Global institutions Global institutions and health financingand health financing

Who are the major players?Who are the major players?

The context (and a The context (and a bit of history)bit of history)

Post war context (1944)Post war context (1944)““This Conference at This Conference at Bretton WoodsBretton Woods, ,

representing nearly all the peoples of the world, representing nearly all the peoples of the world, has considered has considered matters of international money matters of international money and finance which are important for peace and and finance which are important for peace and prosperityprosperity. The Conference has agreed on the . The Conference has agreed on the

problems needing attention, the measures problems needing attention, the measures which should be taken, and the forms of which should be taken, and the forms of

international cooperation or organization which international cooperation or organization which are required. The agreements reached on these are required. The agreements reached on these

large and complex matters are without large and complex matters are without precedent in the history of international precedent in the history of international

economic relations.” July 22, 1944economic relations.” July 22, 1944

Context of the Oil Crisis (1970s-Context of the Oil Crisis (1970s-80s)80s)

►Dramatic rise in debt among poorer Dramatic rise in debt among poorer countries 1970s and 1980scountries 1970s and 1980s

►Growing efforts to coordinate and Growing efforts to coordinate and manage external funding to poorer manage external funding to poorer countriescountries

►Emergence of poverty reduction as the Emergence of poverty reduction as the prime objective of international prime objective of international financial institutions (IFIs)financial institutions (IFIs)

The actorsThe actors

General DiscussionGeneral Discussion

►Which institutions have you heard of Which institutions have you heard of

that might be involved in health policy that might be involved in health policy

formulation, health financing, health formulation, health financing, health

service delivery etc etc?service delivery etc etc?

The main players in global The main players in global healthhealth

►World Health OrganisationWorld Health Organisation►World BankWorld Bank► International Monetary FundInternational Monetary Fund►World Trade OrganisationWorld Trade Organisation► Public Private Partnerships (e.g. GAVI and the Public Private Partnerships (e.g. GAVI and the

Global Fund for AIDS, TB and Malaria)Global Fund for AIDS, TB and Malaria)►National Governments (DFID, USAID)National Governments (DFID, USAID)►NGOs (MSF, Medact, Save the Children, Oxfam)NGOs (MSF, Medact, Save the Children, Oxfam)

World Health OrganisationWorld Health Organisation► The World Health Organization is the UN’s The World Health Organization is the UN’s

specialized agency for health. specialized agency for health. ► EstablishedEstablished: 7 April 1948. : 7 April 1948. ► ObjectiveObjective: The attainment by all peoples of the : The attainment by all peoples of the

highest possible level of health. highest possible level of health. ► Governed by 192 Member States through the World Governed by 192 Member States through the World

Health AssemblyHealth Assembly► WHA composed of representatives from WHO's WHA composed of representatives from WHO's

Member States. Member States. ► The main tasks of WHA are to approve the WHO The main tasks of WHA are to approve the WHO

programme and the budget for the following programme and the budget for the following biennium and to decide major policy questions. biennium and to decide major policy questions.

WHO continuedWHO continuedStrengths:Strengths:► Specialised knowledgeSpecialised knowledge► Proven success record (eradication of Proven success record (eradication of

smallpox)smallpox)► ‘‘Democratic’/consultative decision making Democratic’/consultative decision making

processesprocesses

Weaknesses:Weaknesses:► BureaucraticBureaucratic► Facing a finding crisisFacing a finding crisis►May be influenced by large fundersMay be influenced by large funders

World BankWorld Bank► MissionMission: Fight poverty and improve the living standards of : Fight poverty and improve the living standards of

people in the developing world. people in the developing world. ► Provides loans, policy advice, technical assistance and Provides loans, policy advice, technical assistance and

knowledge sharing services to low and middle income countries knowledge sharing services to low and middle income countries to reduce poverty. to reduce poverty.

► Promotes growth to create jobs and to empower poor people to Promotes growth to create jobs and to empower poor people to take advantage of these opportunitiestake advantage of these opportunities

► Made up of 184 Made up of 184 member countriesmember countries, jointly responsible for how , jointly responsible for how the institution is financed and how its money is spent.the institution is financed and how its money is spent.

► Some 10,000 development professionals from nearly every Some 10,000 development professionals from nearly every country in the world work in the World Bank's Washington DC country in the world work in the World Bank's Washington DC headquarters or in its 109 country offices headquarters or in its 109 country offices

► Now centres its efforts on the reaching the Millennium Now centres its efforts on the reaching the Millennium Development Goals, agreed to by UN members in 2000 and Development Goals, agreed to by UN members in 2000 and aimed at sustainable poverty reductionaimed at sustainable poverty reduction

World Bank continuedWorld Bank continuedHealth, nutrition and population (HNP) Health, nutrition and population (HNP)

programme:programme: ► Development lending US$ 25 billionDevelopment lending US$ 25 billion► 1999 – 199 HNP projects in 84 countries1999 – 199 HNP projects in 84 countries► US$ 9.5 billionUS$ 9.5 billion

► StrengthsStrengths: well funded, powerful, now spends : well funded, powerful, now spends more on health than the WHOmore on health than the WHO

► WeaknessesWeaknesses: Overemphasis on economic growth : Overemphasis on economic growth has led it into trouble, transparency?, has led it into trouble, transparency?, accountability?accountability?

