Course Synthesis Problems in International Health

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Course Synthesis Problems in International
Health

• Stephen Gloyd, MD, MPH
• GH 511
• 4 December 2008

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Global Fund Exercise Objectives

• Real world application of course principles
  engagement
• Understand, in one country
• Burden of disease
• Social, economic, political situation
• Health systems
• Donor and NGO environment
• Policy options
• Impediments to change
• How to put together a major proposal
• Working in teams

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Problems

• What are they? Who defines them? (e.g.,CS, FGM)
• How they differ between countries
• How much they are the same
• Class interaction helps.
• How we define them usually defines our responses
• Why they occur determinants
• Proximate
• Intermediate
• Underlying
• MATRIX

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Under-5 mortality 2003 (WHO 2006 Annual Report)
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Source Center for Global Development (2008) -
http//blogs.cgdev.org/globalhealth/archive/matern
al_child_health/
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Determinants of global health
Underlying
Proximate
Diseases
Intermediate
Interests of rich Status of women Land
tenure Debt-SAPs Weak governments Militarism Imper
ialism
Poverty Disparity Access to education Job
conditions Gender issues Civil strife
Malnutrition Water Sanitation Housing Health
services Health behaviors
Diarrhea Pneumonia Perinatal conditions HIV Injur
y Malaria Measles
Public Health
Medicine
Social-political sciences
Social sciences
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Determinants of health systems

• Investment in Primary Health Care
• Influence of Structural Adjustment Programs
• Recurrent funding crises
• Human resources crises
• Management inadequacies
• International aid that often contributes to the
  problem

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Responses to problems

• Determined by ideology (political, social,
  economic) examples
• capitalism-neoliberalism vs. socialism,
• private vs public responsibility
• technological vs social interventions
• Effectiveness of responses
• Equity strategies Kerala/China/S Korea/Costa
  Rica vs. Pakistan/India/Malawi
• PHC and its variants
• Vertical programs ORT, EPI, VitA, TBAs
• Reintegrated vertical programs (IMCI, PEPFAR)

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Success stories (1950-80)Kerala, Sri Lanka,
China Taiwan, S.Korea Common Policies

• Primary education - Universal and compulsory
  (all)
• Housing, Water, Sanitation for poor (all)
• Food/agriculture subsidies (all)
• Land Reform (all)
• Protection of nascent industries (Taiwan, S.
  Korea)
• Simple health services (all)
• Common Denominator all require government
  intervention, taxation

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Primary Health CareDeclaration of Alma-Ata (1978)

• Health is a fundamental human right/worldwide
  goal and requires inter-sectoral action to attain
• Improved health and peace requires economic and
  social development based on New Intl Economic
  Order
• Governments have responsibility to provide
  adequate health and social measures for health
• Primary health care is appropriate, accessible,
  acceptable, affordable and requires community
  participation
• HFA 2000 requires redirecting resources from
  military to social expenditures (including health)

Source WHO
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Primary Health Care Theory

• Planning
• Budgeting
• Procurement

MOH Central
Tertiary (Provincial) Hospital
Tertiary (Provincial) Hospital
Provincial Health Office
Supervision Drugs, Lab ME
District Health Office
District Hospital
Service support Integration of services
CHW
Health Post
All services
TBA
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• Government is not the solution to our problems.
• Government is the problem.
• Ronald Reagan,
• Inaugural Address, 1981

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Structural Adjustment ProgramsWashington
Consensus (IMF, World Bank)

• Decrease government spending
• Improve terms for foreign investment to increase
  exports
• Privatize economy Free Market Rules
• Reschedule debt over longer period (indefinite)

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Effects of SAPs-especially on poor

• Increased prices
• Unemployment
• Non-living wages
• User fees
• Reduction in education, health care quality
• Social unrest

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SAPs weakened national health systems in Africa

• Ministry of Health (MOH) budgets have been
  slashed, causing
• Poorly maintained and equipped health facilities
• Inadequate transport, communication
• Weak procurement and distribution of medicines
  and supplies
• Inadequate workforce (numbers, salaries, morale)

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Global Distribution of Health Workers in Selected
Countries
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Africa Debt flow 1986
Annual debt payments since the mid-1980s
European Banks
US Banks
15 Billion
African Governments
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US Foreign Assistance

• Objectives of USAID
• Expand US Markets
• Promote US Security
• Promote US Values
• Humanitarian

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How do SAPs relate toInternational aid NGOs?

• AID money linked to SAPs
• Most AID is tied to purchase of goods and
  services from donor country
• Aid is designed to support home country aid
  industry, especially NGOs
• NGOs often substitute for weakened public sector
  in recipient countries
• European donors beginning to change

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How does US Aid Money Flow?

