Chatham House (UK) and the Harvard Global Health Institute have released a new working group paper on “Development Assistance for Health (DAH): Critiques and Proposals for Change” by Suerie Moon and Olawatusin Omole that impressively rounds about some of the key developments in DAH, asking some important questions on the sustainability, feasibility and the politics and governance of global health financing. Are existing resources sufficient and being expended effectively? Who should dole out these resources, how, and how much? And also, from a governance perspective, how should priorities and choices be aligned? These questions have attained special import in the context of a global health fiscal crunch as various entities rebalance and remodel from the financial crisis. Laurie Garrett’s piece on expected cuts in global health captures the parlous nature of the extant budgetary scenario. Needless to say, the overall picture is grim.
The working paper sums up some the prevailing problems of the existing DAH system – lack of total financing, volatility and uncertainty with which its deployed, effectiveness of external financing vis-a-vis domestic health spending (i.e. not having the former displace but supplement the latter) and several surrounding the politics of DAH – how the agenda and attendant priorities are set, coordinating these choices between plethora of actors, holding stakeholders accountable for the choices made and finally, what should the systemic rationale behind future DAH. Proposals to correct existing gaps are pivoted around instituting innovative measures to increase financing (e.g international taxes, levies, etc.), governance oriented reforms that endeavor to develop a more coordinated, efficient, representative and accountable DAH system for donors, recipients, institutions and various channels. Finally, the report also considers broader proposals that could embed DAH into overarching global health instruments (FCTC), potential global mechanisms like a global social protection fund and other issue based conventions on R&D, obesity, alcohol and chronic diseases that would enable DAH to be channelled laterally for issue based concerns.
These questions are being asked in rapidly shifting global health milieu that is being redefined by three concurrent transitions: health, captured by a tension between two public health priorities: communicable and infectious and chronic/non-communicable diseases; geopolitical, marked by an ongoing shift of economic and political power east and the emergence of multiple ‘poles’ of global influence that is and will complicate international cooperation; and a development transition with an impending shift of priorities being discussed under the post-2015 MDG dialogue. No doubt, developments and pressures under these ongoing transitions will have a critical impact on the future global governance of DAH. Existing ideas and proposals, however, need to better grasp the underlying global politics of health and the consequences of these three critical transitions to be able to negotiate proposals and ideas like the ones proposed in the working paper. Here, I will attempt to offer some thoughts on the efficacy of the reforms and proposals under consideration by situating them within some of the emergent fault lines in global health politics, borne out of the transitions underway; it goes without saying that these underlying fault lines will have a significant impact on policymaking in global health.
First, leadership is critical for global health agenda setting and earmarking which health priorities will eventually receive funding. Existing global health institutions like the WHO and World Bank have led the charge on this front. But there is evidence to suggest that this dynamic is changing. In a recent GEG working paper, Devi Sridhar and Ngaire Woods posit that multilateral cooperation in health is gradually being reshaped by a narrow set of countries and actors that seek to inject and impose their priorities over the system at large. ‘Trojan Multilateralism’, as they refer to this dynamic is captured by a process where the success of vertical initiatives (e.g. Global Fund and GAVI) is now influencing and redefining the health agendas of multilateral infrastructures, like the WHO and World Bank, by driving them to focus on similar vertical initiatives at the expense of other health priorities that are more complex and long-term in nature. The rise and triumph of vertical initiatives that largely focus on communicable diseases wrests capital and energy away from other health challenges that require global attention – and importantly negotiation and participation. As Sridhar and Woods argue, the rise of ‘multi-bi’ aid to to multilateral health organizations (30% of non-core funding) signifies an important development; through this practice, donor countries are able to determine how and where their proceeds are being disbursed by multilateral agencies, giving them substantial writ over the programmatic aspects of multilateral health organizations. At the same time, core budgets are being gutted. Take the WTO, their budgetary growth over the decade has been largely confined for discretionary purposes for specified causes. And the same is the case for the World Bank’s health portfolio, which has exponentially risen for targeted campaigns. Troublingly, the rise of such financing policies narrow the global health agenda priority-wise, which has been infectious diseases over the recent past as other problems rise to the fore. According to the recently unveiled Global Disease Burden (GBD 2010), population aging and global demographic shifts have accelerated the onset of chronic diseases, like heart disease and cancer across the world, most acutely in developing countries. Tobacco use contributes to 70% of all lung cancers – the single largest preventable cause of cancer worldwide. Mental disorders such as depression are amongst the leading causes of disability. Lack of access to nutritious foods impairs early child development and growth. Road fatalities cause numerous deaths in the global south. As the list of global health challenges widens, the processes that determine the prioritization and concomitant management of these problems appear to be narrowing. Sectional interests attain precedence. Negotiation and contestation are on the wane. DAH analysts must come to grips with this dynamic and work to widen the discourse surrounding global health to ensure that processes in place are able to ably grapple with gamut of emergent epidemiological concerns, not just problems that are amenable to specific interventions. Critically, we need to figure out how to deploy discretionary funds for these challenges as well.
