BIOE 260: Intro to Global Health Issues

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BIOE 260 Intro to Global Health Issues

• Lecture 6

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Outline

• From colonial medicine to the era of
  international health-aid organizations (IHOs)
• Contribution to the total health expenditure of
  developing countries
• Largest IHOs providing long-term healthcare
  assistance
• Multi-lateral, bi-lateral, non-governmental
• Largest IHOs providing refugee disaster relief
• Multi-lateral, bi-lateral, non-governmental

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Colonial Era ? Present Day

• Humanitarian Motivated
• Protects 1st world from ID too
• Suspicious of Outsiders
• Myths Misunderstandings
• Distrust of wealthy countrymen
• Sustainability Continuity
• RD highly unchanged
• Not profitable, not a priority
• Institutions abroad, brain drain
• Developed world investment to aid local workforce
• More democratic states International Press
• Still oppressive, corrupt regimes
• Political will to provide/receive aid

• Economics Motivated
• Favoritism Racism
• Enforced Vaccination Healthcare
• Non-sustainable
• Research Pharmaceutical development motivated
  by economics
• Governance Transparency lacking

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Total Healthcare Expenditure in Developing
Countries

• Almost the entire cost of health care in the
  developing world is borne by the developing
  countries themselves.
• According to two separate estimates, aid from
  international health organizations (IHOs) in the
  developed countries pays for less than 5 of the
  total health care costs in the developing world.
• Consider Action Aids critique of all development
  aid from countries belonging to the Development
  Assistance Committee (DAC).
• A great deal of money goes into getting aid to
  the intended beneficiaries.

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• http//www.actionaid.org.uk/_content/documents/rea
  l_aid.pdf

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Total Healthcare Expenditure in Developing
Countries

• So while the estimates do not specify exactly
  what they include as health aid, but they
  probably omit
• The value of food relief and other health-related
  disaster relief
• Money spent on water supply and sanitation
  projects, although these activities have
  important health benefits
• Work done in the home offices of IHOs,
• e.g. the publication of manuals for health care
  workers in developing countries, the development
  of model health care systems, the strategic
  planning for campaigns against tropical diseases
• The monetary value of donated health system
  components
• The labor of volunteer health workers
• Research in tropical diseases done at medical
  institutions in the industrialized countries
• Drug development for tropical diseases by major
  pharmaceutical firms (e.g. the anthelminth,
  ivermectin, developed and manufactured by Merck
  Co. at a net loss)
• Development of equipment by international
  companies for use in poor countries (e.g. the
  development of low cost x-ray equipment by GE)

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Total Healthcare Expenditure in Developing
Countries

• Even if all these items were counted, however,
  the total value of the aid from abroad would
  still account for much less than 10 of the total
  health expenditures in the developing world.
• Nevertheless, it is important to note that, in
  the very poorest countries, the percentage of
  health care costs donated by the developed world
  is considerably greater than the 5 average.
• In sub-Saharan Africa (excluding South Africa),
  aid from donor countries averages 20 of total
  health expenditures, according to the World Bank
• In Burundi, Chad, Guinea-Bissau, Mozambique, and
  Tanzania - donor aid pays for more than 50 of
  the total health bill.

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Total Healthcare Expenditure in Developing
Countries

• Although the aid given to the developing world as
  a whole is relatively small in financial terms,
  it can be of crucial importance.
• Research and pilot programs sponsored by agencies
  from the industrial nations have generated many
  of the best ideas for improving health in
  developing countries.
• IHOs are a major source of expert technical
  advice and training for local health
  professionals.
• IHOs produce the major textbooks in tropical
  health, as well as the most important manuals for
  health care workers.

