health at the center of development the major actors seven tensions changing context

Harvard University Initiative for Global Health

Global Health ChallengesSocial Analysis 76: Lecture 25

December 13, 2006

Visiting Instructor: Prof. D.T. Jamison


Health at the Center of Development

The Major Actors

Seven Tensions

Changing Context


Table 12-1 Human Progress in the Twentieth Century: Never Before, Never AgainTable 12-1 Human Progress in the Twentieth Century: Never Before, Never Again


Figure 12-9 Health and DevelopmentFigure 12-9 Health and Development


Notes:Notes: HFA = height for age; BMI = body mass index HFA = height for age; BMI = body mass index


1.1. Eradicate extreme poverty and hunger Eradicate extreme poverty and hunger

2.2. Achieve universal primary education Achieve universal primary education

3.3. Promote gender equality and empower women Promote gender equality and empower women

4.4. Reduce child mortality Reduce child mortality

5.5. Improve maternal health Improve maternal health

6.6. Combat HIV and AIDS, malaria and other diseases Combat HIV and AIDS, malaria and other diseases

7.7. Ensure environmental sustainability Ensure environmental sustainability

8.8. Develop a global partnership for developmentDevelop a global partnership for development

Millennium Development GoalsMillennium Development Goals

189 Heads of State Committed to Achieve by 2015189 Heads of State Committed to Achieve by 2015


Health in the MDGs

18 Health-Related Indicators

48 Indicators

9 Health-Related Targets

16 Targets

3 Health Goals

8 Goals

Broad

Specific


New Funding Mechanisms

New global mechanisms for funding health: Global Alliance for

Vaccines and Immunizations, Global Fund for Aids,

Tuberculosis and Malaria, International Financing Facility--

Immunization

Proliferation of smaller public-private partnerships (more than

50)

Gates Foundation as major funder and agenda setter


Business, Trade and Health

WTO negotiations on access to drugs

Increased business concern over impact of HIV

epidemic on their workforce

Role of multinational business in tobacco,

alcohol and diet



The Major Actors

Seven Tensions

Changing Context


THE LANDSCAPE OF GLOBAL HEALTH PLAYERS IS COMPRISED OF INTERNATIONAL AND GOVERNMENT AGENCIES . . .

UN & Multi-laterals

Bilaterals

WHOUNAIDSUNICEFUNHCRUNDPGlobal FundGAVI

Bretton Woods World BankIMF

USAIDECDfIDSIDAGTZCIDAJICADANIDA

Key players* Scope of activities

Normative research, country supportNormative research, country supportProgram implementationProgram implementationResearch, program implementationFundingVaccine procurement

Funding, researchFunding

FundingTechnical support

Ziad Obermeyer:

A non-exhaustive list of most important players, categorized

Ziad Obermeyer:

A non-exhaustive list of most important players, categorized

Description

Organizations funded by multiple national governments and donors, operating on an international scale and affiliated with the UN

Lending agencies that fund projects to be carried out by national governments

Funding agencies administered by one donor nation to provide grants and knowledge to developing countries


. . . IN ADDITION TO PRIVATE, ACADEMIC, AND NON-GOVERNMENTAL ORGANIZATIONS

GatesWellcomeHewlett Atlantic Philanthropies

MSFOxfamIRCAction Int’lCARE Int’l

Funding

Research

Foundations

NGOs

Private sector

Academia

PharmaceuticalsOther industry

Drug research and manufacturing;Insurance for employees, other health-related activities (formularies, workplace health, etc.)

LSHTMJohns HopkinsHarvard

Key players Scope of activitiesDescription

Private grant-giving groups with a significant proportion of their budget devoted to international health

Independent organizations not affiliated with governments or the UN with specific health-related missions in the developing world

Drug manufacturers; large employers in the developing world that provide health services

Research and academic institutions with significant activities related to global health

Program implementation


The World Health Organization was established on 7 April The World Health Organization was established on 7 April 1948. It is the United Nations specialized agency for health.1948. It is the United Nations specialized agency for health.

WHO is a voluntary association of Member States. In 2004, WHO is a voluntary association of Member States. In 2004, it has 192 Member States.it has 192 Member States.

