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 1. Learning objectives 2. Brief history of international assistance 3. Issues and choices: Donors & Recipients 4. Types of global health ‘actors’ 5. Evaluating effects of international assistance 6. A new approach: The Global Fund 7. Discussion questions 8. Summary 9. Quiz 10. Supplementary information 2 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. 3 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 intergovernmental? Give these questions some thought as you go through the module 4 2 Module sections 1. Learning objectives 2. Brief history of international assistance 3. Issues and choices: Donors & Recipients 4. Types of global health ‘actors’ 5. Evaluating effects of international assistance 6. A new approach: The Global Fund 7. Discussion questions 8. Summary 9. Quiz 10. Supplementary information 5 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 6 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 7 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 8 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 9 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 10 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 11 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 – Provided economic 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 12 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 13 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. 14 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 15 2 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 See supplemental information 16 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) 1. Eradicate extreme poverty & hunger - Reduce by half those living on <$1/day - Reduce by half % suffering from hunger 2. 3. 4. 5. 6. 7. 8. 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 17 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: 1) 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 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 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-fiveyear-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 slumdwellers 18 3 Module sections 1. Learning objectives 2. Brief history of international assistance 3. Issues and choices: Donors & Recipients 4. Types of global health ‘actors’ 5. Evaluating effects of international assistance 6. A new approach: The Global Fund 7. Discussion questions 8. Summary 9. Quiz 10. Supplementary information 19 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. 20 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? 21 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 22 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? 23 4 Module sections 1. Learning objectives 2. Brief history of international assistance 3. Issues and choices: Donors & Recipients 4. Types of global health actors 5. Evaluating effects of international assistance 6. A new approach: The Global Fund 7. Discussion questions 8. Summary 9. Quiz 10. Supplementary information 24 4.1 Three major types of global health actors 1. Multinational organizations A. Organizations within the UN system relevant to health B. Organizations outside of the UN system relevant to health 2. Bilateral -- government-to-government or to sub-government levels 3. Non-governmental organizations (NGOs) Click for supplemental material 25 4.1 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 26 4.1 1. Multinational • 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) 27 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 28 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.” 29 4.1 WHO Priorities • Reducing maternal and child mortality by aiming at universal access to, and coverage with effective interventions and health services • Addressing epidemic of chronic noncommunicable diseases, with an emphasis on reduced risk factors such as tobacco, poor diet, and physical inactivity 2008 WHO Annual Report Primary Health Care 2009 WHO Annual Report Health System Financing • Improving health systems, focusing on human resources, financing, health information and primary health care 30 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 31 4.1 Program example: Poliomyelitis eradication: 1988-2008 1988 350,000 cases 125 countries Almost there, but a few very resistant pockets (internal conflict, religious opposition, etc.) of transmission 2008 1625 cases 17 countries 32 4.1 What are WHO’s strengths? Take one minute to write down words that describe potential strengths of a multinational institution like WHO. Then go to next slide 33 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 34 4.1 What critiques could be made of an organization like WHO? 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 35 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.” 36 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 37 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. 38 4.1 1. Multinational • 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 39 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 40 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 201011 biennium 41 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 42 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 43 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 for foreign 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 44 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/ 45 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 46 4.1 Programmatic distribution of World Bank funds in 2007 47 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 48 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. 