The group of Emerging Voices voiced some questions and concerns about the idea of a global fund for health in the three weeks we spent together. We welcome their often penetrating questions and would like to open the debate on this topic.
Amal Shafik (Egypt), one of the Emerging Voices, phrased her concerns in most detail. Hence, by way of kicking off the discussion, we publish here Amal’s questions and Gorik Ooms’s answer, point by point. Both are part of a larger discussion and should be seen as thoughts rather than firmly crystallized opinions at this stage. Some comments we already received on these thoughts will be posted hereafter. We encourage you to give your own input to the discussion.
Hopefully in the end we might be able to come up with a proposal for a global fund that finds the right balance, respecting the views of both Northern and Southern actors and embedding common values to support mutual goals and – dare we say – the human rights commitments that both sides of the earth share in a wide range of fields.

David Hercot inspired by Kristof Decoster and Rachel Hammonds.

Dear all,

I have mixed feelings too with regards to the different messages during the conference. Are we really in the direction of global support and international funding and responsibility; several questions come to my mind and go into circles without clear answers:

1. Who is behind the shift towards a global fund ? and why?.
2. How will this affect the countries that are thriving for financial self reliance? will it slow down their endeavor or will they abandon their cause?
3. Will this be a monopoly of fund? I hope not , but having different partners is always a blessing.
4. last but not least , who will be the recipients ? corrupt undemocratic governments? or state run organisations?
5. As a noble cause no one can argue against a global responsibility , but the devil is in the details , and so far I didn’t hear much about how will this end up reaching the people ( The rightfully targeted recipients)

But maybe the answers are already there, I will try to know more before reaching a final verdict. With this I rest my case….

Kind Regards
Amal

Dear Amal, and all,

Amal, thanks for these questions. Before I try to answer them one by one, let me give you some personal thoughts (which are probably not shared by all who support the idea of global responsibility for health). Then I’ll come back to your questions.

First, I think the idea of country autonomy, even if attractive, is an anachronism. In the 21st century, no country is truly autonomous. Some rely on food production by other countries. Or even oxygen (not enough trees left in Belgium). Some rely on international cooperation to protect their own citizens from terrorism, or from the risk of becoming drug addicts. Almost all countries rely on almost all other countries to protect their own inhabitants from the impact of climate change. So let’s accept mutual dependence, and let’s try to manage it. And yes, the list includes health. Richer countries should not expect poorer countries to reduce or stabilize greenhouse gas emissions, if they do not want to take responsibility for health in poorer countries.

Second, I do not believe that an uncorrected free market will eventually reduce global inequalities. Free markets rather tend to increase inequalities: they protect the stronger players (families, companies, or even countries), who can use their gains to invest in future comparative advantages. There are always exceptions, but as a general rule one can predict that the rich will most often become richer, while the poor become poorer. That is why not a single richer country has managed to maintain a stable society based on free market economy without substantial regulation and redistribution. Even in the USA, the so-called ‘free market paradise’, 25 percent of the economic product is permanently collected by federal and state governments, and redistributed (and I would argue that present realities in the USA show this is not nearly enough). Of course, a part of the needed redistribution can take place within countries. But there’s a striking difference between 25 to 50 percent of the economic product being redistributed within richer countries, permanently, and less than 0.5 percent of the economic product of the world being redistributed beyond borders. For the sake of a stable global society (which is in my self-interest, and the interest of my children and grandchildren – no ‘noble’ feelings required, even if they would help), we need global redistribution of wealth, and health should be one of the priorities.

Now let me turn to your questions.


1. Who is behind the shift towards a global fund? and why?

I think this is a double question. First, who’s behind the idea of global responsibility for health? Second, who’s behind the creation of a Global Fund for Health to manage that global responsibility?

On the first question, there’s a growing number of people who realize that the objective of Alma Ata (‘health for all’) is inconsistent with one of its assumptions (that primary health care should be provided at a cost affordable to countries and communities, in the spirit of self-reliance). Some countries are simply too poor (and the global free market does not really help them to grow out of poverty. That became very obvious because of the AIDS epidemic). But there is no consensus on this, as I tried to explain in my previous message. Another example: the most recent World Health Report (issued yesterday) acknowledges explicitly that some countries will need international assistance during many years to come; the previous did not.
On the second question, there’s a handful of people (including some at ITM, not everyone), who believe that if international assistance is required during many years or decades, we might as well organize it that way (rather than continuing to pretend assistance is only for a few years), and that the model of the Global Fund (for AIDS, TB and malaria) is probably the most promising one. The key issue here is binding commitments: from poorer countries, about national efforts (to make sure international assistance does not replace national efforts); from richer countries, about international efforts. Only then ministries of health and other ministries contributing to health will be able to make long term plans.
Do we really need a central (global) pool for that, like a Global Fund for Health? In theory, we don’t. In practice, commitments like the one richer countries made a few decades ago (to allocate 0.7 percent of GDP to international assistance) and the one African countries made a few years ago (to allocate 15 percent of the budget to health) have very little impact. Commitments to share the burden of the cost of UN agencies or the World Bank do seem to work better. Even if some richer countries at times did not live up to their commitments, at least everyone knew about it (and in the long run, most countries pay their arrears). Furthermore, I find it difficult to hold poorer countries accountable for their commitments, if richer countries do not live up to them.

