Demographic And Health Analysis: Country Report & Analysis Overview

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Development Partners

David H. Peters, MD, MPH, DrPH, FACPM Johns Hopkins University

Learning Objectives

 Describe the major international agencies involved in global health, as well as their mandates, strengths, and weaknesses

 Describe trends in development assistance and the implications of how development assistance is provided

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Development Partner Mandates, Structures, and Capabilities

Section A

A Complex Global Architecture

OECD G-20

UN agencies

Bretton Woods

>200 multilateral development

agencies

127 bilateral development

agencies

±18,000 international development

nongovernmental organizations

Multinational corporations and

foreign direct investment

Types of International Health Organizations

 Multilateral agencies (>200)  26 UN agencies  20 global and regional funding organizations  90 global health initiatives (McColl, 2008)  Including:

• World Health Organization • World Bank • UN organizations (e.g., United Nations Children's Fund [UNICEF], United Nations

Population Fund [UNFPA], Joint United Nations Programme on HIV/AIDS [UNAIDS], United Nations Development Programme [UNDP])

• Regional Development Banks (e.g., African Development Bank [AfDB], Asian Development Bank [ADB], Inter-American Development Bank [IADB], European Bank for Reconstruction and Development [ERBD], New Development Bank [NDB; Brazil, Russia, India, China, South Africa])

Types of International Health Organizations

 Bilateral organizations (>120)  23 high-income countries in Development Assistance Committee (DAC) of the

Organisation for Economic Co-operation and Development (OECD)  Including:

• United States Agency for International Development (USAID) • President's Emergency Plan for AIDS Relief (PEPFAR; United States) • Japan International Cooperation Agency (JICA) • Department for International Development (DFID; United Kingdom) • Dutch Ministry of Foreign Affairs

Types of International Health Organizations

 Nongovernmental organizations (NGOs) (>18,000)

 International Foundations: • Global Fund to Fight AIDS, TB, and Malaria • GAVI Alliance

 Service and advocacy organizations:

 Technical assistance organizations:

– Catholic Relief Services – CARE – World Lutheran Services – Save the Children – World Vision – Oxfam

– Management Sciences for Health – Family Health International – John Snow International – Jhpiego

Types of International Health Organizations

 Philanthropies  Bill and Melinda Gates Foundation  Ford Foundation  Rockefeller Foundation  Packard Foundation  Corporate foundations:

• Merck Company Foundation • Bristol-Myers Squibb Foundation • MobileExxon Foundation

Types of International Health Organizations

 Universities  >100 U.S. universities with global health programs (Consortium of Universities for

Global Health)

Types of International Health Organizations

 Private for-profit organizations  Pharmaceuticals and medical equipment companies  Consulting firms

International Health Organization Roles

 Legal and regulatory

 Financing

 Convening, coordination, and information sharing

 Influence on policies and programs

 Advocacy

 Technical assistance and support

 Health services delivery

 Research

 Education and capacity building

 Professional collaboration

 Product manufacture, sales, and distribution

What Differentiates Agencies?

 Mandate and mission  Areas of focus

• e.g., humanitarian assistance, specific diseases or populations, research

 Organizational structures  e.g., multilateral, bilateral, NGO, for-profit

 Capabilities  e.g., financial, human, information, technology, in-country experience

 Procedures and practices  Accountabilities  Procurement, disbursement, reporting  Cooperation and flexibility

World Health Organization

 UN Specialized Agency, founded in 1948

 Locations:  Headquarters in Geneva, Switzerland  Six regional offices (each with an elected Regional Director)

 Governance:  World Health Assembly as legislative body (Ministers of Health)  Executive Board and Director General

 194 member states; 147 country offices

 Purpose:  To promote the attainment of all people of the highest possible level of health

