr.
Kellogg
Ford
MacArthur
Seva
See supplemental material information
77
4.3
3. Non-governmental organizations (NGOs)
Membership organizations
(including their international /global health sections)
•
•
•
•
•
•
Global Health Council
American Public Health Association
American Academy of Family Physicians
American Academy of Pediatrics
Rotary International
Global Health Education Consortium
78
4.3
3. Non-governmental organizations (NGOs)
Consulting / contracting organizations (PVOs)
•
•
•
•
•
•
John Snow International
Management Sciences for Health
Abt Associates
IntraHealth International
Family Health International
Academy for Educational Devt.
79
4.3
Non-governmental organizations (NGOs)
Academic institutions
• Rapid increase in global health centers & programs
– A 20010 CUGH survey found >200 such programs
– Involvement in training, research, service
• Some major university programs
–
–
–
–
–
–
–
–
–
–
Duke University
Emory University
Oxford University
Harvard University
Vanderbilt University
University of Toronto
University of Washington
Johns Hopkins University
Univ. of Calif. at San Francisco
London School Hygiene & Tropical Medicine
80
4.3
Non-governmental organizations (NGOs)
Examples of work done by
Philanthropic Foundations
Bill and Melinda Gates Foundation, Carlos Slim, & others
– Collectively these foundations have increased global spending for
HIV/AIDS (from $250M to $7B 1996-2004)
Clinton Global Initiative (CGI): involving the private sector and getting
participant commitments for involvement
-If no follow-up by a CGI participant, no further invitation to the CGI
-Increased investment in research and development
-10/90 gap: Only 10% of the world’s R&D is spent on problems affecting 90%
of the population – See: www.globalforumhealth.org/About/10-90-gap
Rotary Clubs and polio eradication
- a success, maybe, since small pockets of prevalence are resistant to
immunization for religious or other reasons
Foundation can significantly influence government and inter-governmental
organizations
See supplemental information
81
4.3
Non-governmental organizations (NGOs)
Examples of work done by
Philanthropic Foundations
Gates - Grand Challenges in Global Health
•
•
•
•
•
•
•
Create new vaccines
Improve childhood vaccines
Cure latent and chronic infections
Improve nutrition to promote health
Improve drug treatment of infectious diseases
Control insects that transmit agents of disease
Measure disease and health status accurately and economically in
developing countries
• And perhaps, improve health systems and their human resources
See” Gates Foundation’s Living Proof Project that highlights recent successes in various areas
www.gatesfoundation.org/livingproofproject/Pages/progress-sheets.aspx
82
4.3
What tend to be the strengths
and critiques of NGOs?
Take a minute to note down the words that come
to mind about both the strengths and
potential critiques of NGOs
Then go to the next slides
83
4.3
Non-profit NGOs
Strengths
•
•
•
•
•
•
•
•
Great variety of programs to meet many needs
Potentially very flexible with fast response times
Volunteers & non-profit status lower operational costs
Staff with high personal commitment to providing help
Can easily relate to host country organizations
Less tainted by association with government
Lower corruption potential
Campaigns help educate the public to human needs
84
4.3
Non-profit NGOs
Potential critiques
•
•
•
•
Limited accountability and ability to evaluate effectiveness
High motivation not necessarily matched by expertise
May have high volunteer turnover and short stays
May compete or not coordinate actions with similar NGO and
country programs
• Programs often narrowly focused on specific diseases or
problems, with limited attention to infrastructure development
– Specific diseases and problems are more ‘marketable’ to donors
– Program results are easier to document with limited, measurable,
though not necessarily meaningful, objectives, e.g., meals delivered,
educational talks given, persons trained, medicines handed out,
books delivered
85
4.3
Non-profit NGOs
Potential critiques
• Program dependence on external support compromises
sustainability in host country
• NGO salaries can distort host country salary structure and
compete for competent government personnel
– An “NGO Code of Conduct for Strengthening Health Systems” was
developed in 2007 to encourage NGO practices that contribute to
building public health systems and discourage harmful behaviors
(http://ngocodeofconduct.org/)
• Host country can be seriously burdened by many, often
overlapping, NGOs working on targeted programs, each with
its own staffing, audit and accountability requirements
•
.
