Health and Development: The Role of International Organizations

Health and Development Toward a Matrix Approach

Edited by

Anna Gatti and Andrea Boggio

Health and Development

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Health and Development Toward a Matrix Approach Edited by

Anna Gatti and Andrea Boggio

Selection and editorial content © Anna Gatti and Andrea Boggio 2009 Individual content © contributors 2009 All rights reserved. No reproduction, copy or transmission of this publication may be made without written permission. No portion of this publication may be reproduced, copied or transmitted save with written permission or in accordance with the provisions of the Copyright, Designs and Patents Act 1988, or under the terms of any licence permitting limited copying issued by the Copyright Licensing Agency, Saffron House, 6–10 Kirby Street, London EC1N 8TS. Any person who does any unauthorized act in relation to this publication may be liable to criminal prosecution and civil claims for damages. The authors have asserted their rights to be identified as the authors of this work in accordance with the Copyright, Designs and Patents Act 1988. First published 2009 by PALGRAVE MACMILLAN Palgrave Macmillan in the UK is an imprint of Macmillan Publishers Limited, registered in England, company number 785998, of Houndmills, Basingstoke, Hampshire RG21 6XS. Palgrave Macmillan in the US is a division of St Martin’s Press LLC, 175 Fifth Avenue, New York, NY 10010. Palgrave Macmillan is the global academic imprint of the above companies and has companies and representatives throughout the world. Palgrave® and Macmillan® are registered trademarks in the United States, the United Kingdom, Europe and other countries ISBN-13: 978–1–4039–4737–6 hardback ISBN-10: 1–4039–4737–6 hardback This book is printed on paper suitable for recycling and made from fully managed and sustained forest sources. Logging, pulping and manufacturing processes are expected to conform to the environmental regulations of the country of origin. A catalogue record for this book is available from the British Library. Library of Congress Cataloging-in-Publication Data Health and development : toward a matrix approach / edited by Anna Gatti and Andrea Boggio. p. ; cm. Includes bibliographical references. ISBN-13: 978–1–4039–4737–6 (hardback : alk. paper) ISBN-10: 1–4039–4737–6 (hardback : alk. paper) 1. World health–Developing countries. 2. Public health— International cooperation—Developing countries. 3. Health services accessibility—Developing countries. I. Gatti, Anna. II. Boggio, Andrea. [DNLM: 1. Medically Underserved Area. 2. World Health. 3. Developing Countries. 4. Evidence-Based Medicine. 5. Health Services Accessibility. WA 395 H4323 2008] RA441.H425 2008 362.109172’4—dc22 2008029959 10 9 8 7 6 5 4 3 2 1 18 17 16 15 14 13 12 11 10 09 Printed and bound in Great Britain by CPI Antony Rowe, Chippenham and Eastbourne

To Kim Scott To my family and to Anna A.G. A.B.

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Contents List of Figures

ix

List of Tables

x

Acknowledgments

xi

List of Abbreviations and Acronyms

xii

Notes on the Contributors

xiii

Preface Larry Brilliant and Hans Rosling

xix

Introduction: Toward a Matrix Approach Anna Gatti and Andrea Boggio

xxi

Part I: The Global Health Arena

1

1 Global Health: Getting it Right Laurie Garrett and Kammerle Schneider

3

2 The World Health Organization and its Role in Health and Development Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 3

4

Beyond the Matrix: Thinking Three-dimensionally About Social Determinants of Health Ted Schrecker & Ronald Labonté Research and Innovation in Health and Development Stephen A. Matlin

16

56

79

Part II: Health and Development: Perspectives and Experiences

93

5

Health and Evolution Francesco Cavalli-Sforza

95

6

Health and Development: an Economic Perspective David B. Evans

vii

110

viii Contents

7

Health, Development, and Human Rights Stephen Marks

124

8

Health and Development: an Ethics Perspective Andrea Boggio

140

Part III: Global Health and Vulnerability 9 Health and Development: the Role of International Organizations in Population Ageing Chris Phillipson, Carroll Estes and Elena Portacolone

153 155

10 Child Health and Development Linda Richter and Chris Desmond

168

11 Women, Health, and Development Lenore Manderson

183

Part IV: The Interrelation Between Specific Disease and Development 12

13

14

Long-term Impacts of Leading Chronic Diseases in Low- and Middle-income Countries: a Comparative Analysis David Stuckler and Derek Yach Strategies for Financing Universal Access to Health Care and Prevention: Lessons Learnt and Perspective for the Twenty-first Century Sergio Spinaci and Valerie Crowell HIV Epidemic and Response: Social, Economic and Development Impact Yves Souteyrand, Dongbao Yu and Kerry Kutch

197

199

217

229

15 Global TB Control: Persisting Problem, Shifting Solutions Mukund W. Uplekar and Mario C. Raviglione

243

Index

257

List of Figures Figure 4.1 Figure 4.2 Figure 4.3 Figure 10.1 Figure 12.1 Figure 12.2 Figure 12.3

Figure 13.1 Figure 15.1 Figure 15.2

Deaths by cause and WHO region, 2002 Factors affecting health Global expenditures on Health R&D, 1986–2003 Major causes of death among children under five years of age and neonates in the world, 2000–2003 Transition state model of chronic disease epidemiology Correlation of growth with total cardiovascular and chronic disease mortality Correlation of market integration, foreign direct investment, and urbanization with total cardiovascular and chronic disease mortality DAH in US$ millions Progress towards global TB control targets from 1995–2005 Progress in TB control according to WHO regions (1990–2005)

ix

80 81 85 169 203 208

208 219 246 247

List of Tables Table I.1 Table 7.1 Table 12.1

Table 12.2

Table 12.3 Table 12.4 Table 12.5 Table 12.6 Table 12.7 Table 13.1 Table 15.1

Gatti/Boggio matrix Human rights and social justice approaches compared Expected change in infectious and chronic disease mortality rates per 100,000 population from 2002 to 2030 – Data and region categories based on Mathers and Loncar projections Growth rate in infectious and chronic disease mortality rates (per cent per year), 2002 to 2030 – Data and region categories based on Mathers and Loncar 2006 projections Sources of weak global responses to chronic diseases Standardized chronic disease mortality rate ratios, low versus high income countries by age group Twenty-year long-difference models of chronic diseases from 1960 to 2000, high-income countries Decomposition of population ageing and globalization effects on chronic diseases Effect of chronic disease working-age mortality on economic growth Net aid inflows in five African countries (in per cent of GDP) The Stop TB Strategy at a glance

x

xxiv 127

200

200 201 204 209 209 211 221 248

Acknowledgments The book originates from discussions between several contributors and the editors while working at WHO in Geneva. The book would not have been possible without the ideas, dreams, and input that emerged from these discussions. Therefore, we would like to thank the contributors for being part of this project and for providing us with excellent papers. The challenge of fostering health and development globally is very demanding and requires the intelligence, devotion, and passion that our contributors have generously dedicated to this project. We would also like to thank several friends who have shared with us their ideas and challenged ours. In particular, we would like to thank Francesca Celletti, Derek Yach, Jim March, and Luca Cavalli Sforza. A special thank you goes to Larry Brilliant and Hans Rosling who enthusiastically agreed to read the manuscript and write the preface under a tight deadline. Erica Baldacchino provided invaluable assistance in building the index. Finally, we want to thank our publisher, Palgrave Macmillan, for its support throughout the process, and particularly Emily Bown, Virginia Thorp and Mirabelle Boateng for their assistance and patience.

xi

List of Abbreviations and Acronyms All currency amounts are in US dollars AIDS Acquired immune deficiency syndrome ARV Antiretroviral FAO Food and Agriculture Organization of the United Nations GA General Assembly GAVI Global Alliance for Vaccines and Immunization GFATM Global Fund to Fight AIDS, TB, and Malaria HIV Human immunodeficiency virus IAEA International Atomic Energy Agency ILO International Labour Organization IMF International Monetary Fund MDG Millennium Development Goal MDR-TB Multi-drug resistant tuberculosis NGO Nongovernmental organization OECD Organisation for Economic Co-operation and Development TB Tuberculosis TRIPS Trade-related aspects of intellectual property rights UN United Nations UNAIDS The Joint United Nations Programme on HIV/AIDS UNDP United Nations Development Programme UNESCO United Nations Educational, Scientific, and Cultural Organization UNIFEM United Nations Development Fund for Women UNFPA United Nations Population Fund UNHCR Office of the UN High Commissioner for Refugees UNICEF United Nations Children’s Fund UNTS United Nations Treaty Series USAID United States Agency for International Development WHO World Health Organization WTO World Trade Organization

xii

Notes on the Contributors Andrea Boggio is Assistant Professor of Legal Studies at Bryant University. Andrea holds a doctorate in law from Stanford Law School and he held positions at Keele University (UK) and the Institute of Biomedical Ethics at the University of Geneva (and collaborating with the Department of Health, Trade and Human Rights of the World Health Organization). He teaches and researches in several areas of law and ethics, with a particular emphasis on health, human rights, and globalization. Gian Luca Burci is Legal Counsel of the World Health Organization. Prior to assuming that function, Gian Luca served as a senior legal officer in the Office of the Legal Counsel of WHO, as a legal officer in the Office of the Legal Counsel of the United Nations, and as an associate professional officer in the Department of Technical Cooperation of the International Atomic Energy Agency. Gian Luca is the author of numerous articles on topics ranging from UN economic sanctions and peace-keeping operations, to the succession of States, and the law and practice of WHO. Francesco Cavalli-Sforza works as a director, author, and science writer. Francesco directed television and film programs, and has been awarded several prizes in Italy and abroad, in genres ranging from edutainment to documentary, from fantasy to children’s tales, and from promo to corporate. Francesco is the author of popular science books on human evolution and of school textbooks on science, written in joint effort with his father, the human population geneticist Luigi Luca Cavalli-Sforza. Francesco has recently developed a website on Human Evolution, Energy, and the Environment, and is presently working on the project of a theme park on the same subjects. Francesco currently holds an appointment to teach the course of Genetics and Anthropology at the Department of Philosophy of Università Vita-Salute, in Milan, Italy. Valerie Crowell is currently pursuing a PhD in Public Health and Epidemiology at the Swiss Tropical Institute, University of Basel, Switzerland. Valerie’s main interests are in the economics and financing of health systems in lowand middle-income countries, and her present research focuses on the costs and impact of malaria control interventions and strategies. Prior to joining the Swiss Tropical Institute, Valerie spent over four years working at the World Health Organization, first contributing to a follow-up to the work of the Commission on Macroeconomics and Health and then to the Global Malaria Programme. She holds a BA in Economics from Stanford University, xiii

xiv Notes on the Contributors

and an MSc in International Relations from the London School of Economics and Political Science. Chris Desmond is a Research Specialist in the Child, Youth, Family and Social Development Research Programme of the Human Sciences Research Council, South Africa. Chris is an economist working primarily on issues relating to responses to children affected by HIV and AIDS and poverty. Carroll Estes is Professor of Sociology and Founding Director of the Institute for Health and Ageing at the University of California, San Francisco. Carroll has been President of the Gerontological Society of America, the American Society of Ageing and the Association for Gerontology in Higher Education. Research interests include the political economy of ageing, globalization, and issues of older women. David Evans is Director of the Department of Health Systems Financing in the Cluster on Health Systems and Services at the World Health Organization. David holds a PhD in economics and worked as an academic in Australia and Singapore before joining WHO in 1990, initially working on social and economic aspects of tropical disease transmission and control. Subsequently, his work has covered a variety of areas, including the assessment of health system performance and the generation, analysis and application of evidence for health policy. This work now focuses specifically on working with countries on the development of effective, efficient and equitable health financing systems. David has published widely in these areas. Laurie Garrett is currently the Senior Fellow for Global Health at the Council on Foreign Relations in New York. Laurie is the only writer ever to have been awarded all three of the Big ‘Ps’ of journalism: The Peabody, The Polk and The Pulitzer. Laurie is also the best-selling author of The Coming Plague: Newly Emerging Diseases in a World Out of Balance and Betrayal of Trust: The Collapse of Global Public Health. During her time as Senior Fellow for Global Health at the Council on Foreign Relations, Garrett has written several reports and articles, including: HIV and National Security: Where are the Links? (2005); ‘The Next Pandemic?’ (Foreign Affairs, July/August 2005); ‘The Lessons of HIV/AIDS’ (Foreign Affairs, July/August 2005); and ‘The Challenge of Global Health’ (Foreign Affairs, January/February 2007). Laurie is a member of the National Association of Science Writers, and served as the organization’s President during the mid-1990s. She currently serves on the advisory board for the Noguchi Prize, François-Xavier Bagnoud (FXB) Center for Health and Human Rights, and the Health Worker Global Policy Advisory Group. Laurie is an expert on global health with a particular focus on newly emerging and re-emerging diseases, public health and their effects on foreign policy and national security.

Notes on the Contributors xv

Anna Gatti currently lives in California, where she works for Google. Anna holds a PhD in Business Administration, a PhD in Criminology, and a postdoc in Organizational Theory from Stanford. She has worked for years as an economist at the World Health Organization in Geneva, Switzerland. Prior to that, Anna served in several faculty and research positions at Bocconi University, Milan, Italy, Trento University, Italy, the Business School Fundacao Getualio Vargas, San Paolo, Brazil, and at the Goldman School of Public Policy, University of California, Berkeley. Egle Granziera is an Associate Legal Officer in the Office of the Legal Counsel of the World Health Organization. Previously, Egle practiced law in Turin, Italy. An Italian national, Egle holds a graduate degree in law from the University of Turin and a Masters Degree in Business Law from the Free University in Brussels. Riikka Koskenmäki is a Technical Officer (Legal) at the World Health Organization. Riikka served previously with the Ministry of Foreign Affairs of Finland, l’Institut universitaire de hautes études internationales (IUHEI, Geneva, Switzerland), the Iran–United States Claims Tribunal and the International Labour Organization. Her research interests and publications rest in the field of public international law, in particular, international health and institutional law. Riikka holds an L.L.M. from the University of Helsinki and a D.E.A. from IUHEI. Kerry Kutch is a Technical Officer in WHO’s HIV Department. Ronald Labonté holds a Canada Research Chair in Globalization and Health Equity at the Institute of Population Health, Canada. He is Professor in the Faculty of Medicine at the University of Ottawa, and Adjunct Professor, Department of Community Health and Epidemiology at the University of Saskatchewan. Most recently, Ronald chaired the Globalization Knowledge Network for WHO’s Commission on the Social Determinants of Health. He was also a member of the research team that advised the 2002 Royal Commission on the Future of Health Care in Canada on the impacts of globalization and trade on health. Lenore Manderson is a medical anthropologist and a social historian. She is Professor in the School of Psychology, Psychiatry and Psychological Medicine, Faculty of Medicine, Nursing and Health Sciences at Monash University, Australia. For the past 35 years, her research and teaching have focused on gender, health and development, particularly in Southeast Asia and Australia, among dominant, immigrant and indigenous communities. Her current research focuses on chronic illness, disability and inequality. Stephen Matlin joined the Global Forum for Health Research in Geneva as Executive Director in January 2004. Educated as an organic chemist, he worked in academia for over 20 years. This was followed by periods as

xvi Notes on the Contributors

Director of the Health and Education Division in the Commonwealth Secretariat, Chief Education Adviser at the UK Department for International Development and as a freelance consultant in health, education and development. Stephen is a Senior Research Fellow at Oxford University. Stephen Marks is François-Xavier Bagnoud Professor of Health and Human Rights in the Department of Population and International Health at the Harvard School of Public Health. Stephen’s work focuses on the interface of health and human rights, drawing on the disciplines of international law, international politics, international organizations, and international economics. He recently co-edited a book on Development as a Human Right: Legal, Political and Economic Dimensions (2007), a reader on Perspectives on Health and Human Rights (2005), as well as editing Health and Human Rights: Basic International Documents (2006), now in its second edition. Chris Phillipson is Professor of Applied Social Studies and Social Gerontology and Director of the Institute of Ageing at Keele University, UK. He is past President of the British Society of Gerontology. His research interests include issues relating to social exclusion in later life, urbanization and ageing, and the impact of globalization on the lives of older people. Elena Portacolone is a doctoral student in the Department of Social and Behavioural Sciences at the University of California in San Francisco. She is conducting research on social movements led by older adults and on alternatives to nursing homes. Mario Raviglione is the Director of the Stop TB Department at the World Health Organization, where he has worked since 1991. Mario has published more than 150 articles and book chapters, including TB chapters in the last three editions of Harrison’s Principles of Internal Medicine. He is editor of the 3rd edition of Tuberculosis – A Comprehensive International Approach (2006). He has served as a visiting professor in various medical schools and is a member of the Stop TB Partnership Coordinating Board. He graduated from the University of Turin in Italy in 1980, and later trained in internal medicine and infectious diseases in New York and Boston. In 2005, he received the Princess Chichibu TB Global Award for his achievements in TB control. Linda Richter is the Executive Director of Child, Youth, Family and Social Development at the Human Sciences Research Council, South Africa. She is an Honorary Professor in Psychology and an elected Fellow of the University of KwaZulu-Natal, an Honorary Professor in the Department of Paediatrics and Child Health at the University of the Witwatersrand, a Consultant in the Centre for the AIDS Programme of Research in South Africa (CAPRISA), and an Honorary Fellow in the Department of Psychiatry and at the University of Melbourne. She has conducted both basic and policy research in the fields of child and youth development as applied to health,

Notes on the Contributors xvii

education, welfare and social development, and has published more than 150 papers in the fields of child adolescent and family development, infant and child assessment, protein-energy malnutrition, street and working children, and the effects of HIV/AIDS on children and families, including HIV prevention among young people. Her publications include Mandela’s Children: Growing up in Post-Apartheid South Africa (2001), The Sexual Abuse of Young Children in Southern Africa (2004) and The Importance of CaregiverChild Interactions for the Survival and Healthy Development of Young Children (2004). Kammerle Schneider is a research associate in the Global Health Program at the Council on Foreign Relations in New York. Previously, she was a Refugee/IDP Program Officer for the USAID-funded Extending Service Delivery Project. There she also served as the liaison between her agency, USAID, and the International Centre for Migration and Health in Geneva. Prior to this, she had successive internships at Americans for UNFPA and the International Centre for Migration and Health in Geneva, Switzerland. She served as a Peace Corps volunteer in Guatemala from 2001 until 2003. Kammerle holds a Master of International Affairs with a concentration in Migration and Health from Columbia University, and a BA from the University of Washington. Ted Schrecker is a scientist with the rank of Associate Professor at the Institute of Population Health, University of Ottawa, Canada. A political scientist by background, Ted has 25 years of experience in policy analysis as a legislative researcher, academic, and consultant to a variety of government agencies and nongovernmental organizations. Ted has a special interest in the political economy of globalization and in issues at the interface of science, ethics, law and public policy. Yves Souteyrand is the Coordinator of Strategic Information in WHO’s HIV Department. Between 1993 and 2003, Yves was appointed by the French National Agency for AIDS Research (ANRS), as the Head of Public Health and Socio-behavioral AIDS Research. He is an economist trained in health economics and received his PhD from the University of Aix en Provence. Sergio Spinaci is a senior public health expert at the World Health Organization in Geneva, where he has worked since 1989. Since 2006 he has been the Associate Director of the WHO Global Malaria Programme. He is responsible for the WHO/Roll Back Malaria Coordination, representing WHO in the RBM Board and RBM Executive Committee. Before the present role, Sergio worked for the WHO Global Tuberculosis Programme (1989–1999) and he then became the WHO Executive Secretary of the Macroeconomics and Health Unit (2000–2005). Sergio holds a medical degree, diplomas in Tuberculosis, Respiratory Diseases and Occupational Health from the University

xviii Notes on the Contributors

of Turin and a Masters in Public Health from the Harvard School of Public Health. David Stuckler is a junior research fellow at Christ Church College, Oxford. He holds a MPH in health policy from Yale and is finishing a PhD in sociology at Cambridge. His research integrates political economy and public health, and most of his recent work has focused on explaining the unprecedented mortality crisis in postcommunist countries that occurred after the collapse of the Soviet Union. David is also a member of Oxford Health Alliance economics working group and has written extensively on the economics of chronic disease. Mukund Uplekar is a medical officer in the Stop TB Department at the World Health Organization in Geneva. After a long stint in private medical practice and community health research in India, Mukund has been working in international public health for more than a decade. He has worked extensively on formulating evidence-based, global and national strategies related to public–private mix issues in tuberculosis control. He has also been one of the chief contributors to the development and drafting of WHO’s Stop TB Strategy. Derek Yach is Director of Global Health Policy at PepsiCo. Previously he has headed global health at the Rockefeller Foundation, been professor of Public Health and head of the Division of Global Health at Yale University, and is a former Executive Director of the World Health Organization. Dr Yach has spearheaded efforts to build an analytical framework for assessing the impacts of globalization on health in order to find ways of improving global health. At WHO, Derek led development of WHO’s first treaty, the Framework Convention on Tobacco Control, and the development of Global Strategy on Diet and Physical Activity. Derek has an honorary doctorate in science from Georgetown University and master degree in public health from John Hopkins. Dungbao Yo works at WHO’s HIV Department. Before joining WHO, Dungbao worked at the Hunan Institute of Parasitic Diseases, which is the WHO Collaborating Centre for Research and Control of Schistosomiasis in Lake Regions in Hunan, China and at the Division of Policy Study and Information of the National Center for AIDS Prevention and Control, China.

Preface Larry Brilliant and Hans Rosling

This is a serious book, because global health is a topic that calls for serious attention but also because the approach of this book is serious. The authors are evidence-based when they analyze health and development in the world. Their book is free from ideological and humanitarian advocacy. Neither is it a textbook structured to help a student pass an exam. Instead this book brings together a high number of updated analysis and reviews by experienced experts. The authors are active researchers or work in international organizations. The expertise is on how to deliver a better international support to survival and health improvement among those in greatest need in the world. Their thoughtful analysis reveals many ways to improve the international support to global health. The reader will learn many ways to speed up the delivery of a better world health. And much need to be done faster. In 1798 Jenner first reported on successful vaccination against smallpox, and in 1979 WHO declared that smallpox was eradicated after a global delay of 181 years. In 1855 John Snow convincingly reported that provision of safe water will stop cholera, as it also will with many other diarrheal diseases. This achievement is now counting a global service delivery delay of 154 years. In 1882 Robert Koch invented a staining technique that enabled the diagnosis of tuberculosis. We are still left with the same diagnostic procedure that requires examination in light microscopes. Research has not yet delivered a simpler diagnostic test, a delay of 126 years. In 1902 Ronald Ross received the second ever Nobel Prize in Medicine for his discovery of the mosquito transmission of malaria. The global delay in controlling this disease is now counting 106 years. In 1928 Fleming discovered penicillin, but every year three million children still die from pneumonia. The global delay in delivering antibiotics is now 80 years. In 1955 Jonas Salk announced the first polio vaccine and in 1963 Albert Salk followed with the oral vaccine. Much has been achieved with these fantastic vaccines, but polio eradication is still pending after 53 years. In 1984 Luc Montagnier and Robert Gallo discovered that Aids was caused by HIV. This was after an impressive research delay of only three years from the first reported case of Aids. But 24 years later the world has still not reversed the epidemic. It is clear from the above examples that medical discoveries do not yield immediate results in terms of better world health. This book explains the reason for and the character of all these global delays in delivering the seemingly obvious: a universal coverage of the most basic and most cost-effective life-saving intervention that medical research has delivered. xix

xx Preface

The building of health systems in low income countries and international health collaboration seems to be larger intellectual and organizational challenges than to make the brilliant discoveries listed above. This book will allow you to understand why. What is needed to achieve this seemingly straight forward task is enlightened in the first eight chapters in Parts I and II. The authors elucidate the complexity of this undertaking from several complementary approaches that range from human evolution to economics and ethics. Part III addresses the action needed to improve the health of the main vulnerable groups whereas the final part (Part IV) has more of a disease approach. The coverage of issues is comprehensive and well structured, yet each chapter can be read independently in the order each reader sees fit. The evidence-based approach is emphasized by extensive, updated and wellchosen references. The authors also contribute material that is not available in any references. This includes their recent experiences and observations of the strengths and weaknesses of the emerging new international organizations and initiatives. The Sub Saharan region in Africa, which has experienced many of the worst health outcomes, now has the economic growth that it has been lacking for the final decades. Meanwhile the international development aid for health is also increasing and philanthropy is making contributions of an unprecedented size. And, most importantly, governance is improving in several low-income countries in Africa. Most of those countries with the worst health status can make considerable progress in coming decades. It is time for the world to deliver the right support as improved global health is necessary for a secure and sustainable common future. The book should be read by all those wanting to get serious about improving global health, because the time has come when this can and must be done.

Introduction: Toward a Matrix Approach Anna Gatti and Andrea Boggio

Increased development aid and new challenges in global health Global health problems are at the forefront of the international development agenda. Three of the eight Millennium Development Goals (MDGs, http://www.un.org/millenniumgoals/) which were officially established at the Millennium Summit and adopted by the Millennium Declaration in 2000, relate directly to health. It is evident that health is an important contributor to several other developmental goals (Miranda and Patel 2005). The international focus on health issues has brought along increased financial resources. Since 2000, multilateral agencies, bilateral agencies, and private nonprofit organizations have allocated significant funding to global health. Responding to calls for scaling up of AIDS control (Attaran and Sachs 2001), the Global Found to fight Aids, Tuberculosis and Malaria (GFATM, www.theglobalfund.org) was established in 2002 to finance a dramatic turnaround in the fight against these epidemics. Development assistance for health is estimated to have grown from about $6 billion in 2000 to $14 billion in 2005 (Reich et al. 2008). While increased funding for development brings along new opportunities to improve the status of global health, it is crucial that the increased flow of developmental assistance is allocated in efficient ways so that these new opportunities for global health are fully taken advantage of. Questions of efficient allocation entail two levels of analysis: assessing the existing tools employed by international actors in allocating resources (tactic questions of tools) and revisiting some of the fundamental assumptions under which resources are allocated (strategic questions of methods and models).