World Health Organization: Mandates

Source: WHO Constitution. Available at: http://www.who.int/governance/eb/who_constitution_en.pdf. Accessed June 1, 2015. 14

a. Act as the directing and co-ordinating authority on international health work; b. Establish and maintain effective collaboration with the United Nations, specialized agencies, governmental health

administrations, professional groups and such other organizations as may be deemed appropriate; c. Assist Governments, upon request, in strengthening health services; d. Furnish appropriate technical assistance and, in emergencies, necessary aid upon the request or acceptance of

Governments; e. Provide or assist in providing, upon the request of the United Nations, health services and facilities to special groups,

such as the peoples of trust territories; f. Establish and maintain such administrative and technical services as may be required, including epidemiological and

statistical services; g. Stimulate and advance work to eradicate epidemic, endemic and other diseases; h. Promote, in co-operation with other specialized agencies where necessary, the prevention of accidental injuries; i. Promote, in co-operation with other specialized agencies where necessary, the improvement of nutrition, housing,

sanitation, recreation, economic or working conditions and other aspects of environmental hygiene; j. Promote co-operation among scientific and professional groups which contribute to the advancement of health; k. Propose conventions, agreements and regulations, and make recommendations with respect to international health

matters and to perform.

World Health Organization: Special Issues

 Special issues:  Conflict of mandates as normative body, advocacy, and technical assistance  Poor enforcement  High administrative costs, insecure funding, and weak accountability  Fragmented organization

The World Bank Group

 Founded in 1944

 Includes:  International Bank for Reconstruction and Development

(IBRD; low-interest financing based on sovereign)  International Development Association (IDA; interest-free loans and grants)  International Finance Corporation (IFC; financing to private sector)

 Locations:  Headquarters in Washington, DC, USA  120 country offices

 Governance:  Board of Directors (Finance Ministers or Central Bank Governors)  Owned by 188 member states  Executive Director

The World Bank Group: Purpose, Mandates, and Special Issues

 Purpose:  Promote economic development and poverty alleviation

 Mandates:  Provide financial assistance to developing countries  Provide technical assistance, policy advice, research, and analysis  Provide support for capacity development

 Special Issues:  Many areas of activity, of which health is only one (economics, public

administration, education, infrastructure)  Board dominated by wealthy countries  History of pushing rigid free market reform policies  Rigid standards for procurement  Funding largely through governments, which have had controversial investments

UNICEF

 UN specialized fund  Founded in 1946  UN permanent mandate 1953

 Locations:  Headquarters in New York, New York, USA  >190 country offices

 Governance:  Executive Board (government representatives)  Executive Director  39 National Committees established as national NGOs (for fundraising and advocacy)

 Purpose:  Advocate for the protection of children's rights, to help meet their basic needs and

to expand their opportunities to reach their full potential

UNICEF: Mandates

 Originally to provide emergency food and healthcare for children affected by World War II  Establish children's rights as enduring ethical principles and international standards of

behaviour toward children  Mobilize political will and material resources to help countries, particularly developing

countries, ensure a “first call for children” and to build their capacity to form appropriate policies and deliver services for children and their families

 Ensure special protection for the most disadvantaged children—victims of war, disasters, extreme poverty, all forms of violence and exploitation and those with disabilities

 Respond to emergencies to protect the rights of children—in coordination with United Nations partners and humanitarian agencies, UNICEF makes its unique facilities for rapid response available to its partners to relieve the suffering of children and those who provide their care

 Promote the equal rights of women and girls and to support their full participation in the political, social, and economic development of their communities

Source: UNICEF Mission Statement. Available at: http://www.unicef.org/about/who/index_mission.html. Accessed June 1, 2015. 19

UNICEF: Special Issues

 Special issues:  Focus on child rights issues, to the exclusion of others  Questionable effectiveness of child health programs  Specific policies against international adoption of children

Global Fund to Fight AIDS, TB, and Malaria

 International public–private partnership (Swiss foundation), founded in 2002

 Locations:  Headquarters in Geneva, Switzerland  No country offices

 Governance:  International Board (governments, foundations, corporations, multilateral agencies)  Executive Director and Secretariat  Country Coordinating Committees submit financing requests