86
4.3
NGO does not imply non-profit: For-profit
NGOs exist and are important
• Many examples ranging from pharmaceutical and equipment
companies to consulting firms
• Size, complexity, diversity and global network of commercial
sector make the for-profit sector too important to ignore
• Potential advantages, and critiques
–
–
–
–
–
Major resources may be available
Potential for corruption of foreign governments
Public sector has limited leverage over firms’ behaviors
Public-private sector collaborations are increasing
Companies focus primarily on their own commercial objectives
• WHO introduced Essential Drugs List (EDL) in 1977 with ~200
drugs, now >300 drugs, includes few patented drugs. Many
pharmaceutical companies have opposed EDLs in their efforts to
maintain high prices through WTO patent protection
Page 87
4.3
Civil Society and Global Health
• Many organizations interested in and advocate for
global health but do not provide direct assistance
–
–
–
–
–
–
–
–
–
Global Health Council
UN Association of the USA
Council on Foreign Relations
Returned Peace Corps Volunteers
Commissioned Officers Association
Academic Alliances in Global Health
Global Health Education Consortium
Consortium of Universities for Global Health
American Public Health Association, & many others
88
4.3
Public Diplomacy - its everywhere!
‘Bono, Brad Pitt, Other Celebrities Appear in Public Service
Announcement To Raise Awareness of HIV/AIDS, Poverty ‘
‘Davos Succumbs to Star Power’
But, reflect for a moment on not only the advantages but
also the potential disadvantages of linking a project or
‘worthy cause’ to Star Power! Oprah, Bono, George
Clooney, Mia Farrow, and many others…..
89
5
Module sections
1.
2.
3.
4.
Learning objectives
Brief history of international assistance
Issues and choices: Donors & Recipients
Major types of global health ‘actors’
5. Evaluating effects of international assistance
6. A new approach: The Global Fund
7. Discussion questions
8. Summary
9. Quiz
10. Supplementary information
90
5
Evaluating effects of international assistance
• International development assistance has been
provided in increasing amounts for over 60 years.
• Key questions:
– What has been accomplished?
– What are the determinants of success?
Take one minute to write down the words or
terms you think would be most important
determinants to success.
Then advance to the next slides
91
5
Evaluating effects of assistance
• Many studies have been done and books written
–
–
–
–
–
–
–
–
World Bank (program reviews by the Independent Evaluation Group)
OECD (Principles for Evaluation of Development Assistance)
Many WHO evaluations, e.g., Roll Back Malaria study
William Easterly. THE WHITE MAN'S BURDEN: Why the West's Efforts
to Aid the Rest Have Done So Much Ill and So Little Good
Jeffrey Sachs. The End of Poverty: Economic Possibilities for Our Time
Paul Collier. The Bottom Billion: Why the Poorest Countries are Failing
and What Can Be Done About It
Roger Thurow. Enough: Why the World's Poorest Starve in an Age of
Plenty
Nigel Crisp. Turning the world upside down - the search for global
health in the 21st century (http://www.nigelcrisp.com/book.html)
92
5
Effects of assistance*
• The structure and practices of the “aid industry”
haven’t changed much in the last ~50+ years
–
–
–
–
Loans and grants to governments & NGOs
Substantial and generally external technical assistance
Often a substantial amount of funds return to donors
“Supply-emphasis” programs dominate in which initiative tends to
come from donors and often in accord with donor priorities
• The more “positive” reports conclude that aid has not
been very effective aside from a few successes
– Examples of successes: smallpox eradication, immunization levels,
some child and reproductive health programs
*This section based in part by remarks made by Sir Richard Feachem, founding director of the Global
Fund, made in a lecture at Stanford University on 31 January 2010
93
5
Effects of assistance: Competing views
• Too little aid -- Limited results  reduced aid  even less
success; too much aid goes to a few strategic countries for
political or security reasons (e.g., Egypt, Pakistan, Colombia)
• Too much aid – Many countries are not strongly committed
to program development; have inappropriate priorities; and
