The Policy Process and Global Health

Devi Sridhar

Outline of Session

I. Review of Global Health GovernanceII. Case Study 1: Delivery v. TechnologyIII. Case Study 2: Resource AllocationIV. Discussion

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I. Global Health Governance

What is global health governance?

Trends1. Increase in Financing2. Increase in number as well as type of actors

involved3. Expansion in what constitutes ‘health’

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Global Health Institutions

• Multilateral Institutions (e.g. WHO)• Bilateral, or national aid agencies (e.g. USAID)• Civil Society Organisations (NGOs, networks)• Private Foundations (e.g. Gates, Rockefellar)• Private Sector• Various Partnerships among above actors

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II. Delivery v. Technology

• We need innovation in delivery and an examination of the politics of health policy and global funding.

• The gap is only growing between what technology can do and what is actually happening to health in poor communities.

• What is the global framework needed to enable countries to make use of the appropriate technology?

A few examples: India

• Nutritional status of Indian children, even compared to Sub-Saharan Africa, is exceptionally poor.

• In the NFHS-3 (2005-2006), 26% and 49% of urban and rural children under three years were reported underweight. 38% of all Indian children were estimated to be stunted.

Child Mortality• Annually almost 11 million children die before the age of five• The top four killers are diarrhoeal disease, malaria, TB and upper respiratory

infection. • If the solution for HIV/AIDS would be to bring a glass of clean water to everybody

in the world, we would not be able to do that. • As Kevin Watkins, Director of UNDP HDRO, has noted,

– In the next 24 hours diarrhoea caused by unclean water and poor sanitation will claim the lives of 4,000 children.

– The annual death toll from this relentless catastrophe is larger than the population of Birmingham. 2.6 billion people still have no access to even the most rudimentary latrine. Over 1 billion have no source of clean water.

– Global Inequality: In Britain the average person uses 160 litres of clean water each day. In rural Mozambique and Ethiopia, it is around 5-10 litres per day.

– ‘Over 1 million children are, in a perversely literal sense, dying for a glass of water and a toilet’

Source: Watkins, K. 2006, We cannot tolerate children dying for a glass of water, Guardian.

http://www.guardian.co.uk/environment/2006/mar/08/water.comment

Measles

• Easily preventable through immunisation• Primary reason children die is from not being vaccinated• Yet it only costs $1 to vaccinate a child against measles• One child dies of measles every minute in Africa• Measles infects 30-40 million each years and kills over

500,000

Source: Measles Initative http://www.measlesinitiative.org/020206press.html

Innovation is Necessary

• Community Level

• National Level

• Global Level

Community Level

• We need to understand how a community functions, what its concerns are, and how health, in a holistic sense, can be addressed.

Some examples: HIV/AIDS

Avahan Initative in India• $258 Bill and Melinda Gates Foundation HIV/AIDS Prevention

Programme • Takes a business-model approach and focuses on clients, not

beneficiaries.• First tries to understand the causes of HIV/AIDS in each

community then works to prevent it.

Source:Ashok Alexander lecture in Oxford, Scaling up HIV Prevention in India, available at http://www.globaleconomicgovernance.org/health/events_old.php

Reducing Undernutrition

• Much focus on technology such as fortification, supplementation, growth monitoring, and behavioural change

• Yet, as a Save the Children UK study showed, families just do not have enough money. There is a large gap between the price of feeding a family enough nutritious food to be healthy and how much people in developing countries earn.

• The study of 4 developing countries- found that 15-79% of households were too poor to acquire even a basic diet. We use $1 as a measure of rough measure of poverty, in Ethiopia a basic diet costs $1.27 a day for a family of five.

• The real cost of food in Bangladesh, translating that into those who live here in the UK, is a weekly grocery bill of £1700.

Source: Save the Children UK, Minimum Cost of a Health Diet, available at www.savethechildren.org.uk/en/docs/The_Minimum_Cost_of_a_Healthy_Diet_Final.pdf

But important non-economic factors

• Gender: determines access to household resources, intrahousehold allocation. For example, in India, it was found that 10% of households had both an alcoholic and an undernourished child

• Caste Discrimination• Infrastructure: Lack of access to health

facilities

Source: Gender: Harriss,B. 1991. Child Nutrition and Poverty in South India.

Infrastructure: Krishna, A. 2005. Why Growth is Not Enough. Journal of Development Studies, 41, 7.

Solutions

• And solutions are not necessarily technological.• For example, women’s groups: in addition to economic

aspects and saving schemes, they can empower women and educate them on their rights.

• See study by Manadhar et al. 2004, Effect of a Participatory Intervention with Women's Groups on Birth Outcomes in NepalCluster-randomised Controlled Trial. Lancet 364, 9438.

Innovation is Necessary

• Community Level

• National Level

• Global Level

National Level• While solutions might start with the community, the

question is where and how can a sustainable framework be built?

