US4331 – International Health Theory

Sep 29, 2008 - Pertinent Institutions

Tomorrow (Tuesday Sep 30)

• “Global Health Awareness Day”– RGN atrium (right outside these doors)– All day

– Panel discussion from 5-7pm in Amph B– Panel discussion is eligible for your 1-page

summaries!

W.H.O. video “Dealers In Death” can be downloaded from:

download.deonandan.com/dealersindeath.mp4

-Ipod format, but you can view it on your computer screen-If you don’t have appropriate software, download VideoLan for free from www.videolan.org-about 150MB-try not to crash my server

Today….

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

• At the end of WWII…– The world was broken– There was new wealth, new power, new authority, new

hope– There was a desire to see the old ills cast aside– Europe’s financial environment was one of

protectionism and wildly fluctuating exchange rates– The Great Powers met to re-build the world’s financial

system…

…In Bretton Woods, NH

http://www.youtube.com/watch?v=GVytOtfPZe8

The World Bank• Founded in Dec, 1945, as part of the Bretton Woods

agreement• Part of the “World Bank Group”

– a family of five international organizations responsible for providing finance and advice to countries for the purposes of economic development and eliminating poverty

– International Bank for Reconstruction and Development (IBRD)– International Development Association (IDA)– International Finance Corporation (IFC)– Multilateral Investment Guarantee Agency (MIGA)– International Centre for Settlement of Investment Disputes (ICSID)

• “World Bank” usually refers to IBRD +IDA

The World Bank (contd)

• Issues low-interest (IBRD) or no-interest (IDA) loans to developing nations

• Also funds projects directly• List of member countries:

http://go.worldbank.org/Y33OQYNE90

• Afghanistan to Zimbabwe

The World Bank (contd)• Sample interventions:

– $28.5 million project to increase cotton production and exports in Uganda, by increasing production and competition

– $86 million project to improve access to health care in Tanzania

– $12 million to reconstruct areas of Haiti affected by natural disasters

– $31 million to reform system-wide health insurance in Honduras

– $24.6 million to promote privatization of real estate in Moldova

The World Bank (contd)

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

www.fin.gc.ca

The World Bank (contd)

• Headquartered in Washington, DC• Traditionally is headed by an American• Typically deals with governments, not

necessarily individuals or organizations• In effect, the US President has final say in who

is World Bank President• But is ostensibly an international organization

The World Bank (contd)

• Criticisms:

–Governance structure is dominated by wealthy nations (nations with <15% of world’s population control 44% of votes)

–World Bank policies essential re-make Southern economies to service Northern needs

–Prolongs debt cycle

–Funds poorly thought-out, unevaluated, damaging programmes

–Actual agenda is to support US business interests

The World Bank (contd)

• Since WWII, the World Bank has loaned the Developing World more than $330 billion

• Today, the Developing World owes the World Bank more than $160 billion

• It is the Developing World’s largest creditor• Specializes in “Structural Adjustment Programmes” learn

about these next week

The IMF

The IMF

• The International Monetary Fund (IMF)• "an organization of 185 countries working to

foster global monetary cooperation, secure financial stability, facilitate international trade, promote high employment and sustainable economic growth, and reduce poverty".

• Also the product of the post-WWII Bretton-Woods agreement

The IMF (continued)

• Typically headed by a Western European • Funds are provided by donor countries

(Canada is responsible for 3%)• IMF focuses on restructuring economies, not

on funding projects or effecting development

Difference Between World Bank and IMF

• World Bank finances economic development– Funds large development projects– Purpose: to promote economic progress by helping to

raise productivity

• IMF oversees nations’ financial good behaviour– Sets exchange rates– Lends money to governments for emergencies– Makes nations’ monetary policies transparent– Purpose: to oversee and maintain world monetary system

http://www.imfsite.org/operations/driscoll896.html

The IMF (continued)

• Criticisms:– Financial aid bound to too many “conditionalities”– Advocate currency devaluation

• Eg, Jamaican currency moved from being worth more than US dollar to being worth <2 cents

– Responds to crises, does not prevent them– Not perceived as having high success rate

