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International Institutions

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International Institutions

  1. 1. Global institutions andGlobal institutions and health financinghealth financing Who are the major players?Who are the major players?
  2. 2. The context (and a bit ofThe context (and a bit of history)history)
  3. 3. Post war context (1944)Post war context (1944) ““This Conference atThis Conference at Bretton WoodsBretton Woods, representing, representing nearly all the peoples of the world, has considerednearly all the peoples of the world, has considered matters of international money and finance whichmatters of international money and finance which are important for peace and prosperityare important for peace and prosperity. The. The Conference has agreed on the problems needingConference has agreed on the problems needing attention, the measures which should be taken,attention, the measures which should be taken, and the forms of international cooperation orand the forms of international cooperation or organization which are required. The agreementsorganization which are required. The agreements reached on these large and complex matters arereached on these large and complex matters are without precedent in the history of internationalwithout precedent in the history of international economic relations.” July 22, 1944economic relations.” July 22, 1944
  4. 4. Context of the Oil Crisis (1970s-80s)Context of the Oil Crisis (1970s-80s) ►Dramatic rise in debt among poorerDramatic rise in debt among poorer countries 1970s and 1980scountries 1970s and 1980s ►Growing efforts to coordinate and manageGrowing efforts to coordinate and manage external funding to poorer countriesexternal funding to poorer countries ►Emergence of poverty reduction as theEmergence of poverty reduction as the prime objective of international financialprime objective of international financial institutions (IFIs)institutions (IFIs)
  5. 5. The actorsThe actors
  6. 6. General DiscussionGeneral Discussion ►Which institutions have you heard of thatWhich institutions have you heard of that might be involved in health policymight be involved in health policy formulation, health financing, health serviceformulation, health financing, health service delivery etc etc?delivery etc etc?
  7. 7. The main players in global healthThe main players in global health ► 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 thePublic 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)
  8. 8. World Health OrganisationWorld Health Organisation ► The World Health Organization is the UN’s specializedThe World Health Organization is the UN’s specialized agency for health.agency for health. ► EstablishedEstablished: 7 April 1948.: 7 April 1948. ► ObjectiveObjective: The attainment by all peoples of the highest: The attainment by all peoples of the highest possible level of health.possible level of health. ► Governed by 192 Member States through the World HealthGoverned by 192 Member States through the World Health AssemblyAssembly ► WHA composed of representatives from WHO's MemberWHA composed of representatives from WHO's Member States.States. ► The main tasks of WHA are to approve the WHOThe main tasks of WHA are to approve the WHO programme and the budget for the following biennium andprogramme and the budget for the following biennium and to decide major policy questions.to decide major policy questions.
  9. 9. WHO continuedWHO continued Strengths:Strengths: ► Specialised knowledgeSpecialised knowledge ► Proven success record (eradication of smallpox)Proven success record (eradication of smallpox) ► ‘‘Democratic’/consultative decision makingDemocratic’/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
  10. 10. World BankWorld Bank ► MissionMission: Fight poverty and improve the living standards of people in: Fight poverty and improve the living standards of people in the developing world.the developing world. ► Provides loans, policy advice, technical assistance and knowledgeProvides loans, policy advice, technical assistance and knowledge sharing services to low and middle income countries to reduce poverty.sharing services to low and middle income countries to reduce poverty. ► Promotes growth to create jobs and to empower poor people to takePromotes growth to create jobs and to empower poor people to take advantage of these opportunitiesadvantage of these opportunities ► Made up of 184Made up of 184 member countriesmember countries, jointly responsible for how the, jointly responsible for how the institution is financed and how its money is spent.institution is financed and how its money is spent. ► Some 10,000 development professionals from nearly every country inSome 10,000 development professionals from nearly every country in the world work in the World Bank's Washington DC headquarters or inthe world work in the World Bank's Washington DC headquarters or in its 109 country officesits 109 country offices ► Now centres its efforts on the reaching the Millennium DevelopmentNow centres its efforts on the reaching the Millennium Development Goals, agreed to by UN members in 2000 and aimed at sustainableGoals, agreed to by UN members in 2000 and aimed at sustainable poverty reductionpoverty reduction
  11. 11. World Bank continuedWorld Bank continued Health, nutrition and population (HNP) programme:Health, nutrition and population (HNP) 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?