From strategy to tactics: the diagonal approach and the matrix tool In recent decades, the efforts of international players to improve health conditions in poor countries have embraced two different strategies: one focusing on health systems, the other on specific diseases. Under the first of the two strategies, also known as the horizontal approach, health improvement xxi

xxii Introduction: Toward a Matrix Approach

can be achieved mainly by strengthening health systems supporting existing national capacity and assisting the effective implementation and monitoring of national developmental plans. Thus, under this approach, health systems are broken down into their various components and interventions aim to strengthen specific areas and functions. The second of the two strategies, also known as the vertical approach, emphasizes disease-specific approaches to health improvement. The rationale of this strategy is to address specific diseases that affect a population in ways that hinder the social and economic development of a country. Under this approach, the primary focus in on single-disease control programs that aim to improve the health indicators for the targeted disease with interventions that ordinarily affect one or just a few components of the health care system. Discussions on the most effective approach to health interventions have often focused on the dichotomy of vertical and horizontal approaches by documenting the limitations of interventions that rely predominantly on one of the two strategies. Resource allocations based on excessive reliance on the horizontal approach may reduce the chance of reducing at a faster pace the burden of diseases that affect a population in ways that hinder the social and economic development of a country. Reich et al. argue that the problems were particularly severe in Sub Saharan Africa because of ‘low financing of health systems, bad governance, the human resources for health crisis, the high level of poverty of the people, the debt burden, the emergence of new diseases and the deterioration of the social system in many countries’ (Reich et al. 2008). Excessive reliance on the vertical approach has generated concerns about ‘the unintended consequences of creating a fragmented array of uncoordinated programmes supported by multiple donors that recipient countries must struggle to manage [as vertical programs] ‘have sometimes not fully dealt with broader system failures’ (Reich et al. 2008). In the context of HIV/AIDS policies, ‘[a] vertical approach works for a while, and then it hits the ceiling of insufficient health workers and dysfunctional health systems, particularly in countries with high HIV prevalence’ (Ooms et al. 2008). The dichotomy of vertical and horizontal approaches is, however, somehow ‘artificial’ (Uplekar and Raviglione 2007). There is a consensus that both approaches must be taken into account when planning and conducting health interventions. Indeed, both approaches have clearly inspired WHO’s interventions during the last few decades; one gaining occasional popularity over the other in a way that Uplekar and Raviglione define as a ‘pendulum’ (Uplekar and Raviglione 2007). The debate is now converging toward a diagonal approach, which combines both strategies. This approach aims to strengthen the health system of a country while at the same time fighting diseases that are a substantial burden to that country. The 2007 WHO’s report Everybody’s Business: Strengthening Health Systems to Improve Health

Anna Gatti and Andrea Boggio xxiii

Outcomes describes this approach as a strategy aiming to ‘address health systems bottlenecks in such a way that specific health outcomes are met while system-wide effects are achieved and other programs also benefit’ (World Health Organization 2007a). While there is convergence toward considering the diagonal approach as the appropriate model for the efficient allocation of funding increasingly allocated to global health, the challenge is its implementation and execution – especially if one considers that, albeit growing, funding for health development interventions is limited. How can we apply the diagonal approach to health interventions within a specific national context so that funding is allocated efficiently? We propose a matrix as a tactical tool to be used to define optimal allocation of (scarce) resources with reference to health interventions within a specific national context (Table I.1). The matrix has two dimensions: health system components and services and a list of diseases that burden the targeted country. The matrix allows the tracking of proposed health interventions that meet the needs of more than one disease-based intervention and consequently assigning resources based on a combined vertical-horizontal approach. Thus, in approaching a health intervention in a specific country, the proposed framework requires: (1) creating a stack ranking of disease that must be fought in that country; (2) identifing a prioritized set of key components of the health systems (from three to five) that must be strengthened to fight each of the diseases listed; (3) identifying the components of the health systems that are key to more than one disease; (4) considering the potential overlap between programs; (5) selecting which disease program is better suited to strengthen that component; and (6) shifting the funding of the disease program not selected to strengthen the next prioritized health system component that is currently underfunded. Fund shifting requires coordination among the different disease programs by improving and extending existing interactions among the various stakeholders. Additionally, increased collaboration among WHO departments is indeed needed (World Health Organization 2007a). The matrix is based on a simplification of how health interventions affect the interactions within and among the different health system components and diseases. The literature has identified many different ways to operationalize the concept of health systems and services (Frenk 1994; Murray et al. 2000; Murray and Frenk 2008; Rivas-Loría et al. 2006; World Health Organization 2000, 2007b). For the purposes of this book, we adopt (and partially modify) the framework proposed by WHO (World Health Organization 2007a). However, further research is required to identify indicators and to find alternative ways to operationalize the concept that can be displayed on dimension two – that is to say the health system components.

Table I.1

Gatti/Boggio matrix

Dimension 1 – Disease

Dimension 2 - Health System and Services Operationalization

Concept

Sub-Concepts

Primary Health Care Service Delivery

Secondary Health Care

Health Workforce

Variables Community Health Services Medical Centers/PHCs Professional Dental Services Village Health Clinics (VHCs) Pharmacies ... Hospitals Mental Health Services Learning Disabilities Services ... Physicians Nurses Midwives Dentists Pharmacists Laboratory Health workers Environment Health Workers Community Health

Disease Disease Disease Disease Disease Disease ... 1 2 3 4 5 Z

Health System Information

Medical Products, Vaccines and Technologies Health Financing

Workers Other health workers Health Management and Support workers ... Census Household surveys Population-based sources Vital registration system ... National Health Accounts Public Health Surveillance Facility-based sources Health Services data Health System monitoring data ...

Tax-based Financing Social Health Insurance Private Health Insurance Community-based health Insurance Medical savings accounts Innovative financing

Table I.1

Continued

D imension 1 C oncept

– D isease Sub -C oncepts

V ariables

methods ... Stewardship in Health ... Stewardship of Health ... Continuity of Health Leadership & Policies in Ministry Governance/Stew of Health ( in years) ardship Stewardship for health Years of political stability Years of peace Health Education

D isease D isease D isease D isease D isease D isease ... 1 2 3 4 5 Z

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Over the past decades, achievements in global health have been astonishing. Yet, the challenges ahead are daunting. How to best organize health and development resources and efforts remains problematic—as several of the constitutions collected in this volume illustrate well. Although resources allocated to and organizations devoted to global health have been expanded, a critical assessment of how well these resources and organizations are used is essential. The tension between interventions aiming to eradicate or reduce of the burden of specific diseases and interventions aiming to establish and maintain health care systems may create inefficiencies. The matrix approach proposed in the chapter lends itself as a methodological tool to be used by international organizations, funding bodies, and national governments to address some of the organizational inefficiencies that result from the tension between the horizontal approach and the vertical one. However, the quest for a better organizational approach to health and development resources and efforts raises more profound questions of general approach to these interventions. In fact, the current model of global health intervention has clearly failed to deliver much needed solutions. Perhaps the lenses under which we scrutinize global health are inadequate, and rethinking the underlying paradigm of the health and development interventions is the next logical step. Is the current public health paradigm in crisis? Is a new paradigm needed to enhance global development? Are we looking at right indicators, institutions and theories to tackle one of the most critical questions of our time? We believe that future researches in this direction are needed to provide new theories so that new health policy methods and models will be developed. Improving the theoretical framework and tools available to those who are dedicated to the improving of the living conditions of all individuals around the globe is certainly a goal shared by all health and policy institutions and actors.

The book The present edited volume considers the present status of global health interventions with a particular emphasis on the role of international actors. The book is divided in four parts. PartI:- The Global Health Arena presents three contributions looking at the present state of affairs of global health and at the role of WHO, the principal actor of the global health arena. Part II: Health and Development: Perspectives and Experiences examines health and development through the lenses of various points of view: evolution, economics, human rights law, and ethics. Part III: Global Health and Vulnerability explores the role of international organizations with regard to three vulnerable groups: elderly populations, children, and women. Finally, Part IV: The Interrelation Between Specific Disease and Development addresses the role of international organizations within the context of four disease areas: leading chronic diseases, malaria, HIV/AIDS, and TB.

xxviii Introduction: Toward a Matrix Approach

The global health arena In ‘Global Health: Getting it Right’, Laurie Garrett and Kammerle Schneider critically assess the present state of affairs of global health. The authors note that we are in a moment ripe with historic changes. An unprecedented amount of funding is allocated to global health. Yet new approaches are needed. In particular, Garrett and Schneider identify three areas in which public health policies ought to be revisited. First, funding should not go primarily to disease-specific initiatives; it should also be directed toward initiatives aiming to build health infrastructure and to integrate disease-specific initiatives into wider public health programs. Secondly, the global health structure must be reformed in a way that increases the harmonization of money flowing into global health as well as the accountability and transparency of public health governance. Thirdly, programs at a national level must incorporate capitalist principles, develop social entrepreneurship, and build stronger partnerships with the private sector. In ‘The World Health Organization and its Role in Health and Development’, Riikka Koskenmaki, Egle Granziera, and Gian Luca Burci offer an in-depth analysis of the institutional profile of WHO, the key UN body in the area of health and development. After a historical overview of international health cooperation, the authors discuss WHO’s structure showing how this agency operates at a global as well as at the regional and country levels. The authors then discuss WHO’s mandate (‘the attainment by all peoples of the highest possible level of health’) and functions (direction and coordination of international health work, normative functions, and research and technical cooperation). Finally, the authors focus on how WHO’s mandate and functions have evolved over time in the light of changing health and development needs and on WHO’s recent partnerships, forms of collaboration and financing mechanisms, arguing that WHO’s horizontal policies aiming to develop health systems driven by primary healthcare are essential for meeting the challenges developing countries face. In ‘Beyond the Matrix: Thinking Three-dimensionally About Social Determinants of Health’, Ted Schrecker and Ronald Labonté take a close look at how globalization affects the social determinants of health – which the authors define as the conditions in which people live and work, and that affect their opportunities to lead healthy lives. Globalization (and primarily economic and financial globalizations) has a profound impact on the economic determinants of health. Financial markets and monetary and assistance policies of international, public financial institutions (the World Bank in primis) determine countries’ access and use of development aid in ways that often are not helping countries to improve the status of the social determinants of health. The authors then argue that global health problems must be addressed in a three-dimensional fashion by adding to the

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vertical and horizontal perspectives a third level, entailing effective policy responses inspired by health equity considerations. As a starting point of the three-dimensional approach, Schrecker and Labonté refer to what the WHO’s Commission on Social Determinants of Health has proposed: redistribution, regulation, and rights (the three Rs). After discussing how to expand redistribution and rights, the authors argue that it is necessary to create a ‘policy space’ where societies burdened by diseases discuss and negotiate policies without the constraints imposed either by financial markets or by the policies of multilateral institutions like the IMF and the World Bank. In ‘Research and Innovation in Health and Development’, Stephen Matlin looks at what needs to be done in terms of research and innovation to improve the global scene of health and development. The author points out that, in the last ten to 15 years, the landscape of health research for development has changed substantially, with increased investments from philanthropic foundation and the public sector and new actors appearing on the scene, such as the Council on Health Research for Development and the Global Forum for Health Research, appearing on the scene. More recently, various innovative mechanisms have attracted private sector money and new funding mechanisms have been established to support the purchase of available medicines for neglected diseases. Despite research resources to address the health problems of the poor remain relatively scarce, inclusive prioritysetting processes such as the Combined Approach Matrix, which maps the available knowledge, needs and opportunities, must be used to generate priorities for the most relevant and essential research, Matlin argues. Moreover, the shortage of sufficient numbers of adequately trained health researchers must be addressed. However, Matlin concludes it is crucial that less developed counties develop their own capacities and resources so that they would be in a position to conduct research that is relevant to their own health and development needs, taking up the challenge of building and resourcing national health research systems to ensure that they create and systematically utilize research capacities as an integral part of their efforts to improve health.

Health and development: perspectives and experiences In ‘Heath and Evolution’, Francesco Cavalli-Sforza gives an account of human health from an evolutionary perspective. The author argues that health is the product of evolution, and that success in evolutionary strategies explains much of the present state of global health. Throughout human history, and most markedly with modern humans and since the inception of history, cultural evolution has increasingly gained the edge over biological evolution to the extent that life expectancy and unequal distribution of disease burden depend largely upon imbalances in the development of different regions of the world rather than upon any lack of medical knowledge or of healing

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skills. The author concludes that universal health education, imparted from a very early age, and an awareness of the need to control births, are key policy objectives to improve the general state of human health. In ‘Health and Development: an Economic Perspective’, David Evans discusses how economists contribute to an understanding of the links between health and development. In discussing the two ways in which health affects human welfare and development (health is valued for its own sake and is also valued for its potential to increase income and consumption opportunities), the author describes some of the gaps in the available evidence. Finally, the author explores the implications for international organizations seeking to work with countries to improve human development. In ‘Health, Development, and Human Rights’, Stephen Marks considers how the human rights framework contributes to an understanding and shaping of the relationship between health and development from both a theoretical and a practical perspective. After discussing the three main theoretical approaches to health, development and human rights (social justice, a holistic understanding of social process, and capabilities), the author analyses human-rights-based approaches to health and development in practice, with a specific emphasis on the action of international organizations, bilateral donors, and NGOs. In ‘Health and Development: an Ethics Perspective’, Andrea Boggio examines health and development from an ethics perspective. The author argues that international organizations have a moral obligation to redress underdevelopment and outlines two basic principles (beneficence and justice) that international organization ought to follow in designing and implementing their efforts to assist less developed countries in improving the health of their communities. Finally, Boggio argues that ethics offers an ideal framework for incorporating the complexities of global health issues in the reasoning of policy makers.

Global health and vulnerability In ‘Health and Development: the Role of International Organizations in Population Ageing’, Chris Phillipson, Carroll Estes and Elena Portacolone look at ageing as a global phenomenon and as a process transforming developing as well as developed countries. After discussing how populations, particularly in developed countries, are ageing at a rapid rate, the authors discuss the challenges this population is facing, and point out that that international organizations play an instrumental role in shaping policies to address this process. The World Bank, in particular, has adopted costeffectiveness tools in the allocation of health resources that give lower value to health improvement for older people, and favor limitations to the scope of the welfare state by promoting in its place private pension contributory plans. This places enormous pressure on countries to move further in the opening up of public services to competition from global (and especially North

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American) corporate providers and private insurers. International organizations must therefore address late life inequities and the shrinking of welfare measures on a global scale by building an age dimension into development policies. In ‘Child Health and Development’, Linda Richter and Chris Desmond assess international efforts to improve child health. The authors point out that, to be effective in improving child health, international programs on policies must focus on strengthening the institution that is in a unique position to support and strengthen child health: the family. Programs that aim to initiate or expand income transfers to families or households have been launched in various countries around the world with the aim of addressing poverty, which is the primary cause of child health problems. The evidence presented shows that these initiatives have successfully implemented cash transfers to families, thus benefiting children’s health and education. In the long run, developmental assistance must be consistent and stable, and must be supported by a sustained effort on the part of international organizations. However, these efforts must aim at strengthening states as it is not productive to skip over governments or families. Supporting and strengthening governments also requires the strengthening of democratic processes and domestic accountability. In ‘Women, Health, and Development’, Lenore Manderson considers how women’s health has been affected negatively by the processes and structures of development. The author points out that development programs may create (unintended) gender inequities by creating or entrenching women’s subordination and by being gender blind when overlooking or ignoring local gendered sensitivities (such as the reluctance of women to disclose disease symptoms with male physicians) or the fact that women often work a double day, are more likely exposed to health hazards, and often have only limited access to education. Manderson then argues that international efforts must take the economic, social, and cultural determinants of gender inequality into consideration and reports successful initiatives to eliminate or at least to reduce neglected disease and sexual violence – which is a primary source of health problems for women, especially in less developed countries.

The interrelation between specific disease and development In ‘Long-Term Impacts of Leading Chronic Diseases in Low- and MiddleIncome Countries: a Comparative Analysis’, David Stuckler and Derek Yach explore the factors that contribute to global chronic disease patterns. Chronic disease mortality levels and mortality rates are growing faster in poor than in rich countries. The chapter comparatively evaluates prevailing explanations of chronic disease growth using models of chronic disease epidemiology and derives a set of socio-ecological factors which appear to be driving global chronic disease patterns. By using international longitudinal data from 1960 to 2000, the authors demonstrate the significance of these determinants

xxxii Introduction: Toward a Matrix Approach

empirically, which forms the basis for forecasts of their consequences for health and economic growth in developing and developed countries. The conclusion is that more ‘intersectoral action’ – exchanges between the private and the public sectors, more funding and initiatives led by NGOs, and more interdisciplinary collaborations in academia – is needed to understand the social transformations at the broader levels that are driving chronic diseases and to develop feasible and effective strategies to reverse this. In ‘Strategies for Financing Universal Access to Healthcare and Prevention: Lessons Learnt and Perspective for the Twenty-first Century’, Sergio Spinaci and Valerie Crowell extend the argument by presenting data on developmental assistance for health and discussing ways to eradicate malaria. The authors argue that concerns arise with regard to both supporting countries with weak policy and institutional environments and the sustainability and predictability of such funding. Moreover, by focusing on narrow disease-specific targets, performance-based funding frameworks may overlook investments in health systems that are needed to ensure those targets are met. Moving to discussing malaria funding, the Spinaci and Crowell note that, while disease-specific funding has risen over the course of the past few years, development aid has been primarily directed toward funding commodities without concurrent increases in funding for technical assistance to build country capacity and operational research to optimize interventions in the country context. The challenges ahead include investing more in technical assistance and operational research to seek ways of improving the use of aid, strengthening country programs, and stabilizing the markets for commodities upon which future gains depend. Yves Souteyrand, Dongbao Yu and Kerry A. Kutch, discuss HIV/AIDS. In ‘HIV/AIDS, Health and Development’, the authors discuss the two ways in which this epidemic has affected development: by imposing severe burdens on the health sector and by imposing severe constraints on the social, economic, and human development of the communities affected. The case is then made that, to foster development, the burden of HIV/AIDS must be reduced, and that can be done through more effective prevention strategies and expanding access to treatment. In particular, prevention may only be effective if international efforts are multisectoral – that is if they involve the health sector broadly defined – involving a combination of horizontal and vertical strategies. It makes sense, however, that strategies involving nations with weak health systems to direct the funding toward diseasespecific programs and thus to start delivering some services while building up infrastructure in a second step. Disease-specific programs can and should strengthen overall health systems’ capacity. In the final chapter of the book, ‘Global TB Control: Persisting Problem, Shifting Solutions’, Mukund Uplekar and Mario Raviglione discuss the role of WHO and other international organizations regarding global TB control. The chapter presents data about the historical and present trends of TB prevalence

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in the world and trace the history of TB control from the birth of WHO up to the present strategy embraced by WHO (Stop TB Strategy). The historical analysis shows that TB control strategies have changed over time, in what the authors call a swinging pendulum. While until the late 1970s, TB strategies focused on a vertical approach promoting disease-specific measures, during the 1980s, the resources invested in fighting TB were substantially reduced in terms of both human capital and finances. This ‘downswing’ coincided with data suggesting that TB was under control, economic crises and, consequently, with reduced resources in general allocated to healthcare systems, and the emergence of a culture in public health of integrating managerial function and services rather than on fragmenting functions and resources in disease-specific programs. The HIV pandemic of the late 1980s brought TB back to the attention of policy makers. The resurgence of TB led to rethinking managerial integration and developing a new strategy to control TB. The outcome of this period is WHO’s Stop TB Strategy – a comprehensive response to the TB resurgence aiming at integrating disease-specific packages with the functioning systems and services of existing national public health systems. Finally, the authors consider the future challenges for TB control and suggest that the answer lies in looking upstream and that more work needs to be done in understanding and removing the ‘causes of the causes’ that contribute to TB – that is to say, the socioeconomic determinants of TB such as poverty, urbanization, housing, nutrition. At both the international and domestic levels, successful TB control strategies must aim to remove not only the direct causes of TB, but also its upstream determinants – a challenge that the authors suggest is still to be fully incorporated in present policies and practices.

References Attaran, A. and J. Sachs (2001) ‘Defining and Refining International Donor Support for Combating the AIDS Pandemic’, The Lancet, 357(9249): 57–61. Frenk, J. (1994) ‘Dimensions of Health System Reform’, Health Policy, 27(1): 19–34. Miranda, J.J. and V. Patel, ‘Achieving the Millennium Development Goals: Does Mental Health Play a Role?’, PLoS Medicine, 2(10): e291. Murray, C.J.L. et al. (2000) ‘Development of WHO Guidelines on Generalized Costeffectiveness Analysis’, Health Economics, 9(3): 235–51. Murray, C.J.L. and J. Frenk (2008) ‘Health Metrics and Evaluation: Strengthening the Science’, The Lancet, 371(9619): 1191–9. Ooms, G. et al. (2008) ‘The “Diagonal” Approach to Global Fund Financing: a Cure for the Broader Malaise of Health Systems?’, Globalization and Health, 4(6). Reich, M.R. et al. (2008) ‘Global Action on Health Systems: a Proposal for the Tokyo G8 Summit’, The Lancet, 371(9615): 865–9. Rivas-Loría, P. et al. (2006) Lineamientos metodológicos, perfiles de los sistemas de salud, monitoreo y análisis de los procesos de cambio: reforma (Washington, DC: OPS). Uplekar, M.W. and M. Raviglione (2007) ‘The “Vertical–Horizontal” Debates: Time for the Pendulum to Rest (in Peace)?’, Bulletin of the World Health Organization, 85(5): 413–14.

xxxiv Introduction: Toward a Matrix Approach World Health Organization (2000) World Health Report 2000 – Health Systems: Improving Performance (Geneva: World Health Organization). World Health Organization (2007a) Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes. WHO Framework for Action (Geneva: World Health Organization). World Health Organization (2007b) ‘Making Health Systems Work’, Working Paper 9: Aid Effectiveness and Health (Geneva: World Health Organization).

Part I The Global Health Arena

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1 Global Health: Getting it Right Laurie Garrett and Kammerle Schneider

Over the last decade, humanitarian attention to the health of the world’s poor, security concerns over the spread of pandemic diseases, and the recognition that health is a key determinant of economic growth, labor force productivity, and poverty reduction have propelled global health to the forefront of the international development agenda. Correspondingly, since the start of the twenty-first century we have seen the global health landscape transformed by a sixfold increase in foreign aid and private spending (United Nations Secretary-General Ban Ki-Moon 2007).1 There has been a massive increase in the number of nonprofit organizations, faith-based groups, and private actors vying to implement programs with this windfall. This is a fantastic moment for global health; but without mechanisms to harmonize efforts, track the commitments made and the dollars spent, and evaluate the impacts on local communities – this boon could simply add to the chaos, even undermining basic health achievements. From the World Economic Forum in Davos to the TED conference in Monterey, from U2 rock concerts in London to the annual Clinton Global Initiative in New York – the surge is on. Money is showering down on health programs like never before. But with investment comes expectations. In the past, too many UN targets or G8 commitments have fallen short, deeply disappointing people in need. At the level of developing countries, where these activities are targeted, hundreds of foreign entities, both large and small, are competing for the attention of local governments, civil society interest, and the desperately short supply of trained healthcare workers. Ministers of Health say that their days are overwhelmed by long lines of NGOs and bilateral program contractors, each demanding their attention. And all too often, these entities have come to impose their programs on the country – not to genuinely work with the country to meet its needs. However, we have nearly the perfect storm for true change: inspired new global health leadership, political commitment, and the financial resources necessary to find innovative ways to save millions of people every year that now perish needlessly from preventable diseases and find new tools to save 3

4 Part I: The Global Health Arena

still more lives. If we fail to take proper advantage of this moment – instead simply proceeding along paths of action laid out in the 1990s, albeit today with better funding – we risk donor fatigue, wasted resources, and millions of lives lost to preventable disease. Failure to slow the spread of HIV, curtail XDR-TB, close life expectancy gaps, or improve maternal health can no longer be blamed on a lack of commitment or political will. The challenge, therefore for Global Health advocates, is to prove that all this new money is actually making a meaningful difference to those who need it most.