49 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 50 4.1 Multinational Financial Institutions: Potential critiques • They may undermine role of state and national sovereignty – Poor countries may be obliged to adopt potentially harmful policies, e.g., “structural adjustment programs” • • • • Economic considerations may dominate decisions Largest stakeholders (donors) dominate votes Challenge of corruption in recipient countries Correlates of program success may not be present – Country characteristics favoring good loan performance include good administration, stable currency, established legal system, sustained policies over time, lack of social strife, and low corruption. Countries that most need help lack many of these characteristics. 51 4.1 Multinational Financial Institutions: Potential critiques • WB banks & IMF primarily focused on infrastructure – 1950s-70s: primary focus on macroeconomic issues with ‘conditionalities’ set regarding performance & payments – Latter 1970s, Structural Adjustment Policies (SAPs) introduced linking loans to export promotion, open trade, reduced government employment and subsidies, and privatization of many enterprises – Critics argued that SAPs exacerbated poverty for poorest segments of the population and kept poor countries dependent on rich countries Click here to view a five-minute YouTube clip contextualizing SAPs and famine in Niger http://www.youtube.com/watch?v=Iw9OARpp-KI Click here to view a seven-minute YouTube clip of a BBC inquiry into WB policies http://news.bbc.co.uk/nolavconsole/ukfs_news/hi/newsid_5150000/newsid_5150500/bb_rm_5150592.stm 52 4.1 World Trade Organization (1995) • WTO (153 members), deals with trade rules between nations – WTO’s Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS) attempts to balance between long term objective of providing incentives for inventions, and short term objective of allowing poor countries to use life-saving inventions and creations. – Patent protection of certain essential drugs has meant that the high cost of these drugs prevented their use in resource poor countries – After much conflict a compromise was reached on TRIPS* that allows importation or production of essential pharmaceutical products under a compulsory license by the least developed countries. *URL provides extensive information on this issue. See also other GHEC modules on TRIPS and patent conflicts over drug production and importation. http://www.wto.org/english/tratop_e/trips_e/factsheet_pharm00_e.htm 53 4.2 Types of global health ‘actors’ 1. Multinational / inter-governmental organizations A. Organizations within the UN system relevant to health B. Organizations outside of the UN system relevant to health 2. Bilateral -- government-to-government or to sub-government levels 3. Non-governmental organizations (NGOs) 54 4.2 Types of global health ‘actors’ 2. Bilateral aid agencies* • Many of the “rich” 34 OECD countries have official, government owned or controlled aid agencies, e.g., – – – – – – – USAID (U.S. Agency for International Development) DFID (U.K.) SIDA (Sweden) CIDA and IDRC (Canada) DANIDA (Denmark) JICA (Japan) And many others *”Bilateral” nominally refers to aid assistance provided by one government to another government. In practice a donor government may provide funding to NGOs within its own borders, and these then provide assistance to organizations within the recipient countries. Governments can also provide assistance directly to NGOs and other entities in the recipient countries. For example, USAID provides large contracts to US NGOs to provide capacity-building services and tools to recipient countries. 55 4.2 Types of global health ‘actors’ 2. Bilateral aid agencies – US Government: Agencies with Global Health Activities • Dept. of Health & Human Services (DHHS) – Centers for Disease Control & Prevention – National Institutes of Health – Health Resources and Services Administration – Food & Drug Administration • Dept. of Defense • Department of State – USAID – PEPFAR – Peace Corps • Millennium Challenge Corporation • President’s Malaria Initiative • Dept. of Homeland Security • Dept. of Agriculture • US Trade Representative 56 4.2 DHHS Office of Global Health Affairs • Office represents DHHS to other governments, other Federal Departments and agencies, international organizations, and to the private sector on international and refugee health issues – Develops health-related policy and strategy positions – Provides policy guidance and coordination on refugee health policy issues • DHHS is a domestic agency but Health, Education, and Labor appropriations includes $754 million for Global AIDS Source: http://www.globalhealth.gov/office/index.html 57 4.2 Centers for Disease Control (CDC) • Advocates and supports global health promotion, protection and “diplomacy” (~$1B, including ~$600M for AIDS/PEPFAR, $150M for polio / measles elimination, $70M for influenza, $30M for disease detection). Overall CDC