[e-drug] A global health fund: a leap of faith?

[andy@healthlink.org.za]

E-DRUG: A global health fund: a leap of faith?
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[crossposted from DRUGINFO. Copied as fair use.
http://bmj.com/cgi/content/full/323/7305/152
NN]

Hi all

This is a sober assessment of the challenges facing the Global
Health Fund, drawing on the GAVI experience. In particular, the
issue of "transaction costs" to the recipient nations is well
described.

regards
Andy

~~~~

BMJ 2001;323:152-154 (21July)

A global health fund: a leap of faith?

RuairíBrugha, senior lecturer in public health,GillWalt, professor in
international health policy.

Health Policy Unit, Department of Public Health and Policy,
London School of Hygiene and Tropical Medicine, London WC1E
7HT

Correspondence to: R Brugha Ruairi.Brugha@lshtm.ac.uk

After the 2000G8 summit at Okinawa, the leaders of the world's
richest countries announced an ambitious commitment to achieve
substantial reductions in the global burden of disease and death
due to HIV infection and AIDS, tuberculosis, and malaria by 2010.1
A new global health fund, to be highlighted at the forthcoming G8
summit in Genoa, could form the cornerstone for meeting this
commitment. The fund will be heavily dependent on resources from
the richest countries, working in partnership with United Nations'
agencies (especially the World Health Organization), the
commercial sector (especially major pharmaceutical companies),
other donors, non-governmental organisations, and governments of
developing countries. Funds are intended to be additional to
existing aid from multilateral and bilateral agencies and will be
managed and disbursed by a new entity, the Global Health Fund.
This is a major new form of governance (see box 1).

The Global Health Fund follows a plethora of recent global public-
private partnerships to promote wider availability of existing
products and stimulate product development as well as initiatives
with a broader focus on health systems (see box 2).2 Debates
about these partnerships in the past year are relevant to the
proposed global fund; they concern issues such as governance
structures and functions, the balance of power between partners,
the ability of recipient countries to determine how resources are
used, and the balance between support to health systems and
funding of health products. International policymakers are looking
to the Global Alliance for Vaccines and Immunization (GAVI) for
lessons, as this is one of the first such partnerships, with an
established fund for disbursing free vaccines and funds to support
health systems in some countries with a gross domestic product
less than $1000 (£714).


Summary points
----------------------------------------------------------------------- A
new global health fund is being set up to bridge the funding gap for the
control of HIV infection and AIDS, tuberculosis, and malaria

The fund is due to be established this year, but it is not yet clear
exactly what it will support and how it will be run

The planning burden on developing countries could be increased by
the fund if existing global health initiatives are not consolidated and
simplified

Rich countries will need to make large, long term commitments to
the fund if developing countries are to be successfully supported to
sustain new, expensive treatment and preventive services

Box 1 : What is the Global Health Fund?

.It is an alliance of partners from UN agencies, developing
countries, donor governments, foundations, corporations, and non-
governmental organisations .Its purpose is to mobilise, manage,
and disburse additional resources for the control, in the first
instance, of HIV infection and AIDS, tuberculosis, and malaria .It
will purchase drugs and vaccines, but there is no consensus on
how it will do this or whether it will also support developing
countries' health systems .Pledged contributions (as of 25June
2001) amount to $200m from the United States, $180m from the
United Kingdom, $150m from France, and $100m from the Gates
Foundation. These may be one-off contributions

Box 2 : Global public-private partnerships and related websites

.Global Alliance for Vaccines and Immunization
(www.vaccinealliance.org) .Stop TB (www.stoptb.org) .Roll Back
Malaria (www.RBM.who.int) .International Partnership for AIDS in
Africa (www.unaids.org/africapartnership) .European Malaria
Vaccine Initiative (www.emvi.org) .Multilateral Initiative for Malaria
(www.nih.gov/fic) .European Commission Accelerated Action
(www.europa.eu.int/comm/development) .International AIDS Vaccine
Initiative (www.iavi.org)

Governance

Concerns have been raised about the composition and governance
of different global public-private partnerships, including their
representative legitimacy, accountability, and competence.2 In the
case of the Global Alliance for Vaccines and Immunization, UN
agencies (mainly the WHO and Unicef) have had a dominant role,
while commercial representation has been less. Substantial
commitments by bilateral donors such as the Netherlands ($100m)
and Norway ($125m) have qualified them for seats on the board.3
Currently, Mali and Bhutan are the developing countries
represented on the board; it is unclear how they were selected and
how they represent the positions of other developing countries.
Only one non-governmental organisation has representation on the
board, raising similar questions. While the alliance's structures are well
defined and fairly transparent, the processes for selecting some of its
members and for decision making are less so.


After a consultation meeting in Geneva in June 2001there was still
"no envisioned structure for the governing board" of the new Global
Health Fund,4 although working papers for the meeting had
proposed an executive board of about 12-15people. It was
proposed that this would represent all constituencies and create a
