The Challenge of Global Health

Laurie Garrett

From Foreign Affairs, January/February 2007

Summary:  Thanks to a recent extraordinary rise in public and private giving, today more money is being directed toward the world's poor and sick than ever before. But unless these efforts start tackling public health in general instead of narrow, disease-specific problems -- and unless the brain drain from the developing world can be stopped -- poor countries could be pushed even further into trouble, in yet another tale of well-intended foreign meddling gone awry.

Laurie Garrett is Senior Fellow for Global Health at the Council on Foreign Relations and the author of Betrayal of Trust: The Collapse of Global Public Health.

Meanwhile, the Bush administration increased its overseas development assistance from $11.4 billion in 2001 to $27.5 billion in 2005, with support for HIV/AIDS and other health programs representing the lion's share of support unrelated to Iraq or Afghanistan. And in his 2003 State of the Union address, President George W. Bush called for the creation of a $15 billion, five-year program to tackle HIV/AIDS, TB, and malaria. Approved by Congress that May, the President's Emergency Plan for AIDS Relief (PEPFAR) involves assistance from the United States to 16 nations, aimed primarily at providing ARVs for people infected with HIV. Roughly $8.5 billion has been spent to date. PEPFAR's goals are ambitious and include placing two million people on ARVs and ten million more in some form of care by early 2008. As of March 2006, an estimated 561,000 people were receiving ARVs through PEPFAR-funded programs.

The surge in giving has not just come from the United States, however. Overseas development assistance from every one of the nations in the Organization for Economic Cooperation and Development (OECD) skyrocketed between 2001 and 2005, with health making up the largest portion of the increase. And in 2002, a unique funding-dispersal mechanism was created, independent of both the UN system and any government: the Global Fund to Fight AIDS, Tuberculosis, and Malaria. The fund receives support from governments, philanthropies, and a variety of corporate-donation schemes. Since its birth, it has approved $6.6 billion in proposals and dispersed $2.9 billion toward them. More than a fifth of those funds have gone to four nations: China, Ethiopia, Tanzania, and Zambia. The fund estimates that it now provides 20 percent of all global support for HIV/AIDS programs and 66 percent of the funding for efforts to combat TB and malaria.

The World Bank, for its part, took little interest in health issues in its early decades, thinking that health would improve in tandem with general economic development, which it was the bank's mission to promote. Under the leadership of Robert McNamara (which ran from 1968 to 1981), however, the bank slowly increased direct investment in targeted health projects, such as the attempted elimination of river blindness in West Africa. By the end of the 1980s, many economists were beginning to recognize that disease in tropical and desperately poor countries was itself a critical impediment to development and prosperity, and in 1993 the bank formally announced its change of heart in its annual World Development Report. The bank steadily increased its health spending in the following decade, reaching $3.4 billion in 2003 before falling back to $2.1 billion in 2006, with $87 million of that spent on HIV/AIDS, TB, and malaria programs and $250 million on child and maternal health. The bank, along with the International Monetary Fund (IMF), the OECD, and the G-8, has also recently forgiven the debts of many poor nations hard-hit by AIDS and other diseases, with the proviso that the governments in question spend what would otherwise have gone for debt payments on key public services, including health, instead.

When the Asian tsunami struck in December 2004, the world witnessed a profound level of globalized generosity, with an estimated $7 billion being donated to NGOs, churches, and governments, largely by individuals. Although health programs garnered only a small percentage of that largess, many of the organizations that are key global health players were significantly bolstered by the funds.

In January 2006, as the threat of avian influenza spread, 35 nations pledged $1.9 billion toward research and control efforts in hopes of staving off a global pandemic. Since then, several G-8 nations, particularly the United States, have made additional funding available to bolster epidemiological surveillance and disease-control activities in Southeast Asia and elsewhere.

And poor nations themselves, finally, have stepped up their own health spending, partly in response to criticism that they were underallocating public funds for social services. In the 1990s, for example, sub-Saharan African countries typically spent less than 3 percent of their budgets on health. By 2003, in contrast, Tanzania spent nearly 13 percent of its national budget on health-related goods and services; the Central African Republic, Namibia, and Zambia each spent around 12 percent of their budgets on health; and in Mozambique, Swaziland, and Uganda, the figure was around 11 percent.

For most humanitarian and health-related NGOs, in turn, the surge in global health spending has been a huge boon, driving expansion in both the number of organizations and the scope and depth of their operations. By one reliable estimate, there are now more than 60,000 AIDS-related NGOs alone, and there are even more for global health more generally. In fact, ministers of health in poor countries now express frustration over their inability to track the operations of foreign organizations operating on their soil, ensure those organizations are delivering services in sync with government policies and priorities, and avoid duplication in resource-scarce areas.

PIPE DREAMS

One might think that with all this money on the table, the solutions to many global health problems would at least now be in sight. But one would be wrong. Most funds come with strings attached and must be spent according to donors' priorities, politics, and values. And the largest levels of donations are propelled by mass emotional responses, such as to the Asian tsunami. Still more money is needed, on a regular basis and without restrictions on the uses to which it is put. But even if such resources were to materialize, major obstacles would still stand in the way of their doing much lasting good.

One problem is that not all the funds appropriated end up being spent effectively. In an analysis prepared for the second annual meeting of the Clinton Global Initiative, in September 2006, Dalberg Global Development Advisors concluded that much current aid spending is trapped in bureaucracies and multilateral banks. Simply stripping layers of financing bureaucracy and improving health-delivery systems, the firm argued, could effectively release an additional 15-30 percent of the capital provided for HIV/AIDS, TB, and malaria programs.