Member States pay assessed contributions to WHO which Member States pay assessed contributions to WHO which makes up 50% of its budget. makes up 50% of its budget.

The remaining 50% is from voluntary contributions – The remaining 50% is from voluntary contributions – bilateral donor agencies or foundations.bilateral donor agencies or foundations.

World Health Organization (WHO)World Health Organization (WHO)


All Member States have one vote in the World Health Assembly which meets each May in Geneva at the Palais des Nations.

An Executive Board comprised of delegates of 32 countries meets in January and May and also plays a critical governance role including nominating the Director-General each 5 years.

WHO has six regions each of which has an elected Regional Director.

Governance


WHO HeadquartersWHO Headquartersin Geneva, Switzerlandin Geneva, Switzerland

Regional Office for AfricaRegional Office for Africa

Regional Office for the AmericasRegional Office for the Americas

Regional Office for South-East AsiaRegional Office for South-East Asia

Regional Office for EuropeRegional Office for Europe

Regional Office for the Eastern MediterraneanRegional Office for the Eastern Mediterranean

Regional Office for the Western PacificRegional Office for the Western Pacific


Six regional offices (Copenhagen, Washington DC, Cairo, New Delhi, Manila, Brazzaville).

Because Regional-Directors are elected by the Member States of each region they have an independent power base as distinct from Geneva.

In 120 countries, WHO has a country office. The WHO Representative that heads that office reports through the regional offices.

Regional and Country Offices


Halfdan Mahler was Director General for 15 years (1973-1988).

In 1978, at Alma-Ata (now Kazakhstan), the primary health care strategy was launched.

WHO declared the goal of Health for All by the Year 2000 in 1979 based on the primary health care strategy.

WHO shifted from a highly technical and normative agency (e.g. eradication of smallpox) to pushing the HFA policy agenda.

WHO Leadership


Hiroshi Nakajima elected DG in 1988 was extraordinarily ineffectual. During his ten years as DG, the locus of health policy leadership shifted notably to the World Bank.

Gro Harlem Brundtland, former Prime Minister of Norway, was DG 1998-2003. During her tenure she emphasized putting health at the center of the development agenda.

JW Lee was elected DG in 2003 and died in office in 2006. He stressed ARVs for HIV disease and shifted the balance of WHO from normative work to country implementation.

Margaret Chan, former Health Secretary of Hong Kong, will become DG in early 2007.

WHO Leadership (II)


United Nations Children’s Fund United Nations Children’s Fund (UNICEF)(UNICEF)

““UNICEF is mandated by the UNICEF is mandated by the United Nations General Assembly United Nations General Assembly to advocate for the protection of to advocate for the protection of children's rights, to help meet children's rights, to help meet their basic needs and to expand their basic needs and to expand their opportunities to reach their opportunities to reach their full potential.” their full potential.”

UNICEF’s Mission StatementUNICEF’s Mission Statement


The Executive Director is selected by the Secretary-General. Because UNICEF is not governed by one country one vote, it plays a different role.

UNICEF is primarily an implementation agency for children’s health and education programs.

By tradition, the head of UNICEF is usually selected from the USA.

New Executive Director is Anne Venneman, formerly US Secretary of Agriculture

Policy focus of UNICEF shifting back to health form a human rights.

UNICEF


UNAIDSUNAIDS

Reflecting widespread concern with the ability of Nakajima and WHO to Reflecting widespread concern with the ability of Nakajima and WHO to tackle AIDS, six United Nations agencies combined forces in tackle AIDS, six United Nations agencies combined forces in 19961996 to to establish the establish the Joint United Nations Programme on HIV/AIDS Joint United Nations Programme on HIV/AIDS (UNAIDS)(UNAIDS). .

These were the United Nations Children’s Fund (UNICEF), United These were the United Nations Children’s Fund (UNICEF), United Nations Development Programme (UNDP), United Nations Populations Nations Development Programme (UNDP), United Nations Populations Fund (UNFPA), United Nations Educational, Scientific and Cultural Fund (UNFPA), United Nations Educational, Scientific and Cultural Organization (UNESCO), World Health Organization, and World Bank. Organization (UNESCO), World Health Organization, and World Bank.

