I. Multi-national Organizations and Inter-governmental Organizations
These are generally funded by Member States of the United Nations and staffed by nationals from many of these countries.
A. United Nations Organizations. http://www.un.org/aboutun/chart.html.
These include the International Labor Organization (ILO, 1919); Food and Agricultural Organization (FAO, 1945); United Nations Children’s Fund (UNICEF, 1946); World Health Organization (WHO, 1948); UN High Commission for Refugees (UNHCR, 1950); United Nations Development Programme (UNDP, 1965); United Nations Fund for Population Activities (UNFPA, 1969); UN Educational Scientific, and Cultural Organization (UNESCO); UN Drug Control Program (UNDCP); UN World Food Program (UNWFP), and others.
1. WHO. http://www.who.int/:
a. Provides technical assistance and training; formulating and disseminating expert advice, normative standards, and guidelines on a wide variety of topics.
b. Convenes Expert Committees and Technical Advisory Groups; commissions Consultant reports; develops and disseminates the International Classification of Disease (ICD-X) Codes, monographs and manuals. These mechanisms contribute to standard setting and quality assurance.
c. Assists and organizes projects on specific problems and/or target groups according to priorities set by the World Health Assembly. The WHA, composed of all member states, meets each year in May.
d. Organizes and facilitates many training programs; provides fellowships.
e. Is organized in three levels: Geneva headquarters, 6 regional offices (PAHO, WPRO, AMRO, AFRO, SEARO, and EURO), and WHO country representatives (WRs).
f. WHO advantages: Direct access to Ministries of Health (MOH); biomedical and technical expertise; ‘horizontal’ approach to health; strong global level activities; more accepted by many countries since they participate fully in the organization and governance; greater ‘presence’ at country and multi-country regional levels; facilitates information exchange between countries [including TC/DC, technical cooperation between developing countries]; has major role in developing and promulgating internationally recognized standards regarding food, drugs, vaccines, therapies, etc; has ability to develop and promote policies and priorities; has greater potential for coordination with other UN and World Bank agencies.
g. WHO problems and limitations: Often weak country representation based in a traditionally weak ministry (MOH); not infrequently suffers from little programmatic strategy and a narrow biomedical perspective; weak public image; severe funding constraints (at <$1 billion the WHO annual regular budget is only about twice the budget of the SF Dept. of Public Health, including the SF General Hospital; admirable but vague goal (“….the attainment of the highest possible level of health” …and a “…state of complete physical, mental and social well being and not merely the absence of disease…”); uneven leadership of WHO which was increasingly criticized during the 1990s; perceived administrative inefficiencies by US (though probably among the best in UN system); complicated and rigid rule-based recruitment and personnel management; too many doctors and too few other disciplines; often lures most capable persons away from their home countries; expensive headquarters in Geneva and six regional offices; one country-one vote organization (tiny island countries have same votes as mega-countries) and World Health Assembly (WHA) delegation of powers to 31-member Executive Board means that international politics have often had an inordinate effect on personnel selection, programs, and management; Director General and six Regional Directors are all elected, with considerable autonomy with regard to each other; excess central bureaucracy; subject to governmental squabbles (>190 countries in WHA oversee programs; 31-person WHO Executive Board); conflicts between central, regional and country levels; politics of regional directors and their election; fellowship allocation is largely on the basis of country priorities which may lack an overall strategy (eg, preference frequently for high tech skills of limited or inappropriate applicability); loss of AIDS program to UNAIDS due in part to organizational rigidities; large amounts of extra-organizational, ear-marked funding, with potential distortion of core program in favor of vertically oriented donor priorities; trying to be all things to all people at all levels of economic development (in 1990s had >50 programs, now reduced to 30+); failure of many countries (and especially the USA) to pay their quotas on time (US has managed to reduce its quota from 25% to ~22% of total WHO regular budget, to introduce more administrative reforms, and to reduce US support for family planning); very limited funds available to cover operating program costs; often hard to evaluate WHO accomplishments (WHO has been described as “… a procedural organization, where you can observe what it does but not what it produces”), though changes under the former Director-General (DG), Dr. Gro Harlem Bruntland (former Prime Minister of Norway), sought to correct many of these constraints. In 1998-99 WHO went through a massive review and reorganization with outside consultants and high level staff unfamiliar with the special characteristics of WHO, resulting in much anxiety and concern that one set of problems would be replaced by another. In July 2003 Dr. LEE Jong-wook ( S. Korea) become D-G, and the reorganization and redirection of programs has begun again. There are those who believe that top-down programs such as immunization and response to epidemics like AIDS draw badly needed resources away from the development of primary health care and public health services for the majority in poor countries who have virtually no access. Political considerations tend to emphasize measurable variables like infant mortality and life expectancy while giving little attention to less dramatic but nevertheless runaway rates of mental illness, domestic violence, alcohol abuse, malnutrition, and overwork. The argument is sometimes made that immunization campaigns contribute to primary care and public health infrastructure, but one sees little evidence of this.