budget has remained relatively flat • Promotion: Infectious & non-infectious disease, MCH, injury • Protection: Preparedness, detection and response, bioterrorism • Diplomacy: Sustainable systems, natural disasters, refugees, internally displaced, complex emergencies • Other international work • Outbreak investigations • Contributions to multinationals • Training (Field Epidemiology Training Program) 58 4.2 National Institutes of Health (NIH) • Overall NIH budget increased by $500M/year since 2006, currently ~$31B (2010). Global health related funds are relatively small and spread among many different fields – Fogarty International Center (1968). FIC’s research, training, and capacity-building activities are in 100+ countries and involve ~5,000 scientists in U.S. and abroad with a budget of ~$69M – Pre- and post-doctoral FIC global fellowships are available – Multi-institute global health projects: tobacco, HIV/AIDS, bioethics, etc. Each Institute has international focal point and funding depends on institute priority 59 4.2 Health Resources & Services Admin. (HRSA) • In partnership with PEPFAR, HRSA is investing $130 million over five years to transform African medical education and dramatically increase the number of health care workers. – Via Medical Education Partnership Initiative (MEPI), grants are awarded directly to African institutions in 12 countries, working in partnership with U.S. medical schools. The initiative will form a network including about 30 regional partners, country health and education ministries, and more than 20 U.S. collaborators. • The program is designed to support PEPFAR goals to train and retain 140,000 new health care workers and improve the capacity of partner countries to deliver primary health care. Source: www.fic.nih.gov/news/press_releases/2010-mepi.htm 60 4.2 Food and Drug Administration (FDA) • FDA actions are closely watched by other countries and their decisions can have significant effects. The FDA….. – Has regulatory authority for food and drugs and must balance between safety and getting drugs to market – Gets involved in controversies with family planning, AIDS, certification of imported drugs (e.g., generics, drugs from Canada) – Experiences tension on food safety with USDA (e.g., use of antibiotics and hormones in animal feed, pesticides) – Has no tobacco regulatory role – Does not regulate additives and food supplements 61 4.2 Department of State (DOS) • U.S. Agency for International Development (USAID) – Modest technical capacity; primarily operates through contracts to other domestic and foreign organizations – FY 2009 total expenditure of $11.0B ($1.7B to health, $0.8B to education, $0.5B to vulnerable populations per budget report): – 75% of USAID staff is in the field – Programs can be subject to substantial political considerations, e.g., support to Egypt, Israel, El Salvador and Honduras during the ‘Contras’ war • Next few slides are examples of recent and long-standing US government global health initiatives Source on expenditures: www.usaid.gov/policy/afr09/FY2009AFR11-16-09.pdf) 62 4.2 PEPFAR President’s Emergency Plan for AIDS Relief • Up to $48 B over 5 years (2003-2008) including previously committed MTCT funds (maternal-to- child-transmission) programs; $1B for Global Fund for AIDS, TB, Malaria • Focus on 15 countries: Botswana, Côte d’Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam and Zambia • In 2009 President Obama announced reauthorization of PEPFAR. The second round expands fund usage somewhat to address major health system and health worker bottlenecks • PEPFAR Documentary See supplemental information 63 4.2 Peace Corps • Peace Corps, founded in 1961, is an independent agency with a budget of ~$319M – Since start, ~195,000 volunteers to 139 countries (77 at present) – Current Volunteers and Trainees = 7,617 Average age, 28; 94% single; 60% female; – Minorities: 16% of Peace Corps Volunteers – Volunteers over 50: 5% (oldest is 84) – Education: 89% have at least an undergraduate degree, 11% have graduate studies or degrees – Four main sectors in which they work • Education, 35%; health, 22%; business & development, 15%; environment, 14% 64 4.2 Peace Corps Orange: Countries the Peace Corp currently works in Purple: Countries the Peace Corp has worked previously Source: http://www.peacecorps.gov/index.cfm?shell=about.fastfacts 65 4.2 Millennium Challenge Corporation • U.S. Government corporation established in 2004 that gives ~$5B/year to promote economic growth and reduce poverty. Distinctive features include: – Competitive selection: 17 indicators are used to assess country commitments to good governance, economic freedom, and investment in people (especially women and children) • Sample Country Scorecards – Country-led solutions: Countries must identify their priorities for achieving sustainable economic growth and poverty reduction. Proposals are developed in broad societal consultation. – Country-led implementation: Recipient countries set up their own accountable entity to manage and oversee implementation. Fund monitoring is rigorous and transparent, often via independent agents. Source: http://www.mcc.gov/pages/about 66 4.2 President’s Malaria Initiative (PMI) • Launched in 2005, led by USAID, and implemented together with CDC. Works in partnership with Global