corruption and mismanagement reduce aid value
• For an alternative perspective and source of information on
what works and what doesn’t, check out Global Health
Watch’s “Alternative World Health Report”
(www.ghwatch.org/)
94
5
Effects of assistance: Important variables
• Countries that rate relatively high on a substantial number of
the below characteristics are likely to do well, with or without
aid, and if they rate low, external aid accomplishes little
• Characteristics that enhance aid effectiveness:
–
–
–
–
–
–
–
Relatively stable currency
Opportunities for innovation
Open press and communications
Ability to sustain policies over time
Capable and transparent administration
Established and functioning legal system
Relatively stable government with low corruption
95
5
The search for a new approach
• Arising from disappointments about past aid effectiveness
and recent global commitments to reducing disparities, new
approaches to assistance were considered
– Many global partnerships initiated since late 1990s
– Funds from philanthropy greatly increased
– Heightened demands for transparency, accountability,
country commitment and performance
• The Global Fund to Fight AIDS, Tuberculosis and
Malaria illustrates a major attempt to improve aid
effectiveness, to be discussed in the next section
96
6
Module sections
1.
2.
3.
4.
5.
Learning objectives
Brief history of international assistance
Issues and choices: Donors & Recipients
Major types of global health ‘actors’
Evaluating the effects of international assistance
6. A new approach: The Global Fund
7. Discussion questions
8. Summary
9. Quiz
10. Supplementary information
97
6
A new approach: The Global Fund (GF)
• Formed in 2002, the GF is a public/private partnership that
seeks to attract and disburse additional resources to prevent
and treat three major diseases. The Global Fund….
– Is chartered as a charitable NGO without direct government ties
– Has many partners (governments, civil society, private sector and
affected communities) and collaborations with bilateral and
multilateral organizations to supplement existing programs.
– By 2010 has approved $19.3 B for >572 programs in 144 countries.
GF now provides ~25% of all international AIDS financing, ~2/3rds for
tuberculosis and ~75% for malaria.
– Scan the interactive map to understand the burden of these diseases:
• www.globalhealthfacts.org/
98
6
The Global Fund: Defining Characteristics
• The GF differs from the more traditional assistance
institutions. Four key characteristics are:
– 1) Demand-driven
– 2) Performance-based investments
– 3) Administrative transparency
– 4) Anyone can apply
99
6
The Global Fund: Defining Characteristics
• 1) Demand-driven. Based in Geneva and without country
branches, the GF receives and arranges for arms-length
review* of submitted proposals. It does not seek proposals,
has no pre-conceived priorities or desired balance between
different types of programs, recipients, or named diseases,
and does not provide assistance regarding project
preparation. Thus countries and applicants truly “own” their
projects.
*Reviews are by an independent Technical Review Panel of up to 40 experts in
the three diseases and how they relate to health and development. Each expert
is appointed by the Board for a period of up to four Rounds.
100
6
The Global Fund: Defining Characteristics
• 2) Performance-based investments. After project
approval an initial tranche (or “slice”) of funds is
disbursed. Each subsequent tranche is released
only after independent review verifies that the
project continues on track. If deficient performance
is found funding is terminated.
See: www.theglobalfund.org/en/performance/kpi/ for a listing of major performance
indicators impact, effectiveness, grant and portfolio performance, and operation
performance. Examples of impact as a result of supported services are provided
for individual countries at: www.theglobalfund.org/en/performance/impact/?lang=en
101
6
The Global Fund: Defining Characteristics
• 3) Administrative transparency. The GF website
provides great detail, allowing viewers to track
project performance, score cards and
disbursements. Since there is much competition for
funds, projects are well monitored by competing
organizations within countries and whistleblowers
abound.