2. UNICEF. Strong country level activities; positive public image; large but well defined target group; few and usually easily controlled health risks. UNICEF’s problems include sustainability of initiatives, dependence on large extra-budgetary support, vertical approach to health (focus on a specific age group and health risks), coordination with other agencies, and criticism by some of the ‘selective primary care approach,’ ie, most emphasis is on only a few high prevalence problems. In the last few years UNICEF has also been criticized for moving away from “what it does best” and the organization’s original mandate (WATSAN, Immunization, PHC, basic education, etc.), to focus on other issues such as the legal rights of women and children, trafficking of children and women for the sex trade, etc.
3. UNFPA (UN Fund for Population). Technical expertise and training regarding contraceptive methods; materials, supplies and staff program support; and advocacy for population policies. Problems include: vulnerability to shifts in political opinion, especially abortion. UNFPA is continually caught up in the USA abortion / family planning debate and constraints, and has experienced level or reduced funding in recent years. The Cairo conference in the mid-1990s on population and development estimated a world need for ~$20B/year for family planning support vs. about ~$5B available (US spends $8B/year on lawn care!); industrialized countries pledged funds to reduce gap but haven’t delivered. FY2002-03 Bush budget cuts ~$34 million off UNFPA contribution, which could result in ~2 million additional unintended births, ~800,000 induced abortions, and many thousands of maternal and child deaths.
4. UNDP (UN Development Program). Established as a general fund for development activities, UNDP is now the world’s largest multilateral source of grant funding for development cooperation. Strength is intersectoral approach to development; problems include uneven and limited representation at country level and resources spread too thin. UNDP is usually the lead organization over all UN agencies in country.
B. United Nations-Affiliated Programs
1. Global Fund to Fight AIDS, TB and Malaria (GFFTAM– http://www.theglobalfund.org/). Set up to provide substantial additional direct resources to country coordinating groups; a public-private partnership headed by UCSF Professor Richard Feachem, involving governments, pharmaceutical companies, and Foundations (Gates). Three rounds of funding so far, but resources fall far short of demand and pledges. Program has all the advantages, and limitations, of a vertical, disease-specific program. WHO administers it in part, and World Bank writes the checks.
2. UNAIDS. http://www.unaids.org/en/default.asp. Main advocate for global action on the epidemic and a venture of the United Nations family plus the World Bank. Primary role in raising international awareness, monitoring and evaluation, and providing training. They also provide guidelines, technical materials and to a lesser degree technical support for those working at the district and community levels.