60 years of global health Global health has made astonishing achievements since the signing of the constitution of the World Health Organization (WHO) in 1948, which ambitiously defined health as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (World Health Organization 1948). Over the last 60 years, we have seen average life expectancy for humanity, as a whole, skyrocket a full 40 per cent, smallpox successfully eradicated, and under-five child mortality rates cut to the lowest in history. These global health gains have overwhelmingly been due to a combination of public health infrastructural interventions and rising personal wealth and education. But the achievements have not been felt uniformly, either across the community of nations, or within countries. Secretary-General Ban Ki-moon, for example, was born in Korea in 1944 when the average male life expectancy at birth was merely 42 years (Eberstadt and Banister 1992). Today boys born in South Korea have a statistical probability of living 75 years (United Nations 2007). That phenomenal improvement has not been mirrored in Deputy Secretary-General Asha-Rose Migiro’s country of Tanzania, where male life expectancy in the same time period was about 37 years (Egerö and Henin 1973; Henin et al. 1979; Kamuzora and Komba 1991). Today it is merely 51 years (United Nations 2007). This gap, symbolized by the very leadership of the United Nations, is the paramount challenge for global health leaders today. When the Bretton Woods institutions and UN system were created in the mid-twentieth century, the world was divided deeply along the Iron Curtain, in a Cold War pitting the Soviet Union and its allies against NATO and its supporters. WHO, like all of the new international institutions of the day, had to walk a fine line between the ideologically, militarily and economically divided forces. For the first thirty years, these institutions focused their attention on the reconstruction of Europe and Japan, both of which had been devastated by World War II, with most other ventures in the rest of the world receiving only minimal fiscal support. When Robert McNamara took the reins of the World Bank in the mid1970s, he tried to refocus the institution’s resources to addressing Africa, and

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the most impoverished parts of south Asia and Latin America. And the Bank’s efforts might have made a difference, except lurking undetected at that time was a new virus. By the end of the 1980s that virus, HIV, had swept over the planet, virtually unchecked. The HIV/AIDS epidemic dramatically changed the way the world looked at global health. It shook health leaders out of a long period of smug arrogance, in which the developed countries imagined that all the microbes could easily be conquered and health was simply a corollary of economic development. It brought a new, powerful civil society activism to global health. The political zeal and advocacy efforts generated by the AIDS pandemic, amid economic globalization and the end of the Cold War, put health at the top of the international aid and development agenda. Building on the heightened notoriety of global health, during the 1990s the international community created the Millennium Development Goals (MDGs), a set of targets to reach by 2015 in an effort to reduce global poverty and improve the health of the world’s poor. Three of the eight MDGs relate directly to health; and the others address the interconnected nature of poverty, education, and sanitation with health outcomes. As the world confronted the HIV/AIDS pandemic and strove to meet the MDGs, there was a growing sentiment that the traditional system of bilateral agencies and international organizations serving as the primary actors in global health was insufficient. In the past decade, there has been an explosion of new global health players. Private foundations, such as the Bill & Melinda Gates Foundation, innovative global funds, such as the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), the GAVI Alliance (formerly the Global Alliance for Vaccines and Immunizations), and various corporate actors have transformed the global health landscape with large amounts of money and through their ability to respond more immediately to the perceived needs on the ground. A host of disease-specific initiatives such as the Joint United Nations Programme on HIV/AIDS (1996), Roll Back Malaria (1998), and the Stop TB Partnership (1999) have also joined the scene over the last decade, drawing increased attention and funding to specific diseases. The largest increases in global health spending have come from these new partnerships and bilateral donors, while contributions from the multilateral development banks and specialized UN agencies have remained relatively flat (Schieber et al. 2007). Spending on health has also dramatically increased at the country level, in part due to donor forgiveness of long-standing national debts. (According to the World Bank Africa Development Indicators 2007, however, rising GDPs in sub-Saharan Africa, now topping 5 per cent annually, have not resulted in significant improvements in population health. Indeed, some African nations have simultaneously seen their GDPs grow, while life expectancies shrank) (World Bank 2007).

6 Part I: The Global Health Arena

Global health today Unfortunately, the impact of the increased number of national and institutional players, resources, and political support on global health has yet to provide tangible change in health outcomes for all populations. Although some health indicators have improved among certain groups, we have seen increases in gaps in health outcomes for women, children, and marginalized populations – especially in the poorest pockets of humanity – where people are locked in what Harvard’s David Bloom calls ‘mortality traps’ (Bloom and Canning 2007). Despite the great efforts of WHO, UNICEF, UNFPA and the World Bank, to name a few, life expectancy has barely budged in these populations, even as it has soared in nations that once were desperate, like China and India. Today, the life expectancy gap is the widest in human history, with a disparity of five full decades. Each day around 28,000 children under five die from largely preventable causes and 1,400 women die of pregnancy-related complications. In addition, each year, there are 350 to 500 million cases of clinical malaria, and 4 million and nine million people newly infected with HIV and TB, respectively (UNICEF 2007). These diseases and failures in public health continue to disproportionately afflict the poor. In many cases, we do not lack the tools to defeat or curtail disease, but we lack the commitment to think beyond short term wins, and donors’ priorities, politics, and values. Even in parts of the world we have credited as economic success stories – where the Asian Tigers roar, and the Latin miracle twinkles – health remains a striking challenge. The world nervously watches the spread of H5N1 influenza, or bird flu, in Asia, largely in the same locations that featured SARS in 2003. Yellow fever, dengue, and malaria have all returned to Latin America. In additional to infectious diseases, middle-income countries are now burdened by increases in diseases of ‘affluence,’ such as cancer, heart disease and stroke. Maternal health is going backwards in much of the poor world – women are dying in childbirth in many of these countries at a far greater rate than they were half a century ago. Recent United Nations findings on maternal mortality show that a woman living in Afghanistan or Sierra Leone has a one in eight chance of dying in pregnancy or childbirth. This compares with a one in 4,800 risk for a woman in the United States, and a more than one in 17,400 risk for a mother in Sweden (World Health Organization 2007). This logarithmic differential in maternal survival represents the most striking, even egregious, health disparity in the twenty-first-century world. Every effort to improve global health – from bird flu to HIV – comes up against the same set of problems: We simply have not invested the necessary money or technical assistance in health infrastructure: clinics, roads, clean water, sanitation, medical supplies, and the training and management of skilled medical personnel, whether they be doctors, nurses, lab technicians, dentists, pharmacists, midwives or community health workers.

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Medicalization versus public health Far and away the majority of new global health money has been committed to one single disease; HIV/AIDS – a once-paltry million dollar effort – is now a billion dollar enterprise. While the share of global health aid devoted to HIV/AIDS more than doubled between 2000 and 2004 – reflecting the global response to an important need – the share devoted to primary care dropped by almost half during the same time period (World Bank 2006). With increased funding, the world has made progress towards the goal of universal access to HIV/AIDS treatment. The number of people on antiretroviral therapy (ARVs) has increased from 2 per cent to 28 per cent between 2003 and 2006 (World Health Organization et al. 2007). For international donors, making a commitment to provide treatment comes with a great deal of responsibility and a huge price tag. As the number of infected people grows, the number of people that require second line, more expensive, drugs swells. But treatment alone will not end the AIDS pandemic. For every HIV+ individual that went on ARVs in 2006, six more people contracted the virus (UNAIDS 2006; World Health Organization et al. 2007). The current focus on ARVs risks creating a medicine-dominated response to HIV/AIDS, and diverting attention and funds away from the more fundamental political, social, and economic determinants of poverty and the spread of infectious disease. We keep trying to build dams – pharmaceutical dams to hold back the pandemic – but behind those dams the body count of the infected keeps rising, threatening to flood over the top and drown all of our best efforts. Even the Bush Administration’s laudable PEPFAR program, which started out with a fairly minimal mission of providing prevention, care and treatment for a single disease, now finds itself forced to build entire medical delivery systems simply to get anti-HIV drugs to the patients who need them. Further exacerbating the difficulties of treating HIV and scaling up prevention efforts is the current state of health systems and capacity in those countries hardest hit by the pandemic. Decades of neglect have rendered hospitals, clinics, laboratories and health care workers dangerously deficient. Imagine being the health minister of Papua New Guinea, a poor country confronting one of the fastest-growing HIV/AIDS epidemics, with fewer than 300 doctors in the entire nation. Substantial funds have been sent to your country to fight the disease, but you don’t have enough health workers or adequate health facilities to absorb the funding and implement new programs to fight the growing epidemic as well as improve maternal heath, child survival, and fight a host of other less noted public health emergencies. Further compounding the problem, local doctors and nurses often grow so exasperated and demoralized by their dysfunctional health systems that they apply for higher-paying jobs abroad, thus accelerating a ‘brain drain’ at home. There is also an internal brain drain within countries as doctors

8 Part I: The Global Health Arena

and nurses leave public hospitals and health centers lured by more lucrative jobs in clinics run by foreign NGOs, bilateral donors, and faith-based organizations.

Health worker shortage The world is desperately short of health professionals, and the severity of that gap promises to increase sharply in coming years. According to the WHO’s World Health Report 2006, there is a shortage of more than four million healthcare workers in 57 developing countries. One-quarter of physicians and one in 20 of the nurses trained in Africa currently work in the 30 industrialized countries in the Organization for Economic Cooperation and Development. Although sub-Saharan Africa has 24 per cent of the global disease burden, it has only 3 per cent of the healthcare workforce worldwide and accounts for less than one per cent of global healthcare spending. This is in contrast to the Americas where there is 10 per cent of the global disease burden, 37 per cent of the healthcare workforce and more than half of global healthcare spending (World Health Organization 2006b). This dire situation will only continue to deteriorate as the wealthy world ages, and more health attention is thus needed. At the same time, wealthy nations are trying to reduce rapidly inflating health costs by holding down salaries and increasing workloads, making the practices of nursing and medicine less attractive to domestic candidates. Unless radical changes are made swiftly in the United States and other wealthy nations, the gap will soon become catastrophic. Studies show that in 13 years the US will face a shortage of 800,000 nurses and 200,000 doctors (Chen and Boufford 2005). To fill this growing gap, the United States and other wealthy nations are siphoning off doctors and nurses from the developing countries. Rich countries are guilty of bolstering their own healthcare systems by weakening those of poorer nations. For example, due to healthcare worker shortages, 43 per cent of Ghana’s hospitals and clinics are unable to provide child immunizations and 77 per cent cannot provide 24-hour obstetric services for women in labor. As a consequence, the children die of common diseases such as measles, and the mothers die in childbirth. In all of Ghana, there are only 2,500 physicians. Meanwhile, in New York City, alone, there are 600 licensed Ghanaian physicians (World Health Organization 2006a).

Health systems building Investment in strong health systems is the key to improving healthcare worker morale and retention, curtailing the spread of infectious disease and improving the overall health of individuals in any country. The construction of strong health systems requires years of long-term investment. Success is

Laurie Garrett and Kammerle Schneider 9

measured by the number of infections prevented and the number of lives saved. Because infections prevented and lives saved are difficult for donors to quantify and report to constituents, foreign aid giving has been focused on easily measurable advances in specific diseases, such as the number of people provided with AIDS treatment. There are great dangers in funding only disease-specific initiatives and not integrating them into wider public health programs. For example, Rwanda is a country with a relatively low rate of HIV/AIDS (about 3.1 per cent), but with high infant and child mortality rates. Yet, in 2005, almost three-quarters of all donor assistance for health was for HIV/AIDS, while only 2 per cent of the aid was dedicated for healthcare services for child illness. In addition, more than half of the donor-funded health projects in Rwanda are funded for less than 12 months (Republic of Rwanda et al. 2006). Child survival rates in many countries are now decreasing as highly coveted health funding is dedicated to HIV/AIDS, regardless of epidemiological data. Foreign aid spending tends to reflect the priorities of the donor country. On a global basis, recent estimates reveal that AIDS accounts for less than 4 per cent of deaths of children ages zero to 14, while diarrheal diseases, malaria, measles, whooping cough and tetanus account for close to 60 per cent of deaths in the same age group (Mathers and Loncar 2006). Effective and relatively inexpensive preventive measures and/or treatments are available for these infectious diseases. The decision to provide funding to save children suffering from whooping cough versus providing treatment for someone dying of AIDS should not be an either–or proposition. Rich countries have enough money to fund both – what is required now is political commitment and prioritization so that health dollars can be spent most efficiently to upgrade the overall health and wellbeing of societies. Global health aid is often earmarked to be spent for specific purposes: Indeed, WHO’s core budget is trivial compared to the donor funds earmarked for targeted programs. Many countries report difficulties in obtaining sustained, flexible funding that can be used to support building of health systems, including support for training and management of medical personnel and physical infrastructure. Systems and infrastructure are not sexy, they cannot be built in short funding cycles, and they provide little to brag about to constituents. But without viable systems of medical delivery and public health infrastructures, all donors can hope to accomplish, despite spending billions of dollars and euros, is to save some lives at the expense of others; achieve short-term targets without leaving anything in place that allows nations ultimate dignity and self-reliance.

Failures in global health architecture There is a strong, nearly universal sense among health leaders that too many international agencies, bilateral donors, nongovernmental organizations,

10 Part I: The Global Health Arena

and private players are charging forward with uncoordinated efforts, both on the global stage and inside developing countries. Overlapping and imprecise mandates fuel competition for funds, fame, credit and achievement. All too often organizations have set goals for health that are either contradictory to one another or a duplication of efforts. At the country level, this has created a bewildering array of ‘recommendations’ and ‘guidance’ for resource-hungry Ministries of Health. Cambodia, for example, receives around $60 million in foreign aid from 14 bilateral donors and five multilateral agencies and has over 100 NGOs working on the ground. Not surprisingly, much of the Cambodian Minister of Health’s time is taken up with meetings from over 400 visiting donor missions each year (Lane and Glassman 2007). Harmonizing aid flows at the country level is a major challenge for recipient countries. Donor targets, reporting requirements, and the oversight and evaluation of multiple small-scale projects impose enormous transaction costs on already resource-stretched countries, where trained staff are limited. Tanzania has 18 bilateral donors and more than 2,000 individual projects in all sectors, many less of budgets of less than US$1 million. Switzerland and Ireland both give Tanzania approximately $30 million in total aid; however, the former had five projects, while the latter has 404 (Anonymous 2006). Stand-alone programs risk draining necessary human and financial resources from general healthcare. On the other hand, aligning health programs with national health plans, in support of the overall public health and medical treatment infrastructures of nations, will allow a maximum return on investments. There is also a general consensus among the global health community that there is a dire lack of accountability attached to global health money. Much of the global health effort, at all tiers of engagement, remains cloaked in confusion, opaque financing and accounting, and grandstanding. On the donor side, commitments that are publicly proclaimed often fail to materialize fully. On the recipient country side there continue to be vast gaps in accountability and reporting, to both donors and to citizenry. Many countries fail to provide clearly delineated national health budgets, or financial data that allows citizens and donors a roadmap for fiscal spending. Transparency is often lacking entirely for private foundations, nongovernmental organizations, and faith-based groups. Some recipient countries have recently instituted systems where donors are required to sign ‘compacts’ to ensure mutual accountability to guarantee countries receive the promised aid through the agreed-upon mechanisms, in an effort to reduce transaction costs and uncertainty. The 2005 Paris Declaration on Aid Effectiveness calls for the donors, governments, and the UN system to move into a new era of absolute accountability and transparency in all development activities. Results to date for the Paris Declaration are mixed. Although more countries have signed onto it, virtually no NGOs, faith-based organizations or private sector elements are on board. Further, an OECD assessment of country and donor adherence in 2006 to

Laurie Garrett and Kammerle Schneider 11

the Declaration offers few real rays of hope, as the only enforcement mechanism for assuring achievement of the harmonization and alignment targets is moral suasion (OECD 2005).

Investments in health It is a general truism worldwide that the poor pay the greatest percentage of their wealth for health. Illness is an event that often bankrupts poor families, even though the same ailment may represent only a trivial cost to the rich. In many low-income settings, 70 per cent of total health spending is out of pocket, while in high-income settings only 15 per cent of health expenditures are paid out of the pockets of individuals. In Africa, out of pocket spending accounts for almost 50 per cent of total health spending on average, and in 31 African countries, accounts for 30 per cent or more of total health spending (World Health Organization 2006b). In Cambodia and India, families typically pay 80 per cent of their health care costs as out of pocket expenses (World Health Organization 2000). Despite this demonstrated willingness to spend for health, and to embrace entrepreneurial models of delivery, the primary methods for disbursement of funds to poor countries continue to follow the age old charity model. Foreign contractors and NGOs are given the lion’s share of the funds with which they hire personnel and manage projects in local communities. Health is still not fundamentally viewed as an investment, where funding is infused into local economies to create indigenous businesses and eventual local profit centers. For aid to function as a true investment in health systems, it would have well defined exit strategies and would focus on building local technical capacities and systems within the country, rather than creating an artificial superstructure of imported international workers and academic advisors to implement initiatives. Nearly every aspect of health delivery in the developed world involves profit making, in one form or another. Sustainable profit making ventures for health supplies, medicines, delivery chains, and insurance inside poor countries could be owned and operated by indigenous companies with profits forming the basis of taxable revenue growth for the countries. Yet, inserting capitalist principles into health programs in poor countries is viewed as distasteful – by donors and activists. These contradictory views of health spending, with profit making the norm throughout the wealthy world, while it is considered distasteful for the poor, derive from a paternalistic charity model that entraps poor countries in cycles of dependence on the rich world for continual funding of a health programs, rather than creating sustainable health systems. ‘The new challenge for the international community goes beyond how to contribute to pilot programs in health that provide drugs, vaccines and preventive or health care services to how to do so in a way that engages the local and national populations and enables the programs to

12 Part I: The Global Health Arena

expand to a nationwide scale that is sustainable over time,’ explains Dr Barry R. Bloom, Dean of the Harvard School of Public Health (Bloom and Canning 2007). Besides the charity paradigm, another model that has increasingly gained traction in recent years, links social entrepreneurship with the provision of health services. The Scojo Foundation, for example, utilizes a market-based approach to train community members, primarily women, to become ‘vision entrepreneurs’ and sell eye care products within their own communities. Scojo sells glasses to vision entrepreneurs for around two dollars, and vision entrepreneurs in turn sell the glasses to customers for between $3 and $5 depending on location. ‘Glasses have to be approached by a market based perspective – they are a classic example of a product that millions of people need, are affordable, we can deliver, and unless we tap into the power of the market – we will never be able to create a sustainable system,’ said Scojo cofounder and president, Dr. Jordan Kassalow. In most developing countries, the private sector already plays a substantial role in both the financing and delivery of healthcare services (Council on Health Research for Development 2006). But corporate players are often absent from the policy debate. International agencies and global health organizations are currently working to create stronger partnerships with corporate actors. In addition to providing funds the private sector can offer valuable technical expertise to make management of personnel, inventory, supply, procurement, distribution and upkeep more efficient.

Measurement of success No health indicator more clearly illustrates the stark disparities in global health outcomes than maternal mortality. Maternal health is a good measure of the effectiveness and performance capacity of overall health systems. Pregnant women survive childbirth where they have access to skilled medical personnel and safe, clean, and well-supplied health facilities. If mothers and infants thrive, health systems are working, and the opposite also hold true. Improvements in maternal mortality require upgrading the entire health infrastructure. According to WHO, ‘[t]here is a direct relationship between the ratio of health workers to population and survival of women during childbirth and children in early infancy. As the number of health workers declines, survival declines proportionately’ (World Health Organization 2006a).

Promising future We are in a moment ripe for historic changes in global health. Committed agency leaders, NGOs, faith-based groups, and corporate actors are working collectively to think about new ways to break out of patterns of charitable

Laurie Garrett and Kammerle Schneider 13

giving and move towards real sustainable investments in health utilizing the wealth of resources and technical expertise available both on the ground and within international agencies. A number of promising initiatives, declarations and programs are beginning to emerge in an effort to improve global health-funding efficacy through longer-term commitments, more coordinated accountability measures, and collaboration at the highest levels. Inside the UN system, efforts are underway to improve relations between health-related UN agencies, the Global Fund to Fight AIDS, Tuberculosis and Malaria, the GAVI Alliance and the Bill & Melinda Gates Foundation. Calling itself the H-8 (Health-8: WHO, UNICEF, UNAIDS, UNFPA, World Bank, Global Fund, GAVI and Gates), this loose alliance has set its top management tiers to the task of talking to one another to clarify the core responsibilities of each agency, and bring coherence and alignment to their activities to eliminate duplication of efforts and competition for funding. The H-8 process is still quite new, and its future is uncertain. Nevertheless, within UN agencies the process has been received enthusiastically. Within the HIV/AIDS community, UNAIDS, together with the Global Fund, bilateral donors, and other international institutions, have similarly committed to the harmonization and alignment of global HIV/AIDS efforts through the concept of the Three Ones: one agreed HIV/AIDS action framework for coordinating the work of all partners; one national HIV/AIDS coordinating authority with a broad based multisectoral mandate; and one agreed country level system for monitoring and evaluation. At the donor country level, many wealthy governments have embarked upon new initiatives to make aid more effective. The Norwegian government has recently created the Global Campaign for the Health MDGs and committed to funding $10 billion over the next ten years to meet the goals of reducing child mortality, improving maternal health and combating HIV/AIDS, malaria and other infectious diseases. In September 2007, a consortium of wealthy governments and private donors announced the creation of the International Health Partnership (IHP). The IHP seeks to recreate the entire relationship between donors and recipient nations, vastly improving transparency, accountability and mutualism in the programs executed by typically rival agencies. If the IHP succeeds, country governments will have much more control over what outsiders do with and for their people, and will in return radically improve all aspects of strategic planning, civil society engagement and financial processing. The IHP promises very long-term financial commitments – up to a full decade – in exchange for genuine accountability for every dime or euro spent at the country level. The goal is to vastly improve the kinds of strategic developments that poor countries most desperately need – physical infrastructures of health provision, water filtration systems, health human resources training and support, microfinance schemes that set realistic long term goals for individual and community health progress.

14 Part I: The Global Health Arena

Yet, as Harvard health economist William Hsiao has said, ‘more money for health spending does not necessarily mean better health outcomes’ (Hsiao 2007). As a global health community we must stand back and objectively evaluate how we can most effectively take advantage of this moment of extraordinary generosity from the wealthy world and translate it into long-term, sustainable health improvements for all. On the donor side, commitments must become far longer term, transparent, and fully realized within predictable timetables. Donors should not put health programs – whether vertical, horizontal or ‘diagonal’ – in competition with one another. Nor should they solely fund projects based on domestic constituent interest. For recipient countries the greatest challenges are in management: juggling precious human resources, external funds and programs, rural versus urban needs and donor demands. The management balancing act is hard enough on a day-to-day basis, but must expand to encompass strategic goals for health infrastructure and private sector growth that function on decades-long timetables. Achieving such long-range strategic targets will require great wisdom from national leaders, and the full cooperation of donors, NGOs and private philanthropies.

Note 1. National budget funding in 29 reporting countries has reached over $750 million in 2006. Global funding has grown by more than 2,000 per cent since the start of the twenty-first century.

References Anonymous (2006) ‘Public Health Infrastructure And Capacity’, Health Affairs, 25(4): 899. Bloom, D.E. and D. Canning (2005) ‘Mortality Traps and the Dynamics of Health Transitions’, Proceedings of the National Academy of Sciences, 104(41): 16044–9. Chen, L.C. and J.I. Boufford (2005) ‘Fatal Flows – Doctors on the Move’, New England Journal of Medicine, 353(17): 1850–2. Council on Health Research for Development (2006) Human Resources for Health Research: an African Perspective (Geneva: Council on Health Research for Development). Eberstadt, N. and J. Banister (1992) ‘Divided Korea: Demographic and Socioeconomic Issues for Reunification’, Population and Development Review, 18(3): 505–31. Egerö, B. and R.A. Henin (1973) ‘Mortality’, in The Population of Tanzania: An Analysis of the 1967 Population Census, edited by E. Bertil and R.A. Henin (Dar es Salaam: BRALUP and Central Statistical Bureau. Dar es Salaam, Tanzania). Henin, R.A. et al. (eds) (1979) The Demography of Tanzania: An Analysis of the 1973 National Demographic Survey of Tanzania. Volume VI (Dar es Saleem: Bureau of Statistics (United Republic of Tanzania) and Bureau of Resource Assessment and Land Use Planning (University of Dar es Salaam)).

Laurie Garrett and Kammerle Schneider 15 Hsiao, W.C. (2007) ‘Why Is A Systemic View Of Health Financing Necessary?’, Health Affairs, 26(4): 950–61. Kamuzora, C.L. and A.S. Komba (1991) ‘Demographic Trends’, in Health and Diseases in Tanzania, edited by G. M. P. Mwaluko et al. (London: Harper Collins Academic), pp. 279–88. Lane, C. and A. Glassman (2007) ‘Bigger and Better? Scaling Up and Innovation in Health Aid’, Health Affairs, 26(4): 935–48. Mathers, C. D. and D. Loncar (2006) ‘Projections of Global Mortality and Burden of Disease from 2002 to 2030’, PLoS Medicine, 3(11): 2011–30. OECD (2005) ‘Paris Declaration on Aid Effectiveness. Ownership, Harmonisation, Alignment, Reults and Mutual Accountability’, available at http://www.oecd.org/ dataoecd/11/41/34428351.pdf. Republic of Rwanda et al. (2006) Scaling Up to Achieve the Health MDGs in Rwanda: A Background Study for the High-Level Forum Meeting in Tunis June 2006. Schieber, G.J. et al. (2007) ‘Financing Global Health: Mission Unaccomplished’, Health Affairs, 26(4): 921–34. UNAIDS (2006) AIDS Epidemic Update (Geneva: World Health Organization). UNICEF (2007) ‘Informal Meeting of Global Health Leader, July 19, 2007’, available at http://www.unicef.org/health/files/Meeting_of_Global_Health_Leaders__Final_Summary.pdf. United Nations (2007)World Population Prospects: 2006 Revision (New York: United Nations). United Nations Secretary-General Ban Ki-Moon (2007) Declaration of Commitment on HIV/AIDS and Political Declaration on HIV/AIDS: Focus on Progress Over the Past 12 Months (United Nations General Assembly, 61st session, A/61/816). World Bank (2006) Global Monitoring Report 2006: Strengthening Mutual Accountability — Aid, Trade, and Governance (Washington, DC: World Bank). World Bank (2007) ‘Africa Development Indicators (ADI) 2007’, available at http://siteresources.worldbank.org/INTSTATINAFR/Resources/adi2007_final.pdf. World Health Organization (1948) Constitution (Preamble). World Health Organization (2000) World Health Report 2000 – Health Systems: Improving Performance (Geneva: World Health Organization). World Health Organization (2006) ‘The Global Shortage of Health Workers and its Impact, Fact Sheet No. 302, April 2006’, available at http://www.who.int/ mediacentre/factsheets/fs302/en/index.html. World Health Organization (2006) ‘High Level Ministerial Meeting on Health Research for Developing Countries, Accra, from 14–17 June 2006, Health Ministers From Developing Countries Call for More Support for Health Research (Press Release)’, available at http://cdrwww.who.int/countries/gha/news/2006/health_research/en/ index.html. World Health Organization (2007) Maternal Mortality in 2005: Estimates developed by WHO, UNICEF, UNFPA, and The World Bank (Geneva: World Health Organization). World Health Organization et al. (2007) Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector: Progress Report, April 2007 (Geneva: World Health Organization).

