Short Overview of International Cooperation in Health Sector

By: Bikal Dhungel

Development Cooperation and Health are closely related. Health sector consists of substantial portion of development assistance. Aid for other causes like social infrastructure, population policies, water supply and sanitation, environment etc. is also closely related to health. Among the eight Millennium Development Goals (MDGs) established by the United Nations in 2000, five are directly related to health. This implies that the importance of investment in health sector is immense. It is also very essential because the developing world faces the largest share of global burden of diseases. 80% of disease burden is faced by developing countries with only 20% of health spending. Developing countries should not be left alone in this matter because without the support of international community and organisations, they cannot tackle the problem alone. On the other hand, it is a well-known fact that diseases don’t have any borders. An outburst of communicable disease in a part of Africa or Asia can easily reach the shores of Americas through various means. Hence, a state of poor health and vulnerable health condition of some parts of world can be dangerous for all people. A global strategy is needed to fight the burden of diseases and for this reason, the international community is committed to support the developing countries financially. The establishment of World Health Organisation ( WHO ) as a part of United Nations (UN) enhanced the cooperation between developing and developed world in terms of professional consulting and recommendation and recently also in financial support. Along with the WHO, today many non-governmental organisations ( NGOs ), foundations and countries have stepped-in to provide development aid in health sector. This article will provide the basic overview of health sector in relation to developing cooperation. Development Assistance has come a long way. The Marshall Plan initiated by then US secretary of state George Marshall to help re-build Europe can be taken as first such action regarding international assistance. A short chronology of events gives us a quick picture of development of ODA taken by OECD website.                                  

                                                                              1944

The conference of Bretton Woods, New Hampshire, USA lead the establishment of the International Bank for Reconstruction and Development ( World Bank ) and the International Monetary Fund ( IMF )

                                                                              1945

 The United Nations ( UN ) was established to preserve peace through international cooperation

The Food and Agricultural Organisation ( FAO ) of the United Nations was founded.

                                                                              1946

The International Labour Organisation ( ILO ) established as specialised agency associated with the United Nations

The UN General Assembly established UN International Children’s Emergency Fund ( UNICEF ) and UN Educational, Scientific and Cultural Organisation ( UNESCO )

World Bank and IMF start operating

                                                                              1947

Secretary of State George Marshall launches the idea of european recovery program called Marshall Plan

                                                                              1948

The World Health Organisation ( WHO ) is established

The United Kingdom set up the Colonial Development Corporation

Swissaid was formed

                                                                              1951

Lewis Report published by the UN which proposed the establishment of a special UN fund for Economic Development and an International Finance Corporation ( IFC )

                                                                              1957

The European Development Fund for Overseas Countries and Territories is set up

                                                                              1959

The UN create a special fund as an expansion of their existing technical assistance and development activities.

Inter-American Development Bank ( IDB ) is established by 19 Latin American countries and the US

                                                                              1960

The Development Assistance Group ( DAG ) is found as a forum for consultations among aid donors on assistance to less-developed countries.

                                                                              1961

The United States Agency for International Development ( USAID ) established

                                                                               1962

Danish International Development Agency ( DANIDA ) established

                                                                               1968

Establishment of the Canadian International Development Agency ( CIDA )

Norwegian Agency for Development Cooperation ( NORAD ) was formed.

                                                                               1974

German Technical Cooperation ( GTZ ) established. Again abolished in 2010 and a new organisation called GIZ ( German International Cooperation ) was formed.

                                                                               1990

OECD establishes the Center for Co-operation with European Economies in Transition ( CCEET )

Mahbub ul Haq and Amartya Sen Created Human Development Index ( HDI )

                                                                                 2000

The UN Millennium Summit and the Millenium Development Goals ( MDGs )

This shows that International Development has evolved a long way through. Today, the aid givers have increased substantially. Apart from governmental and non-governmental organisations, other private sector donors, private-public partnerships, foundations, individual people and groups emerged as major donors. The figure below shows the major donor countries in terms of real number and percentage of Gross National Income ( GNI ).

