The document discusses global health financing, emphasizing the complexities and changes in donor assistance funding, with the U.S. being the largest contributor. It highlights trends in development assistance for health from 1990 to 2014, noting a period of growth followed by a decline, and the impact of various funding mechanisms on global health governance. Additionally, it covers historical U.S. involvement with the UN and the implications of financial policies on global health initiatives.

1. Global Health Financing
“Follow the money” in order to better understand the
framework for global health governance
Timothy K. Mackey, MAS, PhD
Fundamentals of Global Health
Summer 2016

2. $35.9
billion

3. Fast Facts:
US accounts for largest
source of DAH
($13.1 billion)
$2.9 billion
v.
$5.4
billion?
Increase in funding for
“other” infectious diseases
(including 1.1b for Ebola)
from 2013

4. GLOBAL HEALTH FINANCING
MACRO TRENDS (1990-2014)
1990 -
2000
2000 -
2010
2011 -
2013 2015 Future
Marked by
minor but
stable increases
in DAH. 5.4%
annualized
growth.
Rapid growth
following
launch of
MDGs. Peak of
11.3% annual
growth rate.
Slowing in
growth due to
global fiscal
crisis. 2013-
2014 DAH
dropped 1.6%.
$36.4 billion
less than overall
high in of 38bil
in 2013.
Change in
funding flows.
Plateauing of
DAH? Are the
new SDGs set to
evolve DAH
disbursements?

8. McCoy et al. (2009)
• Older article from 2009; most analysis on
DAC OECD donors
• Data sources comprised of secondary
data from published literature; annual
reports of actors; and unpublished data
(grants etc.)
• Maps and differentiates the source,
management, and spending of global
health funds
• Fragmentation of funding, complicated
and inadequately tracked
• Proliferation of actors with impact not
well known

9. Funding Instruments

10. Funding Instruments

13. Szlezak et al. (2010)
• PLoS Med, Harvard, funded,
commissioned as part of 4 series on
Global Health financing
• (1) essential characteristics of functioning
national health system; (2) case study of
Malaria and changes in partnerships,
research, and delivery; (3) further
research on 3 primary questions of
project.
• Improvement of coordination necessary to
avoid waste, inefficiency and turf wars
• Sustainable financing and equitable
resource sharing
• Ensuring sufficient long-term investment
and creating mechanisms for M&E
• Role and effectiveness?

15. Funding Instruments - IHME
“SOURCE”
“CHANNEL”
“RECIPIENT”

16. Sridhar (2012)
• Multi-Bi Financing? Essentially
earmarked funds provided to multilateral
agencies (vs. multilateral and bilateral)
• Highlights increases in WHO voluntary
contributions and World Bank’s increases
in its trust fund portfolio
• Multi-bi allows funders to realign
objectives of multilaterals with their own
and side step governance structures and
engage in “performance-based” financing
• Priority setting behind the scenes?
Autonomy of multilaterals?

18. Beginning 1980s U.S. withholds or threatens to withhold
arrears, specific programs targeted. 1985 Kassenbaum-
Solomon Amendment made withholding contingent upon
U.N. reform.
U.S. Congress continues withholdings, U.N. does not
recognize reduction in U.S. assessment. By 1998 U.S.
arrears total $1.29 billion. U.N. suffers, with U.S.
representing 2/3rds of total arrears.
By 1998, U.S. risks losing vote in U.N. General Assembly
due to build up of arrears. In response, U.S. Congress
enacts Helms-Biden Act to authorize payments.
Progression to Helms-Biden Legislation
History of U.S. – U.N. Arrears
1990s
1980s
Helms-
Biden

19. Conflict and Cooperation
History of U.S. – U.N. Relationship
• Staged Payments: Authorized
staged payments of arrears to U.N.
• Reforms: Required U.N. reforms
including zero-growth restriction on
U.N. budget and reductions in U.S.
assessments
• Negotiation: U.N. and other
member states eventually agree to
phased reductions in U.S.
assessments
The late Richard
Holbrooke, then
ambassador to the
U.N., was instrumental
in negotiating the
Helms-Biden Act
provisions
Key Facts:
-U.S. historically pays highest U.N. assessments
-Proportionate share lower than poorer countries
-29 countries agreed to higher assessments
-U.N. suffered severe shortages and had to borrow
money for operations

21. 0.000
100.000
200.000
300.000
400.000
500.000
600.000
700.000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010*
Inmillionsof$US
U.S. Contributions to U.N. and U.N. Specialized Agencies
(FY2001-2010)
World Health Organization
United Nations
World Intellectual Property Organization
International Labor Organization
International Atomic Energy Agency
Food and Agriculture Organization

22. 0.000
20.000
40.000
60.000
80.000
100.000
120.000
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010*
Inmillionsof$US
U.S. Contributions to U.N. Specialized Agencies (FY2001-2010)
World Health Organization
World Intellectual Property Organization
International Labor Organization
International Atomic Energy Agency
Food and Agriculture Organization

43. World Health
Organization

44. NEXT:
In-class workshop: Global Health
Financing?

45. In-class Workshop (if time permits): Groups of 4
1) Pick a Global Health Actor: Pick a global health actor to explore.
It can be a country, a multilateral, a bilateral agency, an
NGO/private foundation, or a private sector actor.
2) Identify Key Characteristics: Search the internet to identify the
following key characteristics:
a) Type of actor: What type of actor is this (state government, UN agency,
bilateral, public-private partnership etc.)?
b) What type of instrument is it? : Is it a source, channel, recipient, or some
combination thereof?
c) Organization budget: Google search to try to find out what the
organization’s overall budget is. If information is available, check to see
what it is generally spent on (diseases, health projects, etc.)
3) Student Presentation: Report findings and tell us in general how
influential you think this organization is in the context of the entire
global health system.