  12. 12. IMFIMF ► Conceived at Bretton Woods (July 1944).Conceived at Bretton Woods (July 1944). ► The 45 governments represented sought to build a framework forThe 45 governments represented sought to build a framework for economic cooperation that would avoid a repetition of the policies thateconomic cooperation that would avoid a repetition of the policies that contributed to the Great Depression of the 1930s.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, andPromotes international monetary cooperation, exchange stability, and orderly exchange arrangements;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 balance ofProvide temporary financial assistance to countries to help ease balance of payments adjustment.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 billion to: $97 billion to 84 countries, of which $10 billion to 59 on concessional terms (as of 8/31/04)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 FY2004, ofSurveillance consultations concluded: 116 countries during FY2004, of which 92 voluntarily published their staff reportswhich 92 voluntarily published their staff reports
  13. 13. WTOWTO National health policies are increasingly influenced by trade agreementsNational health policies are increasingly influenced by trade agreements of the WTO. The General Agreement on Trade in Services (GATS) isof the WTO. The General Agreement on Trade in Services (GATS) is the WTO treaty that covers health services.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 global“the only international organization dealing with the global rules of trade between nations. Its main function is to ensure that traderules of trade between nations. Its main function is to ensure that trade flows as smoothly, predictably and freely as possible.”flows as smoothly, predictably and freely as possible.” How does the WTO work?How does the WTO work? ► Through a set of treatiesThrough a set of treaties ► Treaties contain binding rulesTreaties 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
  14. 14. 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-subsidisationUndermining viability of public services by preventing cross-subsidisation  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 public policyMembers can qualify liberalisation promises in order to protect public policy objectives (right to regulate)objectives (right to regulate)
  15. 15. National GovernmentsNational Governments ► Earth summit in Rio de Janeiro (1992): World's governments adopted aEarth summit in Rio de Janeiro (1992): World's governments adopted a programme for action under the auspices of the United Nationsprogramme for action under the auspices of the United Nations ► This included an Official Development Assistance aid target of 0.7% ofThis included an Official Development Assistance aid target of 0.7% of gross national product (GNP) for rich nations, roughly 22 members ofgross national product (GNP) for rich nations, roughly 22 members of the OECD, known as the Development Assistance Committee (DAC).the OECD, known as the Development Assistance Committee (DAC). ► Almost all rich nations have constantly failed to reach theirAlmost all rich nations have constantly failed to reach their agreed obligations of the 0.7% targetagreed obligations of the 0.7% target .. ► Instead of 0.7%, the amount of aid has been around 0.2 to 0.25%,Instead of 0.7%, the amount of aid has been around 0.2 to 0.25%, some $100 billion short.some $100 billion short. Some examples:Some examples: ► USA's aid, in terms of percentage of their GNP is already lowest of anyUSA's aid, in terms of percentage of their GNP is already lowest of any industrialized nation in the world, though paradoxically in the last threeindustrialized nation in the world, though paradoxically in the last three years, their dollar amount has been the highest.years, their dollar amount has been the highest. ► Since 1992-2001 Japan was the largest donor of aid, in terms of rawSince 1992-2001 Japan was the largest donor of aid, in terms of raw dollars. Japan's aid dropped by nearly 4 billion dollars in 2001.dollars. Japan's aid dropped by nearly 4 billion dollars in 2001.
  16. 16. 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 areNot all NGOs are ‘grass roots’ organisations – some are the equivalent of multinational corporationsthe equivalent of multinational corporations
  17. 17. 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 fasterEfficient, streamlined systems often make for faster decision makingdecision making Weaknesses:Weaknesses: ► Accountability?Accountability? ► Conflicts of interests?Conflicts of interests? ► Transparency?Transparency?
  18. 18. More context (and a bitMore context (and a bit more recent history)more recent history)
  19. 19. 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 stabilization andAttention is paid not only to traditional domains of stabilization and adjustment but also to policy areas, such as health and education,adjustment but also to policy areas, such as health and education, which have come to be emphasized in the new orientation aswhich have come to be emphasized in the new orientation as having a direct impact on poverty alleviation.”having a direct impact on poverty 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 competitionPromote diversity and competition ► Growing role/influence of PPPsGrowing role/influence of PPPs
  20. 20. Increasing co-operation continuedIncreasing co-operation continued 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 pledged toMillennium Development Goals (all 191 UN member states have pledged to reach these goals by 2015)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 commodityBased on US model of health care as a private commodity
  21. 21. Effects of co-ordinationEffects of co-ordination ►Health put on the development agendaHealth put on the development agenda ►Coordinating policy managementCoordinating policy management ►Concept of multilateral policy changeConcept of multilateral policy change ►Challenge to Health for AllChallenge to Health for All
  22. 22. Group discussionGroup discussion ►Your are Afghanistan’s Health MinisterYour are Afghanistan’s Health Minister ►Your country has persistently high U5Your country has persistently high U5 mortalitymortality ►Who do you go to for help and why?Who do you go to for help and why?

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