2 The World Health Organization and its Role in Health and Development Riikka Koskenmaki, Egle Granziera and Gian Luca Burci∗

WHO is the lead agency for health within the UN system. Since its establishment in 1948, WHO works for development by fighting diseases and other conditions which affect disproportionately the poor. During the 1990s, health achieved unprecedented recognition as a key driver of socioeconomic progress. As a consequence, promoting development now figures as a top objective in WHO’s agenda (World Health Organization 2007d). This contribution views WHO and its role in health and development from both an institutional and policy perspective. After a brief overview of the history of international health cooperation that preceded WHO’s establishment, the structure of the Organization will be presented to show how WHO can work in support of development both globally and at regional and country levels. WHO’s mandate and functions will then be presented to lay down the framework of WHO’s action, and to show how its mandate and functions have been further defined through the practice of the Organization in the light of changing health needs. In the second part, the contribution turns to discuss selected examples of WHO’s crosscutting policies to exemplify how WHO’s framework has been put into action. The policies discussed are: Health for All and primary health care; health systems development; health as a means of combating poverty; and access to medicines and drugs. This section, in particular, seeks to further understanding of the evolving relation between health and development within WHO and its impact on WHO’s strategies over time. The third part discusses the emergence of new actors and partners in the field of international public health and how WHO interacts with them to achieve public health and development objectives. These developments present both opportunities and challenges for WHO and international health

∗

The authors are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions, policy or views of the World Health Organization.

16

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 17

cooperation at large. The part will analyze these aspects as well as how public– private partnerships for health may be conceived as improvements of the current framework for international collaboration for the benefit of the less developed countries.

Part I: Establishment, mission and functions The genesis and establishment of WHO The establishment of WHO in 1948 was the culmination of nearly one hundred years of international cooperation in public health. Such collaboration had begun to develop in the nineteenth century when faster means of transport, growing international commerce and poor sanitary conditions led to more rapid spread of communicable diseases. After the repeated and severe cholera epidemics in Europe and Northern America, and the rise of nineteenth-century internationalism, governments decided to turn to cooperation to protect the Western hemisphere from infectious diseases of exotic origin (Goodman 1952; Howard-Jones 1950, 1975). As a result, a series of International Sanitary Conferences were convened in the second half of the nineteenth century. They led to the adoption of international sanitary conventions,1 on the one hand, and the establishment of international public health organizations, on the other. As concerns the first international public health organizations, quarantine bodies had been established at the regional level since the 1830s to protect Europe from epidemic diseases (Goodman 1952).2 The first international health agency, the International Sanitary Bureau, was founded at the regional level in the Americas in 1902.3 The first agency at the global level, the Office international d’hygiène publique (OIHP), was established in 1907 with headquarters in Paris. While predominantly European at its inception,4 55 states from various regions eventually adhered to the OIHP. The establishment of these two agencies marked the end of the era of International Sanitary Conferences and the opening of that of permanent international health organizations. At the end of World War I, the League of Red Cross Societies and the League of Nations Health Organization were established in response to the poor health conditions in Europe (Dubin 1995). While the activities of the League of Nations Health Organization were coordinated with those of the OIHP,5 some overlap existed. After the post-war epidemic waves subsided (Baliñska 1995), the Health Organization expanded its activities beyond the traditional field of infectious disease control.6 At the outbreak of World War II most of the activities of both the OIHP and the League of Nations Health Organization were suspended. The Allied and Associated countries established the United Nations Relief and Rehabilitation Administration (UNRRA) for post-war relief operations (Goodman 1952). The

18 Part I: The Global Health Arena

work of its Health Division constituted by far the largest international health program to date. UNRRA was dissolved in 1946 and its activities and funds transferred to the new agencies of the UN System. At the end of World War II, of the existing three worldwide international health organizations, the OIHP, the League of Nations Health Organization and UNRRA, only UNRRA functioned effectively, building a bridge between the pre- and post-war international health work. The three organizations were soon to disappear with the establishment of WHO. Building upon the work and heritage of its predecessors, WHO was to continue most of their functions and activities (World Health Organization 1948; Beigbeder 1995). In 1945 the San Francisco Conference on International Organizations called unanimously for a conference to establish an international health organization as one of the Specialized Agencies of the UN (World Health Organization 1947). The International Health Conference held in New York from 19 June to 22 July 1946 drafted and adopted the Constitution of WHO, signed on 22 July 1946 by the representatives of 51 UN Members and ten other countries (World Health Organization 1946, 1948). The Constitution finally came into force on 7 April 1948, which is commemorated each year as World Health Day.

Structure and statutory bodies Reflecting the universal aspiration of WHO, its membership is open to all states. The membership has always been virtually universal, standing at 193 Members in 2008. The main bodies of WHO are the Health Assembly, the Executive Board and the Secretariat. The Assembly, composed of delegates of all Members, is the supreme decision-making body of WHO. It meets in regular session once a year. The main function of the Health Assembly is to determine the policies of the Organization which includes the adoption of legal instruments. It also appoints the Director-General, supervises the financial policies of the Organization, and reviews and approves the proposed programme budget. In addition, the Health Assembly considers the reports of the Executive Board, which it instructs in regard to matters upon which further action, study, investigation or report may be required (World Health Organization 1946 Chapter V; Greppi 1984). The Executive Board, composed of 34 members, is to give effect to the decisions and policies of the Health Assembly, to advise it and generally to facilitate its work. The Executive Board also has authority to deal with events requiring immediate action (World Health Organization 1946 Chapter VI). Finally, the Secretariat of WHO is staffed by some 8,000 health and other experts and support staff, working at headquarters in Geneva, in the six regional offices, 147 country offices, and liaison offices. The Organization is headed by the Director-General nominated by

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 19

the Executive Board and appointed by the Health Assembly for term of office of five years (World Health Organization 1946 Chapter VII). One of the most distinctive features of WHO is its regionalized structure (Calderwood 1963; Vignes 1977). When drafting the WHO Constitution, it was considered, on the one hand, that the existing three international health organizations needed to be replaced by a single one, as had already been agreed upon at the San Francisco Conference. On the other hand, it was argued that a regionalized structure would be more effective in addressing local health problems and, importantly, the existing regional health organizations should be preserved within the structure of WHO (World Health Organization 1948). Accordingly, the Constitution of WHO provides that the Health Assembly may establish regional organizations, which are an integral part of the Organization (World Health Organization 1946 Arts. 44(b) and 45). WHO has six regional organizations (Africa, the Americas, Eastern Mediterranean, Europe, South-East Asia, and the Western Pacific) established along geographical as well as political lines. Each regional organization consists of an intergovernmental regional committee and a regional office headed by a Regional Director, nominated by the regional committee and appointed by the Executive Board. A notable exception exists for the Americas where the Pan American Sanitary Organization, renamed Pan American Health Organization (PAHO) in 1958, was to be ‘integrated’ with WHO in due course under the WHO Constitution (World Health Organization 1946 Chapter XI). Nonetheless, PAHO still retains its separate identity but serves at the same time as a WHO regional organization (World Health Organization and Pan American Health Organization 1949). Regionalization has been accompanied by decentralization of responsibilities to the regions, which enjoy today a large degree of autonomy. This has posed challenges, inter alia, to the coherence of program planning and general management of the Organization (Godlee 1994). In response, WHO aims to increase the level of common systems across the three levels, including the common global results-based management framework, and corresponding performance and accountability systems (World Health Assembly 2006a). The regionalized structure, which provides multiple opportunities for engaging with countries, is considered as one of the comparative advantages of WHO and an important basis of its legitimacy (World Health Assembly 2006a). The regional and country offices focus on technical support and building national capacities. They allow a close relationship with ministries of health and other national and international partners, which in turn enables WHO to gather information and monitor trends over time and across countries, regions and the globe. WHO is strengthening its country presence and transforming its engagement with countries to be more strategic as foreseen in the Country Cooperation Strategies (World Health Assembly 2006a).7

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Competence WHO’s broad objective enshrined in its Constitution is ‘the attainment by all peoples of the highest possible level of health’ (World Health Organization 1946 Art. 1; Burci 2006). At the time of WHO’s establishment, the universal scope of this objective stood in sharp contrast to most of the earlier international health cooperation, which had focused on the protection of the public health of the western hemisphere (Aginam 2003; Howard-Jones 1950). The preamble of the Constitution, which sets out the context of the WHO’s mandate, contains a set of further visionary principles of continuing importance: WHO is based on solidarity between, and equality of, individuals and populations; health is indivisible, a pillar of peace and security, and dependent upon the fullest cooperation of individuals and States (Grad 2002). The preamble of the WHO Constitution also contains a definition of ‘health’, which is crucial for determining the mandate of the Organization. Health is defined as ‘a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity’. Furthermore, the ‘enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being’ (World Health Organization 1946 preamble). Health is thus a positive state encompassing both the individual and the community and its enjoyment is defined as constituting a human right. Health is a multifaceted and complex topic which cuts across an increasing number of human activities and is in full evolution. Consequently, the mandate of WHO has been further developed and specified through the practice of the Organization while respecting the parameters set by the Constitution. Importantly, health has been further defined not only as an objective of its own, but also as an integral part of economic and social development (World Health Organization 1978). WHO’s constitutional parameters include, besides the concept of health, the responsibility of governments for the health of their peoples and the WHO’s position as a specialized agency of the UN (World Health Organization 1946 preamble, Art. 69). WHO’s mandate is interlinked with that of other agencies and bodies of the UN system (including FAO, UNDP, UNICEF, ILO, UNEP, IAEA, UNFPA, and the UN human rights machinery), and the Organization collaborates and coordinates its activities with these agencies and bodies as appropriate (World Health Organization 1946 Art. 2(b); Beigbeder 1995; Burci and Vignes 2004).

Functions The Organization pursues its broad objective through the wide range of functions and activities enumerated in Article 2 of the Constitution. Despite the global changes following its adoption, the provision has served the Organization well – only the balance among the various functions has shifted according to the changing strategic health priorities of the international community. The broad directions of WHO’s work are established in periodic

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 21

General Programmes of Work (GPW) adopted by the Health Assembly (World Health Organization 1946 Art. 28(g)). More specific strategic priorities are set in the WHO Medium-term Strategic Plan, firstly adopted for the period 2008–2013, defined as strategic objectives, and in the two-yearly programme budget in terms of expected results. The GPW also establishes a Global Health Agenda for all stakeholders because of the involvement of a number of actors in its implementation (World Health Assembly 2006a). The wide range of functions assigned to the Organization may be grouped, for the purpose of this presentation, into three main categories: (1) direction and coordination of international health work, (2) normative functions, and (3) research and technical cooperation. Most of WHO’s normative and technical work supports development in a cross-cutting way.

Direction and coordination of international health work Faced with the destruction of the health systems and immense global health problems in the aftermath of World War II, the direction and coordination of the development and main trends of international cooperation in the field of health were established as the essential purpose of the Organization (World Health Organization Art. 2(a), (b), (j)). The other functions listed in Article 2 of the WHO Constitution were intended rather as means to pursue this central aim (World Health Organization 1947). In practice, WHO sets policies and strategies for international cooperation on specific issues in the field of health and provides health input to cross-cutting issues. For example, in the area of sustainable development and healthy environments, a policy framework on health and poverty reduction was endorsed by the Executive Board of WHO in 2000 (World Health Organization 2000a and Doc. EB105/2000/REC/2), and health was placed on the agenda of the UN General Assembly session on social development in 2000 and the Third United Nations Conference on Least Developed Countries in 2001 (World Health Organization 2001c). Today, the provision of global leadership on matters critical to health remains the core function of the Organization (World Health Assembly 2006a). The emergence of a wide range of global, national and local organizations, as well as public–private alliances and partnerships, in the international health architecture and the request for efficient action to respond to states’ health needs, call for policy coherence, accountability, and synergy of action by all actors (see also Part III below). Therefore, the strengthening of the WHO’s role as the directing and coordinating authority is at the top of its policy agenda (World Health Assembly 2006a). In its relations with other UN agencies, WHO is emphasizing emerging issues, including public health and security, as well as cross-cutting issues that promote development, such as environment, human rights and gender (World Health Assembly 2006a).

22 Part I: The Global Health Arena

Normative functions WHO was granted extensive standard-setting and regulatory powers in its Constitution since the Organization was to take over the administrative role of the international sanitary conventions (World Health Organization 1946 Art. 2 (k), (o), (s), (t), (u) and Arts 19-23). The Constitution provides for three kinds of legal instruments – conventions and agreements, regulations and recommendations – for adoption by the Health Assembly. So far, only one convention, the Framework Convention on Tobacco Control (WHO FCTC), has been adopted in 2003 (Burci 2003; Taylor and Bettcher 2000; World Health Organization 2003c). The WHO FCTC seeks to reduce the prevalence of tobacco use and exposure to tobacco smoke by providing a framework for tobacco control measures to be implemented by the States Parties. It is an evidence-based treaty that, in contrast to previous drug control treaties, asserts the importance of both demand reduction strategies and supply reduction issues. It also addresses the question of liability and international cooperation in tobacco control, among other things (World Health Organization 2003c). In addition to adopting conventions, the Constitution grants the Health Assembly the authority to adopt regulations in five subject areas (World Health Organization 1946 Art. 21).8 Different from conventions, regulations become binding on the Member States unless they ‘contract out’ during a given time period (World Health Organization 1946 Art. 22). WHO has adopted two regulations to date. The WHO Regulations No. 1 regarding nomenclature (including the compilation and publication of statistics) with respect to diseases and causes of death, were adopted in 1948.9 Building on and replacing the previous international sanitary conventions, WHO adopted Regulations No. 2, the International Sanitary Regulations, in 1951 (World Health Assembly 1951). Later renamed the International Health Regulations (IHR), they were revised most recently in 2005 in response to the threat of international disease spread though increasing international travel and trade. The IHR are the international legal instrument designed to help protect all States from the international spread of disease, including public health risks and public health emergencies. To this end, the Regulations require States Parties, inter alia, to assess, report and respond to public health events, in accordance with the IHR, and to strengthen national surveillance and response capacities (World Health Assembly 2005b; World Health Organization 2007e). Whereas WHO has adopted only few legally binding instruments, it adopts or publishes numerous recommendations and other non-binding standards of technical nature (Burci and Vignes 2004). The success of this normative activity is arguably due to the flexibility of the non-binding and sometimes non-formal nature of these standards, which adapt easily to different local circumstances and historical developments, are less difficult to revise to respond to technological developments, and faster to apply at national level. Furthermore, WHO enjoys high credibility as a scientifically and

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 23

technically reliable and neutral organization, which tends to increase reliance on, and compliance with, its technical standards (Beigbeder 1995; Burci and Vignes 2004; Vignes 1991). Proposals to develop legally binding instruments have rarely gained support within WHO and, consequently, health-related legal instruments have been negotiated in other fora (e.g. United Nations 2006). A number of reasons for this reluctance have been put forward by commentators.10 It may be concluded that the Organization has not, to date, fully used its extensive normative powers to achieve its objectives. Commentators have forcefully argued that WHO should more readily engage in lawmaking as the directing and coordinating agency in the field to cope with the changes in the global public health environment (Fidler 2002; Taylor and Hao 2003). The WHO GPW for 2006–2015 provides that the Organization will ‘continue to lead in facilitating the drafting and adaptation of international legal instruments’. It also establishes ‘setting norms and standards, and promoting and monitoring their implementation’ as one of the core functions of WHO (World Health Assembly 2006a). It remains to be seen whether this and the negotiations for the first protocol to the WHO FCTC on illicit trade in tobacco products (DOC./FCTC/COP2/12) imply a shift in the use by WHO of its normative powers.

Research and technical cooperation The Constitution of WHO mandates the Organization to promote cooperation among scientific and professional groups, and to promote and conduct research in the field of health (World Health Organization 1946 Art. 2 (j), (n)). WHO is supported in this role by the consultative Advisory Committee on Health Research. While considering research and its coordination as an essential function of WHO, the Health Assembly decided in 1949 against the establishment of substantial WHO research facilities and to limit its role to supporting national research institutions (World Health Assembly 1949). WHO thus relies on expertise and research made available by Member States and other partners. The main exceptions to this approach are the International Agency for Research on Cancer (IARC) and the two co-sponsored research and training programs executed by WHO – the Special Programme for Research and Training in Tropical Diseases (TDR) and the Special Programme of Research, Development and Research Training in Human Reproduction (HRP). In addition, WHO funds research projects carried out by research institutions and collaborates with the pharmaceutical industry to develop new products for which WHO funds studies and trials. WHO’s focus is on ‘research in neglected areas of importance for better health, in particular on diseases that disproportionally affect developing countries and for poor and disadvantaged groups’ (World Health Assembly 2007b). In the period 2006–2015, WHO will continue to support activities that ‘help to promote health, prevent and control

24 Part I: The Global Health Arena

diseases, strengthen health systems, accelerate the achievement of the healthrelated Millennium Development Goals (MDGs), improve health equity and strengthen the research process itself, the management of knowledge, and the building of capacity in developing countries as needed’ (World Health Assembly 2006a). In addition, WHO will ‘strengthen the role and functioning of its associated research programmes in their areas of comparative advantage. It will support research and associated capacity building and knowledge management that is of particular significance for developing countries and for which coordinated global action is required’ (World Health Assembly 2006a). The Constitution of WHO mandates the Organization to provide technical and emergency support upon the request or acceptance of Member States (World Health Organization 1946 Art. 2 (c)-(g), (i) and (q)). The provision of technical support has been and remains a central component of the work of WHO (World Health Assembly 2006a). The admission to membership of developing countries since the 1960s generated a steep increase in the demand for technical cooperation. In a series of resolutions the Health Assembly defined the principles relating to WHO technical cooperation which should be delivered mainly in ‘establishing and strengthening national health systems, which form an integral part of overall social and economic development’; training of national health personnel; control or eradication of diseases and ‘drawing up of recommendations for establishing norms and standards’ (World Health Assembly 1975a).11 In May 1976, the Health Assembly decided to reorient the work of WHO for the development of technical cooperation (World Health Assembly 1976). The adoption of the Health for All strategy by the Health Assembly in 1981 redefined and strengthened WHO’s approach to technical cooperation which was redirected to address national health systems in a coordinated fashion (World Health Assembly 1981). WHO has been working to improve its technical cooperation both with and within countries. WHO’s regional and country offices have been strengthened and a significant proportion of WHO’s resources has been allocated to them,12 as they are best placed to respond to countries’ specific needs in light of the specific health profiles of different regions. The role of the headquarters is generally to provide policy guidance besides its essential policy-setting and normative functions (World Health Assembly 2007a). The planning of support activities has been changed with the introduction of new modalities, including the Sector-Wide Approach to health development which brings together the governments, donors and implementing agencies, and the WHO Country Cooperation Strategies. WHO is fully engaged in the UN reform efforts including by ‘providing strong support for the United Nations Country Teams under one United Nations leadership’ (World Health Assembly 2006a). In respect of support in emergencies and post-conflict situations, WHO works with the UN Office for the Coordination of Humanitarian Affairs (OCHA) and other partners (World Health Assembly 2006a).

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 25

WHO’s technical cooperation traditionally consists mainly of advisory services. This has raised the question of whether that type of support may be effective if national infrastructures or resources are insufficient to absorb or implement it. Today, WHO sees that its priority is in building sustainable institutional capacity rather than implementing programmes itself. This is conducted by a combination of specific programmes and work on strengthening health systems and influencing broader determinants of health (World Health Assembly 2006a).

Part II: WHO’s horizontal policies promoting development Health for All and primary health care The most significant contribution of WHO to international health policy to date is arguably the process defined as ‘Health for All’ (HFA) and the primary health care approach. HFA marked a reorientation in public health and in the activities and priorities of WHO. While the goal of attaining HFA by the year 2000 was not achieved, important principles and concepts were developed that continue to influence international health policy and the work of WHO (World Health Assembly 2003a). Encouraged by the financial optimism of the 1970s, developing countries were calling for sustained economic and social development, including the promotion of health, throughout the world (Beigbeder 1995; United Nations General Assembly 1974a, b, c, 1975). The HFA approach grew out of the recognition of the enormous inequalities in health worldwide (World Health Assembly 1975b) and the dissatisfaction with the static and fragmented ways of dealing with health, including WHO activities. The then prevailing approach based on health technologies and vertical, disease-specific programs, could not alone solve the immense health problems of the developing countries. A horizontal approach, universally promoting the determinants of health, was rather needed (World Health Organization 1976; Koivusalo and Ollila 1996). In May 1977, the Health Assembly declared that the main social target of governments and WHO in the coming decades ‘should be the attainment by all citizens of the world by the year 2000 of a level of health that will permit them to lead a socially and economically productive life’ and requested the Organization to reorient its activities ‘for the development of technical cooperation and transfer of resources for health’ (World Health Assembly 1977). In 1978, the International Conference on Primary Health Care held in AlmaAta issued a declaration and implementing resolutions setting a new vision for international health, which was based on the following five principles: (1) universal access and coverage on the basis of need; (2) health equity as part of development oriented to social justice; (3) community participation in defining and implementing health agendas; (4) appropriate technology

26 Part I: The Global Health Arena

for each country concerned which is maintainable with resources the country can afford; and (5) intersectoral approaches required for the realization of the highest attainable level of health. The Declaration of Alma-Ata starts by reaffirming health as a fundamental human right. It declares that ‘[t]he promotion and protection of the health of the people is essential to sustained economic and social development’. The Declaration specifies primary health care as the key to attaining the target of health for all by the year 2000 ‘as part of development in the spirit of social justice’. The concept of primary health care itself is based on the basic determinants of health and in Recommendation 1 the Conference further recognized that ‘health is dependent on social and economic development, and also contributes to it’ (World Health Organization 1978). This approach departed from the previous, primarily medical, approach to health and touched deeply the social, political and cultural structures of the societies concerned. Furthermore, in a revolutionary way, the objectives of HFA included changing the approach of peoples to their own health care; the integration of health services into equitable and sustainable health systems; the reform of the distribution of resources; and the integration of health technology and knowledge in the structures for basic health services. Finally, the Conference recommended that high priority be given to the special needs of vulnerable and high-risk groups, including women and children (World Health Organization 1978 Recommendation 8). The Declaration was ‘a first attempt to unify thinking about health in a single policy framework’ (World Health Organization 2007b). As has been accurately stated, HFA reflects ‘a new paradigm for the role of public health’ (Taylor 1992). The Health Assembly endorsed the HFA and WHO’s programs and resources allocation were redesigned in support of the new policy. Governments were encouraged to formulate national, regional and global strategies (World Health Assembly 1979) and even the UN General Assembly endorsed the Declaration (United Nations General Assembly 1979). In 1981, the Health Assembly adopted the Global Strategy for health for all by the year 2000 for the implementation of HFA, which was to guide WHO’s future work and be monitored and evaluated periodically (World Health Assembly 1979; United Nations General Assembly 1981). The monitoring mechanism did not perform as expected, however, due to the lack of adequate health evaluation systems in place in Member States. Despite some progress, a number of factors hampered the implementation of the ambitious strategy. They included insufficient political commitment and funding for health; slow socioeconomic development, failure to achieve equity in access to all primary health care elements, insufficient intersectoral action for health, and rapid demographic and epidemiological changes. Further, poverty had increased worldwide (World Health Organization 1998). In response, WHO defined new, mutually supportive approaches to health development and cooperation in order to make better use of available

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 27

resources and human potential (World Health Assembly 1998b). First, to address the multidimensional nature of health, integrated care should be provided throughout the lifespan. This is particularly important for women, not only because of their status as a vulnerable group, but also in light of their significant role in development processes (World Health Assembly 1998b, 1994). Second, intersectoral and interdisciplinary collaboration should be undertaken through partnerships in line with the growing recognition that many important health determinants are beyond the direct control of the health sector. Since the 1980s, the Organization itself has worked on fields such as environmental health, chemical safety, housing, sanitation, and occupational health. In addition, WHO actively participated in the UN global conferences, organized in the 1990s in the different fields related to economic and social development, to place health in the development agenda.13 The trends of privatization in the health sector and globalization in the world economy made it clear, however, that WHO needed to adopt a new approach to its advocacy for health in social and economic development: it was redirected to extend beyond the UN system, ministries of health and other obvious partners in health, to the economic and nongovernmental fields (World Health Assembly 1998b). In 1996 the Health Assembly stressed the continued validity of HFA as a ‘timeless aspirational goal’ and agreed that a new global health policy should be elaborated drawing on the achievements and shortcomings of the HFA Strategy (World Health Assembly 1995). In 1998 the Health Assembly adopted the ‘World Health Declaration’ (World Health Assembly 1998a), which builds on the Declaration of Alma-Ata and the UN global conferences. Like the Declaration of Alma-Ata, the World Health Declaration stresses the central place of health in social and economic development and a collective commitment to the principles of equity, solidarity and social justice. It underlines Member States’ commitment to address poverty and the basic determinants and prerequisites for health. Member States recommit themselves to strengthening, adapting and reforming health systems ‘in order to ensure universal access to health services that are based on scientific evidence, of good quality and within affordable limits, and that are sustainable for the future’. Finally, the Declaration affirms the intention ‘to ensure the availability of the essentials of primary health care’ (World Health Assembly 1998a). The emphasis, however, appears to have shifted from primary health care to the development of health systems to attain health for all. As we are celebrating the 30th anniversary of the Alma-Ata Conference, the primary health care approach is regaining a prominent place on the policy agenda of WHO. While the principles articulated in the Alma-Ata Declaration remain relevant, they need to be reinterpreted in light of the dramatic changes in the field of health during the past 30 years as well as the lessons learned from the past (World Health Organization 2007b). Primary health care was designed to achieve equitable and sustainable health development

28 Part I: The Global Health Arena

and, in a similar manner to the MDGs (United Nations 2001), it is based on the principles of equity and social justice (Chan 2007b). The primary health care approach is reflected in the WHO’s strategic objectives for the period 2008–2013 (World Health Assembly 2007a) and is essential for achieving the key health-related MDGs. The World Health Report 2008 – Primary Health Care: Now More Than Ever, launched at the 30th anniversary of the Alma-Ata Declaration, argues that a primary health care approach is needed ‘Now More Than Ever’ to respond to the challenges faced by health care in the twentyfirst century. Specifically, the report revisits the ambitious vision of primary health care as a set of values for guiding the development of health systems. (World Health Organization 2008b).

