Governing Global Health

• Author: David E. Bloom
• Position: Clarence James Gamble Professor of Economics and Demography at the Harvard School of Public Health
• Pages: 31-35

Page 31

How better coordination can advance global health and improve value for money

Health problems have never respected borders. leprosy spread from asia to europe in the 4th century B.C., thanks most likely to the army of alexander the Great. the Black Death originated in Central asia and subsequently ripped through europe and the Middle east in the 1340s. Diseases carried across the atlantic by european invaders decimated native populations in the americas in the 17th and 18th centuries.

Health threats have become increasingly global in modern times. In 1918- 19, the Spanish flu took an estimated 50-100 million lives-more than all those killed in World War I. and these days, the ever-greater integration of economies makes it that much easier for diseases, such as HIV/aIDS, to cross borders and leap continents. Moreover, some argue that if avian flu makes the jump to human-to-human transmissible form, the rapidity of its spread could be devastating. exacerbating matters, ill health can be spread through other spillovers of globalization. For example, climate change-driven largely by industrial expansion in the West and emerging markets-promotes desertification and drought (which result in food shortages and malnutrition) and will likely result in population movements (which could have a major impact on health). and national or regional economic policies, such as agricultural subsidies to european and U.S. farmers, hamper the prospects for developing world farmers to climb out of poverty and shrug off the diseases that are strongly associated with poverty and inequality. as the health system has become more global, new players have altered its shape. Private funding, once relatively insignificant, now accounts for nearly one-fourth of all development aid for health. For example, the Bill & Melinda Gates Foundation has emerged as the dominant player in that sector (seePage 32 table 1), with its expenditure accounting for nearly 65 percent of all private aid, worldwide, for health-and equal to more than half of the expenditure of the World Health Organization (WHO), to which essentially all countries belong. It is perhaps noteworthy that much Gates funding goes toward technology development (for example, new drugs and vaccines) that will ultimately translate into new ways of providing direct services. these new actors have dramatically increased the funds available for investment in global health. But depending on such institutions is risky. Private philanthropies are not accountable to the public, and their decisions may not be in line with the most urgent (or the long-term) needs of recipient countries. If their programs are ineffective, if resources decline, or if interest diminishes, recipient countries dependent on such funds may be left in the lurch.

At the same time as private philanthropy has increased, a plethora of financing bodies, bilateral donors, multilateral organizations, and business groups dedicated to tackling global health threats have emerged or expanded. like private donors, these groups are also not necessarily fully accountable to the public; often they respond only indirectly to nationally perceived needs. Bilateral donors contributed more than $8 billion in 2005 to public health, with six countries-the United States, Japan, the United Kingdom, Germany, France, and Canada-accounting for about 80 percent of the funds (see table 2). Most industrial countries are still well below the UN target of devoting 0.7 percent of gross national income to official development assistance; the portion going to health varies widely.

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Is the current system of health governance adequate to oversee the changing array of players and ensure that the right health issues are being tackled fairly, effectively, and efficiently? the answer appears to be no. New diseases have come to the fore, and many countries (including some relatively poor ones), at least partway through the epidemio-logical transition from infectious to chronic diseases, are experiencing a twin burden: they still have high morbidity and mortality from the traditional diseases of poverty, but also face obesity, diabetes, lung cancer, and heart disease. What, if anything, can be done to amend and strengthen current governance arrangements so that they more adequately respond to the challenges at hand? this article examines the successes and failures of the current system of global health governance and suggests the beginnings of a way forward.

Global health achievements

Over the past few decades, the global health governance system has recorded a number of successes. It should be noted here that by governance we mean the manner in which governments, the private sector, and civil society make and implement decisions to promote and protect good health. as such, it includes not only the roles of public and private organizations, but also the formal and informal rules and traditions through which these institutions relate to each other and to the people whose health they seek to defend. Governance also encompasses fostering the exchange of information-about actions and strategies that have proved successful and about those that have not worked.

The most prominent of the...