2. How will this affect the countries that are thriving for financial self reliance? will it slow down their endeavor or will they abandon their cause?

For several reasons, I don’t think so. The first reason is mentioned above: a Global Fund for Health should be based on mutual commitments. It should reward poorer countries that try harder, rather than doing the opposite. The second reason is that, because present international assistance is unreliable, some countries are reluctant to increase their total health expenditure, but rather than refusing assistance, they are tempted to reduce national allocations (thus moving further away from self-reliance). Third, I do believe that health has a positive impact on the economy. So if more reliable assistance based on mutual commitments improves health, it will improve poorer countries’ ability to finance more health themselves. (So paradoxically, not aiming for self-reliance as one of the first objectives of international assistance may well help to achieve self-reliance faster. This paradox is true for national social protection as well. ‘Universal’ social protection measures – in the sense of provided to all, including the richer who might not need it – often seem more effective in reducing poverty than ‘means tested’ efforts aimed at the poorest only.)

3. Will this be a monopoly of fund? I hope not, but having different partners is always a blessing.

Not a monopoly but, in my opinion, a core funding channel, providing assistance for planned recurrent expenditure. From the perspective of poorer countries, there is a trade-off between having many different but small and unreliable partners and having a single big and more reliable partner. But there will always be unanticipated events and needs, for which the flexibility of bilateral aid will be required. So this is a matter of finding the right balance.

4. last but not least , who will be the recipients ? corrupt undemocratic governments? or state run organisations?

The added value of something like a Global Fund for Health – long term predictable assistance, allowing long term planning, like training, hiring and retaining health workers – is the most obvious for well-governed countries, with a serious commitment to health. The Global Fund we have at present does have ways to finance civil society organizations and non-state providers of services; these ways can be used in countries where the government is not a reliable partner. But it would not have the same effect. When it comes to helping the people of countries where the government is not a reliable partner, the comparative advantage of a Global Fund for Health (instead of bilateral aid) is not that obvious. Again, this is a matter of finding the right balance: for some countries a single big government partner would be the best solution, for other countries it would not.

5. As a noble cause no one can argue against a global responsibility, but the devil is in the details, and so far I didn’t hear much about how will this end up reaching the people (The rightfully targeted recipients)

I think the inclusion of civil society in the decision-making platforms of the Global Fund has helped to improve assistance reaching the people. There are several examples of civil society holding their governments accountable by complaining directly to the Secretariat of the Global Fund about medicines not being available. However, the main reasons why Global Fund assistance does not always reach the people who need is most, is its hesitations about strengthening health systems. So people who do not live within the reach of health providers also do no benefit of Global Fund assistance. That problem could be solved by expanding the mandate of the Global Fund. (However, if some of the advocates of health systems strengthening believe that international assistance is not required, it will be tough to expand the mandate of the Global Fund.)

Nonetheless, as mentioned above, a Global Fund for Health would not be a miracle solution. In countries where the government really does not care about the health of the people, there’s not much the international community can do, with or without a Global Fund for Health. In such countries, bilateral aid might be more effective. (Which reveals another paradox: bilateral donors seem more inclined to assist governments directly.)

These are only beginnings of answers, but I hope they are nonetheless useful (and if they contribute to a dialogue within the emerging voices group, I would be very happy).

Take care,

Gorik

12 Responses to Will a global responsibility mechanism to fund health arise and in the end will it affect the people?

  1. Dr Jean Patrick Alfred says:
  2. Dr. Omesh Kumar Bharti, India says:
  3. Gorik Ooms, Belgium says:
  4. Khim Keo Vathanak, Cambodia says:
  5. Dr Omesh Kumar Bharti, India says:
  6. Kristof Decoster, Belgium says:
  7. Amal Shafik, Egypt says:
  8. Gorik Ooms, Belgium says:
  9. Meena Daivadanam, India says:

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