Second, the prospect of ‘thinner’ institutional processes and watered down priorities does not bode well for understanding the role of emerging powers, whose interests and ideas need to be elicited and balanced for the global governance of public health. Structurally, establishment bodies like the WHO and World Bank represent sovereign nations, who determine the core budget of these institutions through a consultative process. If multilateral health processes align themselves with the interests and priorities of western donors and states, as evidenced by the preceding study, it precludes existing institutions from adequately considering the needs and concerns of developing and transitional countries. It is now vital to consider and incorporate the interests of the global south. One note-worthy addition to the global health literature looks at Asia’s role in governing global health, examining the role played by Asia in the governance of a range of global health issues, from development assistance in health, to global health instruments dealing with tobacco control and disease outbreaks, to health research and knowledge products. From this volume and its coverage of DAH, its safe to surmise that major Asian powers (China and India) will fashion their accord with global health institutions strategically, leveraging the knowhow and leadership of western donors and other entities like the Global Fund, GAVI to tackle infectious diseases on their territories whilst expending considerable amount of money to address chronic diseases domestically. Both China and India have upped the ante, in the recent, in terms of domestic health spending given the dominance of chronic diseases to their national disease burden. Combined, both countries are home to more than 34% of the world’s 784 million people aged 60 and older in 2011. China’s proportion of older people will grow from 12% of its total population currently to 34% in 2050; India’s older population will grow from 8% to almost 20% over the same time period. To confront this menace, both countries have increased their domestic public health budgets for the period of 2008-12. Going ahead, it is likely that both Asian powers will balance their global and domestic health agendas, seeking to leverage the support of existing institutions, public and private, to address acute problems like infectious diseases whilst confronting the chronic disease problem domestically. Both countries will likely play a marginal role in existing global health debates; on the ongoing health transition that hopes to redirect attention on the linkage between globalization and health, which has an inordinate impact on chronic diseases, the prospects of their engagement to shift global health priorities within multilateral agencies to focus on chronic diseases are slim, at best.
And finally, how do DAH priorities and choices align with the interests of leading major powers and can one expect a greater emphasis on global health through their foreign policy? Over the past few years, health has ascended as a strategic and core foreign policy issue for several governments, in turn, arriving as a formal and informal priority in global politics. Consequently, it is critical to examine the motives underpinning this shift as nations place a greater premium on health as a foreign policy objective. Is their global health engagement driven by security concerns or by a clear and tangible desire to improve public health abroad? This question is important since the health assistance and other kinds of health oriented engagement they provide will be channelled differently. For example, if a security concern exists, donor countries will find it hard pressed to work with non-state actors and other civil society groups and instead work with recipient governments on narrow, more state oriented concerns like spread of infectious diseases and protecting against biological and chemical weapons, issues that reflect foreign policy and strategic goals, not development or public health issues. If donors conceptualize global health engagement through a health lens, issues like maternal and infant mortality, malnutrition, water and sanitation, issues that often require coalitions between different types of actors will attain precedence. A brief overview of global health diplomacy suggests that fault lines are emerging with western countries like US, UK, Switzerland, other European nations choosing to focus on health issues that affect a critical mass of people in the global south and countries like China, India (and to a certain extent Japan) choosing to deploy health assistance for strategic purposes, that benefit both donors and recipients. Going ahead, this fault line will need to considered at much greater length within existing global health institutions and other vertical initiatives like GAVi and Global Fund that look to emerging countries for financing. A normative gap is emerging in global health diplomacy between the east and west.
This post has considered three developments that will inevitably affect DAH and its efficacy in the near future – programmatic implications associated with the rise of vertical initiatives in global health governance that corrode and color multilateral cooperation in health, the consequent thinning of global health priorities and their potential impact on reducing the ‘globality’ of global health since countries whose public health priorities divert from existing priorities will largely choose to work around the existing system and finally, the influence of global health diplomacy on DAH, especially whilst looking at the ways through countries have chosen to structure their global health choices hitherto and their effect on the global DAH agenda. Collectively, these three areas constitute and foreshadow the deepening of fault lines in DAH as we attempt to confront several critical challenges on the global health front. Stay tuned.