 Purpose:  To attract, manage, and disburse additional resources to make a sustainable and

significant contribution in the fight against AIDS, tuberculosis, and malaria in countries in need, and contributing to poverty reduction as part of the MDGs

Global Fund to Fight AIDS, TB, and Malaria: Mandates

 Mandates:  To provide initial grant funding on the basis of the technical quality of applications

to fight AIDS, TB, and malaria  To provide additional grant funding to fight AIDS, TB, and malaria on the basis of

performance

Global Fund to Fight AIDS, TB, and Malaria: Special Issues

 Special issues:  History of fraud and abuse of funds by recipients  Leadership turmoil  Uncertain funding  Focus on three health conditions  Inability to track results and fund accordingly  Little in-house technical and managerial expertise  Reliance on contracted Local Fund Agents  Competition/cooperation with PEPFAR and Global Health Initiatives (GHIs)

Complexity and Confusion

Complementarities between agencies Mission creep and overlapping mandates

Historical legitimacy of UN and Bretton Woods

Organizational challenges in evolving to reflect dynamic and changing world order

Importance of cross-agency coordination High transaction costs, slow movement

Enhanced emphasis on accountability and achieving results Tensions with country ownership

Growing corporate social responsibility investments Unmapped, and how socially responsible?

U.S. Government Global Health Architecture

25 Adapted from: The Kaiser Family Foundation. (2013). U.S. Global Health Policy: The U.S. Government Engagement in Global Health: A Primer. Available at: https://kaiserfamilyfoundation.files.wordpress.com/2013/02/8408.pdf. Accessed June 1, 2015.

Aid Harmonization and Alignment

Section B

Main Sources of Global Funding for Health

Source: McCoy, D., Chand, S., & Sridhar, D. (2009). Global health funding: how much, where it comes from and where it goes. Health Policy and Planning, 24(6), 407–417. http://doi.org/10.1093/heapol/czp026 2

Development Assistance for Health, by Channel of Assistance

Source: Dieleman, J. L., Graves, C. M., Templin, T., et al. (2014). Global health development assistance remained steady in 2013 but did not align with recipients’ disease burden. Health Affairs (Project Hope), 33(5), 878–886. http://doi.org/10.1377/hlthaff.2013.1432 3

Official Development Assistance (ODA) and Share of GNI From DAC Countries Since 1960

Source: Development Initiatives. Global aid trends – ODA: what you need to know. Available at: http://devinit.org/#!/post/global-aid-trends-need- know. Accessed June 2, 2015.

DAC Countries’ Contributions to ODA as Percent of GNI (2012)

Source: OECD DAC data and Development Initiatives, 2012.

Note: UN Target = 0.7% of GNI

Matching Top Countries for DAH With Top Countries for DALYs

Adapted from: Ravishankar, N., Gubbins, P., Cooley, R. J., Leach-Kemon, K., Michaud, C. M., Jamison, D. T., & Murray, C. J. L. (2009). Financing of global health: tracking development assistance for health from 1990 to 2007. Lancet, 373(9681), 2113–2124. http://doi.org/10.1016/S0140- 6736(09)60881-3 6

Does Development Assistance for Health Crowd Out Government Spending on Health?