• USA Funding

Funds
Non Governmental Organizations (NGOs)
Ministry of Health (MOH)
Indirect Costs
Funds
High Staff Salaries
Direct service delivery
Staff support (cars, housing, offices, etc)
Local NGOs
Phantom aid 60-80 never reaches recipients
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Bilateral Donor Support to Tanzania, 2000-2002

Source Foreign Policy, Ranking the Rich 2004
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Recent developmentsNGOs and AIDS treatment

• Most African countries received Global Fund
  resources for treatment
• USA (PEPFAR) treatment resources mostly through
  NGOs
• Countries divided up among NGOs
• Separate drug procurement, medicines, systems
• National MOHs have lost control in many places

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Donors and NGOs usually leave when funding
ends Manica Province, Mozambique NGOs present
in 1994 Yellow shaded are those NGOs who left by
1998
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MOH characteristics

• Slow, bureaucratic
• Dependent on a few key people (who travel all the
  time)
• Health workers frequently absent (training,
  perdiem)
• Workforce expansion is a principal bottleneck
  limited by Ministries of Finance
• BUT
• Has broad health network more capable of broad
  coverage for poor
• Sometimes best option for sustainable systems
  rapid access
• SWAP and basket funding have been implemented to
  rationalize donor inputs

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What is neededStrengthening national health
systems

• Health work force many, many, many more health
  workers needed
• Management capacity
• Recurrent budget support for workers,
  maintenance, procurement distribution,
• Bricks and mortar infrastructure
• Logistics, ME, IT systems
• Linkages to communities
• Operations research

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Are there alternative models to support poor
countries? Yes.

• Cancel debt of poor countries
• Reverse structural adjustment programs
• Fund the public sector, including recurrent costs
  basket funding
• Increase MOH workforce pay living wage
• Improve maintenance and rehabilitation of
  government health facilities
• Support MOH management and procurement workers,
  drugs, lab
• Local governments and institutions should hire
  NGOs and expatriates to provide technical
  assistance

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USA militarism

• 700 bases globally, 500 billion annual budget
• Defense of Vital American Interests
• Promote US Security (and US corporate interests)
• Promote US Values (democracy vs economic
  neoliberalism)
• Expand US Markets
• Humanitarian?

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Over 30 USA Interventions just since WWII

• China 1945 (anti-communist)
• Greece 1947, 64 (anti-communist)
• Philippines 1945 (fruit, nationalism)
• S Korea 1945 (anti-communist)
• Albania 1949-53 (anti-communist)
• S Korea 1952 (anti-communist)
• Iran 1953 (oil, nationalism)
• Guatemala 1954 (fruit, nationalism)
• Indonesia 1957 (nationalism)
• Guyana 1953 (leftist president)
• Vietnam 1954 (anti-communist)
• Cambodia 1955 (nationalism)
• Cuba 1959 (sugar nationalism)
• Congo 1960 (mining)
• Brazil 1961 (nationalism)
• Dominican Rep 1963 (nationalism)
• Vietnam 1964-75 (anti-communist)

• Greece 1964 (anti-communist)
• Indonesia 1965 (nationalism)
• Cambodia 1969 (anti-communism)
• Chile 1973 (mining - nationalism)
• Angola 1975-80 (oil, anticommunism)
• E Timor 1975 (nationalism)
• Grenada 1979 (nationalism)
• Afghanistan 1979 (Anti USSR)
• El Salvador 1980-89 (nationalism)
• Libya 1981 (oil)
• Nicaragua 1987 (anti-socialist)
• Panama 1989 (canal nationalism)
• Iraq 1991 (oil)
• Somalia 1993 (humanitarian?)
• Bosnia 1999 (humanitarian?)
• Afghanistan 2002 (Anti USSR)
• Iraq 2003 (oil)

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Convergence of American foreign policies

• Economic policies
• (debt, SAPs)

• USAID development policies
• Privatization
• NGO support

Protection of vital interests, e.g.,
Trans-National corporations

• Covert action
• Political turmoil
• Rigged elections
• Assassinations

Military intervention arms sales
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There are reasons to be optimistic

• Increasing understanding of debt and SAPs
  (Bono Geldof, Brad and Angelina, Oprah!)
• Repudiation of neoliberalism in Latin America
• (Brazil, Bolivia, Chile, Venezuela, Argentina,
  Ecuador, Uruguay, Nicaragua)
• Positive experiences with debt reduction
• Kenya universal free education
• Mozambique doubled health budget
• New forms of aid (basket funding, Global Fund)
• Global anti-War movements largest in history
• Professionalism of health workers - despite poor
  salaries and conditions

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What can we do in rich countries?

• Understand (and witness, document) the
  potentially detrimental aspects of US foreign
  policies
• Cancel debt, reverse SAPs (Jubilee, Oxfam, Africa
  Action, Global Exchange, Intl Forum on
  Globalization)
• Work to change forms of international aid (Oxfam,
  Action Aid)
• Direct support to governments
• Involve USA more in basket-funding (European
  model)
• Curb USA Militarism (military, covert action,
  torture, arms industry)

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What to do as health workers?

• Work within (or for) the national health system
• Follow national systems and guidelines
• Be sensitive to inequalities resentments that
  might be present
• Be aware of context

• Observe and document what you see
• Dont expect rapid changes - work for the long
  run
• Remember, resource scarcity is only how we define
  it (e.g., ARVs)

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What can recipient governments do?

• Develop a comprehensive national plans
• Encourage basket funding
• Get Ministries of Finance to approve expansion
  of health sector budgets and workforce
• Encourage donors to finance the national plans,
  including recurrent costs
• Use NGOs at discretion of MOH - (Some new
  programs have MOH distribute )
• Just say no! when donors do not cooperate

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What can we do as individuals?

• Understand health and its underlying determinants
• Work with progressive groups regarding
• Trade, debt, SAPs (Jubilee, WFG, etc)
• Foreign aid
• Militarism arms
• Support equity movements (Oxfam, Results, HAI,
  PIH)
• Be a witness document what you see (SAPs,
  inequalities, war, structural violence -e.g.,
  Charlie Clements, Paul Farmer, MSF, HAI)
• Question assumptions!

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Thank you all for a great class!

• Good luck and keep in touch!