US4331 – International Health Theory

1. US4331 – International Health Theory Sep 29, 2008 - Pertinent Institutions

2. Tomorrow (Tuesday Sep 30) • “Global Health Awareness Day” • RGN atrium (right outside these doors) • All day • Panel discussion from 5-7pm in Amph B • Panel discussion is eligible for your 1-page summaries!

3. W.H.O. video “Dealers In Death” can be downloaded from: download.deonandan.com/dealersindeath.mp4 -Ipod format, but you can view it on your computer screen -If you don’t have appropriate software, download VideoLan for free from www.videolan.org -about 150MB -try not to crash my server

4. Today…. • Let’s look at some of the big organizations that deal in International Health issues…

5. At the end of WWII… • The world was broken • There was new wealth, new power, new authority, new hope • There was a desire to see the old ills cast aside • Europe’s financial environment was one of protectionism and wildly fluctuating exchange rates • The Great Powers met to re-build the world’s financial system…

6. …In Bretton Woods, NH http://www.youtube.com/watch?v=GVytOtfPZe8

7. The World Bank • Founded in Dec, 1945, as part of the Bretton Woods agreement • Part of the “World Bank Group” • a family of five international organizations responsible for providing finance and advice to countries for the purposes of economic development and eliminating poverty • 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) • “World Bank” usually refers to IBRD +IDA

8. The World Bank (contd) • Issues low-interest (IBRD) or no-interest (IDA) loans to developing nations • Also funds projects directly • List of member countries: http://go.worldbank.org/Y33OQYNE90 • Afghanistan to Zimbabwe

9. The World Bank (contd) • Sample interventions: • $28.5 million project to increase cotton production and exports in Uganda, by increasing production and competition • $86 million project to improve access to health care in Tanzania • $12 million to reconstruct areas of Haiti affected by natural disasters • $31 million to reform system-wide health insurance in Honduras • $24.6 million to promote privatization of real estate in Moldova

10. The World Bank (contd) • The Bank obtains its funds from: • Contributions from donor countries • Sale of bonds on world market • Interest from its loans • Canada’s share in IBRD capital is ~3% • For more info see: www.worldbank.org • For more info on Canada’s role, see: www.fin.gc.ca

11. The World Bank (contd) • Headquartered in Washington, DC • Traditionally is headed by an American • Typically deals with governments, not necessarily individuals or organizations • In effect, the US President has final say in who is World Bank President • But is ostensibly an international organization

12. The World Bank (contd) • Criticisms: • Governance structure is dominated by wealthy nations (nations with <15% of world’s population control 44% of votes) • World Bank policies essential re-make Southern economies to service Northern needs • Prolongs debt cycle • Funds poorly thought-out, unevaluated, damaging programmes • Actual agenda is to support US business interests

13. The World Bank (contd) • Since WWII, the World Bank has loaned the Developing World more than $330 billion • Today, the Developing World owes the World Bank more than $160 billion • It is the Developing World’s largest creditor • Specializes in “Structural Adjustment Programmes”  learn about these next week

14. The IMF

15. The IMF • The International Monetary Fund (IMF) • "an organization of 185 countries working to foster global monetary cooperation, secure financial stability, facilitate international trade, promote high employment and sustainable economic growth, and reduce poverty". • Also the product of the post-WWII Bretton-Woods agreement

16. The IMF (continued) • Typically headed by a Western European • Funds are provided by donor countries (Canada is responsible for 3%) • IMF focuses on restructuring economies, not on funding projects or effecting development

17. Difference Between World Bank and IMF • World Bank finances economic development • Funds large development projects • Purpose: to promote economic progress by helping to raise productivity • IMF oversees nations’ financial good behaviour • Sets exchange rates • Lends money to governments for emergencies • Makes nations’ monetary policies transparent • Purpose: to oversee and maintain world monetary system http://www.imfsite.org/operations/driscoll896.html

18. The IMF (continued) • Criticisms: • Financial aid bound to too many “conditionalities” • Advocate currency devaluation • Eg, Jamaican currency moved from being worth more than US dollar to being worth <2 cents • Responds to crises, does not prevent them • Not perceived as having high success rate