Health systems development Public sector health systems have similar problems across the world: inadequate financial resources, insufficient numbers of qualified staff, low pay and motivation, and rising expectations (World Health Organization 2000c, 2008b).14 In addition, insufficient and unequal access to essential public health services persists in many developing countries in particular. The situation is exacerbated by the growing role of the private sector providing care for those better off, as well as competition for the limited health resources. Interventions to deliver specific health outcomes cannot, however, be effective if they are not supported by sustainable and equitable health systems. Furthermore, functioning health systems that reach all of those in need, including the poor and marginalized groups, are essential to meet the challenges faced by the countries, including the implementation of HFA, attaining the MDGs and using health improvements to work as a poverty reduction strategy. Therefore, strengthening health systems is a high priority for WHO (World Health Assembly 2006a). At the country level, radical improvement is needed in many crucial areas, some of which go beyond the traditional competence of the ministries of health. Such fields include financial systems and their management, the health workforce, service delivery, social mobilization, information systems and management, health system design, suitable systems for collecting vital statistics, access to appropriate technology including essential drugs, and the alignment of policies to ensure improved access to care, especially for poor or marginalized populations (World Health Organization 2003d). The principles adopted in the Declaration of Alma-Ata, in particular the primary health care approach,15 are central to WHO’s work in health systems (World Health Organization 2004b, 2008b). According to the Declaration, primary health care reflects, and evolves from, the economic conditions and sociocultural and political characteristics of the country concerned (World Health Organization 1978). While this allows for diversity in health systems (World Health Organization 2004b), the latter must be able to respond to the health needs of populations by delivering the services or implementing the

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 29

health promotion and preventive measures that address priority health problems. A health system led by primary health care would have the following five key strands: (1) to build on the Alma-Ata principles of equity, universal access, community participation and intersectoral approaches; (2) to take account of broader population health issues, reflecting and reinforcing public health functions; (3) to create the conditions for effective provision of services to poor and excluded groups; (4) to organize integrated and seamless care that links prevention, acute care and chronic care across all components of the health system; and (5) continuously to monitor, evaluate and strive to improve performance (World Health Organization 2003d). The World Health Report 2008 – Primary Health Care: Now More Than Ever calls for renewed attention to the primary health care approach, which is, the report argues, the most efficient, fair, and cost-effective way to organize a health system. The report lays down four sets of reforms that reflect a convergence between the values of primary health care, the expectations of citizens and the cross-cutting health performance challenges. The reforms concern universal coverage, service delivery, public policy and leadership (World Health Organization 2008b). The outcome of the Commission on Social Determinants of Health (2008) supports health systems development based on primary health care. In its report, the Commission recognizes that equity is strongly influenced by the way health systems are organized and financed. The Commission identifies primary health care as a model for a system that acts on the underlying social, economic, and political causes of ill health, and thus contributes to better health (World Health Organization 2008a). Turning to the work of WHO and in particular to the interplay between its vertical, disease-focused programs and horizontal programs targeting health systems, the former should be set in the context of a complementary and simultaneous strategy for health system development in order to assure effective and sustainable delivery. At the same time, disease-focused programs represent an opportunity to develop health systems and for that development to be based on primary health care (World Health Organization 2004b). As concerns the response of the Secretariat of WHO to the challenge of improving health systems, its work consists of the following four pillars: 1. A single Framework for Action of six building blocks, with clear goals and expected health outcomes. The building blocks of the framework are: service delivery; human resources for health; information, drugs and technology; financing and governance.16 2. Health systems and health outcome programs: getting results aims at developing a more systematic and sustained approach across WHO’s work that responds better to the needs of Member States.

30 Part I: The Global Health Arena

3. A more effective role for WHO at country level, in particular in lowerincome countries, through improving capacity to diagnose health systems constraints; active and consistent engagement in overall sector policy processes and strategies; focusing towards building national capacity in policy analysis and management; and gearing the tracking of trends in health systems performance towards national decision making. 4. The role of WHO in the international health systems agenda consists of producing global norms, standards and guidance; the shaping of international systems that impact on health; and working with international partners on their support for health systems strengthening, including through global health partnerships and nongovernmental and private sector stakeholders (World Health Assembly 2001b, 2006a; World Health Organization 2007b). The immense task of strengthening health systems has received increasing attention also by other international organizations, including the UN and the World Bank (United Nations General Assembly 2005; World Bank 2007).

Health as a means of combating poverty WHO’s work has focused, since its inception, on fighting diseases and other conditions which have a disproportionate effect on the poor. The underlying principles of the Declaration of Alma-Ata – equity, social justice, universal access to health care, participation of the population, and an intersectoral approach to improving outcomes – underpin the work of WHO during the past 30 years (World Health Organization 2003e). Commitment to these principles, and in particular to that of equity, ensures that WHO’s activities aimed at improving health give priority to health outcomes in poor, disadvantaged, or vulnerable groups (World Health Assembly 1992, 1997, 2007a). The 1990s brought about growing international awareness of the linkages between health and economic and social development in general and of the vicious circle of ill-health and poverty in particular (World Health Organization 2003a). In addition, the international development community paid increasing attention to poverty reduction and health.17 This development culminated in the adoption of the Millennium Declaration in September 2000 by the UN General Assembly, in which the UN Member States resolved, inter alia, to undertake actions to attain healthrelated development objectives (United Nations General Assembly 2000a). At the request of the General Assembly (United Nations General Assembly 2000b), the UN Secretary-General prepared a long-term ‘Road map’ to implement the Declaration. As concerns development and poverty reduction, the ‘Road map’ set out the MDGs to be achieved by 2015, including specific targets and indicators as well as strategies for moving ahead (United Nations 2001). The Declaration and the MDGs place health at the center of the global development agenda. Three of the eight MDGs focus

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 31

directly on health, covering maternal health, infant mortality, HIV/AIDS, malaria and tuberculosis – problems that disproportionally affect the poor. Health is also closely related to the other MDGs.18 The MDGs are interdependent as major improvements in health status are necessary for poverty reduction – and vice versa – ‘making the MDGs a mutually reinforcing framework to improve overall human development’ (World Health Organization 2003g). Seizing the momentum created by the international interest paid to poverty, WHO increased its attention to health and poverty issues, thereby attempting to approach health as a means of combating poverty. Former Director-General Brundtland put the improvement of the health of the poor and other marginalized groups at the top of WHO’s policy agenda in January 2000 (World Health Organization 2000b, 1999). In her seminal report ‘Poverty and health’, she envisioned a role for WHO in influencing international and domestic action to reduce poverty, namely, to generate and disseminate evidence on the relationship between health and development; to establish partnerships with the main development actors; and to catalyze action on the part of governments to make the health of the poor a priority (World Health Organization 2000a). The report proposed, among other things, that WHO would aim at reducing health risks through a broader approach to public health, going beyond the traditional approach to address broader determinants of health, such as clean water and safe food. The report emphasized the role of health systems, especially their capacity to ensure equitable access, to treat patients with respect and to protect them from impoverishment. Following this policy statement and the promulgation of the MDGs, WHO’s work on poverty and health has taken many forms, including increasing advocacy at the global, regional and national levels on the benefits of investing in health; gathering and disseminating evidence in support of the approach; health systems development; working with donors to ensure that aid for health is adequate, effective and targeted at priority health problems; and identifying approaches to support countries in developing policies adapted to local circumstances, with countries emerging from and affected by conflicts presenting a particular challenge (World Health Assembly 2005a). Yet most of WHO’s technical and normative work supports poverty reduction in a cross-cutting way. In the field of policy development, for example, WHO works at the global, regional and national levels, across government sectors, to support the design and implementation of ‘pro-poor’ health policies which prioritize and respond to the needs of poor people (World Health Organization 2003a). Furthermore, WHO seeks to ensure that the health perspective is reflected in Poverty Reduction Strategy Papers and medium-term expenditure frameworks, and it supports countries in developing sector-wide approaches (World Health Organization 2003e).

32 Part I: The Global Health Arena

As concerns WHO’s work on evidence to support the policy, a particularly important initiative was the establishment in 2000 of the Commission on Macroeconomics and Health chaired by Professor Jeffrey Sachs mandated to assess the place of health in global economic development. The Commission’s report evidenced that better health for the world’s poor is not only an important goal in its own right, but can act as a major catalyst for economic development and poverty reduction. The report reaffirmed that health is both a creator and prerequisite of economic development. It found that economic losses from ill-health have been generally underestimated and that the role of health in economic growth has been greatly undervalued. The report stressed that extending the coverage of health services and a small number of critical interventions to the world’s poor could save millions of lives, reduce poverty, increase economic development, and promote global security. The work highlighted the magnitude of resources needed but also the potential return (Commission on Macroeconomics and Health 2002; World Health Organization 2001b).19 The report was central to WHO’s contribution at the World Summit on Sustainable Development (World Health Assembly 2001a) and at the International Conference on Financing for Development (Brundtland 2002b). The WHO Secretariat has used the findings of the report in its work on poverty reduction and resource mobilization. At the country level, governments have established, in line with the report’s recommendations and with WHO’s support, National Commissions on Microeconomics and Health and developed health investment plans (World Health Organization 2003e). The August 2008 report of the Commission on Social Determinants of Health challenges the assumption that economic growth alone will reduce poverty and improve health. It finds that increased economic prosperity tends to benefit populations that are already well-off, leaving others further behind. The report notes that the most important determinants of health arise from the social conditions in which people are born, live, work, and age. The Commission finds that economic growth will improve the health of the poor only when policies are in place that explicitly address these underlying social conditions. Consequently, the Commission calls upon governments to make health a part of all policies, in all sectors, and WHO to strengthen its support for action on the social determinants of health (World Health Organization 2008a). As concerns WHO’s specific work on the quantifiable and time-bound MDGs, WHO’s efforts to support their achievement include, in addition to the work already mentioned above, building systems to track progress and measure achievement, monitoring and reporting20 and providing technical support at the country level. In addition, WHO organizes with the World Bank the High-Level Forum on the Health MDGs. The Forum provides an opportunity to review progress and identify opportunities for accelerating progress toward the health-related MDGs.

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The MDGs have helped ‘to shape WHO’s work on health and poverty’ (World Health Organization 2002b) and provided ‘a new lens through which the WHO can assess existing programmes, and a framework to guide further support’ (Dodd and Cassels 2006). Despite their importance in the international development agenda, they do not, however, restrict the global health mandate of WHO, which extends far beyond the MDGs. The difficulty appears to lie in balancing poverty reduction activities and the MDGs with other health priorities (World Health Assembly 2003c). Yet, as requested by the Health Assembly, WHO ensures ‘that priority actions to support Member States in accelerating progress towards the internationally agreed healthrelated goals, including those contained in the Millennium Declaration, are reflected in the Programme budget 2006–2007, in future budgets, and in the Eleventh General Programme of Work’ (World Health Assembly 2005c), which duration was set to coincide with that of the MDGs.

Access to medicines and drugs Modern medicine depends heavily on the use of drugs and vaccines to treat or prevent illness. Effective drug treatment exists for most of the leading infectious diseases, including acute respiratory infections, HIV/AIDS, malaria, diarrhoeal diseases, tuberculosis and measles. Life-saving drugs have also been developed for the leading noncommunicable diseases, including ischemic heart disease and cerebrovascular diseases (Burci and Vignes 2004). WHO’s activities and initiatives in this area include the elaboration of international pharmaceutical standards and guidelines, as well as the provision of advice to WHO Member States about rational and effective use of medicines. With the intention of influencing the rational selection and use of medicines by national health systems, WHO established in 1977, and continues to update, the Model List of Essential Drugs.21 In addition, in 1978, the World Health Assembly urged Member States to establish national lists of essential medicines and adequate procurement systems (World Health Assembly 1978). The Declaration of Alma-Ata made the provision of essential medicines part of primary health care (World Health Organization 1978). The Conference recommended ‘that governments formulate national policies and regulations with respect to the import, local production, sale, and distribution of drugs and biologicals so as to ensure that essential drugs are available at the various levels of primary health care at the lowest feasible cost’ (World Health Organization 1978 Recommendation 14). Furthermore, specific measures should ‘be taken to prevent the over utilization of medicines’, to incorporate traditional remedies in health care, and to establish effective administrative and supply systems (World Health Organization 1978 Recommendation 14). Since the early 1980s, WHO has made efforts to establish a policy to use intellectual property rights as a tool to cooperate with the pharmaceutical sector and to promote research and development of new drugs for neglected diseases. In 1982, WHO adopted the policy of obtaining ‘patents, inventors’

34 Part I: The Global Health Arena

certificates or interests in patents on patentable health technology developed through projects supported by WHO, where such rights and interests are necessary to ensure development of the new technology. ‘The Organization also decided to that it will ‘use its patent rights, and any financial or other benefits associated therewith, to promote the development, production, and wide availability of health technology in the public interest’ (World Health Assembly 1982). Patents that WHO sometimes holds usually relate to the outcome of research work performed by institutions and funded by WHO. The scope of such a policy is not to benefit from revenues deriving from the patented drugs or process, but rather to avoid that acquisition of exclusive rights becomes an obstacle to the availability of new medicines and vaccines. In addition, WHO may also licence to companies intellectual property rights it owns for the further development of products and, in that case, requests that products be made available to the public sector of developing countries at a preferential price. The World Health Assembly adopted the WHO medicines strategy in 1999 (World Health Assembly 1999). The resolution considered that four factors were crucial for securing and expanding access to essential medicines and vaccines: rational selection and use of essential drugs, affordable prices, adequate and sustainable financing and reliable and rational health and supply systems (World Health Organization 2004a). In addition, the Assembly requested the Director-General to explore the feasibility and effectiveness of implementing a wider cooperation with all concerned partners and to provide enhanced support to Member States in setting up efficient national regulatory mechanisms for quality assurance and in implementing drug monitoring systems. It is also worth mentioning that the World Health Assembly, in subsequent resolutions, has shown a strong commitment to take part in the international debate on access to medicines (World Health Assembly 2002, 2003b, 2004, 2006b, 2006c, 2007d). WHO’s work on access to medicines supports the achievement of the health-related MDGs, in particular Goal 8, Target 17, which provides: ‘In cooperation with pharmaceutical companies, provide access to affordable essential drugs in developing countries’ (United Nations 2000b, 2001). To measure the achievement of the Goal, WHO monitors and reports on the proportion of population with access to affordable essential drugs on a sustainable basis to measure the achievement of the Target (United Nations 2001 Indicator 46). WHO’s work on access to medicines is also important for strengthening health systems and attaining health for all. It thus contributes to WHO’s larger health and development agenda.

WTO Agreements and intellectual property rights Another aspect of paramount importance in considering access to medicines is the entry into force in 1995 of the Agreement on Trade-Related Aspects of Intellectual Property Rights (TRIPS Agreement). Since then, the debate on

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access to, and affordability of, drugs has become increasingly politicized and WHO has tried to adapt its strategies and programmes, and indeed its role as a global health agency, to the complexity of the topic. The TRIPS Agreement provides for minimum standards for the protection of intellectual property rights,22,23 as well as for flexibilities (World Health Organization 2002a) (mainly, but not exclusively, to the benefit of developing countries) such as transition periods, compulsory licensing and public noncommercial use of patents, parallel importations, exceptions from patentability and limits on data protection. Such flexibilities should have an impact on prices by lowering them (Fidler 2006), thus rendering drugs more affordable for poorest countries. At the same time, it should be noted that according to consultations conducted by WHO in developing countries, there is no evidence that the TRIPS Agreement has stimulated innovation in vaccine development, where markets are traditionally weak (Milstein and Kaddar, 2006). In November 2001 WTO Ministerial Conference met in Doha and produced a number of important decisions and statements concerning the overall design and implementation of the legal system created by the WTO agreements, including the TRIPS Agreement. Para. 4 of the Declaration on the TRIPS Agreement and public health states ‘that the TRIPS Agreement does not and should not prevent members from taking measures to protect public health. Accordingly, while reiterating our commitment to the TRIPS Agreement, we affirm that the Agreement can and should be interpreted and implemented in a manner supportive of WTO members’ right to protect public health and, in particular, to promote access to medicines for all’ (World Trade Organization 2001). The Doha Declaration made it clear that an adaptation of patent rules was necessary to protect public health and provided clarifications on the flexibility system as well as principles for the interpretation of the TRIPS Agreement (Correa 2004; So 2004). In her speech at the Doha Conference, the former WHO Director-General Dr Brundtland welcomed the statement that the TRIPS Agreement ‘can and should be interpreted and implemented in a manner supportive of the WTO’s members’ right to protect public health and, in particular, promote access to medicine for all’ (Brundtland 2001).24 Subsequently, WHO restated that it ‘continues to urge Member States to consider using to the full the TRIPS flexibilities with regard to the protection of public health’ (World Health Organization 2003f). The political statement embodied in the Doha Declaration was then spelled out in operational terms on 30 August 2003 in the Decision of the WTO General Council (World Trade Organization 2003) regarding the implementation of Paragraph 6 of the Doha Declaration on TRIPS and Public Health and the subsequent amendment to the TRIPS Agreement of 6 December 2005 (World Trade Organization 2005). The WTO General Council Decision aimed to ensure access to medicines for countries with no or inadequate drugs

36 Part I: The Global Health Arena

manufacturing capacity.25 It waived countries’ obligations under Article 31 (f) of the TRIPS Agreement (World Trade Organization 2003).26 In doing so, it allowed medicines manufactured under compulsory licenses to be exported to countries that lack production capacity, provided that certain conditions and procedures are met.27 Notwithstanding some concerns regarding the difficulties of implementing the Decision (Kongolo 2006) and the actual impact of the WTO’s action on the accessibility of medical products,28 the granted ‘interim waiver’ was made permanent through the aforementioned amendment to the TRIPS Agreement in 2005.

Commission on Intellectual Property Rights, Innovation and Public Health and its follow-up In response to the ongoing debate on the interrelations between intellectual property rights and public health, the World Health Assembly requested the WHO Director-General to establish the terms of reference for an appropriate time-limited body to collect data and proposals from the different actors involved and produce an analysis of intellectual property rights, innovation, and public health, including the question of appropriate funding and incentive mechanisms for the creation of new medicines and other products against diseases that disproportionately affect developing countries. (World Health Assembly 2003b) Consequently, a Commission on Intellectual Property Rights, Innovation and Public Health was established in February 2004. In its report of April 2006 the Commission analysed the various aspects of the relationship between these three areas, mobilizing the available evidence and reviewing the perspectives of different stakeholders (Commission on Intellectual Property Rights Innovation and Public Health 2006; Türmen and Clift 2006). It made recommendations aimed at promoting the accessibility of health care products in developing countries, as well as of innovations relevant to their needs.29 In this regard some commentators suggested that the Commission recommends the use of compulsory licensing for increasing competition and ensuring access to more affordable products (Hoen 2006). It emerged from the work of the Commission, on the one hand, that many stakeholders, including private companies, wish to promote research and development relevant to the need of developing countries; however, notwithstanding the efforts, research and development have not produced adequate results. On the other hand, the Commission concluded that intellectual property rights provide important incentives for the development of new drugs, but do not provide an effective incentive when patient populations are small or poor. Indeed, it has been underscored that ‘intellectual property rights are not the best mechanism to stimulate innovation’ (Musungu 2006).

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 37

Further to the Commission’s request for a global plan of action to secure, inter alia, an enhanced and sustainable basis for needs-driven essential health research and development relevant to diseases disproportionately affecting the poorest countries and for estimating funding needs, the World Health Assembly decided to establish an intergovernmental working group to draw up a global strategy and a plan of action providing a medium-term framework based on the recommendations of the Commission (World Health Assembly 2006b).30 The global strategy and the parts of the plan of action already agreed upon were finally adopted by the World Health Assembly in May 2008 (World Health Assembly 2008).

Future needs Access to essential medicines is crucial for strengthening health systems driven by primary health care, which are, in turn, essential for meeting the challenges the countries face, including the implementation of HFA, attaining the MDGs and for health improvement to work as a poverty reduction strategy. The particular interest of WHO in intellectual property rights should be seen in connection with the impact of patents on public health. Although patent protection has been an effective incentive for the research and development of new medicines and vaccines, it is difficult to predict if it will ensure investments in drugs for neglected diseases predominantly affecting developing countries. Providing access to essential medicines requires a complex and coordinated system involving public and private sectors, as well as civil society. Even though much has been done in the last century, it has been estimated that today one-third of the global population does not have regular access to essential medicines. The situation is even worse when taking into account some low-income countries in Africa and Asia where more than half of the population does not have regular access to drugs. In addition, only one per cent of the medicines developed over the past 25 years were for tropical diseases and tuberculosis (World Health Organization 2004c), meaning that most of the research and development investments are targeting diseases which burden the richest part of the world population.

Part III: New partners, forms of collaboration and financing mechanisms Private–public interactions for health Private commercial companies, philanthropic foundations, NGOs, professional associations and research institutions have become important actors in pursuing the achievement of specific public health goals, alongside governments and international organizations. Such objectives have ranged from

38 Part I: The Global Health Arena

increasing immunization coverage in developing countries and targeting certain diseases (such as malaria, tuberculosis and HIV-AIDS) to reducing maternal, newborn and child mortality, or strengthening local health information systems. Collaboration with the private sector is not a new trend. Since its inception, WHO has understood the importance of creating collaborative relations. In particular, WHO has promoted the development of new drugs through cooperation with the pharmaceutical sector for the benefit of the poorest populations since, at least, the early 1980s (Quick 2001). The intensification and broadening of collaboration with the private sector, while opening new avenues for WHO to deal with the growing challenges on its agenda, has given rise to concerns regarding the independence of the Organization – this is particularly important in view of the normative functions of WHO. Consequently, more acute concerns about safeguarding the reputation of the Organization as an impartial, credible and objective technical and policy-making agency free of undue influence by corporate interests have been raised (Richter 2004). In order to guide the WHO Secretariat in assessing the acceptability of specific relations with the private sector, the Secretariat developed ‘Guidelines on Interaction with Commercial Enterprises to Achieve Health Outcomes’ for governing interactions with commercial companies in the design, implementation and evaluation of technical activity (World Health Organization 2001a). Although they do not represent a policy statement on the Organization’s relations with the private actors, they constitute WHO’s response to requests for a greater transparency in its dealing with industry and a practical guidance for the Secretariat (World Health Organization 2001c). The Guidelines attempt to strike a balance between the need to protect the Organization from undue commercial influence, on the one hand, and the development of interaction with the private sector, on the other hand. They identify the following main forms of collaboration: donations (World Health Organization 1946, 2000a),31 contributions in kind, the secondment of personnel by and cost recovery from companies, product development and the co-sponsorship of meetings. Such forms of collaboration may be acceptable to WHO provided that specific conditions are met (Burci and Vignes 2004).