See www.theglobalfund.org/en/evaluations/?lang=en for information about the GF
Evaluation Library and related materials on the performance of individual
programs
102
6
The Global Fund: Defining Characteristics
• 4) Anyone can apply. In countries where the
government may be weak or corrupt, organizations
and institutions may exist that can successfully
design and implement a project, and by the nature
of GF’s structure, these can be accommodated.
103
7
Module sections
1.
2.
3.
4.
5.
6.
Learning objectives
Brief history of international assistance
Issues and choices: Donors & Recipients
Major types of global health ‘actors’
Evaluating the effects of international assistance
A new approach: The Global Fund
7. Discussion questions
8. Summary
9. Quiz
10. Supplementary information
104
7
Discussion questions*
1. Which types of global health actors are most likely to
involve the communities targeted for intervention in their
decisionmaking and program designs?
2. What resources, besides financial, are necessary to effect
changes in health on a global scale?
3. Why are some diseases, such as HIV/AIDS, targeted so
extensively for intervention? How is this ‘disease focus’
beneficial, and harmful -- and to whom?
4. Why are other diseases ignored? For example, WHO
outlines a list of “neglected tropical diseases.”
*There are no categorically “correct” answers. For some questions country and institutional
context will have a major impact on your answer.
105
7
Discussion questions (continued)
5. Who should define global health priorities? What kinds of
new or improved mechanisms might be developed to
define priorities?
6. Who are the most influential ‘actors’ in global health, why
are they so influential, and are these the most appropriate
actors to have such influence? What other actors would
you like to see more involved?
7. What does ‘accountability’ in global health mean to you?
For example, should private philanthropic organizations be
regulated, and if so, by whom? Should they be
accountable, and if so, for what and by whom?
106
7
Discussion Questions
(continued)
8. Discuss differences in the ways private and governmental
global health actors are likely to approach program design
and implementation
9. Discuss one way in which the use of technology by a global
health actor, such as the Gates Foundation, has improved
health outcomes
10. Discuss ways in which new or increased uses of technology
might undermine health
107
8
Module sections
1.
2.
3.
4.
5.
6.
7.
Learning objectives
Brief history of international assistance
Issues and choices: Donors & Recipients
Major types of global health ‘actors’
Evaluating the effects of international assistance
A new approach: The Global Fund
Discussion questions
8. Summary
9. Quiz
10. Supplementary information
108
8
Summary
• Health has long been an important part of development
assistance, foreign policy and education -- but motivations,
priorities and mechanisms have changed over time
• Development assistance accomplishments over most of the
past 60 years have generally been disappointing
• Since the latter 1990s there has been a rapid rise in the
number, variety and capabilities of organizations involved in,
and funding available for, improving global health
– Available funding is, however, still far short of needs
– The increasingly complex ‘aid industry’ has complicated the work of
both donors and recipients
109
8
Summary, continued
• New assistance approaches can guide program
development in the future. These collaborative partnerships
are seeking better, more transparent ways to set priorities,
allocate funds, and to monitor and evaluate performance.
Programs to watch as they evolve include:
– Global Fund to Fight AIDS, TB and Malaria
– Millennium Challenge Corporation and PEPFAR
– Collaborative partnerships such as Global Alliance for Vaccines &
Immunizations, Roll Back Malaria, International AIDS Vaccine
Initiative, and the Global Health Workforce Alliance
– Major philanthropies such as the Gates and the new Carlos Slim
Foundations
110
8
Summary, continued
• Key characteristics of the emerging and, we hope, more
effective, program assistance models are….
