The new players in global health
governance
Michel Kazatchkine
1998‐2010
• A period of remarkable progress in global
health and access to health services
• A period of innovation in governance,
strategy and ways of delivering on global
health
Background for innovation • End of the 90s : increasing awareness of growing
inequities in a globalizing world and around global
issues: development, health, food, water,
environment. Acute awareness of the impact of
AIDS.
• Shift in paradigm: health considered as an
investment in human capital and an investment for
development, rather than merely as an
expenditure
• Health linked to security
Ground work for innovation
• International community: defines the
global agenda of Millenium development
goals.
• Economists
and
health
experts:
Commission on macroeconomics and
health.
• Political leaders (G8).
• Activists and community mobilization.
Innovation in health strategies: 1998‐
2008
• Shifting from a system‐focused approach to a
problem‐focused approach.
• Global strategies and global plans.
• Focus on results and outcomes.
• Emergence of demand‐driven funding.
• Allocating resources based on evidence
Innovation in delivery and governance: 1998‐2008
• Establishing new inclusive models (including
private sector, philanthropy, civil society,
affected
communities)
for
strategy,
coordination and governance in health.
• Establishing multi‐sector (public‐private)
operative partnerships.
• Introducing innovative finance for health and
development.
Multiple actors involved in Global Health governance
• National governments
• UN: WHO, UNAIDS, UNICEF, UNDP,UNFPA,
WORLD BANK, UN Women, IMF, WTO
• Non‐governmental
organizations
and
affected communities
• Business sector
• Private philanthropic foundations
Examples of innovative initiatives 1998‐2008: UN
• Creation of UNAIDS (1996); UN General
Assembly on HIV/AIDS (2001) ; inter‐agency
UN country teams
• Multi‐stakeholder
participation
and
consultations at World health assembly, and
UNGA on AIDS
• « Every woman, every child » (2010)
Innovative institutions and initiatives : 1998‐2008
• Medicines for Malaria Venture (MMV)
• Global Alliance for vaccines and immunization
(GAVI)
• Global Fund to fight AIDS, tuberculosis and
malaria (GFATM)
• Roll Back Malaria (RBM) and Stop‐TB
partnerships, Global TB drug facility
• Global Alliance for Improved Nutrition (GAIN)
• UNITAID
Resources for health : 1998‐2008
• Increase in domestic resources for health
• Economic growth and increased ability of
individuals to spend on health
• Increase in international resources for
global health
Resources available for HIV in low- and middle-income
countries, 2002-2011
20
$16.8
18
16
US$ billions
14
12
10
8
6
4
2
0
2002
2003
2004
2005
International assistance
Source: UNAIDS, 2012
2006
2007
2008
Domestic resources in lowand middle-income countries
2009
2010
2011
Total resources available,
with estimated range
1998‐2008
• Context of growing inequities and increasing
public awareness of global challenges
• Political leadership
• Societal mobilization
• Resources
• Science focusing on major global health
challenges
• Innovative initiatives
GAVI (1)
• Context at the end of nineties:
Lack of investments in vaccine research
Stagnating progress in the six basic vaccine
immunization program (UNICEF, WHO Children’s
vaccine initiative) and declining rates of immunization
• WHO /UNICEF /World Bank /Gates/ Rockefeller: create
a new entity to bolster the use of existing vaccines; and
provide future purchase guarantees for new vaccines
GAVI (2)
• 1999 : GAVI created as a tax exempt US organization
with its own decision‐making power on funding,
independent of WHO and UNICEF. First contribution by
Bill Gates. Industry has a seat at the Board.
• 2000 : focus decided on low income countries.
Applications to be assessed by an independent panel of
experts, solely on a technical basis.
• No criteria for spending, USD 20 to governements per
child vaccinated.
• Additional earmarked funding to WHO and UNICEF for
technical assistance
GAVI (3): Board
• « A forum for balanced strategic decision making, innovation
and partnerships »
•
•
•
•
•
•
•
•
•
•
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Donor countries: 5
Developing countries : 5
WHO:
1
UNICEF: 1
World Bank : 1
Gates Foundation : 1
Vaccine industry : 2
Civil society : 1
Independent experts : 9
Research institutions : 1
GAVI CEO
GAVI (4)
• Under five mortality has decreased from 12 M in 1990 to 6.9 M in 2011; the annual rate of reduction in mortality has increased from 1.8 to 3.2 % in the period 2000‐2010.
• USD 7.2 b pledged for GAVI for 2011‐2016.
•
•
•
•
•
•
GAVI indicators:
Mission indicators, e.g. under five mortality, deaths prevented
Vaccine indicators, e.g. introducing new vaccines, coverage
Health systems indicators, e.g. DTP3
Financing indicators
Market‐shaping indicators
Global Fund to fight AIDS, TB, Malaria (1)
• 2000: indicators for human development stagnating; link
between health and poverty established; AIDS crisis. No
access to treatment in the developing world.