Private–public partnering arrangements Buse and Walt have defined ‘a global public–private partnerships for health’ as ‘a collaborative relationship which transcends national boundaries and brings together at least three parties, among them a corporation (and/or industry association) and an intergovernmental organization, so as to achieve a shared health creating goal on the basis of a mutually agreed division of labour’ (Buse and Walt 2000a). It became clear already in the 1990s that partnerships could play an important role in putting health on the agenda of other actors/sectors and increasing the societal momentum for

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 39

health improvement (Task force on Health and Development 1996). The creation of partnerships also reflected recognition of the need for a collaborative approach to tackle complex problems for which action by the WHO alone might be inadequate (Brundtland 2002a).32 As recently considered in the context of the UN General Assembly in relation to the achievement of the MDGs, partnerships are vital since the MDGs ‘will only be achieved if the private sector, civil society and governments [are] fully engaged’ (United Nations General Assembly 2006). This reflects the current broad re-evaluation of the relations between the organizations of the UN system and the private sector. These developments have not gone unnoticed by commentators. Partnerships have been perceived by some as a response to market failure to effectively address the health needs of developing countries (Utting and Zammit 2006; Buse and Waxman 2001). They have also been found problematic as partnerships may give the impression of downgrading the role of governments and intergovernmental organizations, while upgrading the status of private players (Martens 2003). By contrast, some commentators and international organizations consider that partnerships are not intended to substitute governments’ commitments and action, but rather to complement and reinforce them (Pinet 2003). In fact, the former WHO Director-General Dr Lee considered that ‘building successful inclusive partnerships cannot be an extra to our core work. It must be the core’ (World Health Organization 2003b). Partnerships are thus not generally considered as a threat by international organizations but as a way to achieve their objectives and the MDGs. To address the concern raised as to partnerships, in November 2005 the High-Level Forum on Health MDGs developed ‘Best practice principles for Engagement of Global Health Partnership Activities at Country Level’ (HighLevel Forum on the Health MDGs 2005). These principles are: ownership, alignment, harmonization, managing for results, governance, and accountability. Global health partnerships are intended as a means to improve health outcomes, to support poverty reduction and the achievement of the healthrelated MDGs. They need to be applied and interpreted in light of specific circumstances related to the structure of the partnership and the partner countries. Partnerships have made a number of contributions. For example, they are important vehicles for fundraising, attracting new stakeholders, raising the profile of certain diseases and coordinating partners’ efforts. In addition, partnerships assure greater civil society and private sector participation in supporting global public goods and stimulate innovation. Partnerships vary notably in terms of their structure, scope and scale. Some of them are informally structured groups whose participants meet periodically to share information or coordinate their activities, such as project collaboration, joint advocacy campaigns, tasks forces or fora and networks.33 Other partnerships are more structured alliances such as WHO programs

40 Part I: The Global Health Arena

with external participation, alliances, functionally independent partnerships, partnership organizations, or UN joint programmes and cooperative arrangements, which launch and manage specific activities as well as raise and provide financial resources for developing countries. As to their scope, while some partnerships target a single disease, such as epilepsy or onchocerciasis, others support health interventions such as immunizations, or component of health systems, such as information gathering. Some partnerships focus on improving access to existing technologies, while others concentrate on the research and development of new products. WHO is currently part of a number of partnerships aimed at creating synergies between public and private sectors, and accessing and mobilizing financial and human resources. It has also agreed to support, host and administer several partnerships and to provide their secretariat. WHO may therefore, at the same time, be a member of a partnership, and thus be part of its ‘corporate identity’ and participate in its decision making; a technical implementing partner in its own right; and the administrative host of the partnership. Providing leadership on engaging in partnerships where joint action is required is one of the core functions of the Organization (World Health Assembly 2006a). The Global Alliance for Vaccines and Immunization (GAVI Alliance), for example, is an unincorporated public–private partnership launched in January 2000. Its main objective is to improve access to sustainable immunization services in the poorest countries. GAVI Alliance also focuses on the development of new vaccines and the promotion of safe injection equipment (www.gavialliance.org). Membership of the GAVI Alliance includes international organizations such as WHO, UNICEF and the World Bank, NGOs, governments and vaccines producers from developed and developing countries and research institutes. The Board of the Alliance sets the programmatic policies and monitors and oversees all programme areas. Its Executive Committee supervises policy development and implementation and conducts a preliminary review of key issues prior to Board discussion.34 It also makes critical, time sensitive decisions that allow the Alliance to function between Board meetings. The GAVI Alliance is supported by the GAVI Secretariat in Geneva and four affiliated charitable entities; namely, the GAVI Fund, the International Finance Facility for Immunization (IFFIm) Company, the GAVI Fund Affiliate and the GAVI Foundation. While the GAVI Fund is the arm of the partnership with fiduciary responsibilities, the IFFIm Company is a charity which provides front-loaded resources to the GAVI Fund Affiliate for GAVI programs. As to the two other affiliate entities, the GAVI Fund Affiliate is in charge of entering into pledge agreements with IFFIm donors and assigning these pledges to the IFFIm Company for subsequent disbursement and the GAVI Foundation provides contracting and administrative services to the GAVI Alliance (www.gavialliance.org).

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To benefit from the GAVI Alliance support, a State needs to file an application including an assessment of the existing immunization services, an immunization plan for which support is needed and evidence of an Interagency Coordination Committee led by the Ministry of Health. Applications are screened by an Independent Review Committee and then by the Board. Recommendations made by the Board are then forwarded to the GAVI Fund whose board takes the final decision on whether to award grants to applicant countries. This system constitutes a departure from traditional funding systems since it relies on government and inter-agency coordination committees to set targets and monitor progress instead of prescribing how resources should be used (Burci and Vignes 2004).

New financing mechanisms Funding matters are gaining importance in the partnership context because of the gap between the funding raised to date and the total amount required. A wide range of mechanisms have been created and improved such as grants, tax breaks and credits, reduction of the cost of capital to investors, and fast-track approvals options (‘push mechanism’) or as advance markets commitments (AMCs) and price commitments (‘pull mechanisms’) (Sundaram and Holm 2005/6). AMCs relate to donor commitments for the future purchase of a specific vaccine and/or medicine, not yet available, at a price that will assure the drug developer a profitable return (www.vaccineamc.org). This innovative approach, pursued for rewarding research, development and production of specific drugs, offers powerful and cost-effective means to stimulate the development and production of new drugs with particular reference to neglected diseases. Positive effects of such a mechanism are threefold: firstly, poor countries will benefit from new drugs to fight against diseases that seriously affect their population; secondly, the pharmaceutical industry will be able to perform research and development in fields that, without such a donor commitment, would not be profitable; and thirdly, donors do not need to divert funds in advance, since they will be requested to pay once the new drug has been developed and manufactured. It has been considered that such a mechanism ‘could result in a generational leap towards the achievement of relevant MDGs’. For example, two pilot AMCs were established in the context of the GAVI Alliance following a request by certain governments.35 After several consultations and research, an expert committee established by GAVI Alliance and the World Bank provided evidence-based recommendations to governments on the vaccines for pneumococcal disease and malaria as the most suitable candidates for the AMC pilots. Pneumococcal disease has been considered appropriate to demonstrate the impact of AMCs on industry decisions, as access to the relevant vaccines depends on private investments in their development and production capacity. Malaria was chosen because the relevant

42 Part I: The Global Health Arena

vaccines are at most advanced stages and they are likely to yield a timely and measurable response to AMC. To implement the AMC pilots, ad hoc legal frameworks containing legal obligations for participants and implementation details need to be elaborated. Such frameworks should specify the market size of the AMC, the price and the requirements of the targeted vaccine, as well as the financial commitments and the obligation to enter into a guarantee and supply agreement with any qualifying manufacturer. The financing structure of the pilots is sufficiently flexible. With regard to the pneumococcal disease AMC pilot, the price per dose is estimated to be within the range of $5–7. The first payments are anticipated to begin in 2010 and last for between nine and ten years. It is expected that the AMC would prevent roughly 5.4 million deaths by 2030. In addition, AMC would provide incentives for companies wishing to invest in the accelerated development and manufacture scale-up of any of the 20 or so vaccine candidates. In respect of the malaria AMC pilot, the price per dose is estimated to be within the range of $6–8 with developing countries responsible for an affordable copayment dose. The first payments are anticipated to begin in 2016 and to last for eleven years. It is expected that the AMC would prevent roughly two million deaths by 2030. In addition to the abovementioned mechanisms, new innovative strategies, such as the International Finance Facility (IFF), have been suggested. Based on donors’ long-term commitments as a guarantee, the IFF collects funds on international capital markets by issuing bonds. This mechanism has thus a multiplier effect and generates additional funds. The aforementioned International Finance Facility for Immunization (IFFIm) constitutes a specific application of the IFF designed to rise funding for GAVI Alliance programs over a ten-year timeframe. GAVI Alliance programs are fundamentally a country-owned process – with countries applying for the funding of the programs that they wish to undertake. Thus, the aim of IFFIm is to accelerate the availability of funds for health and immunization programs through GAVI. The World Bank also plays a role in this context. It serves as a treasury for the IFFIm. In that capacity, it borrows funds in the capital markets on behalf of the IFFIm, manages its liquidity and hedging activities, and administers donor pledges and cash flows (www.iff-immunisation.org). The IFFIm financing transaction may be defined as a securitization of assets. Such a new mechanism provides a significant flow of resources for immunization programs, where historically, the lack of secure financing has impeded program planning and product development efforts. Both IFF and IFFIm should be regarded as innovative schemes for financing development. In addition, the GAVI Alliance has recently developed a co-financing system. As some countries had adopted new vaccines without due consideration of long-term costs necessary within broader health programmes, the GAVI

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 43

Alliance Board decided in 1995 that vaccines should no longer be provided free of charge. Furthermore, GAVI Alliance support should be time-limited and countries should be expected to contribute a fixed amount for the first vaccine, in accordance with their funding capability. That should help ensuring the sustainability of the country programs that support the introduction of new vaccines and allow GAVI to redirect its funds to support new vaccine priorities (www.gavialliance.org). Co-financing reflects a new approach that major actors in the international arena believe should be adopted.

Strengths and weaknesses of partnerships In the light of the foregoing it may be concluded that long-term collaborative relations have made a significant contribution to the improvement of public health and the attainment of health-related development goals. In particular, they have been able to mobilize unprecedented levels of financial resources as well as political attention to address health problems disproportionately affecting developing countries. Yet more needs to be done to reduce inequalities and to ensure a safer world. Recent events have demonstrated that the international spread of diseases and the overwhelming disease burden have a devastating impact on global public health, as well as, unnecessary negative interferences with travel and trade which may affect the economies of all the countries in the world.36 Therefore, it has become vital to align, unify and increase common efforts and activities. Partnerships and alliances are key mechanisms to address threats to health and to social and economic development. However, it is questionable how and to what extent the collaborative relations between the public and the private sector may contribute to addressing the emerging needs. Intergovernmental organizations, such as WHO, are, however, under pressure to look for new mechanisms and to create new and more profitable forms of cooperation. Some existing ones need improvement because, although valuable, collaboration may not have been as uncomplicated or successful as expected. It may also be questioned whether an adequate voice is given in new collaborative approaches to developing countries as the main beneficiaries of those approaches (Lob-Levyt 2001). Dr Chan, the Director-General of the Organization reflected, upon taking office in January 2007, as follows: If you look at the number of partnerships the Organization has, I’m just surprised. How can we manage all these partnerships? The transaction costs are very high. We need to be honest with ourselves and ask the question, are all these partnerships still relevant? If not, either the partnerships have to change or we have to change or both of us have to change to be more relevant. What is important to me is, are we getting the results that matter? Are we doing the right things to make an impact on the health

44 Part I: The Global Health Arena

of the populations that we are serving? These questions have to be asked. (Chan 2007c) There is a need to define a coherent global health architecture, to coordinate and to rationalize the role and the advantages of the multiplicity of actors, as well as to ensure the alignment of health development policies with internationally agreed goals and priorities, especially the MDGs. A crucial question relates to the benefits and risks for participants in public– private partnerships. As far as the private sector is concerned, partnerships have: (i) increased corporate influence in global policy at the national level; (ii) brought direct and financial returns, such as tax breaks and market penetration, as well as direct financial benefits trough brand and image promotion; (iii) enhanced corporate authority and legitimacy through association with the UN and other bodies [. . .]. The costs for the private sector seem to be relatively small in relation to the overall gains: a potential small loss of resources if programmes do not work by huge benefits in public relations when they succeed. (Buse and Walt 2000b) As concerns the nonprofit sectors, it has been considered that ‘the UN’s shift towards accepting the public–private partnership paradigm has already paid off well – from a public interest perspective, however, many of the gains for the corporate sector can be seen as losses’ (Richter 2003). As far as WHO is concerned, if interactions with the corporate and nonprofit sectors are beneficial for the attainment of the WHO’s objectives under its Constitution, it may be questioned whether that poses a risk to its status as the leading public health organization in the UN system.

Concluding remarks As seen above, WHO has stimulated development by fighting disease and promoting a more equitable global health architecture since its inception. The endorsement of the Alma-Ata Declaration in 1979, which recognized, among other things, the close and interdependent linkage between health and development, marked a departure from WHO’s earlier, primarily medical, approach to health and the beginning of a new role for WHO in health and development. Recognition of the multidimensional nature of health, whose promotion requires intersectoral and interdisciplinary collaboration, including with the private sector and other nongovernmental actors, redirected WHO’s policies and activities accordingly. Today, promoting development enjoys an unprecedented prominence on the WHO’s policy agenda. The international attention paid to the links between health and development, and the high priority that health occupies in the debates on priorities for

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 45

development, pose both a remarkable challenge and an opportunity to the Organization. As seen above, most of WHO’s technical and normative work support poverty reduction in a cross-cutting way. Yet innovative approaches are called for in some areas of work. As to WHO’s horizontal policies, the development of health systems driven by primary health care is essential for meeting the challenges developing countries face, including the implementation of HFA, attaining the MDGs and for health improvement to work as a poverty reduction strategy. Furthermore, interventions to deliver specific health outcomes require the support of sustainable and equitable health systems. Despite WHO’s decentralized structure, the impact of WHO’s work on people remains a constant challenge. Director-General Chan has emphasized the need to impact on two groups of people in particular: women and the people of Africa – women because of their role as agents of change and the people of Africa because of extreme poverty and disease burden disproportionately affecting that region (World Health Organization 2007d). The numerous global, national and local organizations, as well as public– private alliances and partnerships, both old and new, in the international health architecture all have a role in the response to the immense global health challenges. The proliferation of actors calls for policy coherence, accountability, and synergy of action by all both at the local and international levels. Therefore, WHO’s role as the directing and coordinating authority in the field of health continues to have vital importance.

Notes 1. The adopted disease-specific sanitary conventions were consolidated into one single text at the eleventh conference held in 1903. That Convention was then replaced by a new Convention in 1912 and complemented by new regulations. Sanitary conventions were negotiated also at the regional level, most notably in the Americas (Howard-Jones 1975). 2. The early regional quarantine bodies and councils include those established in Alexandria (1831), Constantinople (1839), Tangier (1840) and Teheran (1867). Except for the Board in Alexandria, these bodies were discontinued in the course of World War I (Goodman 1952). 3. The name of the International Sanitary Bureau was changed to the Pan American Sanitary Bureau (PASB) in 1923 and the name of the Pan American Sanitary Organization changed to the Pan American Health Organization (PAHO) in 1958 (Howard-Jones 1981; Pan American Health Organization 1992). 4. 11 European States and the United States of America signed the Rome Agreement constituting the Office international d’hygiène publique (OIHP) on 9 December 1907. 5. The Permanent Committee of the OIHP functioned as the Advisory Council of the League of Nations Health Organization. In practice, the two organizations collaborated most notably in the field of epidemiological information.

46 Part I: The Global Health Arena

6.

7.

8.

9.

10.

11.

12. 13.

14.

Consultative and co-operative arrangements existed also with the Pan American Health Organization (Goodman 1952). The League of Nations Health Organisation undertook activities, inter alia, in the fields of nutrition, housing, physical culture, rural hygiene and biological standardization. It established technical committees, published a bulletin and the Weekly Epidemiological Record, started a series of technical co-operation programmes with its Member States and established the Eastern Bureau in Singapore to collect and disseminate epidemiological information. (League of Nations 1931). The WHO Country Cooperation Strategy (CCS) is a medium-term strategic framework for WHO cooperation with particular countries. CCS represents a balance between country priorities and regional as well as Organization-wide orientations and priorities. It is used for WHO’s alignment with national health and development plans and strategies as well as for harmonizing WHO’s work with that of other UN agencies and other partners. See http://www.who.int/ countryfocus/cooperation_strategy/en/. According to Article 21 of the WHO Constitution regulations may be adopted in the following areas: ‘(a) sanitary and quarantine requirements and other procedures designed to prevent the international spread of disease; (b) nomenclatures with respect to diseases, causes of death and public health practices; (c) standards with respect to diagnostic procedures for international use; (d) standards with respect to the safety, purity and potency of biological, pharmaceutical and similar products moving in international commerce; (e) advertising and labelling of biological, pharmaceutical and similar products moving in international commerce’ (World Health Organization 1946). The Nomenclature Regulations have been revised several times, most recently in 1967. They are available at www.who.int/entity/classifications/icd/docs/en/ NOMREGS.pdf. The proposed reasons include complexity of formalizing technical requirements in a rapidly evolving field; uneven development of Member States; WHO’s focus on country level operational activities and eradication of diseases; difficulties encountered when negotiating the International Code of Marketing of Breast-milk Substitutes (World Health Organization 1981); and WHO’s scientific organizational culture (Taylor 1992; Fidler 1998). In Res. WHA28.76, the Health Assembly decided that the types of support should consist of those proven effective or under development by WHO; be flexible and adaptable to the specific needs, conditions and priorities of the countries and include operational components when necessary; and be based on knowledge of the constraints limiting the development process of developing countries. (World Health Assembly 1975b). In 2006–2007, 66.9 per cent and, in 2008–2009, 70.2 per cent, of the total program budgets are allocated to the regions (World Health Assembly 2007a). Including United Nations Conference on Environment and Development (1992), International Conference on Nutrition (1992), International Conference on Population and Development (1994), World Summit for Social Development (1995), Fourth World Conference on Women (1995) and United Nations Conference on Human Settlements II (1996). The World Health Report 2000 broadly defines the health system as comprising all the organizations, institutions and resources that produce actions whose primary purpose is to improve health (World Health Organization 2000c).

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 47 15. In the primary health care approach the primary level acts as a driver for the health care delivery system as a whole. Providing the maximum possible care at the first level of contact, backed up by secondary level facilities that focus on more complex care, is a core objective in many countries. Enabling coordinated, patient-centred care across the continuum of prevention and care requires the development of integrated health systems that are led by primary health care. (World Health Organization 2004b). 16. The building blocks serve three purposes: first, they allow a definition of desirable attributes – what a health system should have the capacity to do in terms of service delivery, health work force, information, etc. Second, they provide one way of defining WHO’s priorities. Third, by setting out the entirety of the health systems agenda, they provide a means for identifying gaps in WHO support (World Health Organization 2007b). 17. See, in particular, the United Nations Conference on Environment and Development (1992), the International Conference on Population and Development (1994), and the World Summit for Social Development and its follow-up (1995 and 2000). 18. Health makes an acknowledged contribution to the achievement of the other Millennium Development Goals (MDGs), particularly those related to education, gender equality and the eradication of extreme poverty and hunger. The MDGs concerning nutrition, water and sanitation, and the environment, are also related to health. 19. At a cost of US$27 billion a year eight million lives could be saved each year by 2010 and that the resulting increased productivity would yield US$186 billion a year. Other areas of recommended action include investing in global public goods, such as research and development geared towards tackling diseases of poor people and countries; human resources, including leadership development, and building ‘close-to-client’ health systems capable of reaching poor populations with essential interventions (Commission on Macroeconomics and Health 2002). 20. WHO identifies indicators for each health-related MDG and target in cooperation with other UN agencies. WHO monitors and reports on 17 of the health-related MDG indicators. Reporting on the achievement of the MDGs complements WHO’s regular work to improve the quality of country-level health data and aims to build capacity in countries to collect, analyze and act on information collected (World Health Assembly 2005a). 21. The list is available at http://www.who.int/medicines/publications/EML15.pdf. It may be noted here that UNICEF and WHO have recognized that the biggest part of medications worldwide ’are not formulated for easy or accurate administration to children’. WHO has therefore prepared a pediatric essential medicines list, the first to address diseases affecting children in developing countries (Brown, 2007). 22. Agreement on Trade-Related Aspects of Intellectual Property Rights, Marrakesh Agreement Establishing the World Health Organization, Annex 1C, UNTS, Vol. 1869. 23. It has been highlighted that the new free trade agreements, negotiated outside the World Trade Organization (WTO), require higher level of intellectual property rights protection in the field of medicines than those mandated by the TRIPS Agreement (Correa, 2006). 24. It should be noted that vaccines have not been specifically mentioned in the Doha Ministerial Declaration. However, it has been considered that the definition of products should be read as including them (Vandoren and J.C. 2003).

48 Part I: The Global Health Arena 25. ‘Eligible importing members’ are any least developed country WTO member and any other WTO member that has made a notification. 26. According to Article 31 (f) of the TRIPS Agreement production under compulsory licensing must be predominantly for the domestic market. That limitation impacts on countries which do not have the capacity to produce pharmaceutical products. 27. Among these conditions is the notification to the TRIPS Council by the eligible importing country of the names and expected quantities of the products, as well as the proof of its incapacity to locally produce them. In that cases license will be granted to only cover the amount necessary to meet the needs of the importing country. Such products need to be clearly identified and cannot be re-exported. 28. It has been highlighted that questions related to drugs prices are much less important than other issues such as inadequate or non-existing infrastructure for delivering system and distribution channels, lack of preventive education, insufficient hygiene, pollution and corruption (Pugath, 2006). 29. While the Commission makes a number of useful recommendations, it has been considered that the report ‘(..) understates the value of intellectual property rights for promoting public health and overstates the role of intellectual property in affecting access to health care. Indeed, the report favours compulsory licensing as a method for improving access to medicines, which is not justified by the evidence available’ (Noehrenberg 2006). 30. The Working Group is expected to present its recommendations to the World Health Assembly in 2008. 31. Article 57 of the WHO Constitution states that The Health Assembly or the Board acting on behalf of the Health Assembly may accept and administer gifts and bequests made to the Organization provided that the conditions attached to such gifts or bequests are acceptable to the Health Assembly or the Board and are consistent with the objective and policies of the Organization. 32. At the same time, it has been noted that a proliferation of ‘partnerships’ could threaten coherence in health policy making (Richter 2005). 33. A useful resource, although somewhat outdated, is the website of the Initiative on Public–Private Partnerships for Health (available at http://www.ippph.org), which contains a master catalogue of partnerships, organized according to various topics, such as activity, disease, product, stakeholders. 34. The Board of the GAVI Alliance is its steering organ. The Board is composed of four members, WHO, UNICEF, the World Bank, and the Bill & Melinda Gates Foundation, whose mandates renewable. In addition, there are thirteen rotating members whose terms, lasting for a three-year period, are non-renewable. 35. AMC Pilot Proposal, 7 September 2006. Document prepared under the guidance of the Italian, UK and Canadian Ministers by the World Bank and GAVI. For more information, see www.cgdev.org/doc/ghprn/AMC_Pilot.pdf. As to the pneumococcal disease AMC pilot, see also at www.gavialliance.org. 36. See, for instance, the outbreaks of SARS and Avian Flu.

References Aginam, O. (2003) ‘The Nineteenth Century Colonial Fingerprints on Public Health Diplomacy: A Postcolonial View’, Law, Social Justice & Global Development Journal, 1: 1–12.

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 49 Baliñska, M.A. (1995) ‘Assistance and Not Mere Relief: the Epidemic Commission of the League of Nations, 1920–1923’, in International Health Organisations and Movements, 1918–1939, edited by P. Weindling (Cambridge: Cambridge University Press). Beigbeder, Y. (1995) L’organisation mondiale de la santé (Paris: IUHEI, PUF). Brown, H. (2007) ‘WHO to Launch First Essential Medicines List for Children’, Bulletin of the World Health Organization, 85(4): 240–52. Brundtland, G.H. (2001) Statement, ‘Globalization, TRIPS and Access to Medicines (Doha, Qatar, 9–13 November 2001)’, available at http://www.who.int/ inf-pr-2001/en/state2001-17.html. Brundtland, G.H. (2002a) ‘Address to the Fifty-fifth World Health Assembly (May 13, 2002)’, available at http://www.who.int/director-general/speeches/2002/ english/20020513_addresstothe55WHA.html. Brundtland, G.H. (2002b) ‘Address to the International Conference on Financing for Development, Monterrey, 20 and 21 March 2002’, available at http://www.who.int/director-general/speeches/2002/english/20020320_financing monterrey.html. Burci, G.L. (2003) ‘Introductory Note. World Health Organization (WHO): Framework Convention on Tobacco Control’, International Legal Materials, 42(3): 515–17. Burci, G.L. (2006) ‘WHO (World Health Organization)’, in Dizionario di diritto pubblico, edited by S. Cassese (Milan: Giuffrè), pp. 6213–17. Burci, G.L. and C.-H. Vignes (2004) World Health Organization (The Hague, London and New York: Kluwer Law International). Buse, K. and G. Walt (2000a) ‘Global Public–Private Partnerships: Part I – a New Development in Health?’, Bulletin of the World Health Organization, 78(4): 549–61. Buse, K. and G. Walt (2000b) ‘Global Public–Private Partnerships: Part II – What are the Health Issues for Global Governance?’, Bulletin of the World Health Organization, 78(5): 699–709. Buse, K. and A. Waxman (2001) ‘Public–private Health Partnerships: a Strategy for WHO’, Bulletin of the World Health Organization, 79(8): 748–54. Calderwood, H.B. (1963) ‘The World Health Organization and its Regional Organizations’, Temple Law Quarterly, 37(1): 15–27. Chan, M. (2007a) ‘Address by Dr. Margaret Chan, Director-General, to the Sixtieth World Health Assembly’, Doc. A60/3, available at http://www.who.int/gb/ebwha/ pdf_files/WHA60/A60_3-en.pdf. Chan, M. (2007b) ‘Address to the Regional Committee for the Americas, Fifty-ninth Session (Washington, DC, Oct. 1, 2007)’, available at http://www.who.int/dg/speeches/ 2007/20071001_washington/en/index.html. Chan, M. (2007c) ‘Interview on Taking Office as Director-General (2007)’, available at http://www.who.int/dg/chan/interviews/taking_office/en/index.html. Commission on Intellectual Property Rights Innovation and Public Health (2006) Report of the Commission on Intellectual Property Rights, Innovation and Public Health, Public health, Innovation and Intellectual Property Rights (Geneva: World Health Organization). Commission on Macroeconomics and Health (2002) ‘Special Theme Issue’, Bulletin of the World Health Organization, 80(2). Correa, C.M. (2004) Implementation of the WTO General Council Decision on Paragraph 6 of the Doha Declaration on the TRIPS Agreement and Public Health (Geneva: World Health Organization). Correa, C.M. (2006) ‘Implication of Bilateral Free Trade Agreements on Access to Medicines’, Bulletin of the World Health Organization, 84(5): 340–51.