The Red Cross

• Actually made up of several loosely or un-affiliated bodies:– National Red Cross (eg, Canadian Red Cross or American

Red Cross) or Red Crescent (in Muslim countries)– International Committee of the Red Cross

• Founded in 1863• Mandate under international law to protect “life and dignity” of

people during armed conflicts– International Federation of Red Cross and Red Crescent

Societies• Founded in 1919• Coordinates national bodies in relief missions for major disasters

The Red Cross (contd)• Funded by donations and by investment revenue• Tasks:

– to promote humanitarian principles and values– to provide relief assistance in emergency situations of

large magnitude– to support the national groups with disaster

preparedness through the education of voluntary members and the provision of equipment and relief supplies

– to support local health care projects– to support the national societies with youth-related

activities

Medecins Sans Frontieres/ Doctors Without Borders

• Founded in 1971 by French doctors after Biafra War (Nigerian Civil War)

• HQ in Geneva• Annual budget of $400 million, provided mostly

by private donors• Nobel Peace Prize in 1999• Intent is to be able to respond rapidly to public

health interventions with complete independence from political, religious and economic influences

MSF (contd)

• Efforts:– Emergency public health care, including medicine and

surgery– Mass vaccination campaigns– Water and sanitation systems– Therapeutic and supplementary nutrition– Distribution of drugs and supplies– Training and health education– Organisation or rehabilitation of health structures– Medical assistance within existing health structures

MSF (contd)

• Criticisms:

Cynically called “MSF syndrome” Eg. www.jha.ac/articles/a192.pdf

Provision of acute medical care frees a government of its welfare responsibilities

Giving aid to people living under tyrannies strengthens the tyranny

World Health Organization (WHO)

• Founded 1948• Agency of the United Nations, dedicated to

global health• HQ in Geneva• Objective: “the attainment by all peoples of

the highest possible level of health”

WHO (contd)

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

WHO (contd)

• Overly bureaucratic• Inefficient (money hole)• Controversial adherence to public health approaches

• health = [environment, access, lifestyle, etc]• Health is "not merely the absence of disease or

infirmity" but also "a state of complete physical, mental and social well-being“

• Some see this as “totalitarian”, a licence to meddle in non-health areas

• Eg, WHO’s position against tobacco advertising• Interventions are poorly evaluated

Criticisms:

Canada: CIDA• Canadian International Development Agency• Federal agency, reports to Minister of International

Cooperation (Bev Oda)• Priorities:

– Social development • E.g. Health, education, child protection

– Economic well-being• E.g. business development projects

– Environmental sustainability • E.g. Land degradation projects

– Governance • Gender equality, human rights, etc

CIDA (contd)• Criticisms:

– Bureaucratic– Most money spent here in Ottawa– Poor evaluation strategies– Little evidence of impact– CIDA goals too tied to Canadian business agenda– CIDA goals not tied enough to Canadian business agenda

Top current recipient of CIDA aid: Afghanistan

Canada - IDRC• International Development Research Council• Canadian crown corporation• Objective is to help developing nations “undertake research

and develop innovations”– i.e. use Canada science and tech to help developing nations

• Mandate is more Canada-centric than CIDA– to support Canada’s foreign and innovation policy– to bring the benefits of Canadian research and development

ability to assist in facing the challenges of the developing world– long-term objective to assign >5% of Canada’s R&D investment

to development assistance

USAID

• United States Agency for International Development

• US federal agency responsible for the most non-military foreign “aid”

• Their website states:– “USAID plays a vital role in promoting U.S.

national security, foreign policy, and the War on Terrorism. It does so by addressing poverty fueled by lack of economic opportunity, one of the root causes of violence today. “

Top current recipient of USAID aid: Iraq

USAID (contd)

– Accusations that CIA uses USAID as a front for espionage activities

– Failure to make interventions culturally suitable– Poor success rate– Most money stays in Washington

Criticisms:

USAID (contd)• PEPFAR

– “President’s Emergency Plan for AIDS Relief”– “a five-year, $15 billion multifaceted approach to combating the

disease in more than 120 countries around the world”– 2003-2008– Aims to:

