Global Health ‘Actors’ and their programs

Global Health ‘Actors’ and their

programsThomas L. Hall, MD, DrPH

Elisabeth T. Gundersen, BA, RN

Trevor P. Jensen, MS, Medical StudentUniv. of California at San Francisco

Global Health Education Consortium

March 13, 2011

Module sections

1. Learning objectives2. 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

1

2

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.

1

3

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 inter-governmental?

1

Give these questions some thought as you go through the module

4

Module sections

1. Learning objectives

2. Brief history of international assistance3. Issues and choices: Donors & Recipients

4. Types of global health ‘actors’




8. Summary

9. Quiz


2

5

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

2

6

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

2

7

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

2

Image: http://www.nps.gov/archive/elro/images/nac_leaguenations_20920.jpg

8

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

2

9

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

2

10

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

2

11

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

2

12

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

2

13

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

2

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

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

2

MDGs are briefly considered in next slides as important and broad sweeping health targets for the coming years

15

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

2

16

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. Achieve universal primary education3. Promote gender equality and empower women4. Reduce by 2/3rds child mortality for < fives5. Reduce by 3/4ths maternal mortality ratio6. Combat HIV/AIDS, malaria & other diseases7. Ensure environmental sustainability8. Develop a global partnership for development

2

17

The 16 targets represented by the 4*4 squares are detailed further in the following linkhttp://unstats.un.org/unsd/mi/pdf/MDG%20Chart%20No%20Text.pdf

1) Reduce extreme poverty by half

2) Reduce hunder by half3) Universal primary schooling4) Equal girls’ enrolment in

primary school5) Women’s share of paid

employment6) Women’s equal representation

in national parliaments7) Reduce mortality of under-five-

year-olds by two thirds8) Measles immunization9) Reduce maternal mortality by

three quarters10) Halt and reverse spread of

HIV/AIDS11) Halt and reverse spread of

malaria12) Halt and reverse spread of

tuberculosis13) Reverse loss of forests14) Halve proportion without

improved drinking water15) Halve proportion without

sanitation16) Imprve the lives of slum-

dwellers

1 2 3 45 6 7 89 10 11 1213 14 15 16

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:

2

18

Module sections


2. Brief history of international assistance

3. Issues and choices: Donors & Recipients4. Types of global health ‘actors’




8. Summary

9. Quiz


3

19

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.

3

20

3

•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?

Key issues for Donors

21

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.

3

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

Module sections




4. Types of global health actors5. Evaluating effects of international assistance



8. Summary

9. Quiz


4

24

Three major types of global health actors1. Multinational organizations

A. Organizations within the UN system relevant to healthB. Organizations outside of the UN system relevant to

health

2. Bilateral -- government-to-government or to sub-government levels

3. Non-governmental organizations (NGOs)

4.1

Click for supplemental material

25

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

4.1

26

1. Multinational

4.1

• 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

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.

*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

4.1

Dr. Margaret Chan

28

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

4.1

“1945, The United Nations Conference in San Francisco, USA, unanimously approves the establishment of a new, autonomous international health organization.”

29

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 non-communicable diseases, with an emphasis on reduced risk factors such as tobacco, poor diet, and physical inactivity

• Improving health systems, focusing on human resources, financing, health information and primary health care

2008 WHO Annual Report

Primary Health Care

4.1

2009 WHO Annual ReportHealth System Financing

30

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

4.1

See Supplemental information

“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%.”

31

1988

350,000 cases

125 countries

Program example: Poliomyelitis eradication: 1988-2008

2008

1625 cases

17 countries

Almost there, but a few very resistant pockets (internal conflict, religious

opposition, etc.) of transmission

4.1

32

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

4.1

33

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

4.1

34

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

4.1

35

WHO – Possible critiques

• 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

4.1

• 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

“1966, The new headquarters building of the World Health

Organization in Geneva is inaugurated.”

36

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

4.1

37

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.

4.1

38

• 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

1. Multinational

4.1

39

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

4.1

40

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 2010-11 biennium

4.1

41

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/

4.1


42

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

4.1

43

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

4.1

44

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/

4.1

45

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

4.1

46

4.1

Programmatic distribution of World Bank funds in 2007

47

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

4.1

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

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

4.1

50

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.