Fund, WHO, Roll Back Malaria, UNICEF, NGOs, etc. • Initial five-year commitment of $1.2 billion; rapid increase in expenditures with $500M allocated for FY 2010 • PMI goal: 50% malaria reduction in 15 focus countries, attained by reaching 85% of most vulnerable groups – children <5 and pregnant women – with effective prevention and treatment measures. PMI supports four key areas – indoor spraying of homes, insecticide-treated mosquito nets, anti-malarial drugs, and treatment to prevent malaria in pregnant women. • Program targets15 worst hit countries in Africa Source: http://www.fightingmalaria.gov/about/index.html 67 4.2 PMI Focus Countries and Malaria Distribution in Africa Major malaria regions in Africa and the targeted countries – darker colors indicate more malaria http://www.fightingmalaria.gov/about/index.html 68 4.2 Bilateral organizations Strengths • Substantial resources from governments • Generally have qualified, long-term staff – Subcontractors also tend to develop substantial expertise • Moderately flexible, responding to changing conditions • In U.S., increasing use of long-term commitments and very large ($20-100 millions), multi-project and country contracts • Can coordinate activities with other bilateral and NGO programs 69 4.2 Bilateral organizations Potential critiques • • • • • Political factors may drive assistance (‘Cold War’ period) Programs may require purchases of drugs, equipment, etc., in donor country, thus increasing costs & decreasing recipient flexibility to find best/cheapest products Programs may be more oriented toward donor’s priorities, industries, programs and capabilities than recipient’s priorities Aid may be poorly coordinated or even competing with other, especially non-governmental, programs Programs may siphon off best host country health workers with higher salaries, better administration, etc. 70 4.2 Bilateral organizations Potential critiques • Foreign aid is politically vulnerable due to a small constituency (e.g., equipment makers, contractors) • The US public supports global health aid, though with misconceptions. A 2009 Kaiser Family Foundation poll found that: – – – – 23% favor decreased aid, 39% same aid, and 26% increased aid Support increases when specific types of health spending are mentioned 52% say U.S. spends too much on “foreign aid,” but only 23% say this about efforts to improve health or fight HIV/AIDS (16%) But, 45% incorrectly choose foreign aid as one of the largest areas of spending by the government, more than choose Medicare or Social Security (33% each) – programs that dwarf foreign aid Source: http://www.kff.org/kaiserpolls/upload/7894.pdf 71 4.2 Net “overseas development aid” from 24 donor countries. Aid includes government and major NGOs. Of the total, top 10 U.S. recipients get 41%, and health, education & nutrition get ~27%. Iraq, Afghanistan & Sudan get ~22% of that aid. Development assistances, 24 DAC countries, 2008 For more detail on U.S. aid, go to: http://www.oecd.org/dataoe cd/42/30/44285539.gif Source: http://www.oecd.org/document/9/0,3343,en_2649_34447_1893129_1_1_1_1,00.html 72 4.3 Types of global health ‘actors’ 1. Multinational / inter-governmental organizations A. Organizations within the UN system relevant to health B. Organizations outside the UN system relevant to health 2. Bilateral -- government-to-government or to sub-government levels 3. Non-governmental organizations (NGOs) 73 4.3 3. Non-governmental organizations (NGOs) • NGOs defined by their extraordinary diversity – – – – – – – – – – Non-profit and profit-based Religious and secular Narrow and broad scope programs Wealthy and shoe-string operations • Big NGOs are called BINGOs Well paid, marginally paid and volunteer staff Long- and short-term commitments Single-country, multi-country and regional focus Single problem and multi-problem focus Single sector and multi-sector focus Emergency relief and development focus 74 4.3 3. Non-governmental organizations (NGOs) Charitable (secular) organizations • • • • • • • • • • • Oxfam CARE Save the Children/UK (& US) International Red Cross Doctors without Borders Project Hope International Rescue Committee CARE Freedom from Hunger Child Family Health International Doctors for Global Health See supplemental information 75 4.3 3. Non-governmental organizations (NGOs) Faith-based organizations (FBOs) • • • • Catholic Relief Services Christian Aid Lutheran World Relief Unitarian Universalist Service Society 76 4.3 3. Non-governmental organizations (NGOs) Philanthropic foundations • • • • • • • • • • • Bill & Melinda Gates Atlantic Philanthropies Carnegie Rockefeller Clinton Global Initiative Carlos Slim Josiah Macy, Jr. Kellogg Ford MacArthur Seva See supplemental material information 77 4.3 3. Non-governmental organizations (NGOs) Membership organizations (including their international /global health sections) • • • • • • Global Health Council American Public Health Association American Academy of Family Physicians American Academy of Pediatrics Rotary International Global Health Education Consortium 78 4.3 3. Non-governmental organizations (NGOs) Consulting / contracting organizations (PVOs) • • • • • • John Snow International Management Sciences for Health Abt Associates IntraHealth International Family Health International Academy for Educational