Source: Ooms, G., Decoster, K., Miti, K., Rens, S., Van Leemput, L., Vermeiren, P., & Van Damme, W. (2010). Crowding out: are relations between international health aid and government health funding too complex to be captured in averages only? Lancet, 375(9723), 1403–1405. http://doi.org/10.1016/S0140-6736(10)60207-3 7

International health aid % of GDP Government health funding % of GDP Government funding 2002 2006 Change 2002 2006 Change

Benin 1.1% 1.0% –0.1% 1.1% 1.5% 0.4% Burkina Faso 0.7% 2.1% 1.4% 1.6% 1.7% 0.1% Stable/increased Ethiopia 0.5% 1.7% 1.2% 2.4% 1.0% –1.4% Decreased Ghana 1.0% 1.2% 0.2% 2.2% 1.3% –0.9% Kenya 0.7% 0.7% 0.0% 1.7% 2.0% 0.3% Madagascar 1.2% 1.6% 0.4% 2.0% 1.0% –1.0% Malawi 4.4% 7.7% 3.3% 4.4% 4.1% –0.3% Decreased Mali 0.8% 1.0% 0.2% 1.5% 1.9% 0.4% Mozambique 1.8% 3.0% 1.2% 2.3% 1.4% –0.9% Decreased Niger 0.8% 1.9% 1.1% 1.4% 1.4% 0.0% Stable/increased Rwanda 1.4% 5.7% 4.3% 1.8% 2.8% 1.0% Stable/increased Senegal 0.8% 0.7% –0.1% 1.3% 3.2% 1.9% Uganda 1.6% 2.2% 0.6% 3.2% 2.2% –1.0% Decreased United Republic of Tanzania 0.4% 2.8% 2.4% 1.5% 2.1% 0.6% Stable/increased Zambia 1.7% 2.4% 0.7% 3.0% 2.2% –0.8% Decreased

Recipient Countries’ View of Aid Channels

8 Source: International Development Association. (2007). Aid Architecture: An Overview of the Main Trends in Official Development Assistance Flows. Available at: http://www.worldbank.org/ida/papers/IDA15_Replenishment/Aidarchitecture.pdf. Accessed June 2, 2015.

The Volatility of Health Aid

9 Source: Godal, T. (2005). Opinion: Do we have the architecture for health aid right? Increasing global aid effectiveness. Nature Reviews Microbiology, 3(11), 899–903. http://doi.org/10.1038/nrmicro1269

Hosting Missions and Report Writing Are Major Burdens at the District Level: Tanzania District Examples

10 Source: In-country interviews; DMO visitor log; team analysis. Karen Caines High Level Forum presentation (2009).

*Assumes around 50 working days per quarter and 100 per half year, although reported to work in excess of that

What Are the Alternatives for Development Assistance?

Sector-Wide Approaches (SWAps)

Joint Assessment of National Strategies (JANS)

Global Health Initiatives

Disparate projects

Projects supporting sectoral policy

Common planning and management

processes

Jointly agreed sectoral program

with pooled funding

Un- earmarked

budget support

Paris Principles of Aid Effectiveness (2005)

 Ownership:  Developing countries should exercise effective leadership over their development

policies and strategies and coordinate development actions  Alignment:

 Donors should base their overall support on national strategies, institutions, and procedures in developing countries

 Harmonization:  Donors actions should be coordinated, transparent, and collectively effective

 Managing for results:  Aid should be managed and implemented in a way that focuses on the desired

results and uses information to improve decision making  Mutual accountability:

 Donors and developing countries should enhance mutual accountability and transparency in the use of development resources

Source: Paris Declaration on Aid Effectiveness. Available at: http://www.oecd.org/dac/effectiveness/34428351.pdf. Accessed June 2, 2015. 12

Oslo Declaration (2007)

 Donors must “push development cooperation models that match domestic commitment and reflect the requirements of those in need and not one that is characterized by charity and donors’ national interests”

Source: Oslo Ministerial Declaration—global health: a pressing foreign policy issue of our time. (2007). Lancet, 369(9570), 1373–1378. http://doi.org/10.1016/S0140-6736(07)60498-X 13

Concluding Thoughts

 There is a large and growing number and type of development partners involved in global health, with overlapping mandates and capabilities  It’s useful to know what they can do well and not do well

 Increasing development assistance in health can provide new opportunity but also unintended consequences

 Supporting global health involves raising sufficient funding and providing it in constructive ways

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