Money or Die

A Watershed Moment for Global Public Health

A WHO malaria project in Cambodia. (Gates Foundation / flickr)

Global health programs now teeter on the edge of disaster. The world economic crisis and the politics of debt reduction are threatening everything from malaria control and AIDS treatment to well-baby programs and health-care worker training efforts. And even if the existing global public health architecture survives this time of parsimony and austerity, it will have been remodeled along the way.

Prior to 2000, the links between global health programs in poor and middle-income countries and changing foreign policy priorities in wealthy nations were weak, largely because the programs themselves were just not that large. In 1999, for example, total health spending in developing countries -- for efforts ranging from clean water provision and government clinics to vaccination campaigns and HIV treatment -- was about $5.6 billion, with the United States government providing roughly a third of that and U.S. private donors another tenth. But over the next decade, the picture changed dramatically, driven by a continuing economic boom and alarm over the expanding AIDS pandemic. 

Read more at at Foreign Affairs' Special Report: Global Public Health.

In the spring of 2000, the Clinton administration officially defined HIV and emerging diseases as national security threats, which expanded U.S. grounds for engagement in global health. At a major international conference that summer, former South African President Nelson Mandela framed equitable access to HIV treatment and prevention as the primary moral challenge of the twenty-first century. The call resonated with antipoverty activists, including the rock star Bono and the economist Jeffrey Sachs; health advocacy groups such as Médecins Sans Frontiers, Partners in Health, and ACT UP; and institutions such as the World Health Organization, UNICEF, and the United Nations AIDS Program. Microsoft founder Bill Gates and his wife, Melinda, stepped up their breathtakingly generous philanthropic efforts in global health through their Gates Foundation. And in his 2003 State of the Union address, U.S. President George W. Bush proposed a multibillion-dollar program to tackle AIDS in Africa -- an effort known as the President's Emergency Plan for AIDS Relief (PEPFAR). 

With the surge in public support for global health came increased attention from private individuals, corporations, and foundations, leading some to call the decade "the age of generosity." By 2008, global health enjoyed an estimated $16 billion pot of public-funding gold -- and with private funding and poor countries' own increased health spending included, the total spent on public health for the world's poor reached about $27 billion.

But then the global financial crisis hit. Countries, organizations, and individuals all felt the squeeze. Many severely reduced their giving. As Europe's economic situation has worsened, the region has reduced its overseas commitment-to-disbursements ratio for everything from famine relief to HIV treatment programs, undermining the credibility of both G-8 and G-20 pronouncements. With the exception of the Scandinavians, countries in the region have tended to view foreign aid in charitable terms, and, as a Brookings Blum Roundtable report noted, "Once global agreements have been couched in terms of charity, the failure to meet global targets can hardly be seen as scandalous because any efforts by the rich world, however small, are deserving of credit." Italy, which donated nearly $1 billion annually from 2001 to 2008, gave nothing in 2009 and has given almost nothing since. Greece provided more than $50 million in global health assistance in 2007 and now gives nothing. Iceland stopped making commitments and contributions in 2008, Portugal in 2009, and Spain in 2010. In 2009, 94 percent of all global health promises made by the European Union and its member countries were actually disbursed, but by the end of 2010 only 78 percent were, and the gap appears to have widened further in 2011.

Donor support to global health from all sources combined increased by roughly ten percent annually from 2002 to 2008. That growth began to slow in 2009 and fell to four percent in 2010. Final numbers for 2011 and 2012 are still being calculated, but it appears that growth has now stopped completely, and it is possible that a slight decline might actually have started. 

As important as the totals is the shift in donor composition. Total private donations excluding from the Gates Foundation have fallen from about $2 billion in 2008 to $1 billion in 2011. And global health spending by nongovernmental organizations (NGOs) and faith-based organizations dropped from $3.7 billion in 2008 to $2.5 billion in 2010. At this point, the two Washingtons -- Seattle and the District of Columbia -- are the last barriers to catastrophe. The Gates Foundation, now combining the philanthropic assets of the Gates family and Warren Buffett, is responsible for 68 percent of all private giving for global health, dwarfing the efforts of even the largest public or international institutions. And the United States government is responsible for 52 percent of all public giving. No other donors come close.


In 1948, the architecture of global public health was simple: The newly created World Health Organization, an independent agency in the broader UN system, dominated everything. For the next half century, the WHO took the lead, setting standards and providing most resources. Its efforts were complemented by those of some national donors, particularly the United States and France, and various other UN agencies and nongovernmental and religious institutions.