The first and current Executive Director is Peter Piot. The first and current Executive Director is Peter Piot.

UNAIDS, WHO Department of HIV/AIDS and the Global Fund for AIDS, UNAIDS, WHO Department of HIV/AIDS and the Global Fund for AIDS, TB and malaria are evolving their respective roles. TB and malaria are evolving their respective roles.


The Global Fund to Fight AIDS, The Global Fund to Fight AIDS,

Tuberculosis and MalariaTuberculosis and Malaria

The Global Fund emerged from a complex series of The Global Fund emerged from a complex series of negotiations reflecting G8 concern about infectious diseases, negotiations reflecting G8 concern about infectious diseases, Kofi Annan’s particular focus on HIV/AIDS. Kofi Annan’s particular focus on HIV/AIDS.

Its stated role is to increase resources to fight three infectious Its stated role is to increase resources to fight three infectious diseases that are either getting worse or showing no sign of diseases that are either getting worse or showing no sign of progress. progress.

The Global Fund board is made up of developed and The Global Fund board is made up of developed and developing country representatives, civil society and industry. developing country representatives, civil society and industry.

First Executive Director is Richard Feachem.First Executive Director is Richard Feachem.


Distribution of Funding after 4 RoundsDistribution of Funding after 4 Rounds


The World Bank GroupThe World Bank Group

The World Bank along with the International Monetary Fund was The World Bank along with the International Monetary Fund was established on 1 July 1944 at Bretton Woods, New Hampshire.established on 1 July 1944 at Bretton Woods, New Hampshire.

The World Bank provides loans, policy advice, technical The World Bank provides loans, policy advice, technical assistance, and knowledge sharing services to low- and middle- assistance, and knowledge sharing services to low- and middle- income countries to reduce poverty and promote growth.income countries to reduce poverty and promote growth.

Headquarters in Washington, DC, and more than 100 country Headquarters in Washington, DC, and more than 100 country offices with about 9,300 staff. offices with about 9,300 staff. Members: 184 countries.Members: 184 countries.


IDA is a key component of the WB portfolio. IDA funds are interest free loans – depending on the interest rate, they are 70-80% a grant.

World Bank is dominated by US trained economists even though other groups work for the bank.

Governance: One $ = One Vote (Sort of)

The World Bank Group


In the late 1970s, the World Bank began lending in health.

During the 1980s, the World Bank increasingly took on a health policy leadership role. The dominance of the World Bank reached a milestone with the publication of the World Development Report 1993 Investing in Health.

Richard Feachem (now head of the Global Fund) was head of the health sector at the World Bank up until the late 1990s.

World Bank


World Bank is structured with regional vice-presidencies. Health program officers in the regional parts of the World Bank formulate concessional and non-concessional loans.

There is also a central group that is meant to formulate policy and provide a common resource to the sector program officers.

Since the departure of Feachem and the resurgence of WHO in the policy arena, there has not been a clear World Bank direction.

World Bank


U.S. Agency for International Development (USAID)U.S. Agency for International Development (USAID)

On 3 November 1961, President John F. Kennedy On 3 November 1961, President John F. Kennedy established USAID as an agency to administer foreign established USAID as an agency to administer foreign economic assistance programs.economic assistance programs.

USAID offers long-range economic and social development USAID offers long-range economic and social development assistance to developing countries.assistance to developing countries.

USAID is headquartered in Washington, DC, and has field USAID is headquartered in Washington, DC, and has field offices in many of the countries where it has programs.offices in many of the countries where it has programs.

Child survival and HIV/AIDS are the main priorities for Child survival and HIV/AIDS are the main priorities for USAID health programs.USAID health programs.


Department for International Development (DFID)Department for International Development (DFID)

DFID is the UK Government department responsible for DFID is the UK Government department responsible for promoting sustainable development and reducing poverty.promoting sustainable development and reducing poverty.

Its central focus of work is the achievement of the MDGs by Its central focus of work is the achievement of the MDGs by 2015.2015.