4.1

51

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-KIClick here to view a seven-minute YouTube clip of a BBC inquiry into WB policieshttp://news.bbc.co.uk/nolavconsole/ukfs_news/hi/newsid_5150000/newsid_5150500/bb_rm_5150592.stm

4.1

52

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

4.1

53

Types of global health ‘actors’

1. Multinational / inter-governmental organizationsA. Organizations within the UN system relevant to healthB. Organizations outside of the UN system relevant to health



4.2

54

4.2


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


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

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

4.2

57

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)

4.2

58

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

4.2

59

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

4.2

60

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

4.2

61

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)

4.2

62

PEPFARPresident’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

4.2


63

Peace Corps

4.2

• 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

Peace Corps

Source: http://www.peacecorps.gov/index.cfm?shell=about.fastfacts

4.2

Orange: Countries the Peace Corp currently works inPurple: Countries the Peace Corp has worked previously

65

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

4.2

66

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

4.2

67

http://www.fightingmalaria.gov/about/index.html

PMI Focus Countries and Malaria Distribution in Africa4.2

Major malaria regions in Africa and the

targeted countries – darker colors indicate

more malaria

68

Bilateral organizationsStrengths

• 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

4.2

69

Bilateral organizationsPotential 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.

4.2

70

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

4.2

71

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.

For more detail on U.S. aid, go to:

http://www.oecd.org/dataoecd/42/30/44285539.gif

Source: http://www.oecd.org/document/9/0,3343,en_2649_34447_1893129_1_1_1_1,00.html

Development assistances, 24 DAC countries, 2008

4.2

72


1. Multinational / inter-governmental organizationsA. Organizations within the UN system relevant to healthB. Organizations outside the UN system relevant to health



4.3

73

• 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

4.3


74

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

4.3



75

Faith-based organizations (FBOs)• Catholic Relief Services• Christian Aid• Lutheran World Relief• Unitarian Universalist Service Society

4.3


76

Philanthropic foundations• Bill & Melinda Gates• Atlantic Philanthropies• Carnegie• Rockefeller• Clinton Global Initiative• Carlos Slim• Josiah Macy, Jr.• Kellogg• Ford • MacArthur• Seva

4.3

See supplemental material information


77

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

4.3


78

Consulting / contracting organizations (PVOs)• John Snow International• Management Sciences for Health• Abt Associates• IntraHealth International• Family Health International• Academy for Educational Devt.

4.3


79

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

4.3 Non-governmental organizations (NGOs)

80

Examples of work done by

Philanthropic FoundationsBill and Melinda Gates Foundation, Carlos Slim, & others

– Collectively these foundations have increased global spending for HIV/AIDS (from $250M to $7B 1996-2004)

4.3


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

Non-governmental organizations (NGOs)

81

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

4.3Examples of work done by

Philanthropic Foundations

Non-governmental organizations (NGOs)

See” Gates Foundation’s Living Proof Project that highlights recent successes in various areaswww.gatesfoundation.org/livingproofproject/Pages/progress-sheets.aspx

82

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

4.3

83

Non-profit NGOsStrengths

• 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

4.3

84

Non-profit NGOsPotential 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

4.3

85

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

• .

4.3

86

Page 87

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

4.3

87

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

4.3

88

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…..

4.3

89

Module sections




4. Major types of global health ‘actors’

5. Evaluating effects of international assistance6. A new approach: The Global Fund


8. Summary

9. Quiz


5

90

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

5

91

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)

5

92

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

5

*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

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/)

5

94

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

5

95

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

5

96

Module sections





5. Evaluating the effects of international assistance

6. A new approach: The Global Fund7. Discussion questions

8. Summary

9. Quiz


6

97

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/

6

98

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

6

99


• 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.

6

100


• 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

6

101


• 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

6

102


• 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.

6

103

Module sections







7. Discussion questions8. Summary

9. Quiz


7

104

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.

7

105

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?

7

106

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

7

107

Module sections








8. Summary9. Quiz


8

108

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

8

109

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

8

110

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)

8

111

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

8

112

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

8

113

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

9

114


6. List at least four major types of global health actors?

5. List at least three functions of WHO

6. List three strengths and three critiques of WHO?

7. 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

9

115


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?

9

116

Thank you for your attention

Tom Hall

[email protected]

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

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.

10

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

Documents

Global Health ‘Actors’ and their programs