• We need strong health systems and arguably, this must come from government

• Institutions within developing countries need to be built so that they provide care, services and treatment in the long-term.

• Yet developing countries exist in a global environment where donors have considerable power.

Innovation is Necessary

• Community Level

• National Level

• Global Level

Global Level: Donors• The problem is that it is easier for donors to fund vertical,

disease specific strategies rather than horizontal solutions.• Project managers can show measurable and objective

outcomes over a short-time scale.• Thus assistance is tied to numerical targets such as the

number of patients on ARVs in one year, the number of children immunized over two years, etc.

• Thus in the current system, although the rhetoric has changed to funding health systems, most global health initiatives are vertical and focus on particular diseases.

Global Level: Developing Countries

• What we need is to have a global conversation where developing countries can put their pressing challenges on the table instead of having a ‘dialogue of the deaf’

• What we have is a situation in which to get donor funding, developing countries have to agree to whatever conditions and accept solutions in often a domestically hostile environment.

Effect that Global Priorities have on the National Level

Case of the MDGs and Mental Health“Unfortunately, mental health was not included explicitly as an MDG or even included as one of the targets. The result is that it is impossible to get it included in the Country Development Plans.”

“Rwanda, recognizing the impact of the 1994 genocide as well as the rising rates of HIV infection, included mental health in the 2002 Poverty Reduction Strategy Paper (PRSP) document. However, when it came time to determine what will be financed within the Poverty Reduction Strategy Credit, mental health was not included, since it is not explicitly mentioned as an MDG. The result is that the Rwandan Ministry of Health cannot finance mental health services out of the World Bank loan/credit funds, even if mental health is an expressed need, an observed need, and a mental health strategy exists.”

Source: WHO, Expert Opinion on Barriers and Facilitating Factors for the Implementation of Existing Mental Knowledge in Mental Services.

Available at www.who.int/entity/mental_health/emergencies/expert_opinion_on_service_development_msd_2007.pdf

Effect that Global Priorities have on the National Level

Case of HIV/AIDS and Primary Care

• Haiti: 80% of the population lives on less than $2 a day• More than 5,000 Haitians on ARVs, prevalence of HIV has dropped from

6% to 3% from 2002 to 2007. • But Haiti has gone backwards since 1985 in every health indicator except

AIDS.

Source: Garrett, L. 2007. The Challenge of Global Health. Washington Post.

Available at: http://www.cfr.org/publication/12508/challenge_of_global_health.html?breadcrumb=%2Fbios%2F1781%2F

We need to be asking question such as:

• What are developing country’s national priorities? Are these the same as international priorities?– Example of HIV/AIDS

• What role do developing countries want global health institutions to play in the delivery of financial assistance and support services for global health? What functions would they like to see the Gates Foundation performing? And the WHO? And the World Bank?

• What changes in the operation and structure of institutions of global health would be required to pursue developing country priorities? Do we need change in the structure of staffing and incentives to make them more responsive to needs and interests of developing countries? Do we need change in the role or accountability of executive boards and leadership of institutions?

Is Ownership Really Important in Health?

• Effectiveness and Sustainability

• Democracy and Self-Determination

• Aligning Decisions with Accountability

Source: Sridhar, D. 2007. The Politics of Access to Essential Medicines. Cambridge Quarterly of Healthcare Ethics

Final Thoughts

• Innovation in Delivery Systems Needed• Gap is only growing between what technology can do and

what is happening in poor communities• Needs to occur at 3 levels– Community: determining what solutions are needed and

obstacles to delivery– National Government: strengthening of health systems– Global Level: creating Policy Space for developing country

governments to set their own priorities

Case 2: Resource Allocation

Govt ODA - DAC (1)

9,577

Gates Foundation (3)

916

Individuals (5)

2,000

Global Fund (9)

1,903

EC (8)

580

NGOs (17)

1,500

Global Health Partnerships

(16)

400

Corporate funds (6)

1,895

World Bank (7)

1,600

Other foundations (4)

100

GAVI (10)

563

WHO (13)

1,650

UNITAID (11)

148

UNICEF (14)

927

UNAIDS (15)

292

LMIC governments (19)

ODA agencies –DAC (12)

7,173

(US = 4,189) (UK = 1,624)

For-Profit Sector (18)

3,000

Govt ODA –non DAC (2)

700

2001 Mortality (millions) vs. 2005 Disbursements of World Bank, U.S. Gov, BMGF, Global Fund

(millions of dollars)

Source: Sridhar, D & Batniji R. MIsFinancing Global Health. Lancet, 2008; 372, 9644.

0

500

1000

1500

2000

2500

3000

0 5 10 15 20 25 30

Dis

bu

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me

nts

($

mil

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ns

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Mortality (millions)

2001 Mortality vs 2005 Total Disbursements

HIV

NCD

Child Health (incl vaccines)

Nutrition

Injury

Water and Sanitation

TBPolio

Malaria

Maternal Health

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