Global institutions play major roles in health financing and policy. The key players discussed are the World Health Organization (WHO), World Bank, International Monetary Fund (IMF), and World Trade Organization (WTO). The WHO is the UN agency for health, working with 192 member states. The World Bank aims to reduce poverty through loans and policy advice to developing countries. The IMF promotes international monetary cooperation and provides temporary financial assistance. The WTO, formed in 1995, ensures trade flows freely through treaties and enforcement mechanisms, which some criticize can undermine public health systems.

1. Global institutions andGlobal institutions and
health financinghealth financing
Who are the major players?Who are the major players?

2. The context (and a bit ofThe context (and a bit of
history)history)

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. 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. The actorsThe actors

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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. More context (and a bitMore context (and a bit
more recent history)more recent history)

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. 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. 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. 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?