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How the world changes! Nearly a generation ago, in 1994, I served as co-author of a major World Bank study, Better Health in Africa. Now I have the privilege to observe health issues around the world as President and CEO of the United Nations Association of the USA (UNA-USA). These experiences give me perspective on changes in global health institutions, policies, and funding.
A generation ago, what was then widely known as "international health" was largely a technical concern of major United Nations agencies, such as the World Health Organization (WHO), United Nations Children's Fund (UNICEF), and the UN Population Fund (UNFPA), bilateral donors, large non-governmental organizations such as CARE and World Vision, and academic institutions such as schools of public health. It seemed to many of us at the time that the landscape of institutions was crowded, at least in comparison with other sectors, and that developing countries had many partners. The United Nations as such did not seem to be a significant player. International health appeared largely as an issue of cooperation between developing countries and their partners in developed countries.
Over the past generation, international health has given way to "global health". This change in terminology, while not yet universal, reflects a profound change in perspective. No longer can countries and institutions see health as a concern limited by national borders, as they often did in the past. Policy makers, public health practitioners and medical providers used to distinguish between "international health" and, at least by contrast and implication, "domestic health". Indeed, so important has global health become that it is increasingly a concern of civil society activists, as we can see by the evident impact of HIV/AIDS in the public policies and domestic and international expenditure patterns of the United States and other countries. The massive growth in contacts across national frontiers, from travel and trade, has facilitated the transmission of infectious diseases from country to country, and created a widespread and keen awareness that communicable diseases do not respect national frontiers. The growth of electronic communication, in turn, has facilitated awareness of these changes.
HIV/AIDS was the first disease to make health a truly global issue in our time. The poorly understood epidemiology of a disease widely prevalent in both wealthy and poor countries, a perception that the leadership of WHO was inadequate to cope with a growing threat, and the successful political activism of HIV-positive people in NGOs such as ACT UP created an environment which by the 1990s required new action from the international community. The response was massive. UNAIDS was launched in 1996, the Security Council held a session devoted to the disease in 2000, the Millennium Development Goals (MDGs) of 2001 called for halting the spread of HIV and other communicable diseases, and the General Assembly held its first ever special session devoted to a single disease in 2001. The Global Fund to Fight AIDS, Tuberculosis and Malaria was created in 2002. In wealthy countries, thanks to the development of new pharmaceuticals, HIV has become a manageable chronic illness, but it remains today a mortal illness for large portions of HIV-positive populations in Africa and other poor areas that are unable to access the needed drugs.
The dangers from more recently emerging health threats, such as SARS, or Severe Acute Respiratory Syndrome, and Influenza A (H1N1), have been global, and have contributed greatly to the awareness that health issues no longer lie within an exclusively technically oriented cadre of "international health" workers. Global health has truly become a concern to us all: to policy makers, financiers, diplomats, a wide range of health service providers, activists, civil society groups, and citizens around the world. Thus, it is not surprising that UN Secretary-General Ban Ki-moon has established a Senior UN System Influenza Coordinator for H1N1.
In the 1990s many developing country officials already felt that they faced a crowded landscape of international health institutions. Over the past several decades the landscape has become much more crowded. Non-state actors have assumed ever greater importance, and the proliferation of global health partnerships has made them an important feature in the global health architecture. Although these partnerships were promoted to better focus health aid, their overlapping and unclear mandates, and a tendency to be highly issue-specific in their activities, have complicated the task of leading donors to recipient countries and managing foreign assistance for maximum impact.
UNAIDS was the first major global health institution created since the UN Population Fund in the 1960s. Public-private partnerships (PPPs) for specific purposes are increasingly populating the global health landscape. The largest and most ambitious of such PPPs, the Global Fund, was the first major new international financial institution established since the less prominent Multilateral Investment Guarantee Agency was created by the World Bank during long negotiations in the late 1970s and 1980s. The Bill and Melinda Gates Foundation has assumed an importance in global health that is greater than that of many bilateral donors. Now the largest private foundation in the world, the Bill and Melinda Gates Foundation has committed nearly $10 billion in global health grants. UNITAID, an international facility for the purchase of drugs to treat HIV/AIDS, tuberculosis, and malaria, was founded in September 2006. The Clinton Foundation was established at the turn of the millennium. Former UN Secretary-General Kofi Annan launched the Global Health Initiative of the World Economic Forum in 2002 to engage businesses in PPPs to tackle HIV/AIDS, malaria, tuberculosis, and health systems.
Among governments, the United States, previously active largely through the United States Agency for International Development (USAID), now has a wide range of agencies with a large global health presence: the National Institutes of Health, sponsoring research and research capacity building; the Centers for Disease Control and Prevention, with disease surveillance and technical cooperation programmes in many countries; the armed forces, with research stations overseas; the US President's Emergency Plan for AIDS Relief (PEPFAR), a programme launched in 2003 by President George W. Bush; and the Global Health Initiative of President Barack Obama. It was natural that the first Chair of the Board of the Global Fund was a US member. The US share of public and private development assistance for health grew from about one-third in 1990 to over one-half in 2007. The growing importance of health in US foreign policy is reflected in the creation of a special Office of International Health Affairs within the State Department. Through the Global Health Initiative of President Obama, the US plans to invest $63 billion over six years to help partner countries improve health outcomes through strengthened health systems.
