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A quarterly magazine of the IMF	December 2007, Volume 44, Number 4

Point of View

In September 2000, the global community committed with great fanfare to meet a set of eight Millennium Development Goals by 2015—three of which center on health: reducing child mortality by two-thirds; reducing maternal mortality by three-fourths; and halting and beginning to reverse the spread of HIV/AIDS, malaria, and other major diseases. With eight years left, how are we doing? The answer is not good; in fact, the world looks set to miss all three of these goals. Could the problem be that the global health system is now outdated and badly in need of an overhaul? F&D asked a few key health players for their insights.

1. Making Markets Work
Joe Cerrell
Director, Global Health Policy & Advocacy,
Bill & Melinda Gates Foundation

The current global health system has achieved stunning, lifesaving successes—from the global eradication of smallpox to smaller daily victories, such as delivering healthy babies in refugee camps in the most war-torn parts of the world. And yet the system also fails. It fails the 2 million children who die each year of vaccine-preventable disease; it fails the millions who die of malaria, tuberculosis, and AIDS; and it fails to mobilize the financial and scientific resources to give every child born in this world an equal chance at a healthy life.

But declaring that the global health system is "broken" suggests a sense of hopelessness, perhaps even defeat. In fact, the global health system is not beyond repair. With increased resources, improved policies, and greater political will, it is possible to transform health conditions in developing countries and save millions of lives. And, as traditional geographic boundaries blur and the fates of nations intertwine, improving global health is not only the moral thing to do: it is essential to the strategic interests of all countries, both rich and poor.

Moreover, the notion that a global health system per se is responsible for health outcomes removes personal and organizational accountability from the equation. Everyone involved in global health has a responsibility to help make the system function better, including developed countries, multilaterals, developing country governments, and civil society organizations, including foundations.

Many strategies are needed to help repair the global health system. One strategy that has tremendous potential, but has been largely neglected until recent years, is to take greater advantage of market dynamics.

Markets—from local craft markets to global markets—have been central to the increase in standards of living for millions in the developed world and are transforming the global economic landscape. But sometimes markets need some scaffolding to function effectively: recently, the Nobel Prize in economics was awarded to three deserving individuals for their work in explaining how incentives, information, and structures affect the functioning of markets, to "distinguish situations in which markets work well from those in which they do not." Influencing market dynamics related to global health can bring about a transformation similar to the one we have seen in developed countries.

Some of the greatest inequities in global health result from markets that are not structured to serve the poor. Every year, millions of people in developing countries die from diseases, including malaria and tuberculosis, that have been all but forgotten in rich countries. For these diseases, the economics of the marketplace are not sufficient to commercially justify the large-scale investment needed to develop and deliver vaccines and drugs; for example, treatment and prevention of tuberculosis are still based on drugs and vaccines that are only partially efficacious and decades behind the promise that cutting-edge science would offer.

Through global advocacy, the Bill & Melinda Gates Foundation is working to address this market failure by promoting innovative health financing mechanisms that provide better incentives to the private sector to create global public goods. The guiding principle is to bring together public agencies and private industry to deal with grossly inadequate health care for the poor resulting from failures of the marketplace.

One of the promising mechanisms we support is the advance market commitment (AMC). A binding contract, the AMC is designed to guarantee viable markets for vaccines addressing neglected diseases. By creating solid financial incentives for biotechnology and pharmaceutical companies to invest in research and development, investment in neglected diseases can become a more viable business decision.

In February 2007, several governments and the Gates Foundation pledged a total of $1.5 billion to the first AMC to speed development of a vaccine targeting pneumococcal disease, a major cause of pneumonia and meningitis that kills 1.6 million people every year. And I am hopeful that AMCs for tuberculosis and malaria will be launched in the near future.

Another innovative financing mechanism we are supporting, the International Finance Facility for Immunization (IFFIm), leverages funds from international capital markets by issuing bonds based on legally binding, long-term donor commitments. These funds support the work of organizations, such as the GAVI Alliance, that support children's immunization programs in poor countries. To date, a billion dollars has been raised, and scheduled payments of an additional $4 billion over the next 20 years promise to save the lives of 5 million people.

For the 2 billion or so people who live on less than $2 a day—and whose access to health care stands in stark contrast to those living in rich countries—markets aren't working well. New financing approaches like the AMC and the IFFIm are showing exciting results. In the years ahead, we must pursue additional ways to make markets work better for the world's poorest people.

2. Finding a Unified Vision
Helene Gayle
President, CARE
J. Stephen Morrison
Director, Africa Program
Center for Strategic and International Studies

Is the global health system broken? Yes and no. Can it be improved? Yes, incrementally, with effort, a long-term view, and commitment.

Currently, global health efforts take place across many different decentralized, semiautonomous entities. Global health hardly constitutes a system if, by system, we mean a unified, coherent entity that has a clearly defined structure, equipped with functional decision-making and governance mechanisms.

In reality, the global health system is a loose and fluid agglomeration with multiple, shifting centers of influence. It comprises the World Health Organization, the 22 assorted UN agencies with health programs of some sort, the World Bank, and new international bodies, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria. It comprises the Western bilateral donors; the developing countries that live with extreme disease burdens and struggle to overcome weak institutional capacities; and the powers, such as China, India, and Russia, that are both recipients of assistance and, increasingly, sources of assistance, new policy models, and scientific and technical innovation. The system comprises more than 120 public-private partnerships focused on discrete health issues, operational and advocacy nongovernmental organizations, and foundations and corporations.