governance structure with executive control over all important
functions. Frequent shifts in the proposed focus of the fund suggest
considerable contention behind the scenes. It may be that decisions
about
the governance of the fund will reflect the outcome of a struggle between
the major players to determine its focus and control its development.

Regard to recipient countries' needs
Another concern is the interface between the global fund and
recipient countries. The UK Cabinet Office Performance and
Innovation Unit stated: "Products purchased through the fund
should be in response to developing countries' requests, be
suitable for delivery in developing countries and be cost-effective,"5
reflecting a concern that national policies and priorities could be
distorted rather than supported.6

Of the 74countries eligible for support from the Global Alliance for
Vaccines and Immunization, by mid-June 25had successfully applied for
support and 20of these are eligible for new or underused vaccines.
Seventeen are planning to introduce hepatitis B vaccine and seven intend
to introduce Haemophilus influenzae type b (Hib) vaccine to their
national
programmes (GAVI Secretariat, unpublished article "Global health
initiatives<Picture: --- >lessons learned from the early days of the
Global Alliance for Vaccines and Immunizations (The Alliance), 23March
2001"). Tensions exist between a supply driven and demand driven
approaches. One of the alliance's targets is that, by 2005,half of the
poorest countries with a high burden of disease and adequate delivery
systems will have introduced Hib vaccine; however, there is not yet
adequate epidemiological evidence in many cases to justify this target.
Inevitably, there is a tension between such targets for the introduction
of new products and the principles of country ownership and keeping
"decision making close to developing countries."5

Procedural costs for recipient countries
Minimising planning burdens and transaction costs for countries
applying for new funds is also problematic. The Global Alliance for
Vaccines and Immunization has tried to limit this "by keeping
principles, policies and procedures as simple as possible" (GAVI
Secretariat, unpublished article "Global health initiatives").
Nevertheless, the alliance's requirements, and those of a future
Global Health Fund, are in addition to other initiatives that are time
consuming for recipient countries.

One example is Sector Wide Approach programmes, which are
being implemented in 19countries of sub-Saharan Africa. The
principle of these programmes is that donors, instead of funding
individual projects or specific disease control programmes, pool
funds to support a country's whole health sector.7 An objective is
to reduce the transaction costs for governments in managing
multiple donor initiatives, with different reporting and financial
management systems. Typically, senior government staff spend
many weeks preparing for and participating in annual or biannual
review meetings with donors and other partners. However,
overstretched government staff are still too often required to
manage a range of parallel and externally driven initiatives with
different planning cycles and procedures and multiple inputs from
local donors and external consultants.

Setting priorities
A potential benefit of the Global Health Fund is that it will focus on
three major diseases (HIV infection and AIDS, malaria, and tuberculosis)
that affect many poor countries. It could help to coordinate international
efforts, reducing potential duplication among the different global
public-private partnerships and health initiatives. At the country level,
it could also reduce fragmentation by working within and supporting
common
frameworks and systems. However, experience has shown the difficulties
of
prioritising and coordinating different aid efforts. Even now, there is
some uncertainty as to the fund's focus. In earlier discussions by donor
organisations it was proposed to include the major diseases of childhood.
More recently, Kofi Annan, the UN secretary general, called it a global
AIDS and health fund (WHO, press release at World Health Assembly,
Geneva,
22May 2001), and a recent announcement has sought to clarify that a
single fund was being proposed.4 Competition between priorities, which
has
been a feature of international health development policies over the past
half century, may well continue as other major diseases are proposed for
support.

Balancing systems and product support

The need for sustainability and for strengthening health systems,
especially in the poorest countries, has almost become a mantra
in international policy statements. Most recognise that developing
countries' health systems are fragile and yet are central to the
delivery of drugs and vaccines. However, there are contested and
unanswered questions about improving health systems, not least in
relation to the respective roles of the private and public sectors.8 None
of these questions will be resolved in the short term<Picture: - -->or in
the initial stages of the Global Health Fund. Confusion exists as to
whether the fund will support health systems: one report suggests that it
should not,5 whereas another consultation meeting envisaged support
for
both healthcare commodities and systems.4

Again the Global Alliance for Vaccines and Immunization provides
useful lessons. For recipient countries that are eligible to receive new
vaccines and system support, $11.9m or 17% of funds has been allocated
to
strengthening health systems while the rest is targeted for providing new
vaccines. The alliance's executive director is reported to have said that
an optimum balance might be 60% of funds for new vaccines and 40% for
strengthening immunisation services.6 To encourage recipient countries
to
meet the targets set, additional funds for strengthening health systems
will be released only once the countries have reached higher levels of