In the 1990s, many observers perceived the leadership of WHO to be weak and ineffective despite the mandate in its constitution to act as the directing and coordinating authority on international health. With publication of the World Bank's World Development Reports Investing in Health (1993), Better Health in Africa (1994) and Health, Nutrition, and Population Sector Strategy (1997), it was widely thought that the mantle of global health policy leadership had shifted from WHO to the World Bank. The 1997 strategy found that the World Bank had become the largest international source of financial support for health programmes in developing countries. This, too, has changed. With its updated 2007 strategy, the World Bank sees its focus specifically on health systems, and reports a relatively smaller financial role internationally. Yet, simultaneously, global programmes and public-private partnerships have assumed a large role in the Bank's overall engagement in health. Meanwhile, thanks to the leadership of Dr. Gro Harlem Brundtland as Director-General from 1998 to 2003, WHO has re-emerged as a major player, even though the number of players has grown considerably.
"Follow the money" -- the mantra of observers of many phenomena -- is instructive in global health, too. The growth in financial resources for global health over the past generation has been massive. Even when adjusted for inflation, development assistance for health quadrupled from 1990 to 2007, reaching nearly $22 billion in that year. The fraction of health assistance channelled through multilateral institutions dropped, even though multilateral assistance is more likely to be responsive to the concerns of recipients than assistance channelled through bilateral donors, foundations, or NGOs. Overseas expenditures by NGOs have grown so much that they accounted for nearly one-quarter of development assistance for health in 2007, while private philanthropy also accounted for over one-quarter of development assistance for health by that same year. Thanks to infusions from the Global Fund and PEPFAR, funding for health in developing countries has tended to shift from the health sector to specific illnesses. These shifts have increased the challenges facing developing country policy makers, who endeavour to ensure balance among diseases and focus on their specific priorities. The challenge of country level management of the political and financial imperatives and incentives created by global consensus, especially on HIV/AIDS, has become more and more important.
What do these tectonic shifts mean for the UN and for developing countries at the country level? Global issues demand increasingly global responses, and health is among the main areas of truly global concern. The UN has largely moved from being a bystander to becoming a forum for dialogue and a major policy player. Concentrating on its comparative advantage as a forum for dialogue and definition of emerging issues, the UN has contributed much -- through the Millennium Declaration, through its leadership on the Millennium Development Goals (MDGs), and through individual initiatives -- to putting health issues before policy makers and public officials around the world, in ways few could have expected a generation ago. The General Assembly Special Session on HIV/AIDS helped to mobilize and formulate global views. Former Secretary-General Kofi Annan played an important role in promoting and articulating the consensus that led to the establishment of the Global Fund. In 2009, Secretary-General Ban Ki-moon and Bill and Melinda Gates agreed to convene major actors on maternal and child health to increase attention, coordination, and resources. In 2005, former US President Bill Clinton established the Clinton Global Initiative to turn ideas into action and help the world move beyond the current state of globalization to a more integrated global community of shared benefits, responsibilities, and values. Global health is one of four areas of concern. Meetings are held in New York to benefit from the presence of senior political and foreign policy officials at the UN. A generation ago, initiatives such as these would have been unthinkable.
With the adoption of the MDGs, the intergovernmental organs of the UN have shown increasing concern for health, above and beyond specific diseases. In 2009, the Economic and Social Council adopted a ministerial declaration on implementing the internationally agreed goals and commitments in regard to global public health. Ministers expressed concern at the lack of overall progress in improving global health and recognized the close relationship between foreign policy and global health. Non-communicable diseases (NCDs) began to assume increasing importance in public dialogue, with an important segment on the declaration of NCDs. Within UNA-USA, the Business Council for the United Nations has organized well-attended meetings on health -- most recently on NCDs -- bringing business executives together with UN officials.
Now it is critical to build bridges between global exhortation and overall policy statements at the UN and the realities of public health action throughout the world, both at the national and especially at the district level. This is not automatic. At the country level and beyond, the sometimes rarefied atmosphere of UN meetings in New York and Geneva and of donor consultative meetings in the Development Assistance Committee of the Organisation for Economic Co-operation and Development in Paris, the possibilities for significant health improvements in developing countries have never been greater. However, the challenges of managing relations and resources from multiple partners in the public and non-governmental sectors, as well as with global programmes and public-private partnerships, ranging from the Global Fund, to the Stop TB Partnership, to Roll Back Malaria -- to mention but a few -- have never been greater. The International Health Partnership, a coalition of international health agencies, governments, and donors, may help. Beneficiary country leadership and transparency in aid management, praised in principle but not widely practiced by donors or recipients, has become imperative. The prospects for joint assessment of national strategies and the consequential willingness of donors to rely on the assessments of donor partners for their financial commitments merit active pursuit. These are formidable challenges, worthy of the capacity building support of the UN. Without the will and capacity for improved beneficiary country leadership, the risks are too great that new financial resources will not lead to expected health benefits. It is up to each of us to do what we can. Let us all focus on the opportunities.