Dr. Onkar Mittal
Along with the dominance of the forces of globalisation, the control of global social, economic and political forces through health interventions is emerging as a key strategy for the internationally dominant order. The World Health Organisation (WHO), which emerged as a new global agency for improvement in international health after the Second World War, is increasingly succumbing to the demands of this new international world dominance structure. It is important to see through the façade of high sounding phrases like public-private partnerships and global compact with the businesses, to its naked reality and formulate a strategy to resist these sinister forces, to prevent them from their anti-people project.
The WHO’s budget is about 3 billion dollars of which only 30% is through the contributions of the member states. The rest comes from the so-called voluntary contributions of the different countries and charities. This so- called ‘voluntary contribution’ by the G-8 countries and international philanthropies, is in fact the main arm to exercise control over the organisation.
Today there are nearly 70 Global Health Public Private Partnerships housed in WHO and in fact they have taken it over. These new funding mechanisms have been created to finance international health in which WHO is a key partner to provide them legitimacy but WHO has no control over these. WHO is used by the vested interests of the transnational corporations today to exercise global control, due to its relatively neutral image.
External aid to the health sector in the developing countries
The global aid landscape is undergoing profound changes in the way aid is financed and delivered. The new aid architecture is marked by the emergence of global funds and non-traditional bilateral donors; a growing role in the aid from private foundations, non-governmental organisations and corporations; and more public-private partnerships.1
External assistance from both traditional and new sources accounts for 7 percent of the health sector spending in developing countries. This figure masks large differences across countries and regions: In Africa this share is much larger at 15 percent. Fifteen of 23 countries where external assistance supports over 20 percent of all health spending are in Africa. Seven countries receive HIV/AIDS funding that is larger than 30 percent of their total public health budget; in some countries this funding exceeds other public health spending.
Aid for health is changing rapidly. New actors such as private philanthropies have rapidly expanded the funds available for investment in global health. In tandem with rising private philanthropy, the channels through which bilateral, multilateral and other donors are providing resources for health have grown. The current aid system is credited with encouraging innovation, flexibility and speed. However issues have been raised about its complexity and the challenges of ensuring coherence and coordination and aligning global programmes with national priorities.
The health sector has seen a rapid scaling up of both traditional and innovative aid flows. There are well over 100 international entities involved in supporting health. Concessional financing for health has more than doubled, from $6.8 billion in 2000 to nearly $17 billion in 2006. The spurt in funding is the result of new (bilateral) programmes such as the US PEPFAR and the increase in funding for health by bilateral donors, private foundations such as the Gates Foundation, and global health funds such as GFATM and GAVI.
Aid-effectiveness issues
While the focus on health is bringing much needed financing to the sector, the narrow concentration on a single issue or subsector can have unintended effects, particularly in the short run.2. For one thing, the pattern of external funding can create imbalances in the health sector and undermine attention to other local health priorities. A sharp increase in vertical funds can also strain absorptive capacity. Since earmarked funds typically pay less attention to investment in health delivery systems, inadequate capacity can translate into the low efficiency and effectiveness of spending.3 But the strengthening of the absorptive capacity usually receives less attention than direct funding for HIV/AIDS in donor commitments.
A heavy reliance on aid to finance public expenditure, especially on health with a high proportion of recurrent costs, raises issues of sustainability of financing, and in turn of service delivery gains, and has implications for the ability of countries to budget and plan for medium and long term. Most funding is short term – for example in Ethiopia and Rwanda 55 percent foreign financed projects are negotiated on an annual basis. This short term pattern of financing introduces uncertainty about aid amounts. Large year to year variations in aid level constrains long term plans for capacity building in the health sector – that is hiring nurses and doctors and scaling up health services – especially in the poorest and most aid dependent countries. The challenges are even more acute in fragile and conflict affected situations, where aid is even more variable and is usually channeled through parallel systems because of weak public financial systems.
Amid the changing aid architecture and the scaling up of financing for health, there is much scope to improve the efficiency and effectiveness of aid delivery and utilisation in the sector. There is a growing awareness that health targets cannot be efficiently attained and sustained without appropriate health delivery systems. Adequate investment in health systems is therefore needed. To support effective scaling up of service delivery, donors will need to strengthen coordination and harmonisation of aid, increase flexibility in funding, provide more predictable and sustainable assistance, and enhance alignment with country-owned and country-led health plans.
In the last decade, over 70 health alliances, or Global Health Partnerships (GHPs) have been created to address today’s complex global health issues. Some of the major GHPs and Initiatives are
GHPs are now the dominant model of organisation in this space. It has been claimed that these alliances have made progress in preventing and fighting diseases. They have won attention and financing for public health challenges at the highest political level. They have been credited with boosting countries’ access to anti-retroviral therapy for HIV/AIDS patients, raised vaccination rates and increased use of directly observed therapy, or DOTS, for tuberculosis. The working group on Global Health Partnerships established by the High Level Forum on Health Millennium Development Goals also found that GHP attract new partners into the global fight against specific diseases and spur innovation.