• provide antiretroviral treatment (ART) to 2 million HIV-infected people • to prevent 7 million new infections• support care for 10 million people

– Focused on: Botswana, Cote d'Ivoire, Ethiopia, Guyana, Haiti, Kenya, Mozambique, Namibia, Nigeria, Rwanda, South Africa, Tanzania, Uganda, Vietnam, and Zambia

– Created by Bush II

USAID (contd)

• 1/3 of funds are directed to abstinence-only programmes

• Refuses to fund “safe needle exchange” programmes• Refuses to fund programmes working with

commercial sex workers• Only supports branded (not generic) anti-retroviral

drugs• Sets its own agenda, rather than responding to a

country’s priorities

Criticisms of PEPFAR:

The Global Fund• The Global Fund to Fight AIDS, Tuberculosis and Malaria• Started in 2002, as a result of an article in The Lancet by Jeffrey

Sachs and Amir Attaran– “[more money]directed toward funding projects which are proposed and

desired by the affected countries themselves, and which are judged as having epidemiological merit against the pandemic by a panel of independent scientific experts“

– More grants to countries, rather than loans• Created and funded by G8 nations

– Additional funds from a variety of sources• E.g. Bill Gates donated $500 million• Bono created “Product Red” project to produce $ for Global Fund

• Funding is based on proven performance, so very evaluation focused

The Global Fund (contd)

• Criticisms:– Do poor nations have the capacity to absorb the

money flowing in? May need startup grants for infrastructure

– Outcomes are indicator based, but what if there is no baseline data?

Gates Foundation• Founded by Bill and Melinda Gates in 2000, HQ in Seattle• One of largest charitable orgs in the world• Goals:

– Globally: enhance healthcare and reduce extreme poverty– In USA: expand educational opportunities and access to

information technology

Gates Foundation (contd)

• Global health budget equals that of WHO• Infectious disease budget equals that of USAID• Funds vaccine research for a number of

diseases, with special research attention on HIV

Clinton Foundation

• Founded by Bill and Hillary Clinton • Goal: "strengthen the capacity of

people throughout the world to meet the challenges of global interdependence.“

• Aims to make HIV/AIDS care more affordable

• Funds large scale HIV/AIDS treatment and prevention programmes

Issues with Global Health Funding Bodies• Fragmented landscape with diverse players in overlapping

coalitions• Funding agendas are often separate from the needs of the

target nation– E.g. why fund a needle exchange programme in a country with

minimal drug use?• Projects are often very disease-specific, and thus miss

underlying causes of suffering• Few evaluation strategies

– Poor indicators chosen, or chosen to be vague• Poor donor coordination• Divest local government of responsibility• Minimal though to greater impacts

Example….

Gasifier machine:

-creates electricity from cow dung

But…

-who has the dung?-who gets the electricity?

Millennium Development Goals (MDGs)

• In 2000, the Millennium Summit was held by the UN, and 8 achievable goals were agreed upon, to be achieved by 2015

• Part of the the “UN Millennium Declaration”

MDGs (contd)• Eradicate extreme poverty and hunger

– Reduce by half the proportion of people living on less than one U.S. dollar a day.– Reduce by half the proportion of people who suffer from hunger.

• Achieve universal primary education – Ensure that all boys and girls complete a full course of primary schooling.

• Promote gender equality and empower women – Eliminate gender disparity in primary and secondary education preferably by 2005, and at all levels by 2015.

• Reduce child mortality – Reduce the mortality rate among children under five by two thirds.

• Improve maternal health – Reduce by three quarters the maternal mortality ratio.

• Combat HIV/AIDS, malaria, and other diseases – Halt and begin to reverse the spread of HIV/AIDS.– Halt and begin to reverse the incidence of malaria and other major diseases.

• Ensure environmental sustainability – Integrate the principles of sustainable development into country policies and programmes; reverse loss of

environmental resources.– Reduce by half the proportion of people without sustainable access to safe drinking water (for more

information see the entry on water supply).– Achieve significant improvement in lives of at least 100 million slum dwellers, by 2020.

• Develop a global partnership for development – Develop further an open trading and financial system that is rule-based, predictable and non-discriminatory.