DFID assists mainly the poorest countries of sub-Saharan DFID assists mainly the poorest countries of sub-Saharan Africa and Asia. It also works for poverty reduction and Africa and Asia. It also works for poverty reduction and sustainable development in middle-income countries, e.g. those sustainable development in middle-income countries, e.g. those in Latin America and Eastern Europe. in Latin America and Eastern Europe.

Because of its size (nearly the same dollar figure as USAID) Because of its size (nearly the same dollar figure as USAID) and policy sophistication, DFID has major influence on the ‘like-and policy sophistication, DFID has major influence on the ‘like-minded donor group’.minded donor group’.



The Major Actors

Seven Tensions

Changing Context


In every new health or development initiative, there will be a debate about who should set priorities.

Local priority setting should better reflect local needs and understanding of barriers to progress. Local priority setting can also lead to capture by existing urban elites and/or may reflect global priorities from 10 or 20 years earlier.

Global priority setting and targets allow for effective fund-raising, monitoring and evaluation of success but can be divorced from local realities.

1. Local vs Global Priorities


Should new programs or resources be channeled to government or NGOs (local or international)?

WHO, other UN and Bretton Woods must largely work with governments by constitutional mandate.

Without government cooperation large-scale programs are unlikely to succeed.

NGOs in some settings can be much more effective program implementers but what is the long-term impact of expanding NGOs on the development of health systems?

2. Government vs NGOs


Long-run debate as to whether focusing on disease control programs (e.g. polio eradication, DOTS, 3X5, Onchocerciasis Control Programme) or investing in physical and human infrastructure of health systems is a better strategy.

Debate still present but disease control programs are more sophisticated in trying to spin their programs as ‘building health systems’.

Empirically not clear which strategy works better.

3. Disease Control Programs vs Building Health Systems


Most effort is on long-term health and development programs.

United Nations High Commission for Refugees, International Committee for the Red Cross, WHO Emergencies Department and many NGOs respond to humanitarian emergencies.

Tension in global health community between the demands of the current crisis and the goals of long-term sustainable health improvement.

4. Crisis Intervention vs Long-Term Program Development


Many advocate and public health workers focus on current program delivery to make a difference.

Investing scarce resources in research on how to tackle problems more effectively is often unpopular.

Experience with malaria eradication efforts or tuberculosis control demonstrates that ignoring research (both fundamental and operational) can be very costly in the long-run.

5. Action vs Research


Some argue the main barrier to improving global health in the poorest countries is the lack of resources.

Others point to the low budget execution rates for existing grants and loans. They argue the absorptive capacity for many poor countries is limited by lack of institutional development.

Proponents of the institutional view argue we should invest more in human resource development and managerial training.

6. Dollars vs Institutions


A classic UN argument is that the real impediment to progress is the lack of coordination between international and/or national actors.

Sector-wide Approaches (SWAPs) are one way to address both problems of coordination and local priority settings.

The alternative view is that letting many actors pursue different approaches may lead to innovative effective models being tested and developed.

7. Coordination vs Thousand Flowers



The Major Actors

Seven Tensions

Changing Context


Globalization of trade, information flow, capital, human resources and research technology is changing how global health institutions function.

Information gap between parts of high-income and middle-income world is dramatically narrowed.

Health policy and strategy cannot develop in isolation from developments in trade and politics.

Globalization


For sub-Saharan Africa and for global institutions, the HIV epidemic has dramatically transformed health policy.

The epidemic has such an overwhelming impact on Eastern and Southern Africa that it forces global institutions to formulate their strategies in terms of HIV.

Riding the tiger – is the enormous concern and response to HIV going to carry other programs along with increased resources or decrease attention for all other problems?

HIV Epidemic


At the time of HFA 2000, WHO was the only major multilateral actor in health. Now, there is the GFATM, GAVI, other public-private partnerships, and the prospect of many more.

Unlikely to see a reversal of the trend towards more and more quasi-autonomous actors on the international landscape.

Will the profusion of actors merely increase transaction costs for everyone? Will it increase total resource flows? Does it shift the balance of power away from developing countries in global health policy formulation?

Many More Actors

health at the center of development the major actors seven tensions changing context

Documents

funding health

health servicesresearch

workplace health

maternal health combat

global partnership

global alliance

international scale

important players