• 1998‐2000: first call for universal treatment (Abidjan); debates
over price of drugs/ affordability and feasibility; treatment
versus prevention; economic rationale developed to fight
malaria; first global plan against TB.
• 2000: Okinawa G8 : « do something concrete on diseases of
poverty » »
• 2001: intense period of political thinking and , planning on
global health
• 2001: Kofi Annan calls for the creation of a global fund
Evolution of Funding (2002‐2010)
January 2012
Core Slideset
Key Indicator Results (2004‐2011)
0
Source: Global Fund Grant Data
January 2012
Core Slideset
GP/021209/9
Partnership Approach to Governance A diverse partnership reflected in the Board
and Country Coordinating Mechanisms
• Donors
• Recipient
Countries
● Private Sector
• Private
Foundations
Public Sector
(Governments
and Agencies)
Private
Sector
Civil
Society
Technical
Agencies
and
Partnerships
● NGOs from
Global North
● NGOs from
Global South
● Communities
living with, and
affected by, the
diseases
● WHO
● UNAIDS
● World Bank
● UNITAID
● RBM
● Stop TB
Partnership…
GLOBAL FUND GUIDING PRINCIPLES
1. Operate as a financial instrument, not as an implementing entity 2. Make available and leverage additional financial resources
3. Support programs that reflect country ownership and respect country‐led formulation and implementation 4. Operate in a balanced manner in terms of different regions, diseases and interventions 5. Pursue an integrated, balanced approach to prevention, treatment and care
6. Evaluate proposals through independent review processes
7. Establish a simplified, rapid and innovative grant‐making process and operate transparently, with accountability. The fund should make use of existing international mechanisms and health plans.
8. Focus on performance by linking resources to the achievement of clear, measurable and sustainable results.
Global Fund Financing by Principal Recipient Type (end 2011)
Source: Global Fund Grant Data
January 2012
Core Slideset
Expenditures by Service Delivery Area for HIV (cumulative, by 2010 reporting cycle)
Source:
Global Fund
unpublished
Enhanced
Financial
Reporting
data 2010
January 2012
Core Slideset
Innovative finance (1)
• Increasing pressure on public sector
development assistance; private sector
contributions to new initiatives far below
original expectations
• 2004‐2006 : testing ideas : transaction fees
,e.g telephone, hotel, credit card bills; lottery
returns ; private bond‐issuing arrangements
Innovative finance (2)
• Global Fund: Product Red (2006)
• Global Fund: Debt to health (2007)
• GAVI IFFIm,: raising funds through a bond issue
(2006)
• GAVI Advanced market commitments (2007)
• Global transaction taxes:
– Tax on air travel : UNITAID (2006)
– Tax on financial transactions (2012)
Innovative finance (3)
• UNITAID: focus on drug and diagnostics procurement, and shaping market dynamics
• Affordable Medicines for malaria, AMFm
Global Health governance 2000‐2011
• Moving from rigid systems –based approaches to a pragmatic problem‐based approach
• Public‐private partnerships
• Civil society moving from an outside pressure group to become an inside stakeholder
• Gates Foundation now largest non ‐governmental funder of health but also a large center of expertise and priority setting
• Weakening authority of WHO
• Global health aligned with economics and politics Economic growth is rapidly changing the world order
2000
High income
Upper middle income
Lower middle income
Low income
Source: IMF data, extrapolated 2017‐2020
Economic growth is rapidly changing the world order
2010
2011
2008
2009
2006
2007
2004
2005
2002
2003
2000
2001
High income
Upper middle income
Lower middle income
Low income
Source: IMF data, extrapolated 2017‐2020
Increasing income inequality between richest and poorest countries
Gross National Income per capita
in nominal US dollars
Year
Richest
countries
Poorest
countries
Ratio
1980
$ 11 840
$ 196
60
2000
$ 31 522
$ 274
115
2005
$ 40 730
$ 334
122
WHO Commission on Social Determinants of Health 2008
Global Health governance, 2012 debate
• Shift from low to middle income countries
• Less alignment between global health and
economic and political trends
• World less « global » and more « multi‐polar »,
trend towards a regionalization of strategic
governance and of funding for development.
• Moving from G8 to G20
• Some regions moving faster than others with
increasing disparities between regions.
Global Health governance, 2012 debate
• Constrained economic and financial context
• Strong focus on efficiency, with policy implications
• Decreased political mobilization
• Decreased focus on « global » efforts
• Increased costs of delivering health
Global Health governance, 2012 debate
• Fierce debates over the costs and benefits
of the innovations discussed today
• These innovations represent however a
significant step forward in our collective
efforts to address global health challenges
and the post‐2015 period.