Global Health Initiatives: Pre-and Post-2015
The Center for Science in Public Policy at the Hudson Institute has a new in-depth review of global health initiatives pre and post 2015. With the Millennium Development Goals (MDGs) ending in 2015 and new Sustainable Development Goals (SDGs) on the way to take their place, we took a look at what worked and what didn’t in global health initiatives. We wanted to see if the new SDGs used any past take-home lessons for the post 2015 period.
There is no lack of global health initiatives over the last 35 years. From WHO’s dramatic agenda at Alma Ata in 1978, Health for All by the Year 2000, to the African Union’s Abuja Declaration of 2001 where countries pledged to contribute at least 15% of their GDPs to healthcare, to WHO’s “3 by 5” HIV/AIDS program to cover 3 million people by the year 2005, to World Bank evaluations of its multi-million dollar health investments, and the more recent Lancet Commission recommendations for Universal Health Coverage, endorsed by well-known health and development experts, including former and current World Bank presidents, Lawrence Summers and Dr. Jim Yong Kim.
There are a lot of lessons learned in the new report – a diary of the last 35 years of global health initiatives and a virtual blow by blow description of how they came about and what they did and did not do. The following three lessons, from among many, are highlighted here:
Lesson One: Without the political will, good governance, and transparency of nation states who receive global aid, all the technology, affordable drugs, and new ideas of Universal Health Coverage won’t bring about the ambitious goals of the SDGs. From their own evaluations we found that many of the global initiatives of the WHO, World Bank, and others had either failed to reach their goals or didn’t set up proper evaluations in the first place to know if they had. And, despite the billions of dollars spent on these programs, one World Bank evaluation said, that little was known about what the Bank had “bought” for its investments. Dr. Chan, Director-General of WHO as far back as 2008 concluded: “As we have seen, powerful interventions and the money to purchase them will not buy better health outcomes in the absence of efficient systems for delivery.” The proof of this was the outbreak and response to the Ebola crisis in Africa. Despite all the global health aid over the last quarter of a century, there were no efficient health systems in place. Liberia was one of only six African countries to meet the Abuja Declaration goal of allocating 15% of its national budget to health and was unprepared to deal with Ebola.
Lesson Two: Without local ownership, in both the design and implementation of health care programs, we can’t expect local organizations and health care providers to make global initiatives work. WHO and the World Bank jumped into designing and executing large, complex global health programs starting in the 1990s. In an internal evaluation of WHO’s HIV/AIDS program which set out to treat 3 million people by 2005 and never achieved this goal, WHO’s critique was that the agency was not itself an implementing agency. It was in over its head, particularly with pre-qualifying anti-retroviral (ARV) drugs, staffing at local levels, and supply chain systems to move and store drugs. Indeed, the WHO had to de-list 36 of the ARV drugs it had pre-qualified for lack of proof of bio-equivalency. As membership organizations that are subordinate to the health officials of its member countries, these organizations cannot assume direct implementation responsibilities. The top-down design process requires a high level of government investment and, without local involvement and ownership, doesn’t work and continues to foster dependence on international aid.
Lesson Three: Avoid biting the hand that feeds you. The WHO must learn to accept how the world works now, and that government aid is now a minority shareholder. Governments still have important, but different, roles than before. With new players in the landscape of foreign aid and the growth of institutions and skilled professionals in developing countries, the new roles for donor and multilateral governments are to raise awareness, convene resources and facilitate talent and ideas attacking global health problems. Today, of all financial flows from developed to developing countries, 80% are private, including capital investment, remittances, and philanthropy. Most observers would regard this a good thing since means that local entrepreneurs, NGOs, businesses, and families are receiving private funds that they put to use to better their lives. Civil society is thriving and is empowered to take over its own endeavors. Developing countries are “business ready” and so forth. But, not so fast; at this year’s annual World Health Assembly, convening on May 18, a draft resolution, “Overarching Framework of Engagement with Non-State Actors,” is winding its way onto the agenda. The resolution is worried that, “The health landscape has become more complex in many respects. Among other things, there has been an increase in the number of players in global health governance.”
These “players” are the NGOs and foundations providing boots on the ground to save lives, the volunteers from all over the world helping AIDS orphans, the missionaries who have provided almost half of many African countries’ health care services over the years, and the companies that have given some $94 billion in product donations, research on neglected diseases, and cash donations between 2000 and 2011. The resolution then goes on to single out private businesses as “the most important institutional conflicts of interest” with WHO. If the WHO cannot embrace the growth of civil society with its diversity, choice, and prosperity that economic growth and democracies create, it risks staying on the back burner of health history.
The good news here is that there is a role for these global health institutions, other than worrying about losing market share. But, they will have to fight their instincts to command and control, and instead listen to all the new players, including local health care providers, entrepreneurs, foundations, academics, volunteers, businesses, and NGOs. They will need to let the post-2015 global health initiatives be demand- driven from the people who need them and know how to best help themselves.