– Demand driven (recipient initiated, planned and implemented)
– Accountable (performance-based investments in which future
support is contingent on good and effective use of past support)
– Transparent (all major steps in the application, approval and project
management phases are visible to anyone)
– Scalable (if relevant, the project can go to “scale,” i.e., expand to a
much larger scale. Too many “pilot programs” go nowhere!)
– Supplemental (aid should supplement, not replace local funds)
– Collaborative (programs partner, coordinate and/or collaborate with
other relevant public and private sector programs)
– Capacity-building (institutional and organizational capacities are
strengthened by the assistance received)
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8
Summary, continued
• Each type of global health ‘actor’ has strengths, constraints
and vulnerabilities. Persons involved in global health
must…..
–
–
–
–
Match their talents and interests to the organization
Ensure program needs are those of the recipient, not the donor
Work to eEnsure early and extensive recipient involvement
Work to make programs “go to scale” and become sustainable
• There are global health jobs in government, multi-laterals,
NGOs, and academia -- but, there is an increasing
expectation of expertise on the part of those involved
112
8
Summary continued
• Both private and public global health actors have a major
role in setting global health priorities
• A common focus among many global health actors is how
to use technology effectively to improve health in resource
poor settings
113
9
Quiz (These questions are not yet available in quiz form. See how far
you can get answering the questions on paper or in your mind.)
1. Name two health-related Millennium Development Goals
(MDGs) (Bonus points if you can link it to a specific global
health initiative or program)
2. Give two examples of multinational / intergovernmental
organizations
3. Give an example of a bilateral organization
4. Give three examples of a non-governmental organization
5. Name three of the five interrelated organizations in the
World Bank System. Give two examples of ways these
organizations contribute to global health
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9
Quiz (These questions are not yet available in quiz form. See how far you can
get answering the questions on paper or in your mind.)
6.
5.
6.
7.
List at least four major types of global health actors?
List at least three functions of WHO
List three strengths and three critiques of WHO?
What is the organizational objective of the Global Alliance
for Vaccines and Immunizations?
8. Describe the main characteristics of “bilateral aid” and
name one bilateral aid agency
9. Name one way in which the policies of the World Trade
Organization (WTO) impact global health
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9
Quiz (These questions are not yet available in quiz form. See how far
you can get answering the questions on paper or in your mind.)
10. Describe two ways in which the Center for Disease Control
contributes to global health
11. What is PEPFAR? Name at least one critique of PEPFAR
12. What is the organizational objective of the Global Health
Workforce Alliance?
13. Discuss one critique of a private philanthropic organization,
such as the Gates Foundation
14. Name at least three defining characteristics of the Global
Fund. What are the presumed advantages of this approach?
116
Thank you for your
attention
Tom Hall
[email protected]
And do check out
the “Resources”
section of GHEC’s
website
www.globalhealthedu.org
“Dream of a hungry cow”
Corns stalks, Mogadishu, Somalia
Worldwatch Institute
117
10
Supplementary information
• Chapter 17, Education and Careers in Global Health. In: Understanding
Global Health. Wm. Markle et al., McGraw Hill Medical, 2007
• Chapter 15. Working Together to Improve Global Health. In: Essentials
of Global Health. Richard Skolnik. Jones & Bartlett, 2008
• Chapters 2 and 3. The Historical Origins of Modern International Health,
and International Health Agencies, Activities, and Other Actors. In:
Textbook of International Health, 3rd Edition. A-E Birn, Y. Pillay, T.
Holtz. Oxford Univ. Press, 2009
• Global Health Watch: An Alternative World Health Report. Available at:
http://www.ghwatch.org/
• Enough: why the World’s Poorest Starve in an Age of Plenty. Roger
Thurow and Scott Kilman.
118
Acknowledgments
• We express our great appreciation to….
– Brent Gordon and Justin Parizo, first year UCSF
medical students in 2010
– Thomas Novotny, professor, School of Public
Health, San Diego State University, developed an
earlier version of this module
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Global Health ‘Actors’ and their programs