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International Health Organizations

• A large number of organizations of various sizes
  provide international health aid
• We will consider the functions of the largest
  International Health Organizations (IHOs)
• IHOs are usually divided into three groups
• Multilateral organizations
• Bilateral organizations
• Non-governmental organizations (NGOs)

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IHOs Providing Long-term Health Care Assistance

• Multilateral Agencies
• Multilateral means that funding comes from
  multiple governments (as well as from
  non-governmental sources) and is distributed to
  many different countries.
• The major multilateral organizations are all part
  of the United Nations (www.un.org)
• The World Health Organization
• The World Bank
• UN Economic and Social Council
• "Separate, autonomous organizations which, by
  special agreements, work with the UN and each
  other through the coordinating machinery of the
  Economic and Social Council."

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IHOs Providing Long-term Health Care Assistance

• The World Health Organization (WHO)
• The premier international health organization
• An "intergovernmental agency related to the
  United Nations
• According to its constitution (1948) its
  principal goal is "the attainment by all peoples
  of the highest possible level of health
• The principal work of the WHO is directing and
  coordinating international health activities and
  supplying technical assistance to countries. It
• Develops norms and standards
• Disseminates health information
• Promotes research
• Provides training in international health
• Collects and analyzes epidemiologic data
• Develops systems for monitoring and evaluating
  health programs
• www.who.org

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IHOs Providing Long-term Health Care Assistance

• WHO has 3 main divisions
• The World Health Assembly
• The governing body that meets once a year to
  approve the budget and decide on major matters of
  health policy.
• All the 190 or so member nations send
  delegations.
• Elects 34 member nations to designate health
  experts for the Executive Board
• The Executive Board
• Meets twice a year and serves as the liaison
  between the Assembly and the Secretariat
• The Secretariat
• Carries on the day-to-day work of the WHO.
• A staff of about 8,500, with 30 of the employees
  at headquarters in Geneva, 30 in six regional
  field offices, and 40 in individual countries,
  either as country-wide WHO representatives or as
  representatives of special WHO programs.
• The Pan American Health Organization (PAHO),
  the regional field office for the WHO in the
  Americas, carries on some additional autonomous
  activities as it predates the WHO.
  www.paho.org

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WHO Regions Regional offices
 Africa HQ Brazzaville, Congo  Americas
HQ Washington, DC, USA  Eastern Med HQ
Cairo, Egypt  Europe HQ Copenhagen, Denmark
 South East Asia HQ New Delhi, India
 Western Pacific HQ Manila, Philippines
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IHOs Providing Long-term Health Care Assistance

• The WHO biannual budget
• Assessed contributions from the member nations
  constitute the regular budget.
• In 2006, contributions totaled 1 billion
• WHO allocates assessed contributions
• Since 2000, voluntary ("extra-budgetary")
  contributions - from governments and private
  philanthropies - have exceeded the regular budget
• For 2005-2006 the total budget was 2.2 billion
• Donors may earmark voluntary contributions for
  special programs
• For the period 1994-95 the total budget was
  1,872 million
• 628 million disease prevention and control
  programs
• 181 million the program for the prevention and
  control of AIDS and other sexually transmitted
  diseases
• 118 million the program for integrated control
  of tropical diseases
• 80 million tropical disease research
• 404 million The programs in the area of health
  system infrastructure health systems
  development, organization of health systems based
  on primary health care, development of human

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IHOs Providing Long-term Health Care Assistance

• The World Bank
• The other major "intergovernmental agency related
  to the UN" heavily involved in international
  health.
• Loans money to poor countries on advantageous
  terms not available in commercial markets.
• The total amount of loans for
• Millennium Development Goal (MDG) related
  projects 4,721 M
• 350 million of which targets improvements in
  maternal child health and combating infectious
  disease (HIV/AIDS, malaria,)
• www.worldbank.org

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IHOs Providing Long-term Health Care Assistance

• The UN Economic and Social Council
• There are 3 UN Economic and Social Council
  subsidiary agencies heavily committed to
  international health programs
• The United Nation Children's Fund (UNICEF)
• The United Nations Population Fund (UNFPA)
• The United Nation Development Program (UNDP)