Devt. 79 4.3 Non-governmental organizations (NGOs) Academic institutions • Rapid increase in global health centers & programs – A 20010 CUGH survey found >200 such programs – Involvement in training, research, service • Some major university programs – – – – – – – – – – Duke University Emory University Oxford University Harvard University Vanderbilt University University of Toronto University of Washington Johns Hopkins University Univ. of Calif. at San Francisco London School Hygiene & Tropical Medicine 80 4.3 Non-governmental organizations (NGOs) Examples of work done by Philanthropic Foundations Bill and Melinda Gates Foundation, Carlos Slim, & others – Collectively these foundations have increased global spending for HIV/AIDS (from $250M to $7B 1996-2004) Clinton Global Initiative (CGI): involving the private sector and getting participant commitments for involvement -If no follow-up by a CGI participant, no further invitation to the CGI -Increased investment in research and development -10/90 gap: Only 10% of the world’s R&D is spent on problems affecting 90% of the population – See: www.globalforumhealth.org/About/10-90-gap Rotary Clubs and polio eradication - a success, maybe, since small pockets of prevalence are resistant to immunization for religious or other reasons Foundation can significantly influence government and inter-governmental organizations See supplemental information 81 4.3 Non-governmental organizations (NGOs) Examples of work done by Philanthropic Foundations Gates - Grand Challenges in Global Health • • • • • • • Create new vaccines Improve childhood vaccines Cure latent and chronic infections Improve nutrition to promote health Improve drug treatment of infectious diseases Control insects that transmit agents of disease Measure disease and health status accurately and economically in developing countries • And perhaps, improve health systems and their human resources See” Gates Foundation’s Living Proof Project that highlights recent successes in various areas www.gatesfoundation.org/livingproofproject/Pages/progress-sheets.aspx 82 4.3 What tend to be the strengths and critiques of NGOs? Take a minute to note down the words that come to mind about both the strengths and potential critiques of NGOs Then go to the next slides 83 4.3 Non-profit NGOs Strengths • • • • • • • • Great variety of programs to meet many needs Potentially very flexible with fast response times Volunteers & non-profit status lower operational costs Staff with high personal commitment to providing help Can easily relate to host country organizations Less tainted by association with government Lower corruption potential Campaigns help educate the public to human needs 84 4.3 Non-profit NGOs Potential critiques • • • • Limited accountability and ability to evaluate effectiveness High motivation not necessarily matched by expertise May have high volunteer turnover and short stays May compete or not coordinate actions with similar NGO and country programs • Programs often narrowly focused on specific diseases or problems, with limited attention to infrastructure development – Specific diseases and problems are more ‘marketable’ to donors – Program results are easier to document with limited, measurable, though not necessarily meaningful, objectives, e.g., meals delivered, educational talks given, persons trained, medicines handed out, books delivered 85 4.3 Non-profit NGOs Potential critiques • Program dependence on external support compromises sustainability in host country • NGO salaries can distort host country salary structure and compete for competent government personnel – An “NGO Code of Conduct for Strengthening Health Systems” was developed in 2007 to encourage NGO practices that contribute to building public health systems and discourage harmful behaviors (http://ngocodeofconduct.org/) • Host country can be seriously burdened by many, often overlapping, NGOs working on targeted programs, each with its own staffing, audit and accountability requirements • . 86 4.3 NGO does not imply non-profit: For-profit NGOs exist and are important • Many examples ranging from pharmaceutical and equipment companies to consulting firms • Size, complexity, diversity and global network of commercial sector make the for-profit sector too important to ignore • Potential advantages, and critiques – – – – – Major resources may be available Potential for corruption of foreign governments Public sector has limited leverage over firms’ behaviors Public-private sector collaborations are increasing Companies focus primarily on their own commercial objectives • WHO introduced Essential Drugs List (EDL) in 1977 with ~200 drugs, now >300 drugs, includes few patented drugs. Many pharmaceutical companies have opposed EDLs in their efforts to maintain high prices through WTO patent protection Page 87 4.3 Civil Society and Global Health • Many organizations interested in and advocate for global health but do not provide direct assistance – – – – – – – – – Global Health Council UN Association of the USA Council on Foreign Relations Returned Peace Corps Volunteers Commissioned Officers Association Academic Alliances in Global Health Global Health Education Consortium Consortium of Universities for Global Health American Public Health Association, & many others 88 4.3 Public Diplomacy - its everywhere! ‘Bono, Brad Pitt, Other Celebrities Appear in Public Service Announcement To Raise Awareness of HIV/AIDS, Poverty ‘ ‘Davos Succumbs to Star Power’ But, reflect for a moment on not only the advantages but also the potential disadvantages of linking a project or ‘worthy cause’ to Star Power! Oprah, Bono, George Clooney, Mia Farrow, and many others….. 