There seems to be a consensus within the establishment that GHPs work. Therefore the discussion is shifting from ‘Do we need such partnerships and what do they add?’ to ‘What will it take to increase their effectiveness and reap their full benefits?’ In one of the reviews undertaken by the Gates foundations, the following deficiencies have been acknowledged:
GHP often explicitly or implicitly tie technology and policy recommendations to their grants. Tying funds to policy/technology shifts has created uncertainty and a sense of being forced without discussion. In some cases, when a policy has shifted towards a newer technology or treatment guideline, key stakeholders have received mixed signals about the decision. Often they do not receive evidence, such as cost-benefit analyses, to support change. Neither the policy rationale, nor whether there is room for flexibility is communicated. Some GHPs do not discuss the trade-offs and logistics of using new technologies. Finally in some cases, country officials and local NGOs report that GHP chosen policy/technology solutions were not the most appropriate for the countries given financial and health systems constraints: Some examples of this are: – GAVI has pushed countries to use pentavalent hepatitis B vaccine; PEPFAR requires countries to use FDA approved anti-retroviral medicines; Global Fund puts its weight behind the WHO policy on Artemisinin Combination Therapy (ACT) use for malaria; The Stop TB partnership/ Global Drug Facility favours four drug combinations for TB treatment.
Countries invest heavily in writing applications for GHP funding. They often hire external consultants, but these experts do not always understand what is feasible, and tend to leave before implementation. As a result plans can be difficult to execute because no one has planned for what to do after the cheque arrives.
GHPs have created too many inadequately structured country coordination forums. These are particularly in HIV/AIDS. In actuality there is very little coordination to show for this proliferation. Every GHP wants its own coordination mechanism. Roles and responsibilities of these coordinating bodies are not clearly defined. Coordination meetings achieve little real progress. Country officials lack experience in running such meetings. The costs of poor coordination at the central level wind up falling on the front line district management teams.
‘One size fits all’ processes that GHPs find tempting to impose on countries do not recognise their diversity, and GHPs have trouble dealing with system level issues.
To complicate matters, GHPs have not communicated adequately or effectively with countries and partners. Communication between them is often one way and the feedback loop from countries is weak. Furthermore, because GHPs are relatively new vehicles, the relationship between GHPs and their partners at the global and country level have not been solidified. Indeed this weakness amplifies all other problems.
New Initiatives in GHPs
The need for more coherence in aid for health is recognised by several new initiatives. Among these are the creation of the group of eight heads of the following health agencies – the World Bank, the World Health Organisation, the Joint United Nations Programme on HIV/AIDS, the United Nations Children’s Fund, the United Nations Population Fund, GFATM, GAVI Alliance, and Gates Foundation – was formed by leaders of these institutions to strengthen collaboration to achieve better health outcomes. The International Health partnership includes a number of bilateral donors, the group of eight agencies, as well as several partner countries. The main goals of partnership are to improve health systems, provide better coordination among donors and support countries in developing their own health plans.
The constitution of WHO came in force in the year 1948. It has completed sixty years of its existence. WHO is the directing and coordinating authority on international health within the United Nations system. WHO experts produce health guidelines and standards, and help countries to address public health issues. WHO also supports and promote health research. Through WHO, governments can jointly tackle global health problems and well being.
193 countries are WHO’s members. They meet every year at the World Health Assembly in Geneva to set the policy for the organisation, approve the organisation budget, and every five years, to appoint the Director General. Their work is supported by a 34 member executive committee which is elected by the Health Assembly.
WHO has 8000 public health experts, doctors, epidemiologists, scientists, managers and other professionals from all over the World in 147 country offices, six regional offices and its headquarter in Geneva in Switzerland. There is WTO observer status to WHO on trade related aspects of IPR and access to patents and drugs.
It credits itself with many great achievements, one of the greatest is said to be eradication of small pox. Some of the achievements it credits itself with are: the Alma Ata declaration of health for all and primary health care in 1978, 1983 – Institut-Pasteur- France identifies HIV, in 1988 – Polio Eradication Initiative launched, in 2003, the first global health treaty on tobacco control and the recognition of SARS and its control and year 2004 – the adoption of a global strategy on diet and physical activity for health.
Marginalisation of WHO
WHO should have exclusive right to be the leader in public health. Its constitution assigns it the directing and coordinating authority on international health work. However, this leading role has been marginalised in the last three decades from within the UN and from outside. Today there is no one voice in international public health, which raises problem of legitimacy, cooperation and effectiveness.
UNICEF: has a high profile and effective operational role at the country level, filling the void left by WHO.