19. The Red Cross • Actually made up of several loosely or un-affiliated bodies: • National Red Cross (eg, Canadian Red Cross or American Red Cross) or Red Crescent (in Muslim countries) • International Committee of the Red Cross • Founded in 1863 • Mandate under international law to protect “life and dignity” of people during armed conflicts • International Federation of Red Cross and Red Crescent Societies • Founded in 1919 • Coordinates national bodies in relief missions for major disasters

20. The Red Cross (contd) • Funded by donations and by investment revenue • Tasks: • to promote humanitarian principles and values • to provide relief assistance in emergency situations of large magnitude • to support the national groups with disaster preparedness through the education of voluntary members and the provision of equipment and relief supplies • to support local health care projects • to support the national societies with youth-related activities

21. Medecins Sans Frontieres/ Doctors Without Borders • Founded in 1971 by French doctors after Biafra War (Nigerian Civil War) • HQ in Geneva • Annual budget of $400 million, provided mostly by private donors • Nobel Peace Prize in 1999 • Intent is to be able to respond rapidly to public health interventions with complete independence from political, religious and economic influences

22. MSF (contd) • Efforts: • Emergency public health care, including medicine and surgery • Mass vaccination campaigns • Water and sanitation systems • Therapeutic and supplementary nutrition • Distribution of drugs and supplies • Training and health education • Organisation or rehabilitation of health structures • Medical assistance within existing health structures

23. MSF (contd) • Criticisms: • Cynically called “MSF syndrome” • Eg. www.jha.ac/articles/a192.pdf Giving aid to people living under tyrannies strengthens the tyranny Provision of acute medical care frees a government of its welfare responsibilities

24. World Health Organization (WHO) • Founded 1948 • Agency of the United Nations, dedicated to global health • HQ in Geneva • Objective: “the attainment by all peoples of the highest possible level of health”

25. WHO (contd) • Tasks: • Funds projects • Conducts surveillance (e.g. SARS) • Develops tools (e.g., indicators) • Defines standards (e.g. DOTS) • Conducts research (e.g. dietary recommendations) • Educational campaigns (e.g. YOU can stop TB!) • Compiles ICD (international classification of diseases) • Manages and maintains data

26. WHO (contd) Criticisms: • Overly bureaucratic • Inefficient (money hole) • Controversial adherence to public health approaches • health = [environment, access, lifestyle, etc] • Health is "not merely the absence of disease or infirmity" but also "a state of complete physical, mental and social well-being“ • Some see this as “totalitarian”, a licence to meddle in non-health areas • Eg, WHO’s position against tobacco advertising • Interventions are poorly evaluated

27. Canada: CIDA • Canadian International Development Agency • Federal agency, reports to Minister of International Cooperation (Bev Oda) • Priorities: • Social development • E.g. Health, education, child protection • Economic well-being • E.g. business development projects • Environmental sustainability • E.g. Land degradation projects • Governance • Gender equality, human rights, etc

28. CIDA (contd) • Criticisms: • Bureaucratic • Most money spent here in Ottawa • Poor evaluation strategies • Little evidence of impact • CIDA goals too tied to Canadian business agenda • CIDA goals not tied enough to Canadian business agenda Top current recipient of CIDA aid: • Afghanistan

29. Canada - IDRC • International Development Research Council • Canadian crown corporation • Objective is to help developing nations “undertake research and develop innovations” • i.e. use Canada science and tech to help developing nations • Mandate is more Canada-centric than CIDA • to support Canada’s foreign and innovation policy • to bring the benefits of Canadian research and development ability to assist in facing the challenges of the developing world • long-term objective to assign >5% of Canada’s R&D investment to development assistance

30. USAID • United States Agency for International Development • US federal agency responsible for the most non-military foreign “aid” • Their website states: • “USAID plays a vital role in promoting U.S. national security, foreign policy, and the War on Terrorism. It does so by addressing poverty fueled by lack of economic opportunity, one of the root causes of violence today. “ Top current recipient of USAID aid: Iraq

31. USAID (contd) • Accusations that CIA uses USAID as a front for espionage activities • Failure to make interventions culturally suitable • Poor success rate • Most money stays in Washington Criticisms:

32. USAID (contd) • PEPFAR • “President’s Emergency Plan for AIDS Relief” • “a five-year, $15 billion multifaceted approach to combating the disease in more than 120 countries around the world” • 2003-2008 • Aims to: • provide antiretroviral treatment (ART) to 2 million HIV-infected people • to prevent 7 million new infections • support care for 10 million people • Focused on: Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia • Created by Bush II

33. USAID (contd) Criticisms of PEPFAR: • 1/3 of funds are directed to abstinence-only programmes • Refuses to fund “safe needle exchange” programmes • Refuses to fund programmes working with commercial sex workers • Only supports branded (not generic) anti-retroviral drugs • Sets its own agenda, rather than responding to a country’s priorities

34. The Global Fund • The Global Fund to Fight AIDS, Tuberculosis and Malaria • Started in 2002, as a result of an article in The Lancet by Jeffrey Sachs and Amir Attaran • “[more money]directed toward funding projects which are proposed and desired by the affected countries themselves, and which are judged as having epidemiological merit against the pandemic by a panel of independent scientific experts“ • More grants to countries, rather than loans • Created and funded by G8 nations • Additional funds from a variety of sources • E.g. Bill Gates donated $500 million • Bono created “Product Red” project to produce $ for Global Fund • Funding is based on proven performance, so very evaluation focused

35. The Global Fund (contd) • Criticisms: • Do poor nations have the capacity to absorb the money flowing in? May need startup grants for infrastructure • Outcomes are indicator based, but what if there is no baseline data?

36. Gates Foundation • Founded by Bill and Melinda Gates in 2000, HQ in Seattle • One of largest charitable orgs in the world • Goals: • Globally: enhance healthcare and reduce extreme poverty • In USA: expand educational opportunities and access to information technology

37. Gates Foundation (contd) • Global health budget equals that of WHO • Infectious disease budget equals that of USAID • Funds vaccine research for a number of diseases, with special research attention on HIV

38. Clinton Foundation • Founded by Bill and Hillary Clinton • Goal: "strengthen the capacity of people throughout the world to meet the challenges of global interdependence.“ • Aims to make HIV/AIDS care more affordable • Funds large scale HIV/AIDS treatment and prevention programmes

39. Issues with Global Health Funding Bodies • Fragmented landscape with diverse players in overlapping coalitions • Funding agendas are often separate from the needs of the target nation • E.g. why fund a needle exchange programme in a country with minimal drug use? • Projects are often very disease-specific, and thus miss underlying causes of suffering • Few evaluation strategies • Poor indicators chosen, or chosen to be vague • Poor donor coordination • Divest local government of responsibility • Minimal though to greater impacts

40. Example…. Gasifier machine: -creates electricity from cow dung But… -who has the dung? -who gets the electricity?

41. Millennium Development Goals (MDGs) • In 2000, the Millennium Summit was held by the UN, and 8 achievable goals were agreed upon, to be achieved by 2015 • Part of the the “UN Millennium Declaration”

42. MDGs (contd) • Eradicate extreme poverty and hunger • Reduce by half the proportion of people living on less than one U.S. dollar a day. • Reduce by half the proportion of people who suffer from hunger. • Achieve universal primary education • Ensure that all boys and girls complete a full course of primary schooling. • Promote gender equality and empower women • Eliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015. • Reduce child mortality • Reduce the mortality rate among children under five by two thirds. • Improve maternal health • Reduce by three quarters the maternal mortality ratio. • Combat HIV/AIDS, malaria, and other diseases • Halt and begin to reverse the spread of HIV/AIDS. • Halt and begin to reverse the incidence of malaria and other major diseases. • Ensure environmental sustainability • Integrate the principles of sustainable development into country policies and programmes; reverse loss of environmental resources. • Reduce by half the proportion of people without sustainable access to safe drinking water (for more information see the entry on water supply). • Achieve significant improvement in lives of at least 100 million slum dwellers, by 2020. • Develop a global partnership for development • Develop further an open trading and financial system that is rule-based, predictable and non-discriminatory.