89 5 Module sections 1. 2. 3. 4. Learning objectives Brief history of international assistance Issues and choices: Donors & Recipients Major types of global health ‘actors’ 5. Evaluating effects of international assistance 6. A new approach: The Global Fund 7. Discussion questions 8. Summary 9. Quiz 10. Supplementary information 90 5 Evaluating effects of international assistance • International development assistance has been provided in increasing amounts for over 60 years. • Key questions: – What has been accomplished? – What are the determinants of success? Take one minute to write down the words or terms you think would be most important determinants to success. Then advance to the next slides 91 5 Evaluating effects of assistance • Many studies have been done and books written – – – – – – – – World Bank (program reviews by the Independent Evaluation Group) OECD (Principles for Evaluation of Development Assistance) Many WHO evaluations, e.g., Roll Back Malaria study William Easterly. THE WHITE MAN'S BURDEN: Why the West's Efforts to Aid the Rest Have Done So Much Ill and So Little Good Jeffrey Sachs. The End of Poverty: Economic Possibilities for Our Time Paul Collier. The Bottom Billion: Why the Poorest Countries are Failing and What Can Be Done About It Roger Thurow. Enough: Why the World's Poorest Starve in an Age of Plenty Nigel Crisp. Turning the world upside down - the search for global health in the 21st century (http://www.nigelcrisp.com/book.html) 92 5 Effects of assistance* • The structure and practices of the “aid industry” haven’t changed much in the last ~50+ years – – – – Loans and grants to governments & NGOs Substantial and generally external technical assistance Often a substantial amount of funds return to donors “Supply-emphasis” programs dominate in which initiative tends to come from donors and often in accord with donor priorities • The more “positive” reports conclude that aid has not been very effective aside from a few successes – Examples of successes: smallpox eradication, immunization levels, some child and reproductive health programs *This section based in part by remarks made by Sir Richard Feachem, founding director of the Global Fund, made in a lecture at Stanford University on 31 January 2010 93 5 Effects of assistance: Competing views • Too little aid -- Limited results reduced aid even less success; too much aid goes to a few strategic countries for political or security reasons (e.g., Egypt, Pakistan, Colombia) • Too much aid – Many countries are not strongly committed to program development; have inappropriate priorities; and corruption and mismanagement reduce aid value • For an alternative perspective and source of information on what works and what doesn’t, check out Global Health Watch’s “Alternative World Health Report” (www.ghwatch.org/) 94 5 Effects of assistance: Important variables • Countries that rate relatively high on a substantial number of the below characteristics are likely to do well, with or without aid, and if they rate low, external aid accomplishes little • Characteristics that enhance aid effectiveness: – – – – – – – Relatively stable currency Opportunities for innovation Open press and communications Ability to sustain policies over time Capable and transparent administration Established and functioning legal system Relatively stable government with low corruption 95 5 The search for a new approach • Arising from disappointments about past aid effectiveness and recent global commitments to reducing disparities, new approaches to assistance were considered – Many global partnerships initiated since late 1990s – Funds from philanthropy greatly increased – Heightened demands for transparency, accountability, country commitment and performance • The Global Fund to Fight AIDS, Tuberculosis and Malaria illustrates a major attempt to improve aid effectiveness, to be discussed in the next section 96 6 Module sections 1. 2. 3. 4. 5. Learning objectives Brief history of international assistance Issues and choices: Donors & Recipients Major types of global health ‘actors’ Evaluating the effects of international assistance 6. A new approach: The Global Fund 7. Discussion questions 8. Summary 9. Quiz 10. Supplementary information 97 6 A new approach: The Global Fund (GF) • Formed in 2002, the GF is a public/private partnership that seeks to attract and disburse additional resources to prevent and treat three major diseases. The Global Fund…. – Is chartered as a charitable NGO without direct government ties – Has many partners (governments, civil society, private sector and affected communities) and collaborations with bilateral and multilateral organizations to supplement existing programs. – By 2010 has approved $19.3 B for >572 programs in 144 countries. GF now provides ~25% of all international AIDS financing, ~2/3rds for tuberculosis and ~75% for malaria. – Scan the interactive map to understand the