IMFIMF► Conceived at Bretton Woods (July 1944). Conceived at Bretton Woods (July 1944). ► The 45 governments represented sought to build a framework The 45 governments represented sought to build a framework

for economic cooperation that would avoid a repetition of the for economic cooperation that would avoid a repetition of the policies that contributed to the Great Depression of the 1930s.policies that contributed to the Great Depression of the 1930s.

► Now an international organization of 184 member countries. Now an international organization of 184 member countries. ► AimsAims: :

Promotes international monetary cooperation, exchange stability, Promotes international monetary cooperation, exchange stability, and orderly exchange arrangements;and orderly exchange arrangements;

Fosters economic growth and high levels of employment; Fosters economic growth and high levels of employment; Provide temporary financial assistance to countries to help ease Provide temporary financial assistance to countries to help ease

balance of payments adjustment. balance of payments adjustment. ► StaffStaff: approximately 2,700 from 141 countries : approximately 2,700 from 141 countries ► Total QuotasTotal Quotas: $311 billion (as of 8/31/04) : $311 billion (as of 8/31/04) ► Loans outstandingLoans outstanding: $97 billion to 84 countries, of which $10 : $97 billion to 84 countries, of which $10

billion to 59 on concessional terms (as of 8/31/04) billion to 59 on concessional terms (as of 8/31/04) ► Technical Assistance providedTechnical Assistance provided: 367 person years during FY2004 : 367 person years during FY2004 ► Surveillance consultations concluded: 116 countries during Surveillance consultations concluded: 116 countries during

FY2004, of which 92 voluntarily published their staff reportsFY2004, of which 92 voluntarily published their staff reports

WTOWTONational health policies are increasingly influenced by trade National health policies are increasingly influenced by trade agreements of the WTO. The General Agreement on Trade in agreements of the WTO. The General Agreement on Trade in

Services (GATS) is the WTO treaty that covers health services.Services (GATS) is the WTO treaty that covers health services.

What is the WTO?What is the WTO?► An organisation of 148 membersAn organisation of 148 members► Established 1995Established 1995► Formed from GATTFormed from GATT► Function:Function:“the only international organization dealing with the “the only international organization dealing with the

global rules of trade between nations. Its main function is to global rules of trade between nations. Its main function is to ensure that trade flows as smoothly, predictably and freely as ensure that trade flows as smoothly, predictably and freely as possible.”possible.”

How does the WTO work?How does the WTO work?► Through a set of treatiesThrough a set of treaties► Treaties contain binding rules Treaties contain binding rules ► A trade court punishes infringementsA trade court punishes infringements► Treaties combine to prevent evasion of free trade promisesTreaties combine to prevent evasion of free trade promises► Countries are monitored in periodic trade reviewsCountries are monitored in periodic trade reviews

WTO continued…WTO continued…Common criticisms of the WTO:Common criticisms of the WTO:► That they reduce national autonomy (right to regulate) by:That they reduce national autonomy (right to regulate) by:

Forcing marketisation of public servicesForcing marketisation of public services Undermining viability of public services by preventing cross-Undermining viability of public services by preventing cross-

subsidisationsubsidisation Outlawing monopoly provisionOutlawing monopoly provision Putting limits on public health actions by testing their ‘necessity’Putting limits on public health actions by testing their ‘necessity’

Commonly cited merits of the WTO:Commonly cited merits of the WTO:► WTO safeguards of right to regulateWTO safeguards of right to regulate

Public services are not coveredPublic services are not covered The treaty does not require privatisationThe treaty does not require privatisation Members choose what to ‘liberalise’Members choose what to ‘liberalise’ Members can qualify liberalisation promises in order to protect Members can qualify liberalisation promises in order to protect

public policy objectives (right to regulate)public policy objectives (right to regulate)

National GovernmentsNational Governments► Earth summit in Rio de Janeiro (1992): World's governments Earth summit in Rio de Janeiro (1992): World's governments

adopted a programme for action under the auspices of the adopted a programme for action under the auspices of the United NationsUnited Nations

► This included an Official Development Assistance aid target of This included an Official Development Assistance aid target of 0.7% of gross national product (GNP) for rich nations, roughly 22 0.7% of gross national product (GNP) for rich nations, roughly 22 members of the OECD, known as the Development Assistance members of the OECD, known as the Development Assistance Committee (DAC).Committee (DAC).