This situation began to change in 1990, when then WHO Director-General Hiroshi Nakajima ousted the leadership of the agency's Global Program on AIDS, at that point the only international effort to tackle the AIDS pandemic. The fracas spawned a cross-UN effort to build an alternative organization that might handle the issue better, and the result was the emergence in 1994 of the United Nations AIDS Program, which combined the HIV efforts of six UN agencies, including the WHO. This was followed soon afterward by the creation of the Global Alliance of Vaccine Initiatives (GAVI), a Geneva-based agency that coordinates dozens of UN, local government, bilateral, and private immunization efforts to ensure steady global supplies of affordable vaccines. WHO's immunization programs were put under the GAVI umbrella in 2000, and two years later the Gates Foundation's major public health-giving began, further eroding WHO's dominance. 

The year 2002 also saw the launch of the Global Fund to Fight AIDS, Tuberculosis, and Malaria, a Geneva-based multilateral organization that functions independently from the UN system but in close harmony with UN institutions; within a few years, it would be disbursing more than $2 billion annually, becoming the dominant financier of malaria and tuberculosis programs worldwide and the second-largest underwriter of HIV programs. Then PEPFAR's arrival in 2003 shattered the old order, bringing literally tens of thousands of new religious and secular organizations into the sector. Power followed the money, and by 2005 the annual World Health Assembly, which governs WHO, was convening to listen to Gates' suggestions, and today few policy initiatives or normative standards set by the WHO are announced before they have been casually, unofficially vetted by Gates Foundation staff.

If increased giving reshaped the sector's architecture, however, so has the recent reduction in revenue. The world has grown more dependent on U.S. public and private support, Europe has diminished its overall support and moved most of its remaining euros and pounds into GAVI and the shrinking Global Fund, and the WHO budget and influence is eroding further. The Global Fund's situation has grown so dire, with its commitments now outpacing actual revenues by nearly $6 billion and European support plummeting 16 percent in 2011, that in January its board called upon Executive Director Michel Kazatchkine to resign, replacing him with the retired Brazilian bank executive Gabriel Jaramillo. Since the shake-up, donor faith in the fund has been partially restored, with the Obama administration promising a 27 percent increase in U.S. support for FY 2013 (pending congressional approval). But logjams in disbursement have kept some African health groups from being able to pay their employees, and pharmaceutical outages have been reported in several countries.

The WHO is also facing problems. Director-General Margaret Chan is popular, and China's support for her is daunting, but the fact that her reelection bid is unopposed -- the first time in six decades that has happened -- is telling. Recently, 12 percent of the organization's headquarters staff was let go, and funding has dropped sharply. The WHO operates on two-year budget cycles, which peaked in 2006-7 at $5.4 billion; the current 2012-13 budget is down to $3.9 billion, for a decline of $1.5 billion. The biggest drop is in the agency's voluntary donations, which have fallen 50 percent since 2008. This grim picture worsened in the third quarter of 2011 as currency speculation drove the value of the Swiss franc up 32 percent against the U.S. dollar, forcing further staff reductions for an agency whose revenues are in dollars but payroll in francs. The WHO is still evaluating the full impact of this currency crisis. Chan has taken advantage of the budgetary stress to force much-needed major reforms, eliminating nonperforming divisions and refocusing the organization on core missions. But the budget crisis is sapping staff morale and undercutting some programs.

The fight against malaria might be the public health effort most endangered by the crisis. Thanks to an aggressive attack on several fronts, in recent years, cases of and deaths from malaria have plummeted worldwide, and some even dream of eradicating the disease entirely. But until an effective vaccine is ready for primetime, the fight against it requires steady vigilance and financing. The bed nets that protect sleeping babies from biting mosquitoes must be replaced periodically; supplies of antimalarial medicines must be replenished; mosquito elimination programs need to be adequately funded. The battle has been waged with money from the Global Fund, but that outfit is now deep in the hole and unable to offer new support until 2014. Many existing ant-malarial programs will be able to survive until then, but some older ones are set to expire earlier, and new or expanded ones would be extremely useful. Where additional money will come from is unclear. Awa Marie Coll-Seck, the executive director of the WHO-based Roll Back Malaria Partnership, predicts that "today's gains will be reversed, and we will lose many more lives to this disease."

The fight against tuberculosis faces similar problems. As with malaria, successes in controlling tuberculosis are quickly reversed when targeted programs cease -- and here the danger of stop-and-start efforts is even greater -- since interruptions in eradication programs lead directly to the development of drug-resistant bacteria. Thanks to the earlier surge in financing of TB programs, according to the WHO, 200,000 fewer people died annually of the disease in 2009 than in 2003. But about 80 percent of this victory was attributable to Global Fund support, and disbursements plummeted in 2010. While the net number of tuberculosis cases fell, moreover, the burden of multidrug-resistant disease skyrocketed, largely as a result of suboptimal or interrupted treatment. By the end of 2011, according to combined UN agency reports, about 85 percent of highly drug-resistant TB cases were going completely untreated, allowing community spread of the mutant strains.