In this decade, the international mobilization to improve public health in the developing world has outstripped our expectations. Consciousness of the importance of global health has spread; new norms have taken root; historically unprecedented levels of new resources have been dedicated to achieving tangible, positive health results; and large numbers of vulnerable and impoverished people have seen their health improve.

Several key factors—almost all of them outside the international and bilateral institutions that are formally charged with improving global health—have driven these changes. Infectious diseases themselves have been a critical push factor. By the beginning of this decade, the
HIV/AIDS pandemic had attained a drama, scale, and visibility that could not be ignored. This push was reinforced by SARS, avian influenza, and, more recently, extensively drug-resistant tuberculosis.

World leaders took up the call to action, as did Bono and other celebrities. The freshly launched Gates and Clinton Foundations have swung into action, as have new media-savvy advocacy groups demanding affordable medications, as well as corporate powers whose workforces and images were under threat.

Until very recently, when global health was a back-burner issue—inadequately funded, underpowered, and largely ignored—the lack of a coherent, unified system appeared to matter little. When global health graduated in this decade to become almost a mainstream foreign policy priority, and when resources committed to health in the developing world rose dramatically and conspicuously, the confusing cacophony of efforts became more visible, and we began to wonder if this system had broken down. In reality, it has not fallen apart. It has simply muddled along as before, lagging behind global health's ascent as a priority.

There are obvious advantages to the looseness of the current system: in some respects, it encourages innovation, speed, and flexibility. But there are also inherent, complex problems that, as the stakes have risen for global health, have become more pressing. Coordination and integration of efforts internationally have been lacking and have shown little success in minimizing the herd behavior of donors and the piling on of bureaucratic reporting burdens. Sustaining momentum and bringing forward adequate resources to meet true demand remain great challenges.

It has been systemically difficult to focus attention and achieve results on the chronic health deficits in developing country workforces, which are exacerbated by competitive, commercial recruitment to wealthier settings. The same can be said for linking expanded global health commitments to broader development concerns: climate change, safe water, debt relief, and global trade regimes. Major donors face serious internal challenges. Among the U.S. agencies that carry out health programs overseas, there is no unified, coordinated vision to guide U.S. efforts. Instead, there is an array of fragmented initiatives. The United States is not alone among donors in facing this problem.

Considerable progress has been made lately, particularly in programs for such high-priority diseases as HIV/AIDS. But even if there is a continued outpouring of financial support and political leadership dedicated to global health, we should anticipate that the complex, unresolved challenges that bedevil current global health efforts will become more, not less, onerous and costly and will begin to visibly test the limits of current arrangements. Now is the time to begin a serious discussion through a focused multilateral and public-private forum on how to construct a better-functioning global public health system.

3. Targeting the Health MDGs
Tore Godal
Special Advisor to the Norwegian Prime Minister and founding Executive Secretary of GAVI

Achieving the health Millennium Development Goals (MDGs)—reducing child mortality; improving maternal health; and combating HIV/AIDS, malaria, and other diseases—by 2015 will be difficult. Although progress has been made, many countries are off track. There is a real danger that the appalling mortality figures for children and pregnant women will continue unless countries, aid agencies, nongovernmental organizations, and development partners renew their efforts.

One attempt to address the inefficiencies in the existing global architecture of health aid is the Global Campaign for the Health Millennium Development Goals. This rapidly unfolding campaign encompasses several actions that aim to accelerate progress on the basis of common principles:

• Countries decide their own health priorities and create national health plans to achieve them. Aid agencies will coordinate their work to fit and support these plans.
• Aid agencies will not add to the reporting, information collecting, and administration requirements that fall to governments and health workers.
• More attention will be given to results, so that the money spent is linked to the results achieved in work on women's and children's health, HIV/AIDS, tuberculosis, and malaria. The objective is to get the greatest value for money spent.
• Aid agencies will work in ways that strengthen countries' health systems as a whole. That means increasing the flexibility of funding so that countries can build systems that respond to local needs and ensure that skilled health workers and medicines are in place where they are needed. It also means making and delivering long-term commitments.
• All parties will benefit from openness and accountability, primarily beneficiary populations, but also voters whose taxes are spent on development work and contributors to charities. They all have a vested interest in knowing that money is being spent, and health care provided, in a fair, open, honest, and effective way. Independent evaluation processes will be critical to this principle and will ensure that resources are used effectively.

The campaign, announced on September 26, 2007, in New York, by Norwegian Prime Minister Jens Stoltenberg, signals a commitment to finding better ways of achieving value for money and ensuring that the most vulnerable groups have access to essential services. The day after the launch, some of the largest development assistance donors committed $9.7 billion in new finance for MDG 6—combating HIV/AIDS, malaria, and other diseases—in the period 2008–10.

The campaign builds on other initiatives, such as the International Health Partnership, launched in early September by U.K. Prime Minister Gordon Brown. This partnership aims to improve the coordination of support for national health plans and brings together developing countries, international health organizations, and major donor countries.

Because the campaign's principles place so much emphasis on working with countries to meet their national health plan goals, actions will be tailored to each country and included with its national health plan. Partners will commit to coordinated action around the national health plan and to engage in "one conversation" with governments.

Development partners will closely coordinate their work with other stakeholders, facilitated by the newly established Heads of Health Agencies (the "Health 8": World Health Organization; World Bank; UNICEF; UN Fund for Population Activities; UNAIDS; GAVI Alliance; Global Fund to Fight AIDS, Tuberculosis and Malaria; and Bill & Melinda Gates Foundation).