Global Responsibilities for Health Care

Accountability for global health efforts that are NOT being made Gorik Ooms Department of Public Health, Institute of Tropical Medicine, Antwerp, Belgium MacMillan Center for International and Area Studies at Yale, USA May 2010

1. Are governments of poor countries accountable for potential domestic resources they are NOT spending on health? If so, to whom? 2. Are the International Monetary Fund (IMF) and the World Bank accountable for policies that are based on mutual NON-responsibility between states for global health? If so, to whom? 3. Are governments of rich countries accountable for the potential financial resources they are NOT allocating to international health aid? If so, to whom? 4. Challenges for mutual accountability, if we accept that responsibility for health is both national and international

Are governments of poor countries accountable for potential domestic resources they are NOT spending on health? If so, to whom?

Possible answers: They are accountable to their inhabitants, because these all have a right to health, and it’s the government’s responsibility to realize that right; They are accountable to governments of donor countries, because it is just not fair to ask for aid, and then reduce domestic resources; They are accountable to inhabitants of other countries because poor health fuels epidemics (and they spill over), and poor health fuels unhappiness and ‘grunge’ (and that spills over too…)

Are the IMF and the World Bank accountable for policies that are based on mutual NON-responsibility between states for global health? What is mutual NON-responsibility between states for global health? What do the IMF and the World Bank have to do with this? To whom are the IMF and the World Bank accountable?

A few words about mutual NON-responsibility The February 2000 floods in southern Mozambique were so predictable that MSF created a base with rescue team and rubber boat in Chowke, three days before the city was flooded; During the days before the floods, MSF could not find funding for this rubber boat (US$ 2000 to buy it); During the days after the floods, donors were stumbling over each other to finance helicopters for MSF operations (US$ 2000 to rent it for an hour). The days before: no crisis -> ‘sustainable’ solutions (rich countries do not feel responsible) The days after: crisis -> ‘sustainability’ no longer matters (rich countries are willing to pay, because it is only for a while; a temporary solution for a temporary crisis)

More contradictions… After the floods, many families were left without food reserves -> food distributions ; Food distributions are never perfect, always some households are left out -> malnourished kids -> therapeutic feeding center; Some kids did not get better, they were malnourished not because of the floods, but because of AIDS, and chronic diarrhea; AIDS treatment for these kids would have cost US$ 2000 for 10 years (same kids were rescued at US$ 2000 per hour)... Helicopters: Yes! Antiretroviral medicines? No!

So how did AIDS treatment get started then? As an emergency response!

Different concepts of sustainability: Ann Veneman, executive director of UNICEF, about interventions to address child mortality: “These plans and budgets should emphasise the continuum of care from maternal to neonatal to child survival. But they should also ensure that interventions are prioritised and phased in according to the ability of both the health system to deliver them at scale, and of governments to afford them and to sustain them in the longer term .” The World Health Report 2008 of the WHO: “In a significant number of these low-expenditure, low-growth health economies, particularly in sub-Saharan Africa and fragile states, the steep increase in external funds directed towards health through bilateral channels or through the new generation of global financing instruments has boosted the vitality of the health sector. These external funds need to be progressively re-channelled in ways that help build institutional capacity towards a longer-term goal of self-sustaining , universal coverage.”

Different concepts of sustainability: The World Bank’s ‘Health Financing Revisited: A Practitioner’s Guide’: “Although the practical definition of fiscal sustainability may change for programs supported by the IMF and IDA, it is extremely unlikely that such definitions will be divorced from a country’s capacity to accommodate expenditures financed with aid within the domestic budget constraint in a reasonable period of time , while maintaining sustainable levels of debt to GDP and debt service to exports.” Michel Kazatchkine, executive director of the Global Fund to fight AIDS, Tuberculosis and Malaria: “The Global Fund has helped to change the development paradigm by introducing a new concept of sustainability. One that is not based solely on achieving domestic self-reliance but on sustained international support as well.”

So what do the IMF and the World Bank have to do with this? Peter Piot, former executive director of UNAIDS, during a speech at the World Bank: “ ...when I hear that countries are choosing to comply with medium-term expenditure ceilings at the expense of adequately funding AIDS programmes, it strikes me that someone isn’t looking hard enough for sound alternatives... For countries emerging from conflict, the Bank has pioneered a careful programme of exceptions, running a calculated risk on the grounds that inaction would be riskier still. Let us now do something similar for AIDS, a risk far greater than conflict for many countries.”