50 Part I: The Global Health Arena Dodd, R. and A. Cassels (2006) ‘Health, Development and the Millennium Development Goals’, Annals of Tropical Medicine & Parasitology, 100(5–6): 379–87. Dubin, M.N. (1995) ‘League of Nations Health Organization’, in International Health Organisations and Movements, 1918–1939, edited by P. Weindling (Cambridge: Cambridge University Press). Fidler, D. (1998) ‘The Future of the World Health Organization: What Role for International Law?’, Vanderbilt Journal of Transnational Law, 31: 1079–126. Fidler, D. (2002) Global Health Governance. Overview of the role of International Law in Protecting and Promoting Global Public Health. Discussion Paper No. 3 (London/Geneva: Centre of Global Change and Health, London School of Hygiene and Tropical Medicine and WHO). Fidler, D. (2006) ‘Legal Review of the General Agreement on Trade in Services (GATS) from a Health Policy Perspective: Draft, Globalization’, Trade and Health Working Papers Series, 182. Godlee, F. (1994) ‘The World Health Organisation: The Regions - Too Much Power, Too Little Effect’, British Medical Journal, 309: 1566–70. Goodman, N.M. (1952) International Health Organizations and Their Work (London: J. & A. Churchill Ltd.). Grad, F.P. (2002) ‘Public Health Classics: The Preamble of the Constitution of the World Health Organization’, Bulletin of the World Health Organization, 80(12): 981–4. Greppi, E. (1984) ‘Organizzazione Mondiale della Sanità (O.M.S.)’, in Novissimo Digesto Italiano, Appendice (Torino: UTET). High-Level Forum on the Health MDGs (2005) ‘Best Practice Principles for Engagement of Global Health Partnership Activities at Country Level, Paris, 14–15 November 2005’, available at http://www.hlfhealthmdgs.org/Documents/GlobalHealth Partnerships.pdf. Hoen, E. (2006) ‘Report of the Commission on Intellectual Property Rights, Innovation and Public Health: a Call to Governments’, Bulletin of the World Health Organization, 84(5): 421–3. Howard-Jones, N. (1950) ‘Origins of International Health Work’, British Medical Journal, 1(4661): 1032–7. Howard-Jones, N. (1975) Scientific Background of the International Sanitary Conferences 1851–1938 (Geneva: World Health Organization). Howard-Jones, N. (1981) The Pan American Health Organization: Origins and Evolution (Geneva: World Health Organization). Koivusalo, M. and E. Ollila (1996) International Organizations and Health Policies (Saarijärvi: STAKES/HEDEC). Kongolo, T. (2006) ‘Intellectual Property and Public Health. Unpleasant Marriage’, The Geneva Post, 185–208. League of Nations (1931) League of Nations Health Organisation (Geneva: League of Nations). Lob-Levyt, J. (2001) ‘A Donor Perspective’, Bulletin of the World Health Organization, 79(8): 771–2. Martens, J. (2003) ‘The Future of Multilateralism after Monterrey and Johannesburg, Dialogue on Globalization’, Dialogue on Globalization: Occasional Papers, 10: 1–52. Milstien, J. and M. Kaddar (2006) ‘TRIPS and Priority Vaccines’, Bulletin of the World Health Organization, 84(5): 360–5. Musungu, S.F. (2006) ‘Benchmarking Progress in Tackling the Challenges of Intellectual Property, and Access to Medicines in Developing Countries’, Bulletin of the World Health Organization, 84(5): 366–70.

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 51 Noehrenberg, E. (2006) ‘Report of the Commission on Intellectual Property Rights, Innovation and Public Health: an Industry Perspective’, Bulletin of the World Health Organization, 84(5): 419–20. Pan American Health Organization (1992) Pro Salute Novi Mundi: A History of the Pan American Health Organization (Washington, DC: Pan American Health Organization). Pinet, G. (2003) ‘Global Partnerships: a Key Challenge and Opportunity for Implementation of International Health Law’, Medicine and Law, 22(4): 561–78. Pugatch, M.P. (2006) ‘Political Economy of Intellectual Property Policy-Making’, The Geneva Post, 161–92. Quick, J.D. (2001) ‘Partnerships Need Principles’, Bulletin of the World Health Organization, 79(8): 776. Richter, J. (2003) We the People or We the Corporations? Critical Reflections on UN–Business ‘Partnerships’ (Geneva: International Baby Food Action Network and Geneva Infant Feeding Association). Richter, J. (2004) ‘Public–private Partnerships and Health for All – How Can WHO Safeguard Public Interests?’, Globalism and Social Policy Programme, 5: 1–8. Richter, J. (2005) ‘Global Partnerships and Health for All. Towards an Institutional Strategy (Unpublished Paper)’. So, A.D. (2004) ‘A Fair Deal for the Future: Flexibilities Under TRIPS’, Bulletin of the World Health Organization, 82(11): 815–21. Sundaram, L. and K. Holm (2005/6) ‘Public–Private Partnerships for Health’, Sustainable Development International, 16: 1–4. Task Force on Health and Development (1996) Highlights of the Fifth Meeting (Geneva: World Health Organization). Taylor, A.L. (1992) ‘Making the World Health Organization Work: A Legal Framework for Universal Access to the Conditions for Health’, American Journal of Law & Medicine, 18: 301–46. Taylor, A.L. and D. W. Bettcher (2000) ‘WHO Convention on Tobacco Control: a Global “Good” for Public Health’, Bulletin of the World Health Organization, 78(7): 920–9. Taylor, A.L. and G. Hao (2003) ‘Global Health Governance and International Law’, Whittier Law Review, 25(2): 253–72. Türmen, T. and C. Clift (2006) ‘Public Health, Innovation and Intellectual Property Rights: Unfinished Business’, Bulletin of the World Health Organization, 84(5): 338. United Nations (2001) Road Map Towards the Implementation of the United Nations Millennium Declaration, Report of the Secretary-General of the United Nations, UN Doc. A/56/326. United Nations (2006) Convention on the Rights of Persons with Disabilities, adopted on 13 December 2006 by the UN GA Res. A/RES/61/106; text in UN Doc. A/61/611. United Nations General Assembly (1974a) Declaration on the Establishment of a New International Economic Order, GA Res. 3201 (S-VI), UN Doc. A/RES/S-6/3201. United Nations General Assembly (1974b) Programme of Action on the Establishment of a New International Economic Order, GA Res. 3202 (S-VI), UN Doc. A/RES/S-6/3202. United Nations General Assembly (1974c) Charter of Economic Rights and Duties of States, GA Res. 3281 (XXIX), UN Doc. A/RES/29/3281. United Nations General Assembly (1975) Development and international economic co-operation, GA Res. 3362 (S-VII), UN Doc. A/RES/S-7/3362.

52 Part I: The Global Health Arena United Nations General Assembly (1979) Health as an integral part of development, GA Res. 34/58, UN Doc. A/RES/34/58. United Nations General Assembly (1981) Global Strategy for Health for All by the Year 2000, GA Res. 36/43, UN Doc. A/RES/36/43. United Nations General Assembly (2000a) United Nations Millennium Declaration, GA Res. 55/2, UN Doc. A/55/49. United Nations General Assembly (2000b) Follow-up to the outcome of the Millennium Summit, GA Res. 55/162, UN Doc. A/RES/55/162. United Nations General Assembly (2005) 2005 World Summit Outcome, GA Res. 60/1, UN Doc. A/RES/60/1 (2005). United Nations General Assembly (2006) ‘First Informal Thematic Debate. Partnerships Towards Achieving the MDGs: Taking Stock, Moving Forward’, available at http://www.un.org/ga/president/61/follow-up/thematic-mdg.shtml. Utting, P. and A. Zammit (2006) ‘Beyond Pragmatism. Appraising UN–Business Partnerships’, Markets, Business and Regulation Programme, 1: 1–53. Vandoren, P. and V. E. J.C. (2003) ‘The WTO Decision on Paragraph 6 of the Doha Declaration on the TRIPS Agreement and Public Health’, The Journal of World Intellectual Property, 6(6): 779–93. Vignes, C.-H. (1977) ‘La régionalisation de l’Organisation mondiale de la Santé’, in Le régionalisme et l’universalisme dans le droit international contemporain, Colloque SFDI, Bordeaux, 1976 (Paris: Pedone), pp. 189–200. Vignes, C.-H. (1991) ‘The World Health Organization’s Contribution to International Law’, in Desarrollo progresivo del derecho internacional: aportaciones de organizaciones, tribunales y parlamentos internacionales (Buenos Aires: Consejo de Estudios Internacionales Avanzados, Cooperación Académica Internacional). Wiist, W.H. (2006) ‘Public Health and the Anticorporate Movement: Rationale and Recommendations’, American Journal of Public Health, 96(8): 1370–5. World Bank (2007) Healthy Development: The World Bank Strategy for Health, Nutrition, and Population Results (Washington, DC: World Bank). World Health Assembly (1949) Coordination of research, Res. WHA2.19, WHO Official Records, No. 21. World Health Assembly (1951) Adoption of the International Sanitary Regulations (WHO Regulations No. 2), Res. WHA4.75, WHO Official Records, No. 35. World Health Assembly (1975a) Assistance to developing countries, Res. WHA28.75, WHO Official Records, No. 226. World Health Assembly (1975b) Programme budget policy with regard to technical assistance to developing countries, Res. WHA28.76, WHO Official Records, No. 226. World Health Assembly (1976) Programme budget policy, Res. WHA29.48, WHO Official Records, No. 233. World Health Assembly (1977) Technical cooperation, Res. WHA30.43, WHO Official Records, No. 240. World Health Assembly (1978) Action programme on essential drugs, Res. WHA31.32, WHO Official Records, No. 147. World Health Assembly (1979) Formulating strategies for health for all by the year 2000, Res. WHA32.30, WHA32/1979/REC/1. World Health Assembly (1981) The meaning of WHO’s international health work through coordination and technical cooperation, Res. WHA34.24, WHA34/1981/REC/1. World Health Assembly (1982) Policy on Patents, Res. WHA35.14, WHA35/1982/REC/1.

Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 53 World Health Assembly (1992) Health and development, Res. WHA45.24, WHA45/ 1992/REC/1. World Health Assembly (1994) Women, health and development, Res. WHA45.25, WHA45/1994/REC/1. World Health Assembly (1995) WHO response to global change: renewing the health-for-all strategy, Res. WHA48.16, WHA48/1995/REC/1. World Health Assembly (1997) Report of the task force on health in development, Res. WHA50.23, WHA50/1997/REC/1. World Health Assembly (1998a) World Health Declaration, annexed to Health-for-all policy for the twenty-first century, Res. WHA51.7, WHA51/1998/REC/1. World Health Assembly (1998b) Statement by the Director-General at the 51st Health Assembly, WHA51/1998/REC/2. World Health Assembly (1999) Revised drug strategy, Res. WHA52.19, WHA52/1999/ REC/1. World Health Assembly (2001a) Report of the WHO Commission on Macroeconomics and Health. Report by the Director-General, Doc. A55/5. World Health Assembly (2001b) Strengthening health systems in developing countries, Res. WHA54.13, WHA54/2001/REC/1. World Health Assembly (2002) Ensuring accessibility of essential medicines, Res. WHA55.14, WHA55/2002/REC/1. World Health Assembly (2003a) International Conference on Primary Health Care, Alma-Ata: Twenty-fifth Anniversary, Doc. A56/27, available at ftp.who.int/gb/ archive/pdf_files/WHA56/ea5627.pdf. World Health Assembly (2003b) Intellectual property rights, innovation and public health, Res. WHA56.27, WHA56/2003/REC/1. World Health Assembly (2003c) WHO’s Contribution to Achievement of the Development Goals of the United Nations Millennium Declaration. Report by the Secretariat, Doc. A56/11, available at http://www.who.int/gb/ebwha/pdf_ files/WHA56/ea5611.pdf. World Health Assembly (2005a) Achievement of Health-related Millennium Development Goals. Report by the Secretariat, Doc. A58/5, available at http://www. who.int/gb/ebwha/pdf_files/WHA58/A58_5-en.pdf. World Health Assembly (2005b) Revision of the International Health Regulations, Res. WHA58.3, WHA58/2005/REC/1. World Health Assembly (2005c) Accelerating achievement of the internationally agreed health-related development goals, including those contained in the Millennium Declaration, Res. WHA58.30, WHA58/2005/REC/1. World Health Assembly (2006a) Eleventh General Programme of Work, 2006-2015, Doc. A59/25, Annex 2, adopted by Res. WHA59.4, WHA59/2006/REC/1. World Health Assembly (2006b) Public health, innovation, essential health research and intellectual property rights: towards a global strategy and plan of action, Res. WHA59.24, WHA59/2006/REC/1. World Health Assembly (2006c) International trade and health, Res. WHA59.26, WHA59/2006/REC/1. World Health Assembly (2007a) Medium-term strategic plan 2008–2013, Res. WHA60.11, Doc. A/MTSP/2008–2013, PB/2008–2009. World Health Assembly (2007b) WHO’s Role and Responsibilities in Health Research, Res. WHA60.15. World Health Assembly (2008) Global strategy and plan of action on public health, innovation and intellectual property, Res. WHA61.21, WHA61/2008/REC/1.

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Riikka Koskenmaki, Egle Granziera and Gian Luca Burci 55 World Health Organization (2003c) Framework Convention on Tobacco Control, adopted by the Fifty-sixth World Health Assembly on 21 May 2003 and annexed to Res. WHA56.1 (WHO FCTC), UNTS, vol. 2302, p. 166. World Health Organization (2003d) Health Systems Including Primary Health Care, Doc. EB113/11, available at http://www.who.int/gb/ebwha/pdf_files/EB113/ eeb11311.pdf. World Health Organization (2003e) Influence of Poverty on Health, Doc. EB113/12, available at http://www.who.int/gb/ebwha/pdf_files/EB113/eeb11312.pdf. World Health Organization (2003f) ‘Statement of the World Health Organization on WTO access to medicines decision. Statement WHO/10’, available at http://whqlibdoc.who.int/statement/2003/statement_03_10.pdf. World Health Organization (2003g) World Health Report 2003 – Shaping the future (Geneva: World Health Organization). World Health Organization (2004a) ‘Equitable Access to Essential Medicines: a Framework for Collective Action’, WHO Policy and Perspectives on Medicines, 8: 1–6. World Health Organization (2004b) Health Systems Including Primary Health Care, Doc. A/57/14, available at http://www.who.int/gb/ebwha/pdf_files/WHA57/ A57_14-en.pdf. World Health Organization (2004c) WHO Medicines Strategy 2004–2007 – Countries at the Core (Geneva: World Health Organization). World Health Organization (2007a) Challenging Inequity Through Health Systems: Final Report (Geneva: Knowledge Network on Health Systems. WHO Commission on the Social Determinants of Health). World Health Organization (2007b) Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes: WHO Framework for Action (Geneva: World Health Organization). World Health Organization (2007c) International Travelers and Health (Geneva: World Health Organization). World Health Organization (2007d) Report by the Director-General to the Executive Board at its 120th session, Doc. EB120/2 (Geneva, Monday 22 January 2007), available at http://www.who.int/gb/ebwha/pdf_files/EB120/b120_2-en.pdf. World Health Organization (2007e) World Health Report 2007 – A Safer Future: Global Public Health Security in the 21st Century (Geneva: World Health Organization). World Health Organization (2008a) Commission on Social Determinants of Health (2008) Closing the Gap in a Generation: Health Equity Through Action on the Social Determinants of Health (Geneva: World Health Organization). World Health Organization (2008b) World Health Report 2008 – Primary Health Care: Now More Than Ever (Geneva: World Health Organization). World Health Organization and Pan American Health Organization (1949) Agreement Concluded between WHO and PAHO of 24 May 1949, reproduced in World Health Organization: Basic Documents, Forty-sixth Edition (Geneva: WHO, 2007). World Trade Organization (2001) Doha Ministerial Declaration, WT/MIN(01)/DEC/2. World Trade Organization (2003) Implementation of Paragraph 6 of the Doha Declaration on the TRIPS Agreement and Public Health. Decision of the General Council of 30 August 2003, WT/L/540 and Corr.1. World Trade Organization (2005) Amendment of the TRIPS Agreement, WT/L/641.

3 Beyond the Matrix: Thinking Three-dimensionally About Social Determinants of Health Ted Schrecker and Ronald Labonté

Increased availability of antiretroviral therapy (ART) for HIV infection is a global health success story. According to UNAIDS, in just the three years from 2003 to 2006, the estimated number of people receiving ART in low- and middle-income countries quintupled (from 400,000 to just over two million); in sub-Saharan Africa, where the need is greatest, the number of recipients of ART increased thirteenfold. However, the figure of two million is still far short of the estimated seven million people in need of ART (UNAIDS 2007), and despite this shortfall in treatment access the concentration of health system effort and donor funding on AIDS treatment has been criticized as examples of a ‘vertical’ orientation that neglects the need to strengthen health systems as a whole. Among the criticisms, one with special force is that scaling up AIDS treatment and similar vertical programs actually weakens health systems, creating an internal brain drain of health personnel from public health systems to which they are indispensable to relatively better funded, disease-specific programs. Another is that the lack of personnel available for follow up in weakened health systems leads people not to maintain their ART regime, increasing the risk of that new drug-resistant HIV strains will develop (Wakabi 2008; Anonymous 2008). Here we do not assess these criticisms, beyond observing that it is essential to strengthen health systems in developing countries so that they can offer a basic minimum standard of prevention and treatment to all citizens. Such an effort would, among other desirable consequences, ameliorate one of the major ‘push factors’ driving both the internal brain drain and the emigration of health professionals that threaten the viability of health systems in many developing countries (Chen et al. 2004). Based on cost calculations originating with the WHO’s Commission on Macroeconomics and Health, the effort would also require commitment by the industrialized world to a substantial increase in development assistance for health, sustained over a long period of time (Ooms et al. 2006). Even such a dramatic initiative would represent an inadequate and excessively narrow response to the causes of poor health: a 56

Ted Schrecker and Ronald Labonté 57

complex of socioeconomic factors now referred to as the social determinants of health (SDH). Described most simply, social determinants of health are those living and working conditions that make it relatively easy for some people to live long and healthy lives, and all but impossible for others. A research or policy focus on SDH is therefore: (a) based on recognition that healthcare is only one of several influences on health, and not always the most important (Evans and Stoddart 1990; Marmot and Wilkinson 2006); and (b) almost unavoidably about disparities in health and their relation to underlying social conditions (Diderichsen et al. 2001). Especially in environments characterized by pervasive social disadvantage, even when healthcare is available it represents a belated and not always successful effort to undo damage and end suffering that could readily have been avoided by earlier interventions outside the health sector. Thus, oral rehydration therapy (ORT) is highly effective in preventing child deaths from diarrheal disease, but it cannot prevent the recurrence of the condition (Stillwaggon 2006); that requires mobilizing resources for investment in provision of water and sanitation infrastructure, which remain dangerously inadequate throughout much of the developing world, most conspicuously for low-income populations (United Nations Development Programme 2006; Hutton and Bartram 2008). And to return to the topic of HIV infection, the best possible access to ART neither replaces nor substitutes for the adequate nutrition that may protect both against initial HIV transmission and subsequent opportunistic infection (Stillwaggon 2006), or for protection against economic insecurity and desperation that increase the probability of exposure to HIV transmission: in the extreme, by way of the well-documented practice of ‘survival sex’ (Wojcicki and Malala 2001; Wojcicki 2002; Schoepf 2004; Tawfik and Cotts Watkins 2007; Oyefara 2007). Although no authoritative list of key social determinants of health exists, we (and many others) take as a starting point the proposition that ‘many of the most devastating problems that plague the daily lives of billions of people are problems that emerge from a single, fundamental source: the consequences of poverty and inequality’ (Paluzzi and Farmer 2005). These problems are big, untidy, complicated, and largely outside the remit of health professionals (except as advocates) and health ministries. Addressing them effectively requires going beyond considerations of the design of health systems, adding a third dimension of social and economic policy to the matrix of horizontal and vertical initiatives. At the national or subnational level, this third dimension entails effective policy responses that are coordinated, health-focused multisectoral initiatives; in the European Union, ‘health in all policies’ has been suggested as a rubric for organizing such responses (Ståhl et al. 2006). Further complicating the issue, many solutions inescapably involve challenges to existing accumulations of wealth, power and privilege; specifically, they require either redesigning ‘those central engines in society that generate and distribute

58 Part I: The Global Health Arena

power, wealth and risks’ (Diderichsen et al. 2001) or compensating for their effects.

Globalization: how and why it matters Our emphasis on the international frame of reference reflects the fact that those engines now routinely operate on a transnational scale, as a consequence of globalization: ‘a process of greater integration within the world economy through movements of goods and services, capital, technology and (to a lesser extent) labor, which lead increasingly to economic decisions being influenced by global conditions’ (Jenkins 2004). For example, the production of goods is now routinely organized across multiple national borders, and extremely large amounts of money move seamlessly and almost instantly around the world: while the total value of foreign direct investment (to build new production facilities or acquire existing assets) in 2006 was US$1.2 trillion, the daily value of foreign exchange transactions on the world’s financial markets is now estimated at US$3.2 trillion (United Nations Conference on Trade and Development 2007; HFX Foreign Exchange 2007). An important element of globalization not fully captured by the quoted definition is the extent to which global integration has created a global marketplace, as domestic and foreign policy alike operate from an initial presumption in favor of private property rights and market-based allocations of resources. Thus, some authors refer to neoliberal globalization or simply to ‘neoliberalization’ (Harvey 2005; Eide 2005). Given our focus on poverty and economic vulnerability, it is essential to address the claim that ‘globalization is good for your health, mostly’ because countries that integrate into the global economy more rapidly (for instance, through trade liberalization) experience more rapid growth and are therefore better able to reduce poverty (Feachem 2001). Some countries, such as Vietnam and China, have achieved impressive growth rates and poverty reduction track records while at the same time opening their borders to imports and foreign investment and rapidly deregulating domestic markets. However, they and other fast-growing Asian economies were selective about the process of economic integration, and retain a considerable degree of state control over economic development (Rodrik 2007). In Vietnam growing economic inequality, the dismantling of a system of basic healthcare provision linked to agricultural production cooperatives, and the implementation of a series of market-oriented or neoliberal healthcare reforms have drastically increased the cost of healthcare for much of the population; a similar pattern can be observed on a much larger scale in China (United Nations Country Team Viet Nam 2003; Akin et al. 2004). Globally, progress toward poverty reduction remains modest against a background of unprecedented abundance (Kawachi and Wamala 2007; Chen and Ravallion 2004). Indeed, economic growth has proved to be a remarkably ineffective mechanism

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for reducing poverty (Woodward and Simms 2006). Calculations for Latin America, a region with persistently high levels of economic inequality, show that even a little redistribution of income through progressive taxation and targeted social programs would go farther in terms of poverty reduction than many years of solid economic growth; disturbingly, a recent Asian Development Bank report suggests that economic inequality in many countries in that region is rising toward Latin American levels (Paes de Barros et al. 2002; de Ferranti et al. 2004; Asian Development Bank Economics and Research Department 2007). In another approach to studying the relations among globalization, growth and health, Cornia and colleagues (Cornia et al. 2008) carried out an econometric exercise based on data from 136 countries in which they first identified five main influences on mortality: material deprivation; psychological stress; unhealthy lifestyles; inequality and lack of social cohesion; and technical (in this case, medical) progress. They then identified a range of variables that affect these influences, classifying the variables as either: (a) related to policy choices made in the context of globalization (for instance, GDP growth, income distribution, immunization rates); (b) endogenous, and therefore unrelated to globalization for purposes of the analysis (medical progress); or (c) describable as ‘shocks’ (for instance, wars and natural disasters, HIV/AIDS). The final stage of their analysis consisted of a simulation that compared trends in life expectancy at birth (LEB, the most basic health outcome) over the period 1980–2000 with those that would be predicted based on a counterfactual set of assumptions in which trends in all the relevant variables did not follow the actual 1980–2000 pattern, but rather remained at the 1980 value or continued the trend they followed over the pre-1980 period. Thus, it was assumed in the counterfactual (for instance) not only that income distribution within countries, one of the globalization-related variables, did not change over the period 1980–2000, but also that there was no progress in medical technology and that HIV incidence remained at its 1980 level. The results of this simulation indicated that, on a worldwide basis, over the period 1980–2000 globalization cancelled out most of the progress toward better health (as measured by LEB) attributable to the diffusion of medical progress, and the effects of shocks (wars, natural disasters and AIDS) combined with globalization to result in a slight worldwide decline in LEB as compared with the counterfactual. The most conspicuous declines in life expectancy occurred in the transition economies and the former Soviet Union (where globalization accounted for essentially the entire decline) and sub-Saharan Africa (where globalization contributed almost as much as the AIDS epidemic to a decline of nearly nine years in LEB, despite some offsetting benefits from the diffusion of medical progress). It can be objected that the diffusion of medical progress is at least partly a consequence of globalization, rather than an endogenous variable; in other words, that the analysis overstates the negative consequences of

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globalization. However, evidence like the decline of access to healthcare in China and Vietnam and the stagnation of immunization rates in sub-Saharan Africa, affected by such phenomena as declining commodity prices, debt crises, and structural adjustment conditionalities (discussed later in this chapter), suggests that the diffusion of medical progress may be occurring in spite of globalization rather than because of it. Conversely, the treatment of HIV infection as a shock analogous to natural disaster can be seen as problematic, because of evidence linking vulnerability to HIV infection with globalization. Relevant pathways include not only poverty and economic insecurity (Wojcicki and Malala 2001; Wojcicki 2002; Schoepf 2004; Tawfik and Cotts Watkins 2007; Oyefara 2007), but also the global diffusion of western fashion and consumer goods. Several recent African studies find a link between interests in consumption and risky sexual behavior, with recent survey data finding a higher prevalence of HIV among relatively better educated young adults with some – although not much – money (Stoebenau 2006; Smith 2000; Mishra et al. 2007; Luke 2005). Cornia and colleagues admit the limitations associated with lack of data on such variables as diet and smoking and the choice of indicators of globalization, and note that ‘the establishment of a causal nexus between globalization policies and health cannot be but tentative’ (Cornia et al. 2008). Despite these limitations, the study represents a remarkable rebuttal of claims about globalization’s health benefits, notably including those in the ‘growth superstars,’ India and China (Cornia et al. 2008). Such outcomes are at least partly explained by the fact that ‘global markets are inherently disequalizing’ and their operations are ‘asymmetrical’ in several ways (Birdsall 2006). In a longer literature review that expands on this insight, we have provided a (non-exhaustive) inventory of seven sets of pathways that lead from globalization to deterioration in SDH: trade liberalization; labor markets and the global reorganization of production; debt crises and the structural adjustment response; financial liberalization and financial crises; the restructuring of cities in response to the global marketplace; natural resources and environmental exposures; and the marketization of health systems (Labonte and Schrecker 2007b). At least one additional pathway, involving the transformation of food systems, would need to be added in the next iteration of the analysis (Rayner et al. 2006; Popkin 2006; Hawkes 2006, 2005; Chopra and Darnton-Hill 2004). Here, we address only a few sets of pathways.