burden of these diseases: • www.globalhealthfacts.org/ 98 6 The Global Fund: Defining Characteristics • The GF differs from the more traditional assistance institutions. Four key characteristics are: – 1) Demand-driven – 2) Performance-based investments – 3) Administrative transparency – 4) Anyone can apply 99 6 The Global Fund: Defining Characteristics • 1) Demand-driven. Based in Geneva and without country branches, the GF receives and arranges for arms-length review* of submitted proposals. It does not seek proposals, has no pre-conceived priorities or desired balance between different types of programs, recipients, or named diseases, and does not provide assistance regarding project preparation. Thus countries and applicants truly “own” their projects. *Reviews are by an independent Technical Review Panel of up to 40 experts in the three diseases and how they relate to health and development. Each expert is appointed by the Board for a period of up to four Rounds. 100 6 The Global Fund: Defining Characteristics • 2) Performance-based investments. After project approval an initial tranche (or “slice”) of funds is disbursed. Each subsequent tranche is released only after independent review verifies that the project continues on track. If deficient performance is found funding is terminated. See: www.theglobalfund.org/en/performance/kpi/ for a listing of major performance indicators impact, effectiveness, grant and portfolio performance, and operation performance. Examples of impact as a result of supported services are provided for individual countries at: www.theglobalfund.org/en/performance/impact/?lang=en 101 6 The Global Fund: Defining Characteristics • 3) Administrative transparency. The GF website provides great detail, allowing viewers to track project performance, score cards and disbursements. Since there is much competition for funds, projects are well monitored by competing organizations within countries and whistleblowers abound. See www.theglobalfund.org/en/evaluations/?lang=en for information about the GF Evaluation Library and related materials on the performance of individual programs 102 6 The Global Fund: Defining Characteristics • 4) Anyone can apply. In countries where the government may be weak or corrupt, organizations and institutions may exist that can successfully design and implement a project, and by the nature of GF’s structure, these can be accommodated. 103 7 Module sections 1. 2. 3. 4. 5. 6. Learning objectives Brief history of international assistance Issues and choices: Donors & Recipients Major types of global health ‘actors’ Evaluating the effects of international assistance A new approach: The Global Fund 7. Discussion questions 8. Summary 9. Quiz 10. Supplementary information 104 7 Discussion questions* 1. Which types of global health actors are most likely to involve the communities targeted for intervention in their decisionmaking and program designs? 2. What resources, besides financial, are necessary to effect changes in health on a global scale? 3. Why are some diseases, such as HIV/AIDS, targeted so extensively for intervention? How is this ‘disease focus’ beneficial, and harmful -- and to whom? 4. Why are other diseases ignored? For example, WHO outlines a list of “neglected tropical diseases.” *There are no categorically “correct” answers. For some questions country and institutional context will have a major impact on your answer. 105 7 Discussion questions (continued) 5. Who should define global health priorities? What kinds of new or improved mechanisms might be developed to define priorities? 6. Who are the most influential ‘actors’ in global health, why are they so influential, and are these the most appropriate actors to have such influence? What other actors would you like to see more involved? 7. What does ‘accountability’ in global health mean to you? For example, should private philanthropic organizations be regulated, and if so, by whom? Should they be accountable, and if so, for what and by whom? 106 7 Discussion Questions (continued) 8. Discuss differences in the ways private and governmental global health actors are likely to approach program design and implementation 9. Discuss one way in which the use of technology by a global health actor, such as the Gates Foundation, has improved health outcomes 10. Discuss ways in which new or increased uses of technology might undermine health 107 8 Module sections 1. 2. 3. 4. 5. 6. 7. Learning objectives Brief history of international assistance Issues and choices: Donors & Recipients Major types of global health ‘actors’ Evaluating the effects of international assistance A new approach: The Global Fund Discussion questions 8. Summary 9. Quiz 10. Supplementary information 108 8 Summary • Health has long been an important part of development assistance, foreign policy and education -- but motivations, priorities and mechanisms have changed over time • Development assistance accomplishments over most of the past 60 years have generally been disappointing • Since the latter 1990s there has been a rapid rise in the number, variety and capabilities of organizations involved in, and funding available for, improving global health – Available funding is, however, still far short of needs – The increasingly complex ‘aid industry’ has complicated the