Catch 22 Rich countries are reluctant to take long term responsibility for health in poor countries… IMF and World Bank assume that international aid for health is not reliable, therefore fiscal space is limited… Poor countries are discouraged from using all the available aid to increase expenditure, but they will not refuse the aid, they would rather decrease their domestic contribution… Rich countries find out that ‘aid does not work’, so they discontinue, or try yet another approach… IMF and World Bank are right to assume that international aid for health is not reliable…

To whom are the IMF and the World Bank accountable? Branko Milanovic, a World Bank economist: “ Global bodies tend to be either irrelevant if representative, or if relevant, to be dominated by the rich. A stark example of the latter situation is provided by the quota and the voting rights enjoyed by member countries of the IMF. There, as well as in the World Bank, votes do not follow either what may be deemed a truly global one person = one vote formula, or the international formula of one country = one vote (as, for example, in the United Nations General Assembly). The voting rights match rather closely the one dollar = one vote rule.”

Are governments of rich countries accountable for financial resources they are NOT spending on international health aid? Public health expenditure in G8 countries (2006) Total (% of GDP) Public (% of total) Canada 10.0% x 70.4% = 7.0% of GDP France 11.0% x 79.9% = 8.8% of GDP Germany 10.6% x 76.9% = 8.2% of GDP Italy 9.0% x 77.2% = 6.9% of GDP Japan 8.1% x 81.3% = 6.6% of GDP Russia 5.3% x 63.2% = 3.3% of GDP UK 8.2% x 87.3% = 7.1% of GDP USA 15.3% x 45.8% = 7.0% of GDP International aid for health? 0.03% of GDP

Remember one possible answer to the question about governments of poor countries being accountable to for the potential domestic resources they are not spending on health: “They are accountable to inhabitants of other countries because poor health fuels epidemics (and they spill over), and poor health fuels unhappiness and ‘grunge’ (and that spills over too…)” If you agreed with that, would you agree that governments of rich countries are accountable to their own inhabitants , for the epidemics they are not stopping elsewhere, and for the ‘grunge’ they are not ending elsewhere?

Reasons for international ‘grunge’ It requires very (very) little efforts from rich countries, to make a huge (huge) difference in poor countries There is something wrong with the politics of globalization: Our world view for primary distribution of wealth is a global one, without state borders (the ‘global free market’) Our world view for secondary redistribution of wealth is globe composed of states, with clear state borders (national ‘social protection’)

Low-income countries: one billion people, with an average Gross Domestic Product (GDP) of US$565 per year. If they can spend US$3 out of every US$100 on health, that makes US$17 per person per year. High-income countries: one billion people with an average GDP of US$43,000 per year. If they could spend US$0.13 out of every US$100 on international aid for health, that would make US$56 per person per year.

The problem with two very different superimposed world views, one global (free market), one national (social protection); based on the economic theory of Gunnar Myrdal: A free market does not evolve towards equilibrium, but away from equilibrium Economic growth centers (families, clans, cities, regions) invest their gains in more comparative advantages Economic growth centers continue to ‘win’ the competition, and attract human skills and capital from elsewhere, a self-amplifying dynamic The government needs to intervene constantly, impose taxes and invest them in social protection, to create equal opportunity But what if the self-amplifying dynamic happens at the global level, and the correction at the national level?

Mahboob Mahmood, quoted by Kishore Mahbubani, in ‘Beyond the age of innocence: rebuilding trust between America and the World’: “ The central promise of militant Islam is creation of a just society. The importance of the notion of justice in Islamic societies cannot be overemphasized—in these societies, freedom, democracy and rule of law are weak memes—but justice is a strong meme. The delivery of justice is and has always be the kernel of Islamic socio-political thought. Up to today, militant Islam has succeeded by emphasizing the injustice of the prevailing order—… A good policy will only succeed if it is capable of addressing and defeating militant Islam on the grounds of its central promise and its ultimate incapability—the creation of a just society.”

Thomas Pogge: “ Responsibility for a person’s human rights falls on all and only those who participate with this person in the same social system . It is their responsibility, collectively, to structure this system so that all its participants have secure access to the objects of their human rights.” What is the social system we want to promote? The family, the city, the nation, the state, the globe? Or a combination?

Challenges for mutual accountability, if we accept that responsibility for health is both national and international There is no global government… Can we agree, by convention (respecting state sovereignty) on minimum domestic efforts? Can we agree, by convention, on burden sharing between all rich countries? Can we agree, by convention, on some kind of institution that oversees and coordinates both?

Global Responsibilities for Health Care

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