Health at the Center of Development The Major Actors Seven Tensions Changing Context

1. Global Health ChallengesSocial Analysis 76: Lecture 25December 13, 2006Visiting Instructor: Prof. D.T. Jamison Harvard University Initiative for Global Health

2. Health at the Center of Development The Major Actors Seven Tensions Changing Context Harvard University Initiative for Global Health

3. Table 12-1 Human Progress in the Twentieth Century: Never Before, Never Again Harvard University Initiative for Global Health

4. Figure 12-9 Health and Development Harvard University Initiative for Global Health

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7. Notes: HFA = height for age; BMI = body mass index Harvard University Initiative for Global Health

8. Millennium Development Goals 189 Heads of State Committed to Achieve by 2015 • Eradicate extreme poverty and hunger • Achieve universal primary education • Promote gender equality and empower women • Reduce child mortality • Improve maternal health • Combat HIV and AIDS, malaria and other diseases • Ensure environmental sustainability • Develop a global partnership for development Harvard University Initiative for Global Health

9. Health in the MDGs 8 Goals Specific 16 Targets 3 Health Goals 48 Indicators 9 Health-Related Targets 18 Health-Related Indicators Broad Harvard University Initiative for Global Health

10. 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 Harvard University Initiative for Global Health

11. 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 Harvard University Initiative for Global Health

12. Health at the Center of Development The Major Actors Seven Tensions Changing Context Harvard University Initiative for Global Health

13. Ziad Obermeyer: A non-exhaustive list of most important players, categorized THE LANDSCAPE OF GLOBAL HEALTH PLAYERS IS COMPRISED OF INTERNATIONAL AND GOVERNMENT AGENCIES . . . Description Key players* Scope of activities UN & Multi-laterals Organizations funded by multiple national governments and donors, operating on an international scale and affiliated with the UN WHO UNAIDS UNICEF UNHCR UNDP Global Fund GAVI Normative research, country support Normative research, country support Program implementation Program implementation Research, program implementation Funding Vaccine procurement Lending agencies that fund projects to be carried out by national governments World Bank IMF Funding, research Funding Bretton Woods USAID EC DfID SIDA GTZ CIDA JICA DANIDA Bilaterals Funding agencies administered by one donor nation to provide grants and knowledge to developing countries Funding Technical support Harvard University Initiative for Global Health

14. . . . IN ADDITION TO PRIVATE, ACADEMIC, AND NON-GOVERNMENTAL ORGANIZATIONS Description Key players Scope of activities Private grant-giving groups with a significant proportion of their budget devoted to international health Gates Wellcome Hewlett Atlantic Philanthropies Foundations Funding Independent organizations not affiliated with governments or the UN with specific health-related missions in the developing world MSF Oxfam IRC Action Int’l CARE Int’l Program implementation NGOs Drug manufacturers; large employers in the developing world that provide health services Pharmaceuticals Other industry Drug research and manufacturing; Insurance for employees, other health-related activities (formularies, workplace health, etc.) Private sector Research and academic institutions with significant activities related to global health LSHTM Johns Hopkins Harvard Research Academia Harvard University Initiative for Global Health

15. World Health Organization (WHO) The World Health Organization was established on 7 April 1948. It is the United Nations specialized agency for health. WHO is a voluntary association of Member States. In 2004, it has 192 Member States. Member States pay assessed contributions to WHO which makes up 50% of its budget. The remaining 50% is from voluntary contributions – bilateral donor agencies or foundations. Harvard University Initiative for Global Health

16. Governance 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. Harvard University Initiative for Global Health

17. WHO Headquarters in Geneva, Switzerland Regional Office for Africa Regional Office for the Americas Regional Office for South-East Asia Regional Office for Europe Regional Office for the Eastern Mediterranean Regional Office for the Western Pacific Harvard University Initiative for Global Health

18. Regional and Country Offices 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. Harvard University Initiative for Global Health

19. WHO Leadership 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. Harvard University Initiative for Global Health

20. WHO Leadership (II) 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. Harvard University Initiative for Global Health