work of both donors and recipients 109 8 Summary, continued • New assistance approaches can guide program development in the future. These collaborative partnerships are seeking better, more transparent ways to set priorities, allocate funds, and to monitor and evaluate performance. Programs to watch as they evolve include: – Global Fund to Fight AIDS, TB and Malaria – Millennium Challenge Corporation and PEPFAR – Collaborative partnerships such as Global Alliance for Vaccines & Immunizations, Roll Back Malaria, International AIDS Vaccine Initiative, and the Global Health Workforce Alliance – Major philanthropies such as the Gates and the new Carlos Slim Foundations 110 8 Summary, continued • Key characteristics of the emerging and, we hope, more effective, program assistance models are…. – Demand driven (recipient initiated, planned and implemented) – Accountable (performance-based investments in which future support is contingent on good and effective use of past support) – Transparent (all major steps in the application, approval and project management phases are visible to anyone) – Scalable (if relevant, the project can go to “scale,” i.e., expand to a much larger scale. Too many “pilot programs” go nowhere!) – Supplemental (aid should supplement, not replace local funds) – Collaborative (programs partner, coordinate and/or collaborate with other relevant public and private sector programs) – Capacity-building (institutional and organizational capacities are strengthened by the assistance received) 111 8 Summary, continued • Each type of global health ‘actor’ has strengths, constraints and vulnerabilities. Persons involved in global health must….. – – – – Match their talents and interests to the organization Ensure program needs are those of the recipient, not the donor Work to eEnsure early and extensive recipient involvement Work to make programs “go to scale” and become sustainable • There are global health jobs in government, multi-laterals, NGOs, and academia -- but, there is an increasing expectation of expertise on the part of those involved 112 8 Summary continued • Both private and public global health actors have a major role in setting global health priorities • A common focus among many global health actors is how to use technology effectively to improve health in resource poor settings 113 9 Quiz (These questions are not yet available in quiz form. See how far you can get answering the questions on paper or in your mind.) 1. Name two health-related Millennium Development Goals (MDGs) (Bonus points if you can link it to a specific global health initiative or program) 2. Give two examples of multinational / intergovernmental organizations 3. Give an example of a bilateral organization 4. Give three examples of a non-governmental organization 5. Name three of the five interrelated organizations in the World Bank System. Give two examples of ways these organizations contribute to global health 114 9 Quiz (These questions are not yet available in quiz form. See how far you can get answering the questions on paper or in your mind.) 6. 5. 6. 7. List at least four major types of global health actors? List at least three functions of WHO List three strengths and three critiques of WHO? What is the organizational objective of the Global Alliance for Vaccines and Immunizations? 8. Describe the main characteristics of “bilateral aid” and name one bilateral aid agency 9. Name one way in which the policies of the World Trade Organization (WTO) impact global health 115 9 Quiz (These questions are not yet available in quiz form. See how far you can get answering the questions on paper or in your mind.) 10. Describe two ways in which the Center for Disease Control contributes to global health 11. What is PEPFAR? Name at least one critique of PEPFAR 12. What is the organizational objective of the Global Health Workforce Alliance? 13. Discuss one critique of a private philanthropic organization, such as the Gates Foundation 14. Name at least three defining characteristics of the Global Fund. What are the presumed advantages of this approach? 116 Thank you for your attention Tom Hall thall@epi.ucsf.edu And do check out the “Resources” section of GHEC’s website www.globalhealthedu.org “Dream of a hungry cow” Corns stalks, Mogadishu, Somalia Worldwatch Institute 117 10 Supplementary information • Chapter 17, Education and Careers in Global Health. In: Understanding Global Health. Wm. Markle et al., McGraw Hill Medical, 2007 • Chapter 15. Working Together to Improve Global Health. In: Essentials of Global Health. Richard Skolnik. Jones & Bartlett, 2008 • Chapters 2 and 3. The Historical Origins of Modern International Health, and International Health Agencies, Activities, and Other Actors. In: Textbook of International Health, 3rd Edition. A-E Birn, Y. Pillay, T. Holtz. Oxford Univ. Press, 2009 • Global Health Watch: An Alternative World Health Report. Available at: http://www.ghwatch.org/ • Enough: why the World’s Poorest Starve in an Age of Plenty. Roger Thurow and Scott Kilman. 118 Acknowledgments • We express our great appreciation to…. – Brent Gordon and Justin Parizo, first year UCSF medical students in 2010 – Thomas Novotny, professor, School of Public Health, San Diego State University, developed an earlier version of this module 119