► Almost all rich nations have constantly failed to reach Almost all rich nations have constantly failed to reach their agreed obligations of the 0.7% targettheir agreed obligations of the 0.7% target. .

► Instead of 0.7%, the amount of aid has been around 0.2 to Instead of 0.7%, the amount of aid has been around 0.2 to 0.25%, some $100 billion short.0.25%, some $100 billion short.

Some examples:Some examples:► USA's aid, in terms of percentage of their GNP is already lowest USA's aid, in terms of percentage of their GNP is already lowest

of any industrialized nation in the world, though paradoxically in of any industrialized nation in the world, though paradoxically in the last three years, their dollar amount has been the highest. the last three years, their dollar amount has been the highest.

► Since 1992-2001 Japan was the largest donor of aid, in terms of Since 1992-2001 Japan was the largest donor of aid, in terms of raw dollars. Japan's aid dropped by nearly 4 billion dollars in raw dollars. Japan's aid dropped by nearly 4 billion dollars in 2001.2001.

NGOsNGOs► Varied areas of specialisation:Varied areas of specialisation:

Emergency/Crisis (e.g. ICRC)Emergency/Crisis (e.g. ICRC) Development (e.g. Oxfam)Development (e.g. Oxfam) Vulnerable populations (e.g.Save the Children)Vulnerable populations (e.g.Save the Children) EtcEtc

Strengths:Strengths:► Closer links to civil societyCloser links to civil society► Specialised areas of expertiseSpecialised areas of expertise

WeaknessesWeaknesses::► Uncertain funding (can be influenced by funders)Uncertain funding (can be influenced by funders)► Not all NGOs are ‘grass roots’ organisations – some Not all NGOs are ‘grass roots’ organisations – some

are the equivalent of multinational corporationsare the equivalent of multinational corporations

PPPsPPPs► Relatively new in the area of global health policyRelatively new in the area of global health policy► Biggest players are GAVI and the Global FundBiggest players are GAVI and the Global Fund

Strengths:Strengths:► Well fundedWell funded► Efficient, streamlined systems often make for faster Efficient, streamlined systems often make for faster

decision makingdecision making

Weaknesses:Weaknesses:► Accountability?Accountability?► Conflicts of interests?Conflicts of interests?► Transparency?Transparency?

More context (and a More context (and a bit more recent bit more recent

history)history)

Recent history: Increasing co-Recent history: Increasing co-operationoperation

► Globalisation seen as a force changing the world.Globalisation seen as a force changing the world.► UN Conference on Trade and Development:UN Conference on Trade and Development:

““Attention is paid not only to traditional domains of Attention is paid not only to traditional domains of stabilization and adjustment but also to policy areas, such as stabilization and adjustment but also to policy areas, such as health and education, which have come to be emphasized in health and education, which have come to be emphasized in the new orientation as having a direct impact on poverty the new orientation as having a direct impact on poverty alleviation.” alleviation.”

► World Bank’s Health Policy Model (1993):World Bank’s Health Policy Model (1993): Foster environments that enable households to improve healthFoster environments that enable households to improve health Improve spending on healthImprove spending on health Promote diversity and competition Promote diversity and competition

► Growing role/influence of PPPsGrowing role/influence of PPPs

Increasing co-operation Increasing co-operation continuedcontinued

Policy network levers:Policy network levers:► Poverty reduction strategy paper (PRSP) (World Bank and IMF led)Poverty reduction strategy paper (PRSP) (World Bank and IMF led)► Sector wide approach (SWAp)Sector wide approach (SWAp)► Millennium Development Goals (all 191 UN member states have Millennium Development Goals (all 191 UN member states have

pledged to reach these goals by 2015)pledged to reach these goals by 2015)

Examples of joint policy management:Examples of joint policy management:► HIPC (highly indebted poor countries)HIPC (highly indebted poor countries)► IDA (International Development Association)IDA (International Development Association)► HNP (Health, Nutrition & Population)HNP (Health, Nutrition & Population)► Donor aidDonor aid

Criticisms:Criticisms:► The network is a policy elite not a scientific responseThe network is a policy elite not a scientific response► It limits attention to social causes of ill-healthIt limits attention to social causes of ill-health► Efficacy and evidence base of Essential Package questionedEfficacy and evidence base of Essential Package questioned► Local control questionedLocal control questioned► Based on US model of health care as a private commodity Based on US model of health care as a private commodity

Effects of co-ordinationEffects of co-ordination►Health put on the development Health put on the development

agendaagenda►Coordinating policy managementCoordinating policy management►Concept of multilateral policy change Concept of multilateral policy change ►Challenge to Health for AllChallenge to Health for All

Group discussionGroup discussion

►Your are Afghanistan’s Health Your are Afghanistan’s Health MinisterMinister

►Your country has persistently high U5 Your country has persistently high U5 mortalitymortality

►Who do you go to for help and why?Who do you go to for help and why?