C. World Bank Group (1944).
Consists of five major organizations (International Bank for Reconstruction and Development [IBRD] lends money at world market competitive rates to low and middle income countries; International Development Association [IDA] provides concessionary loans to lowest income countries [low or no interest, long payouts]; International Finance Corporation [IFC] fosters development through investment in the private sector; Multilateral Investment Guarantee Association [MIGA] provides insurance forforeign investors against losses caused by noncommercial risks, such as expropriation, currency inconvertibility and transfer restrictions, and war and civil disturbances; The International Centre for Settlement of Investment Disputes (ICSID) provides arbitration of investment disputes. The World Bank Group is not really a UN agency. It is the largest external source of funding for education and health programs. The US is the largest voting member (15% of total vote), as determined by GDP. The International Money Fund (IMF) is a separate agency, concerned mostly with stabilizing economic systems and currencies.
IBRD : This is the main banking organization of the Group. Separate regional Development Banks include Asian Development Bank [ADB], Inter-American Development Bank [IDB], and African Development Bank.
Increasingly the Bank is the main funding source for health. It is dominated by economists, financial experts, and development specialists, and has a small core of health specialists, including now six CDC assignees as well as assignees from various country development offices.
Health, nutrition, and population (HNP) projects have rapidly risen in importance and represent about 5% of all investments (total bank projects ~$20+ billion per year); first HNP loans were made in 1970, rising to 154 active and 94 completed HNP projects for a total of $13.5 billion in 1996; countries with GDP of <$6000 per capita are eligible for such loans which, though made at slightly less than commercial rates, are advantageous because of the fiscal and program development that must accompany them and because of the technical assistance involved in the loan project development.
IDA: For countries with <$1000 per capita, these are concessionary or ‘soft’ loans with low or no interest and/or long paybacks. The Heavily Indebted Poor Countries (HIPCs) use this mechanism, which provides funds at about 0.25% as well as significant technical assistance in loan development process. Several donor countries also provide trust funds through the bank system which may be used for specific projects, research, or loan development costs. Three major HNP objectives: improve HNP outcomes of poor, enhance performance of health care systems, secure sustainable health care financing; strategies include: decentralization, partnerships with non-governmental organizations (NGO) providers, more direct public involvement in decisions regarding funding, rural and urban development, environmental sanitation, etc. World Bank advantages : The Bank has substantial funds (>$13 billion HNP spent so far); bank imposed ‘conditionalities’ (to getting a loan) can encourage and facilitate reforms (e.g., the Structural Adjustment Program, or ‘SAP’, which seeks to increase exports, decrease imports, reduce urban/rural imbalance, decrease subsidies, increase taxes, promote realistic currency valuation, strengthen foreign exchange reserves, increase production and efficiency, decrease consumption); careful pre-project planning is required. Loans are increasingly coordinated with other multilateral and bilateral agencies and programs. WB focus is on infrastructure development; extensive research capability and learning from experience. It has produced many excellent publications, has offered ‘flagship course modules’ for training senior managers and technicians, and provides distance learning through use of satellite and video transmissions.
World Bank problems and limitations : Economic considerations may dominate decisions; other development projects may have adverse effects on health activities, eg, dam construction which displaces persons, expands schistosomiasis, reduces bottom land, increases malaria; country resentment against bank requirements and priorities; efforts to increase financial support by charging for health services have resulted in reduced care for the poor and increased morbidity in some countries (WB’s ‘structural adjustment program’ came under much criticism by UNICEF and has been considerably softened); increasing awareness of and attempts to reduce corruption in development aid.
