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Global Health ‘Actors’ and their programs

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. Learning objectives

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Global Health ‘Actors’ and their programs

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  1. 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

  2. 1 Module sections • Learning objectives • Brief history of international assistance • Issues and choices: Donors & Recipients • Types of global health ‘actors’ • Evaluating effects of international assistance • A new approach: The Global Fund • Discussion questions • Summary • Quiz • Supplementary information

  3. 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.

  4. 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 inter-governmental? Give these questions some thought as you go through the module

  5. 2 Module sections • Learning objectives • Brief history of international assistance • Issues and choices: Donors & Recipients • Types of global health ‘actors’ • Evaluating effects of international assistance • A new approach: The Global Fund • Discussion questions • Summary • Quiz • Supplementary information

  6. 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 • 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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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 • Providedeconomic 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

  13. 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

  14. 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.

  15. 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

  16. 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 2 See supplemental information

  17. 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) • Eradicate extreme poverty & hunger - Reduce by half those living on <$1/day - Reduce by half % suffering from hunger • 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

  18. 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: 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-five-year-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 slum-dwellers 1 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 18

  19. 3 Module sections • Learning objectives • Brief history of international assistance • Issues and choices: Donors & Recipients • Types of global health ‘actors’ • Evaluating effects of international assistance • A new approach: The Global Fund • Discussion questions • Summary • Quiz • Supplementary information

  20. 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.

  21. 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?

  22. 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

  23. 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?

  24. 4 Module sections • Learning objectives • Brief history of international assistance • Issues and choices: Donors & Recipients • Types of global health actors • Evaluating effects of international assistance • A new approach: The Global Fund • Discussion questions • Summary • Quiz • Supplementary information

  25. 4.1 Three major types of global health actors • Multinational organizations A. Organizations within the UN system relevant to health B. Organizations outside of the UN system relevant to health • Bilateral -- government-to-government or to sub-government levels • Non-governmental organizations (NGOs) Click for supplemental material

  26. 4.1 • 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

  27. 1. Multinational 4.1 • 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)

  28. 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

  29. 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.”

  30. 4.1 WHO Priorities 2008 WHO Annual Report Primary Health Care • Reducing maternal and child mortality by aiming at universal access to, and coverage with effective interventions and health services • Addressing epidemic of chronic non-communicable diseases, with an emphasis on reduced risk factors such as tobacco, poor diet, and physical inactivity • Improving health systems, focusing on human resources, financing, health information and primary health care 2009 WHO Annual Report Health System Financing

  31. 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

  32. 2008 1625 cases 17 countries Program example: Poliomyelitis eradication: 1988-2008 4.1 1988 350,000 cases 125 countries Almost there, but a few very resistant pockets (internal conflict, religious opposition, etc.) of transmission

  33. What are WHO’s strengths? 4.1 Take one minute to write down words that describe potential strengths of a multinational institution like WHO. Then go to next slide

  34. 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

  35. What critiques could be made of an organization like WHO? 4.1 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

  36. 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.”

  37. 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

  38. 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.

  39. 1. Multinational 4.1 • 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

  40. 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

  41. 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 2010-11 biennium

  42. 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

  43. 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

  44. 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 forforeign 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

  45. 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/

  46. 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

  47. 4.1 Programmatic distribution of World Bank funds in 2007

  48. 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

  49. 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.

  50. 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

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