The one bright spot on the global public health landscape is vaccination programs, which are promising, well-funded, and backed by powerful political interests. Thanks to GAVI's efforts, vaccine-preventable diseases in children have plummeted and millions fewer youngsters now die every year from such things as measles, pertussis, polio, and diphtheria. And new vaccines are being rolled out to help prevent bacterial pneumonia, cervical cancer in women, and viral diarrhea in children. Because of its successes and potential, GAVI has attracted a great deal of donor interest even during these hard times; it is now the most financially solvent outfit in the field. 


On November 8, 2011, U.S. Secretary of State Hillary Clinton called on the United States to go beyond PEPFAR's original bold vision and aim to create an "AIDS-free generation" worldwide. This would be "one of the greatest gifts America could give the World," she insisted, adding, "HIV may be with us in the future, but the disease it causes need not be. Investing in our future would be the smartest investment we could make." The goal could be attained, she said, by throwing resources and human talent at three objectives: reducing mother-to-child transmission through the provision of antiretroviral drugs, reducing sexual transmission through the funding of male circumcisions, and accelerating prevention by providing treatment to already infected populations.

All this would take several billion additional dollars annually -- more than the U.S. Congress has allocated to date and certainly more than it is likely to favor in the future, given concerns about excessive public spending and debt. Republicans in the House of Representatives have been lukewarm about foreign aid and global health programs. Florida Representative Ileana Ros-Lehtinen (R-Fla.), for example, the chair of the House Committee on Foreign Affairs, has suggested that these are "misplaced priorities," asking, "What is the return on our investment?" During the FY 2012 Continuing Resolution squabbles, the House Republicans sought to slice $700 million out of global health spending; the Senate did not agree. In December 2011, House Republicans suggested the FY 2013 budget should reflect a 13 percent cut in all foreign assistance spending. Republican presidential candidates Mitt Romney, Ron Paul, and Newt Gingrich have called for severe cuts in foreign assistance spending as part of a general drive to reduce the federal debt and deficit. (Rick Santorum, in contrast, has called for expanding global health and humanitarian aid, chiding the others for "pandering to an anti-foreign-aid element out there.")

Ironically, such objections to the expansion, or even maintenance, of the existing U.S. foreign assistance budget, come at a time when aggressive measures have been taken to rein in waste, improve efficiency, and measure outcomes. The Obama administration has pushed through significant reforms of USAID, PEPFAR, and other agencies, shifting global health programs from the NGO and consultant-focused efforts that marked the early days of PEPFAR to direct government-to-government planning and execution. The administration has also bolstered local decision-making, training, and ownership of these efforts, trying to help developing countries follow South Africa's unfolding example of reducing external donor support and make HIV and other public health efforts locally funded.

These moves, together with similar ones on the part of some other donor countries, as well as economic growth in some recipient countries, hold out hope that public health efforts in poor countries can eventually be weaned off their dependency on rich countries' fickle largesse. But that will take years, perhaps even decades. In the meantime, the structure of global health efforts is like a house of cards, highly vulnerable to prevailing winds. In 2011, for example, ministries of health throughout the African Great Lakes and East African region were dependent on external sources for 15 to 40 percent of their basic budgets. Their great recent achievements in HIV treatment, malaria prevention, tuberculosis care, maternal survival, and child health would likely evaporate were donor dollars to disappear.

In relative terms, the funds required are not large. Combined charitable giving for all causes by individuals in the United States and the United Kingdom hit $300 billion in 2011, but the bulk of this giving goes to domestic issues, and what goes to foreign causes is often dominated by surges of support for relief efforts for shocking natural disasters. Total estimated expenditures worldwide on health care in 2010, meanwhile, hit $5.3 trillion, with U.S. domestic spending accounting for nearly half of that. Even at its recent peak, the amount of money spent on the health of the world's poorest people, who suffer most of humanity's infectious and preventable diseases, represented merely .0005 percent of worldwide health spending. 

Like it or not, the burden of reducing suffering and increasing the health of the world's poor now falls largely on the backs of the two Washingtons. The Gates Foundation is doing extraordinary work, but it operates without accountability or transparency and needs competition. Bill Gates has admitted as much himself in multiple interviews, acknowledging that his efforts wield an uncomfortably large amount of unchallenged power over global health. So far, Congress has spared global health drastic budget cuts, but the White House 2013 budget request signals that pressure for reductions is building. It would be a catastrophe were the "age of generosity" to end so soon after it began, leaving millions without life-sparing medicines and tools they have come to rely upon.


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