D. Bilateral or Bi-national Organizations. Involves relationship between only two parties, eg, donor and recipient countries
1. Bilateral government aid agencies.
b. US Agency for International Development (USAID) is main US health foreign aid agency. It is affiliated with the Dept. of State (DOS) and under appropriations umbrella of Senate Foreign Relations Committee and hence is highly politicized. Other departments involved in international health include, to name a few, NIH, DOD, USDA, CDC, HRSA, and other HHS agencies that have funds for HIV, immunizations and a few other programs per appropriations initiated by the Labor, Health, Education, and Pensions Committee. While these departments and agencies should all be working closely together in theory, the reality is quite different and there is a great deal of contentiousness at the moment surrounding turf, funding, and political agendas. Foreign aid is 0.10% of US GDP, the lowest of the ‘rich’ countries; it represents ~14.6% of total world assistance and is supplemented by private sector contributions from many sources.
c. Peace Corps. Established in 1961, the PC has fielded more than 170,000 volunteers serving in 136 countries. Present deployment is about 7500 volunteers in 71 countries. About 59% are women and >83% have undergraduate degrees and most of the rest, advanced degrees.
d. Other countries: (With indication of % of GNP to development aid in late 1990s) — Australia (0.36%), Canada (0.38%), Denmark (0.96%), Finland (0.32%), France (0.55%), Germany (0.31%), Italy (0.15%), Japan (0.28%, or 23.4% of total), New Zealand (0.23%), Sweden (0.77%), United Kingdom (0.28%).
e. Characteristics of bilateral aid agencies: Provide grants, loans, training, and technical assistance; in US, USAID increasingly tends to provide substantial long-term support to US academic, technical assistance and NGO institutions to support country programs, eg, 1/3 of US bilateral aid goes to ‘big NGOs’ (BINGOs) in $20-60M multi-year contracts.
f. Advantages: Bilateral aid is moderately flexible; substantial resources; increasingly long-term commitments; potential to coordinate health activities with other bilateral development support; governments and subcontractors tend to build up substantial expertise.
g. Problems and limitations: Priorities often closely linked with foreign policy and political considerations of donor country; purchasing and hiring constraints are designed to ensure that much of the assistance money returns to donor country; programs may be oriented toward donor country’s industries and programs, and minimally responsive to recipient country priorities; foreign aid is a politically vulnerable program with a very small constituency of support; aid may be poorly coordinated with other bilateral programs; programs may be less apt to have well qualified career specialists in international health and other relevant areas.
2. Non-Government Organizations. Thousands of health-related Private Voluntary Organizations (PVOs) / Non-Governmental Organizations (NGOs) in both donor and recipient countries provide international health assistance. Examples of the several different types include:
Foundations : Ford, Carnegie, Bill & Melinda Gates, Hewlett, Packard, Kellogg, MacArthur, Rockefeller, etc.
Secular Private Organizations (PVO and NGO) : Helen Keller International, Oxfam, CARE, Save the Children/UK (&US), International Red Cross, Doctors without Borders, Project Hope, International Rescue Committee
Faith-based Organizations (FBO) : Many PVOs and NGOs are also FBOs. Missionary groups also fall into this category. Catholic Relief Services, Christian Aid, Lutheran World Relief, Unitarian Universalist Service Society, World Vision
Contracting Agencies (CA) : For-profit companies bid on government RFAs and RFPs (request for applications/proposals) to win development contracts such as Basic Support for Institutionalizing Child Survival (BASICS) funded primarily by USAID and other international development organizations Examples of CAs include John Snow International (JSI), Management Sciences for Health (MSH), and the Academy for Educational Development (AED).
Private Corporations : Pharmaceutical Corporations: Merck; Pasteur Merieux Connaught (PMC); Smith-Kline Beecham (SKB); Wyeth-Lederle. Increasingly, corporations are becoming involved in international health and development through humanitarian aid, research, foundations for giving, and exploitation of foreign commercial markets.
NGO characteristics : Extraordinarily diverse organizations, including religious and secular, narrow and broad scope programs, wealthy (BINGOS) and shoe-string, paid staff and volunteers, long- and short-term commitment, single- and multi-country focus, single problem and multi-sector focus, emergency, relief and development focus.
NGO advantages : can (potentially) have high flexibility, lower costs, limited bureaucracy, high commitment of staff (ie, not just a job), grassroots orientation, community-based and participatory, and cultural sensitivity; may be better able to avoid graft, corruption and political entanglement; national constituencies increase public awareness, involvement, and political support.