21. United Nations Children’s Fund (UNICEF) “UNICEF is mandated by the United Nations General Assembly to advocate for the protection of children's rights, to help meet their basic needs and to expand their opportunities to reach their full potential.” UNICEF’s Mission Statement Harvard University Initiative for Global Health

22. UNICEF 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. Harvard University Initiative for Global Health

23. UNAIDS Reflecting widespread concern with the ability of Nakajima and WHO to tackle AIDS, six United Nations agencies combined forces in 1996 to establish the Joint United Nations Programme on HIV/AIDS (UNAIDS). These were the United Nations Children’s Fund (UNICEF), United Nations Development Programme (UNDP), United Nations Populations Fund (UNFPA), United Nations Educational, Scientific and Cultural Organization (UNESCO), World Health Organization, and World Bank. The first and current Executive Director is Peter Piot. UNAIDS, WHO Department of HIV/AIDS and the Global Fund for AIDS, TB and malaria are evolving their respective roles. Harvard University Initiative for Global Health

24. The Global Fund to Fight AIDS, Tuberculosis and Malaria The Global Fund emerged from a complex series of negotiations reflecting G8 concern about infectious diseases, Kofi Annan’s particular focus on HIV/AIDS. Its stated role is to increase resources to fight three infectious diseases that are either getting worse or showing no sign of progress. The Global Fund board is made up of developed and developing country representatives, civil society and industry. First Executive Director is Richard Feachem. Harvard University Initiative for Global Health

25. Distribution of Funding after 4 Rounds Harvard University Initiative for Global Health

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27. The World Bank Group The World Bank along with the International Monetary Fund was established on 1 July 1944 at Bretton Woods, New Hampshire. The World Bank provides loans, policy advice, technical assistance, and knowledge sharing services to low- and middle- income countries to reduce poverty and promote growth. Headquarters in Washington, DC, and more than 100 country offices with about 9,300 staff. Members: 184 countries. Harvard University Initiative for Global Health

28. The World Bank Group 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) Harvard University Initiative for Global Health

29. World Bank 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. Harvard University Initiative for Global Health

30. 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. Harvard University Initiative for Global Health

31. U.S. Agency for International Development (USAID) On 3 November 1961, President John F. Kennedy established USAID as an agency to administer foreign economic assistance programs. USAID offers long-range economic and social development assistance to developing countries. USAID is headquartered in Washington, DC, and has field offices in many of the countries where it has programs. Child survival and HIV/AIDS are the main priorities for USAID health programs. Harvard University Initiative for Global Health

32. Department for International Development (DFID) DFID is the UK Government department responsible for promoting sustainable development and reducing poverty. Its central focus of work is the achievement of the MDGs by 2015. DFID assists mainly the poorest countries of sub-Saharan Africa and Asia. It also works for poverty reduction and sustainable development in middle-income countries, e.g. those in Latin America and Eastern Europe. Because of its size (nearly the same dollar figure as USAID) and policy sophistication, DFID has major influence on the ‘like-minded donor group’. Harvard University Initiative for Global Health

33. Health at the Center of Development The Major Actors Seven Tensions Changing Context Harvard University Initiative for Global Health

34. 1. Local vs Global Priorities 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. Harvard University Initiative for Global Health

35. 2. Government vs NGOs 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? Harvard University Initiative for Global Health

36. 3. Disease Control Programs vs Building Health Systems 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. Harvard University Initiative for Global Health

37. 4. Crisis Intervention vs Long-Term Program Development 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. Harvard University Initiative for Global Health

38. 5. Action vs Research 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. Harvard University Initiative for Global Health

39. 6. Dollars vs Institutions 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. Harvard University Initiative for Global Health

40. 7. Coordination vs Thousand Flowers 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. Harvard University Initiative for Global Health

41. Health at the Center of Development The Major Actors Seven Tensions Changing Context Harvard University Initiative for Global Health

42. Globalization 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. Harvard University Initiative for Global Health

43. HIV Epidemic 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? Harvard University Initiative for Global Health

44. Many More Actors 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? Harvard University Initiative for Global Health