(Source: OECD Statistics, 2013)

It shows that largest economies of the world are not necessarily the most generous donors. The United States is the largest donor in terms of total sum but it lies on 20^th position in terms of % of GNI. Similarly, Japan, the third largest economy in the world is fourth largest donor in terms of total amount but lies one position ahead of the United States in terms of % of GNI. The United Kingdom on the other hand is 6^th largest economy of the world (World Bank) is 2^nd largest donor in terms of total amount, fifth in terms of percentage of GNI and has almost reached the Millennium target of 0.7%. The UK government has committed to reach the goal by 2013 and aid remained untouched even during the time of Economic Recession. Other countries that have reached the millennium target shown in the figure above are small countries like Norway, Sweden, Luxembourg and Denmark. Norway and Sweden have crossed the threshold of 1% of GNI. Unfortunately, it also seems unlikely that other countries on the donors list will meet their millennium target by the end of 2015.

The figure below shows the per capita aid disbursement per recipient in 2008. Among the recipients, most of the countries either have on-going conflicts or even war. Gaza, Afghanistan, Iraq, Democratic Republic of Congo and Lebanon have long lasting conflicts and are very dependent on international aid. 

 

(Source: World Development Report 2008)

Also in terms of total flow, shown in Figure below, the major recipients are countries that are facing on-going conflicts. 

However, each country is different in which sector it provides aid the most. The figure below shows that most US aid, goes for Peace and Security whereas only 19% for economic growth.  A quick look about the situation of development aid was necessary to drill more about the aid and development cooperation in health sector because otherwise it is easy to get confused. People ask why there was not enough support in terms of health. That is why, looking at the aid story will give us a picture that health is not the only sector receiving less support but everything else get less support. Aid in terms of percentage of GDP of recipient is way too low. It can barely change anything.  

Development Aid in Health Sector:

Aid in health sector had its take-off after World War II through the establishment of various organisations and international bodies. Apart from Rockefeller Foundation ( established in 1913 ) and Wellcome Trust ( established 1936 ), most of the major donors and contributors in health sector were established after war. Establishment of the UN followed with UNICEF (1946), WHO (1948), UNFPA (1969) and UNAIDS (1994). Private foundations like Bill and Melinda Gates Foundation (2000) and other privately initiated institutions like Medicin Sans Frontieres (1971) emerged as a major contributor in health especially in developing countries. The figure shows the percentage of Health funding by big actors like Unicef or WHO. 

The total fund balances of UN Agencies are alone $5.66 billion. The Bill and Melinda Gates Foundation has an endowment of 38.3 billion (Source: Gates Foundation) for charitable purposes whose substantial part goes for Healthcare. The Rockefeller Foundation has an endowment of $ 3.6 billion which includes a giving amount of $135 million (Source: Rockefeller Foundation). Since its establishment in 1913, Rockefeller Foundations contribution in Health sector has been huge for example in launching the influential public health schools of today like Johns Hopkins and Harvard.

Thanks to the effort of above mentioned organisations as well as other private initiatives, the 20^th century was a huge success in Healthcare and disease prevention. Also in terms of disease reduction, it is a huge milestone since many diseases that killed humans in the previous centuries could be treated with the help of modern medicines. Without the help from today’s developed countries especially in the form of knowledge transfer and financial support, this would not have been possible. The major achievements in the health sector in 20^th century have been as follows:

-          - Eradication of Smallpox by 1977

-          - Polio remains in only handful countries

-          - Diptheria, whooping cough, measles and tetanus are rare or absent in many parts of the world.

-          - Child mortality has declined almost everywhere

-          - Vaccination Programs

-          - Decline in deaths from coronary heart disease and stroke

-          - Family Planning

-          - Safer and healthier foods

-          - Motor-vehicle safety etc

Moreover, the world is on the best way of providing a universal healthcare. The use of information technology has supported the care for example the use of mobile technology. A patient in rural area does not need to come to the city for minor illnesses. The doctor sitting in urban areas can provide treatment through a mobile phone. The availability of internet and e-health can help the rural dwellers to retrieve information about healthcare. Hence, aid in modern day technology has helped to improve the health of people who would not have an access to healthcare in the absence of these technologies. The figure below shows that from 1973 onward a trend to health aid is moving upwards. Especially from the beginning of 21^st century, the growth is at faster rate. This can be attributed to Millennium Development Goals which accelerated the development aid in real terms even though most of the countries are yet to fulfill their promises to reach 0.7% of their Gross National Income. But what we can highlight is, health is important, development cooperation in health sector is most important and ignoring health sector will have bigger consequences in the future. 