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IHOs Providing Long-term Health Care Assistance

• The United Nation Children's Fund (UNICEF)
• Established in 1946
• The world's most vulnerable children are its top
  priority, so it devotes most of its resources to
  the poorest countries and to children under 5
• The majority of its program (non-administrative)
  budget is spent on health
• Runs many of the child health programs in
  cooperation with WHO
• worlds largest supplier of malaria bednets
• provides vaccines to 40 of the worlds children
• In 2005 UNICEF
• Received about 2.8 billion in contributions, all
  voluntary - 56 from governments and 44 from
  private sources.
• The US government is the largest single donor to
  UNICEF
• But the per capita input from the US, including
  private sources, is much less than that from
  Canada, Switzerland, the Netherlands, and the
  Scandinavian countries
• Spent 157 million on HIV/AIDS, 373 million on
  child immunizations

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http//www.unicef.org/about/annualreport/2005/fina
nces/index.html
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IHOs Providing Long-term Health Care Assistance

• The United Nations Population Fund (UNFPA)
• Spent about 144 million of its 450 million
  budget (2005) on reproductive health programs,
  with 58 priority countries receiving 67.5 of
  this money. Priority is based on rate of
  population growth and poverty
• The United Nation Development Program (UNDP)
• Allocated 141 million, out of a total budget for
  field expenditures of 1 billion, to "health,
  education, employment."
• Major health concerns are AIDS, maternal and
  child nutrition, and excessive maternal
  mortality.
• In conjunction with the WHO the World Bank it
  sponsors the Special Program for Research
  Training in Tropical Diseases (TDR)
• www.unfpa.org www.undp.org

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http//www.unfpa.org/upload/lib_pub_file/615_filen
ame_annual-report_05.pdf
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IHOs Providing Long-term Health Care Assistance

• Bilateral Agencies
• Bilateral agencies are governmental agencies in a
  single country which provide aid to developing
  countries.
• The largest is the US Agency for International
  Development (USAID)
• Through its Bureau for Global Health, with an
  annual budget gt1.6 B in 2006, USAID
• Supports field health programs
• Advances research/innovation in areas relevant to
  its health goals
• Transfers new technologies to the field
• Most of this aid is channeled through
  "cooperating agencies" private IHOs which
  receive grants/contracts with USAID
• Most of the industrialized nations have a similar
  governmental agency
• Political and historical reasons often determine
  which countries receive donations from bilateral
  agencies and how much they receive.
• E.g. France concentrates on its former colonies,
• E.g. Japan gives mostly to developing countries
  in Asia.
• www.info.usaid.gov

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IHOs Providing Long-term Health Care Assistance

• Non-governmental Organizations
• The Bill Melinda Gates Foundation
• In 2000, the global health assistance landscape
  was drastically changed with the establishment of
  the Bill and Melinda Gates Foundation
• As of April 2006, the Gates Foundation has
  consisted of four divisions,
• Core operations (PR, finance administration,
  HR, etc.)
• Global Health Program
• Global Development Program
• United States Program
• Hence, the Gates Foundation is not a direct
  assistance provider, but rather a funding source
  for IHOs. Nevertheless due to the enormous amount
  of funds at its disposal the foundation holds
  tremendous sway as to the focus of IHO efforts
  and has quickly became a major influence upon
  global health.

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IHOs Providing Long-term Health Care Assistance

• The Bill Melinda Gates Foundation
• Consider that the approximately US800 million
  that the foundation gives every year for global
  health
• approaches the regular annual budget of the WHO
• is comparable to the funds given to fight
  infectious disease by the USAID
• provides 17 (US86 million in 2006) of the world
  budget for the attempted eradication of
  poliomyelitis (polio)
• As of 2006, the foundation has an endowment of
  approximately US33.7 billion
• To maintain its status as a charitable
  foundation, it must donate at least 5 of its
  assets each year.
• Thus the donations from the foundation each year
  would amount to over US1.5 billion at a minimum.
• Furthermore, in June 2006, Warren Buffett pledged
  10 million Berkshire Hathaway shares (valued at
  30.7 billion) spread over multiple years through
  annual contributions, essentially creating a
  matching fund that doubles the Foundation's
  annual giving.