World Bank emerged as a major player in health sector in the 1980s. The bank already claims superior expertise in health sector reforms. It has made 11 billion lending in the health sector in 15 years and 1.38 billion to the health sector in the year 2002. The bank’s assistance in public health exceeds WHO’s total resources. It is the single largest source of international funding for health. The WB and IMF do not accept UN coordination and leadership, which works with one member-one vote. WHO-World Bank cooperation is risked by WHO getting associated with bank’s ideology privileging role of market in provision of health and pension to the benefit of TNCs.
UNAIDS: January 1996 – lack of confidence in WHO’s abilities to tackle the main health, social, economic issues of AIDS epidemic, on parts of other UN organisation and donors led to the establishment of UNAIDS.
Health and Trade: In its relationship with WTO, WHO finds itself in the difficult position to plead for the rights and interests of the developing countries, while WTO and similarly the World Bank tend to place economic liberalisation above the health concerns of the poor countries.
WHO and the private sector
WHO is a member of most of the key GHPs listed in the section above. In addition, it collaborates with Prince of Wales Business Leaders Forum, Rotary International, the Conference Board (comprised of Senior Executives from all Industries World Economic Forum).
WHO has worked with Association of Oil and Gas Producers to help establish strategic health management principles and guidelines for this Industry. It has a cooperation agreement with the World Alliance for Community Health – a not-for-profit organisation set up by international mining companies.
WHO collaborates with a number of private sector firms- Merck and Co (for a Onchocerciasis Control programme), Glaxosmithkline (for lymphatic filariasis and malaria control), Novartis group (for malaria and leprosy), Pasteur Merieux Connaght (polio). It works in collaboration with the International Federation of Pharmaceuticals Manufacturers Association (IFPMA) and various industry groups. Several of its programmes are supported by business related foundations.
WHO maintains close collaboration with number of business issued or business related foundations – Nippon Foundation – leprosy, Rotary International – Polio, El Lilly – Mental Health, Lions Club international (blindness), Rockefeller Foundation (vaccines, tropical diseases, research and other), David and Lucille Packard Foundation ( Reproductive Health), Hewelette Foundation (human reproduction) and the United Nations Foundation – Ted Turner – 1998.
There are 189 NGOs in official relationship with WHO.
An endowment of $1.7 billion has been made to WHO by the Bill and Melinda Gates Foundation.4 The William H. Gates foundation co-founded by Bill Gates and his wife Melinda Gates focuses on child and maternal health in developing countries. It gave $200 million to WHO in 1998.
IFPMA was admitted into official relationship with WHO since 1971.
UN & TNC – from opposition to cooperation
A code of conduct was formulated to regulate transactions between TNCs and host governments in 1974. The UN established an inter-governmental commission on TNCs (UNCTC) under UNCTAD. This led to:
However political and economic realities changed in 1980s. In July 2000, Kofi Annan launched the global compact. Even before that in May 2000, Dr. Gro Harlem Brundtland exhorted the WHO to reach out to private sector, we need open and constructive relationship with private sector, she declared. Corporate influence at UN was already too great. New partnerships were leading down a slippery road towards partial privatisation and commercialisation of UN system itself. UNSG office, UNICEF, UNDP, WHO and UNESCO were partnering with corporations known for human, labour and environmental rights violations. Global compact and its cousin partnerships were threatening the mission and integrity of UN.
Corpwatch – Alliance for Corporate Free United Nations in June 2002 proposed to redesign the global compact as global accountability compact.5 Financial scandals of late 2001 and 2002 (Enron, World Com and Others) have given new arguments to the promoters of “Corporate Free UN” or at least those who wish the UN to exercise good caution in its relations with corporate sector. In March 1999 – ‘tangled up in blue’ – a document was produced as part of international campaign to document and expose growing number of partnerships between various UN agencies and corporations with poor human and environmental rights record.6
WHO is not in a position to play an overarching role of a global agency guiding the health systems to provide universal access to health services by all citizens of the world. The health services in the developing countries are increasingly failing to deliver the goods. The GHPs despite bringing in massive resources, have failed to deliver the necessary improvements. WHO has little voice in these GHPs, despite being a key member. These GHPs are independent of the UN principles of democratic global governance by consensus and they exercise their influence by virtue of sheer money power at their command. Considering that political economy of health production is increasingly acquiring more important role for the global political economy, it is the task of the revolutionary forces to critique the WHO along with critiquing the inequitable and technocentric health systems in their countries to build an alternative vision for the humanity.
End notes:
1 The following section is on the basis of global monitoring report of World Bank 2008
2 For example in Rwanda donor funding in health was unevenly allocated, with $47 million for HIV/AIDS, $ 18 million for malaria (which is the leading cause of morbidity and mortality in the country), and only $1 million for management of childhood diseases. Likewise, in Ghana malaria is the leading cause of sickness and mortality, but donor funding to fight malaria has recently been 60 percent of amount allocated to HIV/AIDS.