NGO problems and limitations : They vary depending on organization but common problems include limited funds, limited technical expertise, hard to ‘scale up’ small but ‘successful’ pilot projects, difficult to move toward local sustainability; hard to coordinate efforts between many PVOs, which often are in competition for funds and visibility; and mixed blessings of missionary groups, especially in Africa (eg, higher quality care, more stable infrastructure, expatriates, proselytizing)
E. Schools of Public Health
Training new professionals
F. Other Organizations and Associations These additional partners in international health inform both the technical and policy themes. They also are pivotal in the exchange of information and communication between the various partners that work in the development field.
American Public Health Association, International Health Section – as part of a larger international body called the World Federation of Public Health Associations
Global Health Council – formerly the National Council of International Health, is a U.S.-based, nonprofit membership organization that was created in 1972 to identify priority world health problems and to report on them to the U.S. public, legislators, international and domestic government agencies, academic institutions and the global health community.
Various Networks – The CORE Group, National Cooperative Business Association (NCBA), Food Aid Management (FAM), US Coalition for Child Survival, among many others both domestic and international. These groups are used to network, exchange technical information, provide updates to their members – particularly with email for those in the field, and group together to form a more forceful and engaging group for the larger organizations (UN, USAID) to work with more easily
II. Current international health assistance issues
A. During the past decades the ‘model’ and ‘focus’ for health assistance, per Paul Basch’s Textbook of International Health (Oxford Univ. Press, 2nd ed.), have progressed through these stages: (1) intergovernmental reconstructionist / peace and political stability, leading to international cooperation (1940-50s); (2) medical / diseases, leading to health and development, and to institution building (1950-70s); (3) community / clients, leading to programs and projects such as Primary Health Care (PHC), Health for All in 2000, Child Survival (1970-1980s); (4) and economic / providers, leading to emphasis on productivity and efficiency (1980-1990s). Now, the major issues and debates center around the following themes, with brief comments in brackets:
1. Degree of management decentralization (strong support for decentralization now somewhat lessened due to many examples of poor management capabilities at lower levels, and recognition of need for much more training, and selective decentralization)
2. Degree and nature of community input into program development (good verbal support for community input but limited substantive support and substantial problems making such input operational)
3. Relative emphasis on primary health care vs. selective health services [earlier emphasis on broadly defined PHC, then subsequently on selective, high priority services, eg, maternal and child care (MCH), and expanded program in immunization (EPI), but more recently there has been some re-thinking of and renewed support for PHC]
4. Relative emphasis on urban vs. rural programs (lots of talk about giving more attention to rural areas but de facto emphasis has been on urban ones)
5. Improved health as an input to, or an output of, development (December 2001 WHO report on Macroeconomics and Health strongly supports notion of health as both an input to and output of the development process)
6. Relative emphasis on public vs. private sector (increasing emphasis on private sector services but their cost-effectiveness and the degree to which they serve lower income populations has been disappointing)
7. Relative emphasis on narrowly defined projects vs. broad sectoral programs (eg, disease-specific projects or programs vs. broad support of the health, education or agriculture sector)
8. Extent and type of ‘conditionality’ used to promote change (there has been some decrease in the perceived efficacy of conditioning assistance to the attainment of specified targets and goals)
9. Relative emphasis on public vs. private funding of services (initial strong support for private funding has somewhat lessened due to disappointing results and the perceived reduction in service utilization by poor)
10. ALL International Organizations can distort government health programs and result in donor-organization ‘overload’ for host country decision-makers; may siphon off better qualified (and desperately needed) host country personnel with higher salaries, perks, and reduced bureaucracy, each come with their own agenda and don’t coordinate development assistance, and much of the funding is actually spent on (DONOR country employees and companies) overhead, staff salaries, travel expenses, housing, and consulting services and commodities