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IHOs Providing Long-term Health Care Assistance

• For comparison, prior to 2000
• In the United States
• The largest NGO devoted to international health
  was Project Hope, with an annual budget exceeding
  150 million in 2006
• Worldwide, the most important NGO in long-term
  international health was Oxfam International.
• Founded in the United Kingdom in 1943, it now has
  affiliates in 10 other countries, including the
  United States.
• www.projhope.org
• www.oxfam.org

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IHOs Providing Long-term Health Care Assistance

• Aside from the Gates Foundation, non-governmental
  organizations (NGOs), also known as private
  voluntary organizations (PVOs), provide
  approximately 20 of all external health aid to
  developing countries.
• Most of these organizations are quite small many
  are church-affiliated.
• In the very poorest countries, hospitals and
  clinics run by missionary societies are
  especially important.
• Data from Uganda indicates that church mission
  hospitals are much more efficient than government
  health facilities, with mission
• doctors treating 5X as many patients as their
  counterparts in government facilities
• nurses attending 2X as many patients as
  government nurses do

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IHOs Providing Refugee and Disaster Relief

• Natural disasters, e.g. earthquakes, floods,
  volcanic eruptions
• The majority of deaths occur in the first few
  hours or days
• Likewise most of the lives that are saved are
  saved early on and saved by local efforts at
  disaster relief
• In the event of a major disaster, however,
• The resources of a poor country can be
  overwhelmed and, by destruction of an already
  tenuous economic and social infrastructure, set
  the stage for famine and epidemics
• Relief aid provided by IHOS in the days
  immediately following the disaster can play a
  major role in averting health crises and
  re-establishing a functioning society.
• Famines and refugee crises
• tend to develop slowly, often preceded by warning
  signs of the impending emergency
• IHOs can coordinate relief efforts with national
  agencies in a timely fashion.

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IHOs Providing Refugee and Disaster Relief

• UN agencies are probably the most important of
  the IHOs in these scenarios
• 6 major UN organizations are involved in refugee
  and disaster relief
• UNICEF, WHO, UNDP (also involved in long-term
  assistance)
• World Food Programme (WFP)
• UN High Commissioner for Refugees (UNHCR)
• Food and Agriculture Organization (FAO)
• However, several very large NGOs are active in
  refugee and disaster relief, notably
• International Committee of the Red Cross (ICRC)
• Médecins Sans Frontières

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IHOs Providing Refugee and Disaster Relief

• Multi-lateral Agencies
• United Nations Organizations
• The Department of Humanitarian Affairs
• Established in 1992, coordinates UN activities in
  this area.
• Operates on a 24-hr basis via the UN Disaster
  Assessment Coordination Team, which can be
  deployed immediately to an affected country.
• The WHO
• Division of Emergency and Humanitarian Action
• coordinates the response of the international
  relief community
• supplies technical assistance and emergency drugs
  and equipment
• UNDP
• Special function is organizing rehabilitation
  efforts in the disaster-struck area

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IHOs Providing Refugee and Disaster Relief

• UNICEF
• 20 of its 2005 budget (480 million) went to
  regular emergency relief

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IHOs Providing Refugee and Disaster Relief

• http//www.unicef.org/emerg/files/HAR_2006_final.p
  df

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IHOs Providing Refugee and Disaster Relief

