Global Health Financing“Follow the money” in order to better understand the framework for global health governance

Timothy K. Mackey, MAS, PhDFundamentals of Global Health

Summer 2016

$35.9 billion

36.4 billion in DAH (2015)

1.5 trillion DOD project(400bil over budget)

Fast Facts:

US accounts for largest source of DAH ($13.1 billion)

$2.9 billion v. $5.4 billion?

96.6% increase

Increase in funding for “other” infectious diseases (including 1.1b for Ebola)

from 2013

GLOBAL HEALTH FINANCINGMACRO TRENDS (1990-2014)

1990 -2000

2000 -

2010

2011 -

2013 2015 Future

Marked by minor but

stable increases in DAH. 5.4% annualized

growth.

Rapid growth

following launch of

MDGs. Peak of 11.3% annual

growth rate.

Slowing in growth due

to global fiscal crisis. 2013-2014

DAH dropped

1.6%.

$36.4 billion less than

overall high in of 38bil in

2013. Change in funding flows.

Plateauing of DAH? Are the new

SDGs set to evolve DAH

disbursements?

McCoy et al. (2009)

• Older article from 2009; most analysis on DAC OECD donors

• Data sources comprised of secondary data from published literature; annual reports of actors; and unpublished data (grants etc.)

• Maps and differentiates the source, management, and spending of global health funds

• Fragmentation of funding, complicated and inadequately tracked

• Proliferation of actors with impact not well known

Funding Instruments

Funding Instruments

Szlezak et al. (2010)

• PLoS Med, Harvard, funded, commissioned as part of 4 series on Global Health financing

• (1) essential characteristics of functioning national health system; (2) case study of Malaria and changes in partnerships, research, and delivery; (3) further research on 3 primary questions of project.

• Improvement of coordination necessary to avoid waste, inefficiency and turf wars

• Sustainable financing and equitable resource sharing

• Ensuring sufficient long-term investment and creating mechanisms for M&E

• Role and effectiveness?

Funding Instruments - IHME

“SOURCE”

“CHANNEL”

“RECIPIENT”

Sridhar (2012)

• Multi-Bi Financing? Essentially earmarked funds provided to multilateral agencies (vs. multilateral and bilateral)

• Highlights increases in WHO voluntary contributions and World Bank’s increases in its trust fund portfolio

• Multi-bi allows funders to realign objectives of multilaterals with their own and side step governance structures and engage in “performance-based” financing

• Priority setting behind the scenes? Autonomy of multilaterals?

Beginning 1980s U.S. withholds or threatens to withhold arrears, specific programs targeted. 1985 Kassenbaum-Solomon Amendment made withholding contingent upon U.N. reform.

U.S. Congress continues withholdings, U.N. does not recognize reduction in U.S. assessment. By 1998 U.S. arrears total $1.29 billion. U.N. suffers, with U.S. representing 2/3rds of total arrears.

By 1998, U.S. risks losing vote in U.N. General Assembly due to build up of arrears. In response, U.S. Congress enacts Helms-Biden Act to authorize payments.

Progression to Helms-Biden LegislationHistory of U.S. – U.N. Arrears

1990s

1980s

Helms-Biden

Conflict and CooperationHistory of U.S. – U.N. Relationship

• Staged Payments: Authorized staged payments of arrears to U.N.

• Reforms: Required U.N. reforms including zero-growth restriction on U.N. budget and reductions in U.S. assessments

• Negotiation: U.N. and other member states eventually agree to phased reductions in U.S. assessments

The late Richard Holbrooke, then ambassador to the U.N., was instrumental in negotiating the Helms-Biden Act provisions

Key Facts:-U.S. historically pays highest U.N. assessments-Proportionate share lower than poorer countries-29 countries agreed to higher assessments -U.N. suffered severe shortages and had to borrow money for operations

World Health Organization

NEXT: In-class workshop: Global Health

Financing?

In-class Workshop (if time permits): Groups of 4

1) Pick a Global Health Actor: Pick a global health actor to explore. It can be a country, a multilateral, a bilateral agency, an NGO/private foundation, or a private sector actor.

2) Identify Key Characteristics: Search the internet to identify the following key characteristics:

a) Type of actor: What type of actor is this (state government, UN agency, bilateral, public-private partnership etc.)?

b) What type of instrument is it? : Is it a source, channel, recipient, or some combination thereof?

c) Organization budget: Google search to try to find out what the organization’s overall budget is. If information is available, check to see what it is generally spent on (diseases, health projects, etc.)

3) Student Presentation: Report findings and tell us in general how influential you think this organization is in the context of the entire global health system.