However, it should also be understood that Health is a single entity, there are many areas within health for example fighting Malaria might be more important than any other disease, may be reproductive health should have higher priority than any other. That is why the cooperation needs to be differentiated, that should be country specific according to the need of a country and rather than focusing on treatment policies, prevention measures should also be focused. For this reason, there are many specializations designed for particular purposes since Health is a broad topic. Aid Organisations differentiate health aid mainly into three types (Source-OECD):

i)                    Health, general

o   Health Policy and administrative management

o   Medical Education/Training

o   Medical Research

o   Medical Services

ii)                   Health, basic

o   Basic health

o   Basic health infra-structure

o   Basic nutrition

o   Infectious disease control

o   Health Education

o   Health Personnel Development

iii)                 Population Policies/Programmes and Reproductive Health

o   Population Policies and management

o   Reproductive Health Care

o   Family Planning

o   STI Controls including HIV Aids

o   Personnel Development for population and reproductive health

In addition to this, organisations and individual governments have aid targeted for particular purposes. US President’s Emergency Plans for AIDS Relief ( PEPFAR ) supports nations to battle HIV/AIDS. It was estimated that in 2003, only 50,000 people were receiving treatment for HIV/AIDS in sub-saharan Africa. By 2008, the number raised to 9.7 million after the support of PEPFAR (Source: PEPFAR website). Similarly, Malaria, which kills over 1 million people yearly and makes 300-600 million people suffer (Source: Unicef) has attracted its own working group that are focused on fighting Malaria. Within the big foundations like BMGF, there are sub-groups that are committed to tackle Malaria only.  The following table provides few organisations that are actively engaging in Malaria and TB.

Malaria Organisations and Projects -          Africa Fighting Malaria -          African malaria Network Trust -          Friends of the Global Fight Against AIDS, Tuberculosis, and Malaria -          Global Malaria Action Plan -          Malaria Consortium -          National Institute of Malaria Research -          Nothing But Nets -          Spread the Net -          Unitaid -          Malaria Foundation International

Tuberculosis Organisations and Projects -          Stop TB Partnerships -          Socialist Health Association: Fight Against TB -          Support to the Global Plan to stop Tuberculosis -          Provision of Anti-Tuberculosis Drugs -          Multi-Country Tuberculosis Control -          ……

Multi-national organisations have also emerged as donors for health sector in the form of private-public partnership (PPP).  Since the Global Fund’s inception, businesses, corporations and social enterprises through to philanthropic foundations and individuals have contributed to the work of the organization in a variety of ways (Source: Global Fund website):

·         - Financial contributions and marketing campaigns

·        -  Pro bono services and core competency partnerships

·         - Support for advocacy and governance, globally and locally

·         - In-country co-investments and operational contributions

Concluding everything, Health Sector has many actors, there are international organisations, there are organisations that channel funds to those areas that need them, there are developing countries government who work with such organisations, then local groups within developing countries. They are responsible for providing healthcare facilities in poorest countries. If any one of them is not playing their role in a responsible way, it is the poorest who should suffer. Shortfalls in international organisations are mostly about irregularity of their finance, problems with poor countries are for example wrong priority. They spend more than necessary for security reasons but less for health and education. It is because the ruling class mostly enjoy private healthcare which are costly for the poorest and it is not in the interest of the rich to take care of the poor. Moreover, few politicians in developing countries have openly told that if they solve the problem themselves, they will not receive any aid, which they can swallow on the way to the poor. If foreign countries are determined to solve their problems anyway, why should they care? As long as this practice continues, we will not see proper growth of well-being in poor countries. However, this can be the matter of different discussion. This article highlighted some of the basic facts of health sector cooperation, bit in an unstructured way but this is why it is called a blog and not an academic journal.