• The World Food Program (WFP)
• Supplies food relief in disasters
• Coordinates the activities of NGOs involved in
  food relief, as well as assisting them with
  transportation and logistics.
• In 2006, WFP
• spent 2.28 billion (91 of its direct
  expenditures) on relief
• distributed 4.25 M tons of food aid 1.7 M went
  to emergency operations 1.95 M went to
  protracted relief and recovery efforts
• www.wfg.org
• The Food and Agriculture Organization (FAO)
• Technically an "intergovernmental agency related
  to the UN"
• Helps developing countries prepare for famine
• Global Information and Famine Early Warning
  System
• Food Security Assistance Scheme, which helps
  developing countries set up national food
  reserves
• In disasters its principal role is to assist in
  the re-establishment of agricultural production.
• www.fao.org

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IHOs Providing Refugee and Disaster Relief

• The UN High Commissioner for Refugees (UNHCR)
• the major international organization for the
  world's 20 million refugees
• provides international protection to refugees
• attempts to find long-lasting solutions to their
  problems
• aids refugees directly and coordinates the work
  of NGOs involved in refugee relief
• Although it has no formal authority over
  displaced persons, upon request of the UN General
  Assembly and the Secretary General, UNHCR has
  provided assistance to displaced persons
• e.g. Bosnia and Herzegovina, Somalia, and Rwanda
• In 2005, UNHCR spent almost 1.1 billion on its
  programs overall
• www.unhcr.org

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http//www.unhcr.org/publ/PUBL/449267630.pdf
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IHOs Providing Refugee and Disaster Relief

• Bilateral Agencies
• As is the case with long-term health care, most
  of the developed countries have a governmental
  agency dedicated to providing disaster relief.
• In the United States
• USAID spent 403 million on relief aid in FY2006
  through its Office of Financial Disaster
  Assistance to purchase distribute disaster
  relief supplies and to support relief activities
• water and sanitation, health, food security,
  agriculture, nutrition, shelter, capacity
  building, livelihoods, protection, income
  generation, psychosocial support, and demining
• The US Armed Forces also assist in disaster
  relief on occasion

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IHOs Providing Refugee and Disaster Relief

• Non-Governmental Organizations
• The International Red Cross Red Crescent
  Movement
• The International Red Cross and Red Crescent
  Movement is the largest of the world's
  humanitarian NGOs.
• It has three components
• the International Committee of the Red Cross
  (ICRC)
• the International Federation of Red Cross Red
  Crescent Societies
• the 160 or so individual national Red Cross
  societies
• e.g. the American Red Cross
• http//www.redcross.int/

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IHOs Providing Refugee and Disaster Relief

• The International Red Cross Red Crescent
  Movement
• The seven fundamental principles of the Movement
  are
• Humanity
• Impartiality
• Neutrality
• Independence
• i.e. autonomy vis-à-vis national governments
• Voluntary service
• Unity
• i.e. for each country, only one national society,
  open to all and serving the entire country
• Universality

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IHOs Providing Refugee and Disaster Relief

• The International Committee of the Red Cross
  (ICRC)
• is a Swiss organization, founded in 1863
• mandated by the Geneva Conventions to protect and
  assist prisoners of war and civilians in
  international armed conflicts
• It may also offer its services in civil wars
• Its functions include
• visiting and treating prisoners of war and
  political detainees and providing them with a
  communication service with the outside world
• setting up surgical hospitals or providing
  expatriate teams to work in existing hospitals
• providing other types of medical assistance and
  relief, especially rehabilitation of war-disabled
  patients
• development and dissemination of educational
  materials concerning health care of prisoners and
  victims of war
• the book Surgery for Victims of War is especially
  well-known
• In 2005, the ICRC expended about 593 million on
  protection, assistance, and preventive action
  programs
• www.icrc.org

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IHOs Providing Refugee and Disaster Relief

• The International Red Cross Red Crescent
  Movement
• The International Federation of Red Cross and Red
  Crescent Societies
• main mission is to provide disaster relief
• receives its principal support from the
  individual national societies
• issues international appeals for emergency aid
• works closely with the national Red Cross
  societies in the affected countries
• often serves as the organizing agency for the
  relief efforts of smaller organizations
• In 2005 it supplied
• US215 M in disaster supplies, transportation,
  storage
• US13 M in contributions to national societies
  other organizations
• www.ifrc.org