immunisation coverage. Understandably, donors want to see their
funding
improving results. Ironically, failure to meet targets could indicate the
need for greater support to weak health systems rather than withholding
of
funds. Governments that qualify for health systems support, have the
"liberty to use the support in whatever way that leads to the planned
result" (GAVI Secretariat, unpublished article "Global health
initiatives"). However, the funds allotted represent only small
percentages of countries' projected annual recurrent budgets for health
care.

If countries receive extra funds from a global health fund they will have
to decide whether to manage such funds separately, in vertical
programmes
with separate management and financial monitoring systems, or to
submerge
the additional funds within overall government health budgets. Choosing
the latter would reduce transaction costs but may be less attractive to
donors and might delay the achievement of targets, reducing performance
based rewards. New drugs and vaccines will also place new demands on
weak
health systems. Seemingly minor changes, such as a change in first line
antimalarial treatment from chloroquine to sulphadoxine-pyramethamine,
can
take years to achieve.9 Some of the new tools, such as a vaccine to
prevent HIV infection, will require new delivery systems, needing much
greater levels of investment in health systems. In addition, when new
products are introduced commercial companies may well want to attach
additional conditions to their use, requiring parallel planning,
management, and evaluation systems.9 High value drugs in the hands of
poorly paid and demoralised health workers in the public sector are also
liable to leak into uncontrolled private sector channels.

Conclusions

The Global Health Fund is sending out a crucial message that rich
countries have a moral and political imperative to do something
about three diseases that are wreaking devastation in many poor
countries. The fund may underwrite the purchase of drugs,
vaccines, and other commodities where markets are too weak to
respond and stimulate pharmaceutical companies to conduct
research to develop new drugs and vaccines. It is only through a
global fund that this kind of concerted global action between major
corporate and public sector players can be achieved.

However, there are many challenges in implementing such an
initiative. Firstly, the scale of the commitment will need to be
sufficient to justify the level of input of international and national
policymakers. Estimates of the cost of scaling up existing programmes to
tackle the three diseases suggest the need for an additional $9-15bn10 or
$10-20bn11 annually. Commitments to the fund to date have been small
(see
box 1). Secondly, considerably greater investment in health systems will
be needed to deliver new treatment programmes, whether from the fund or
from other sources. Thirdly, if there is a time limit to the international
commitment, poor countries that alter their drug policies to incorporate
expensive new drugs could be left with unsustainable costs at a future
date. Finally, the urgency with which the global fund is now being
promoted to be operational by the end of this year 4 suggests that the
complexities of implementation have been underestimated.

Malaria, tuberculosis, and HIV infection are not new. Now they are
finally receiving the degree of attention they deserve, it is important
that the goodwill and commitment engendered through this initiative are
not lost in failure for lack of attention to making the global fund work
well. Achieving good governance for decision making will be the first
step.

Acknowledgments

We thank Mary Starling for helpful comments on earlier drafts of
this article.

Footnotes

Competing interests: None declared.

References
1. Ministry of Foreign Affairs of Japan. G8 communiqué Okinawa
2000.www.mofa.go.jp/policy/economy/summit/2000/communique.h
tml

2. Buse K, Walt G. Global public-private partnerships. Part 11:
What are the health issues for global governance? Bulletin WHO
2000; 78: 699-709[Medline].

3. Hardon A.Immunisation for all? A critical look at the first GAVI
partners meeting. HAI Europe 2001;6(1).
www.haiweb.org/pubs/hailights/mar2001/index.html (accessed 12July
2001).

4. Comprehensive summary of press briefing held at Palais des
Nations on 5June following a two-day consultation on the Global
Health and AIDS Fund held in Geneva on 3and 4June 2001.
Geneva: United Nations Information Service, 2001.

5. Performance and Innovation Unit. Tackling the diseases of
poverty: Meeting the Okinawa/Millennium targets for HIV/AIDS,
tuberculosis and malaria. London: Performance and Innovation
Unit, Cabinet Office, 2001:46-51. www.cabinet-
office.gov.uk/innovation/

6. Development today. Nordic Outlook on Development Assistance,
Business &the Environment , 2001:11(8).

7. Cassels A, Janovsky K. Better health in developing countries:
Are sector-wide approaches the way of the future? Lancet 1998;
352: 1777-1779[Medline].

8. Smith E, Brugha R, Zwi A. Working with private sector providers
for better health care, an introductory guide. London: Options and
LSHTM, 2001.

9. Shretta R, Walt G, Brugha R, Snow R. A political analysis of
corporate drug donations: the example of Malarone in Kenya.
Health Policy Planning 2001; 16(2): 161-170[Medline].

10. Performance and Innovation Unit. Tackling the diseases of
poverty: Meeting the Okinawa/Millennium targets for HIV/AIDS,
tuberculosis and malaria. London: Performance and Innovation
Unit, Cabinet Office, 2001:25-30. www.cabinet-
office.gov.uk/innovation/

11. Sachs J. The links of public health and economic development.
Office of Health Economics 8th annual lecture. London: Office of
Health Economics, 2001.
www.ohe.org/sachs%20edited%20OHE%20transcript%20final%202
30501doc.pdf


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