3 An example of absorptive capacity constraints at the sector level is in Ethiopia, where the capital budget execution rate for external assistance has been found to be low at 15-20 percent, compared with 80 percent for domestic resources.
4 Bill and Melinda Gates Foundation: Guided by the belief that every life has equal value, The Bill and Melinda Gates Foundation works to help all people lead healthy, productive lives. In developing countries, it focuses on improving people’s health and giving them chance to lift themselves out of hunger and extreme poverty. In United States, it seeks to ensure that all people – especially those with fewest resources- have access to opportunities they need to succeed in school and life. Based in Seattle, the foundation is led by CEO Petty Stonesifer and co-chair William H. Gates Sr. under the direction of trustees Bill and Melinda Gates and warren Buffet. It has asset endowment of $35.9 billion, total grant commitments since inception are $16.5 billion and total grant payments in 2007 are $2.007 billion. Some of the illustrative Grant commitments are:
5 Bayer and UN Global Compact:
* When most of us hear the brand name ‘Bayer’ we think aspirin. But Bayer AG, based in Germany is a major producer of pharmaceuticals, pesticides, and plastics. The company employs 1,20,000 people worldwide and its annual sales are $28 billion.
* Bayer considers itself a ‘founding member’ of the UN global compact, but its dedication to the Compact’s nine human rights and environmental principles should be seen in the context of an extremely controversial corporate history. Bayer has been using its membership in the Compact to deflect criticism by the watchdog groups, without addressing the substance of the criticism. Bayer’s use of Global Compact is a classic case of ‘bluewash’ – using the good reputation of UN to present a corporate humanitarian image without a commitment to changing real world behaviour.
Bayer has a long history of giving profits precedence over human rights and environmental concerns. Some of its crimes include inventing chemical warfare (moisture gas) during the first world war, manufacture of poison gas used in gas chambers in Germany during second world war to kill jews, using human guinea pigs for pharmaceutical research. Some of its managers were convicted as war criminals during the Nuremberg Trials. It exerts a large influence over German and European politics. It was listed as one of the 10 worst corporations by the multinational monitor. It did not respond to the allegations but instead attacked their critics.
6 Tangled UplnBlue Corporate Partnerships at the United Nations.
Published by TRAC – Transnational Resource & Action Center. www.corpwatch.org. September 2000.
This report states that Secretary General Kofi Annan has encouraged all UN agencies to form partnerships with the private sector. The centrepiece of this initiative is his Global Compact, launched with the agencies for environment (UNEP), labour (ILO) and human rights (UNHCHR) in July, 2000. This report argues that corporate influence at the UN is already too great, and that new partnerships are leading down a slippery slope toward the partial privatisation and commercialisation of the UN system itself. The Secretary General’s office and UN agencies such as UNICEF, UNDP, WHO, and UNESCO are partnering with corporations known for human, labour and environmental rights violations. The Global Compact and its cousin partnerships at other UN agencies threaten the mission and integrity of the United Nations.
According to the report: The Global Compact has four major problems:
1. Wrong Companies: The Secretary General has shown poor judgment by allowing known human rights, labour and environmental violators to join. 2. Wrong Relationship: Clearly the UN must have interactions with corporations, as when they procure goods and services or to hold them accountable, but it should not aspire to ‘partnership.’ 3. Wrong Image: The UN’s positive image is vulnerable to being sullied by corporate criminals, while companies get a chance to ‘bluewash’ their image by wrapping themselves in the flag of the United Nations. 4. No Monitoring or Enforcement: Companies that sign-up get to declare their allegiance to UN principles without making a commitment to follow them.
The report says that the new guidelines for UN cooperation with corporations state that companies that violate human rights ‘are not eligible for partnership.’ • Mr. Annan violated the guidelines just a few days after they were published by inviting Shell to join the Global Compact and its envisaged partnerships. • The UN claims that it lacks the capacity to monitor corporations’ activities. This creates a Catch-22 situation. Without monitoring capacity the UN will not be able to determine, under its guidelines, if a corporation is complicit in human rights violations. • The Guidelines also provide for the limited corporate use of the UN logo. This presents a potential marketing bonanza for companies like Nike.
The report makes a call for:
1. Toward a Corporate Free UN – If the Global Compact and other corporate partnerships represent the low-road, then there are four key steps that can be taken to build a high-road.
2. Support the Code of Conduct on transnational corporations and human rights being drafted by the UN Sub-Commission on Human Rights.
3. Support UN-brokered multilateral environmental and health agreements which can reign in abusive corporate behaviour on a global scale.
4. Pressure the US government to pay the UN the money it owes with no strings attached.
5. Support and promote The Citizens Compact, which calls for a legally binding framework for corporate behavior.
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