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IHOs Providing Refugee and Disaster Relief

• Medecins Sans Frontieres (MSF)
• MSF
• Founded in 1971 in France
• 6 operational centers in Europe
• 13 delegate offices throughout the developed
  world
• Provides health aid to victims of war and natural
  disasters
• Also
• provides aid in "chronic emergencies" (e.g.
  Somalia, Sudan)
• Assists in several long-term health projects
• publishes a series of field manuals/texts on
  disaster medicine
• In 2005
• spent over US536 M on its operations and
  humanitarian activities
• sent 4,768 volunteers into the field
• www.msf.org

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http//www.msf.org/msfinternational/invoke.cfm?obj
ectid992D03D9-5056-AA77-6C9F7BBBE9771A9Fcomponen
ttoolkit.articlemethodfull_html
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IHOs Providing Refugee and Disaster Relief

• Medecins Sans Frontieres (MSF)
• Unlike the Red Cross, MSF
• will enter war-torn areas without the permission
  of authorities
• considers one of its functions to be speaking out
  on human rights abuses
• (Note charter does include the same principles
  of impartiality and neutrality followed by the
  Red Cross)
• Usually means drawing attention to cases of human
  rights violations that MSF considers
  under-reported
• On occasion MSF will take a strong stand and
  denounce egregious violations, which can render
  its work more difficult and dangerous

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IHOs Providing Refugee and Disaster Relief

• CARE International
• Founded as CARE USA in 1946 to provide aid to
  war-devastated Europe
• Since 1980 affiliated CARE agencies have been
  established in 10 countries, leading to the
  creation of CARE International, headquartered in
  Brussels.
• In disasters, CARE has special expertise in
  transportation of supplies and logistics.
• Best known for providing food relief in the form
  of "care-packages", but the activities of CARE
  have expanded greatly over the past 50 years
• In the FY2005 budget,
• 514 million (91 of total spending) went to
  support programs
• 149 million on emergency aid
• 365 million to programs that promoted long-term
  development
• www.care.org
• http//www.care.org/newsroom/publications/annualre
  ports/2005/annual2005_full.pdf

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IHOs Providing Refugee and Disaster Relief

• Catholic Relief Services (CRS)
• CRS specializes in providing food relief
• In 2005, of 300 million in revenue
• 185 M on emergency assistance programs
• 48.7 M on health programs
• 83.3 M on HIV/AIDS programs
• 24.9 M on welfare efforts for the poorest, most
  vulnerable people
• More than half spent on food, warehousing and
  freight, and advances to implementing partners
• CRS works closely with Caritas, the international
  organization of Catholic charities
• www.crs.org

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Role of International Health Organizations

• Closing considerations
• This talk minimizes the complexity of the realm
  of IHOs
• We have discussed only the largest organizations
  and have not mentioned by name many excellent,
  somewhat smaller NGOs, with long records of
  valuable contributions to health care in
  developing countries
• Also, the discussion has been oriented to an
  American audience
• Omitting specific mention of outstanding
  bilateral aid agencies and NGOs in Japan, France,
  the United Kingdom and other industrial nations

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Role of International Health Organizations

• Closing considerations
• There are about 65 official multi-lateral and
  bilateral IHOs
• The total number of NGOs worldwide has been
  estimated at 1,500
• Several hundred US NGOs engage in international
  health work
• Other developed countries also have their own
  independent NGOs
• Not unusual to find 200 IHOs operating in the
  world's poorest countries at the same time
• Each of them tends to have its own priorities
• Unfortunately - despite some liaison committees
  and coordinating agencies, international
  meetings, and informal contacts - cooperation
  among these many organizations is not all it
  could be.

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HW Due Next Time

• Task 4
• Mini-update 1