Globalization of production and labor markets Globalization’s most conspicuous manifestation may be the fragmentation and reorganization of production and service provision across multiple national borders in global commodity chains or value chains, in which each element of production is located where it contributes most to overall returns

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while reducing financial risks (Krugman 1995; Gereffi and Korzeniewicz 1994; Gereffi 1999; Dicken 2007). An important element of this process is ‘outsourcing,’ in which production is undertaken not by subsidiaries or affiliates of a parent transnational corporation, but rather by notionally independent contract manufacturers and service providers (Milberg 2004). Global reorganization of production has been underpinned by drastic reductions in the cost of information processing and goods transportation, and facilitated by trade liberalization, but it is not a simple consequence of trade policy change. A ‘new international division of labor,’ in which labor-intensive manufacturing operations were relocated outside the industrialized countries to low-wage jurisdictions, often to Export Processing Zones (EPZs) that offered a variety of special incentives for foreign investors, was described in 1977 – a full 18 years before the establishment of the World Trade Organization (Frcbel et al. 1980). The case of Mexico’s maquiladora export-oriented manufacturing plants and zones is often cited to show the consequences of pursuing integration into global value chains: growing economic and social inequalities among workers (Hualde 2004); falling wages and deteriorating working conditions (Cypher 2004, 2001); eventual loss of some jobs to jurisdictions, notably China, that can offer even lower labor costs (Anonymous 2003); and increased workplace hazards and industrial pollution, exposure to which is in turn related to labor market position (Kopinak and Barajas 2002; Kopinak 2002; Scott Frey 2003). These are not the only effects of economic integration, and research in other countries emphasizes that distribution of gains and losses will depend on the niches that individual workers, firms and national economic policies are able to carve out in global value chains (Nadvi 2004; Jenkins 2005). Substantial opportunities may exist for employment and income gains (Kabeer and Mahmud 2004), but: ‘Global value chain pressures are [also] associated with increasing casualization of labour and excessive hours of work’ (Nadvi 2004). More recent research points to the emergence of a genuinely global labor market, driven in part by the integration of India, China and the former transition economies into the global marketplace (World Bank 2007, 1995; Woodall 2006); the size of the global labor force will roughly double as a result. Divergent views exist of the consequences, but many observers argue that it will mean sustained, worldwide downward pressure on wages and salaries (Woodall 2006; Ferguson and Schularick 2007). Less disagreement exists about the sharp decline in the wages of, and demand for, so-called lowskilled workers that has been associated with deindustrialization in the rich countries (Nickell and Bell 1995). This is part of a larger pattern identified by international relations scholar Robert Cox, who has argued that globalization divides labor forces into a hierarchical structure of ‘integrated, precarious, and excluded’ workers (Cox 1999). This typology is evident, for instance, in 1997 survey data from Brazil, Chile, Colombia, Costa Rica, El Salvador, Mexico,

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Panama and Venezuela showing that ‘the occupational structure has become the foundation for an unyielding and stable polarization of income,’ with lower income personal service, agricultural, commercial and industrial workers making up 74 per cent of the working population; an intermediate stratum of technicians and administrative employees 14 per cent, and higher-income professionals, employers and managers just 9 per cent (United Nations Economic Commission for Latin America and the Caribbean 2000). Analysis of these data links ‘the need to participate competitively in the world economy’ to labor market deregulation, increased flexibility, and the growth of economic insecurity (United Nations Economic Commission for Latin America and the Caribbean 2000). The tendency of labor markets to magnify inequality in the context of globalization is not confined to one region. The World Bank has conceded that despite its optimistic predictions for global growth and the expansion of a global middle class, labor market changes will lead to increased economic inequality in countries accounting for 86 per cent of the developing world’s population over the period until 2030, with the ‘unskilled poor’ being left farther behind (World Bank 2007), even before taking into account the shift of income shares from labor to capital that is evident in many national economies. Health can be affected not only by the economic insecurity associated with labor market changes but also, and more directly, by hazardous working conditions. An extensive review of studies published as of the late 1990s identified a clear preponderance of findings that precarious or contingent work is associated with deteriorations in health and safety protection (Quinlan et al. 2001a, b) – an especially important observation in view of the worldwide growth in the prevalence of such employment (International Labour Organization Socio-Economic Security Programme 2004). Mead’s prediction, made in the context of trade liberalization, that ‘[t]he First and Third worlds will not so much disappear as mingle’ (Mead 1992) was perhaps an exaggeration, but it does capture a key element of labor market dynamics in the so called borderless world.

Debt crises, structural adjustment, and the International Monetary Fund External debt has long been identified as a constraint on the ability of many developing countries to meet basic health-related needs. The etiology of ‘debt crises’ varies from country to country and over time (Strange 1998; Naylor 1987; Lever and Huhne 1985; Hanlon 2000; George 1988), but a stylized list of major causes includes: (a) the oil price shocks of 1973 and 1979–80, which had an especially severe impact on low income, oil-importing countries; (b) aggressive lending by banks seeking to invest deposits from oilexporting countries; (c) a rapid increase in real interest rates post-1979

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generated by the monetary policies of the US Federal Reserve (the ‘Volcker shock,’ after the then-Chair of the US Federal Reserve Board), meaning that debtor countries often had to roll over existing debt at much higher interest rates; (d) falling world prices for the primary commodities that are the key exports of many developing economies; and (e) capital flight, which are discussed briefly in the next section of this chapter. As a response to debt crises, ‘structural adjustment’ entered the development policy lexicon when the IMF and the World Bank – institutions in which decision making is dominated by the large industrialized economies (Woods 2006) – offered loans to facilitate the rescheduling of external debt. These were conditional on a relatively standard package of neoliberal macroeconomic policies including deregulation, privatization of (presumably inefficient) state-owned firms, reduction of domestic government spending, trade liberalization and the reorganization of production around export-oriented sectors (Woods 2006; Milward 2000; Babb 2005). Structural adjustment measures were ostensibly designed to create the conditions for sustained economic growth in countries where they were applied: short-term pain for long-term gain, in other words. By the mid-1980s, informed observers were critical of this expectation (Lever and Huhne 1985), and in retrospect it is clear that the measures were designed primarily to protect debtor countries’ ability to repay external creditors and thus to protect the shareholders of major banks, especially in the United States, against defaults that could threaten their survival (Bienefeld 2000). The destructive effects of the resulting economic dislocations and domestic austerity measures were described in 1987 by a UNICEF study of ten countries, using an analytical framework that linked changes in government policies (expenditures on education, food subsidies, health, water, sewage, housing and child care services) with selected economic determinants of health at the household level (food prices, household income, mothers’ time) and selected indicators of child welfare (Cornia et al. 1987). An extensive body of more recent research has similarly described the negative effects of structural adjustment policies in many countries in terms of increasing economic inequality and insecurity and leading to deterioration in health outcomes.1 Whatever else structural adjustment programs did, they did not solve the debt problems of many developing countries – a point tacitly accepted by the industrialized world in the late 1990s with the launch of the Heavily Indebted Poor Countries (HIPC) initiative, which provided partial debt cancellation for a limited number of countries. Although debt cancellation made possible increases in public spending on such basic needs as health and education in several recipient countries (Gupta et al. 2002), as of 2005 many HIPCs had seen only modest decreases in their debt service obligations, and three had actually seen increases (United Nations Department of Economic and Social Affairs 2005); this is partly because, for some countries, cancellation of debts owed to multilateral institutions simply maintained their ability

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to pay private creditors.2 In addition, the majority of the world’s poor live in countries that are not statistically desperate enough to qualify for debt cancellation despite high external debt burdens (Labonte and Schrecker 2004). Both limitations arise from the fact that a ‘sustainable’ debt load was defined, ‘balancing the need to include strategic G7 allies and the desire to help keep costs down’ (Martin 2004), with reference to a ratio of debt service to annual export revenues, based on what have often turned out to be optimistic projections of export earnings and commodity prices. The amount of debt relief on offer was expanded in 2005, as the initiative was renamed the Multilateral Debt Relief Initiative (MDRI), but the list of eligible countries has not been extended, nor has the criterion for debt sustainability changed (Hurley 2007). In every region of the developing world except sub-Saharan Africa, debt service payments have consistently exceeded development assistance receipts (Labonte and Schrecker 2007b), and in subSaharan Africa the fiscal situation of many governments is so tight that any drain on scarce finances represents a serious constraint. In 2005 the UN Millennium Project, established to assess the chances of achieving the MDGs and associated targets by 2015, echoed many earlier critiques in recommending that: ‘Debt sustainability’ should be redefined as ‘the level of debt consistent with achieving the Millennium Development Goals,’ arriving in 2015 without a new debt overhang. For many heavily indebted poor countries this will require 100 per cent debt cancellation. For many heavily indebted middle income countries this will require more debt relief than has been on offer. (UN Millennium Project 2005) A related issue, studiously ignored by the G8 and key multilateral institutions, involves the legitimacy of requiring payment of ‘odious debts’ incurred by corrupt and repressive regimes, often while rulers were looting national economies and public treasuries (Mandel 2006b; King et al. 2003). Although the terminology of structural adjustment is no longer in official use and the IMF is now less significant as a lender of last resort, the Fund retains a powerful influence in many developing countries. Private investors view IMF acceptance of macroeconomic policies as a seal of approval, and the IMF and the World Bank must sign off on a country’s policies as a condition for debt cancellation under the MDRI, and for some other forms of development assistance as well. A key institutional mechanism is the preparation of a national Poverty Reduction Strategy Paper (PRSP); as of September 2007 64 countries either had prepared PRSPs or were in the process of preparing them. It is difficult to be against poverty reduction, but the PRSP process appears to replicate some aspects of earlier macroeconomic conditionalities, again often with priority given to incorporating national economies into the global marketplace (Gore 2004; Cheru 2001; Cammack 2004). On the other hand, in 2006 one of the harshest critics of the PRSP

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process had muted his criticism somewhat, noting ‘[m]ost PRSPs do not include decisive measures to redistribute wealth and promote equality’ by way of such measures as land reform, but emphasizing as well the potential value of the process and the importance of domestic policy reforms (Cheru 2006). The contrast between basic needs and the priorities of the global marketplace is brought into especially sharp focus by the IMF’s practice of specifying public sector wage expenditure ceilings as part of the price of approval. Experience in several countries suggests that the effect is to prevent governments from hiring badly needed health personnel and teachers even when the needed funds are available in the form of development assistance, which the IMF regards as intrinsically unreliable. The IMF initially disputed these criticisms, but in 2007 both internal and external assessments confirmed that public sector wage bill ceilings were often recommended to governments; that IMF projections of future development assistance receipts were consistently low, leading to excessive caution with respect to future public expenditure; and that in 29 sub-Saharan countries, IMF strictures meant that just 27 cents of every incremental dollar in development assistance was budgeted for new programs, with the balance used for paying down domestic debt and accumulating foreign exchange reserves (Working Group on IMF Programs and Health Spending 2007; International Monetary Fund Independent Evaluation Office 2007). From the standpoint of textbook public finance, placing public health and education spending in the same category (‘fiscal expansion’) as roads, weapons or for that matter pyramids is understandable; from the perspective of concern with population health, the practice is highly questionable.

The rising power of the global ‘economic electorate’ In the global marketplace, conditionalities demanded by multilateral lenders are complemented by the ‘implicit conditionality’ (Griffith-Jones and Stallings 1995) created by the hypermobility of capital in global financial markets. Financial crises arising from rapid disinvestment can reduce the value of national currencies by 50 per cent or more, plunging millions into poverty and economic insecurity; historically, these effects have often been compounded by the austerity measures undertaken to reassure investors. On one estimate, financial crises cost the developing world an average of US$150 billion per year in lost GDP during the 1995–2002 period (Griffith-Jones and Gottschalk 2004). Employment (whether formal or informal) is the primary source of livelihood for the majority of people almost everywhere in the world, and experience in ten countries has been that in the aftermath of financial crises employment tends to recover much more slowly than GDP (van der Hoeven and Lübker 2006). Such crises exemplify what the former head of the IMF, writing in the aftermath of the Mexican peso crisis of 1994– 95, called the ‘swift, brutal and destabilizing’ consequences that ensue when

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policies are not ‘deemed basically sound’ by investors (Camdessus 1995). This blunt observation about the power of markets is notable for its author as much as for its content, which is now almost universally acknowledged. Somewhat less dramatically, investor concern about policies that might be adopted by the Workers’ Party in Brazil (in advance of the 2002 elections) or the African National Congress in South Africa (after democratization) reduced the value of the country’s currency by roughly 40 per cent in each case, arguably leading the governments in question at least temporarily to accept high unemployment and limited social expenditure rather than risk further depreciation of their currencies (Koelble and Lipuma 2006; Evans 2005). In South Africa, the result was ‘dismal development and excellent macroeconomic outcomes’ (Streak 2004), with the former including negative employment growth in every year between 1996 and 2000 and an official unemployment rate of over 30 per cent; unofficial unemployment rates, using a broader measure, were and are considerably higher (Kingdon and Knight 2005). Writing about Latin America as a whole, economist John Williamson argues that ‘levying heavier taxes on the rich so as to increase social spending that benefits disproportionately the poor’ is conceptually attractive, but ‘it would not be practical to push this very far, because too many of the Latin rich have the option of placing too many of their assets in Miami’ (Williamson 2004). Williamson’s observation underscores the point that the actors whose portfolio choices collectively constitute the wisdom of the markets include not only investment managers in New York, London and Geneva, but also wealthy individuals in low- and middle-income countries seeking lower risks and freedom from ‘social control’ such as taxation and regulation (Beja 2006). The magnitudes in question are substantial. On one estimate, the accumulated value of flight capital from 25 African countries between 1970 and 1996, plus imputed interest earnings, was considerably higher than the entire value of the combined external debt of those 25 countries in 1996 (James and Ndikumana 2001). Similarly, while Argentina was undergoing an economic collapse that saw the peso lose more than 60 per cent of its value against the US dollar and its GDP decline by 11 per cent in 2002, it was estimated that the value of assets held abroad by Argentine residents equaled the total value of the country’s foreign debt (Centro de Estudios Legales y Sociales 2003). Apparently, this will be true even after taking into account the effects of a settlement that was negotiated between the Argentine government and its creditors on terms relatively favorable to Argentina (Anonymous 2005). These cases bear out the claim of an economic historian two decades ago that ‘[t]here would be no “debt crisis” without large scale capital flight’ (Naylor 1987), and underscore a point made by Sassen: globalization is resulting in the rise of ‘a sort of global, cross-border economic electorate’ (Sassen 1996). Wherever in the world the members of this electorate live, their property rights in financial assets enable them to superimpose their preferences on

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those expressed by domestic polities, even in countries with well-functioning democratic institutions.

Thinking three-dimensionally about health Reducing health disparities by way of their social determinants is inextricably linked with social protection policy, economic management and development strategy. This requires expertise beyond that of many professionals normally concerned with health, as well as aptitude and opportunities for transdisciplinary collaboration; it may also involve direct challenges to the values of the global marketplace. Some researchers therefore look elsewhere for solutions. The authors of a 2008 Lancet series on maternal and child undernutrition acknowledged the importance of poverty and food insecurity, yet ‘excluded [from their evaluation] several important interventions that might have broad and long-term benefits, such as education, untargeted economic strategies or those for poverty alleviation, agricultural modifications, farming subsidies, structural adjustments, social and political changes, and land reform’ (Bhutta et al. 2008). A more comprehensive response is needed to the challenges of global (ill-)health. Normatively, this response can be framed in the language of health equity: ‘the absence of unfair and avoidable or remediable differences in health among population groups defined socially, economically, demographically or geographically’ (Solar and Irwin 2007). Health equity is a far-reaching and potentially subversive concept since if one defines what is avoidable and remediable with reference to the resources available to meet basic health-related needs globally, rather than just within a particular country’s borders, most health disparities are also health inequities. Although the point cannot be explored further here, the multiple interconnections between rich and poor across national borders that characterize contemporary globalization provide the basis for compelling philosophical arguments in support of such a global perspective (Ruger 2006; Pogge 2005, 2002; Moellendorf 2002). It is increasingly acknowledged that ‘[g]lobal actors and institutions. . . are obligated to remedy global inequalities that exist in affluence, power, and social, economic and political opportunities’ (Ruger 2006). Much can and must be done on a local, regional and national scale. However, a need also exists for coordinated action on an international scale by national governments and multilateral institutions: thinking locally and acting globally, to turn the familiar aphorism around. What organizing principles and policy instruments are appropriate? Borrowing terminology from the Finnish social policy research unit STAKES (GASPP team 2005), the Globalization Knowledge Network3 of WHO’s Commission on Social Determinants of Health argued for the redistribution (of resources both within and among countries), regulation, and ‘enforceable social rights’ as entry points for three-dimensional thinking about health and

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its social determinants (Labonte et al. 2007). Here we offer only selected illustrations of the first and third of these ‘three-Rs.’ The need for redistribution is clear from the discussion of health systems early in this chapter. Even if low-income country governments were to increase their public spending on health care to 15 per cent of their central government budgets, and many are a long way from doing this,4 providing a basic minimum standard of health services to all their citizens would require approximately US$30 billion in annual development assistance for health (Ooms et al. 2006), as against the current figure of US$12–14 billion in development assistance for health provided to all countries for all purposes. To reiterate, however: a basic insight of the SDH approach is that healthcare is only part of the equation, and that poverty (however defined) and economic insecurity must be addressed in order to achieve widespread improvements in population health and reductions in health disparities. Even to meet the MDGs, which are ambitious against the background of recent achievements yet modest in the global scheme of things,5 the best available calculations indicate the need for an approximate overall doubling of current development assistance levels sustained over many years (UN Millennium Project 2005; Commission for Africa 2005). Yet the overall value of development assistance dropped slightly in 2006 relative to 2005, a year in which development assistance figures were inflated by one-off cancellations of debts owed by oil-rich Iraq and Nigeria (Organization for Economic Co-operation and Development 2007), and there is limited evidence that the donor community is willing to make the multiyear commitments to increased aid that are necessary for effective planning by recipient countries and to provide a time frame over which accountability for results can meaningfully be established. Although we focus on development assistance here, it cannot be emphasized too strongly that it is only one essential element of a broader agenda of global redistribution incorporating (for instance) trade policy (Collier 2006) and debt cancellation (Mandel 2006a). As for rights, it has been argued that ‘[t]he international human rights framework is the appropriate conceptual structure within which to advance towards health equity through action on SDH’ (Solar and Irwin 2007). The need for institutional innovation is illustrated in the context of trade policy, not discussed here because extensive treatments are available elsewhere (Blouin et al. 2008), by the dramatic contrast between formal mechanisms for dispute resolution that now exist under the WTO regime and the lack of any comparable supranational mechanism in the area of human rights. Proposals for institutional solutions are not lacking. For example, the UN Special Rapporteur on the Right to Health (under the International Covenant on Economic, Social and Cultural Rights) has identified potential conflicts with trade policy and recommended ‘that urgent attention be given to the development of a methodology for right to health impact assessments in the context of trade’ (Hunt 2004). Research on access to essential medicines

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shows that domestic legislative entrenchment of health-related rights, ideally giving them constitutional status, is important for implementation (Hogerzeil et al. 2006; Hogerzeil 2006); in the context of water supply, human rights have been identified as a potentially important policy counterweight to commodification and the adoption of commercial models of service provision (Mehta 2005, 2003). It has been argued that ‘it is a violation of human rights if governments are forced to cut expenditure required to meet basic human needs (the rights enshrined in the UN Charter and elsewhere, for basic education, health, water, shelter and food) in order to pay debt service,’ and that defining debt sustainability on this basis implies a requirement for debt cancellation an order of magnitude greater than offered under MDRI (Mandel 2006a). Apart from legislative entrenchment, the human rights rubric is valuable as perhaps the most internally consistent and widely accepted basis for challenges to the values of the global marketplace, exemplified by the IMF’s approach to public expenditure on health and education, in which health and the prerequisites for health are commodities or objects of expenditure like any others. For example, taking the right to health seriously requires redistributive policies, yet Layna Mosley, one of the most accomplished investigators of how global financial markets actually work (Mosley 2003), points out that ‘those societies most in need of egalitarian redistribution may have, in terms of external financial market pressures, the most difficulty achieving it’ (Mosley 2006). Rights and redistribution must therefore be supported by reforms at the international level to ensure that the necessary ‘policy space’ is available to those societies, ensuring (for instance) that genuine efforts to improve health through redistributive policies are constrained neither by financial markets nor by the policies of multilateral institutions like the IMF.

Future uncertain All this presupposes and requires commitment to both domestic and international policies that are informed and driven by ethical concerns (Labonte and Schrecker 2007a) rather than simply by the interests of the most powerful actors within a particular nation-state – or, as stated by the Chair of the Commission on Social Determinants of Health, commitment to ‘a vision of the world where people matter and social justice is paramount’ (Marmot 2005). This observation has important methodological implications. For example, critical research on the health impacts of structural adjustment programs can be dismissed with the observation that if the chosen counterfactual is a continuation of business as usual, which would in many cases have involved (continued) hyperinflation and complete isolation from international financial markets, structural adjustment may appear the least destructive option. On the other hand, if the comparison is with an alternative set of policy

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options that would have given priority to meeting basic needs (‘adjustment with a human face,’ in the words of the 1987 UNICEF study), with the embrace of those priorities by such institutions as the World Bank and IMF, or with institutionalization of the human right to health in a way that would give rise to effective claims on resources, then the verdict is likely to be quite different. It is easy to dismiss such hypotheticals as utopian, but difficult in their absence to envision a livable future for those not among globalization’s winners. Recognition is spreading of the need to overhaul global institutions in a way that responds to the destructive consequences of globalization. Thus, Cheru and Bradford present a program of coordinated actions in support of achieving the MDGs, in which industrialized countries would adopt ‘a holistic view of all their actions toward developing countries that goes beyond aid to trade, investment, capital flows debt, environment, health standards, agriculture and macropolicy management’ (Cheru and Bradford 2005). This prescription was developed as part of the work of the Helsinki Process on Globalization and Democracy, a multinational effort jointly hosted by the governments of Finland and Tanzania. Another illustration is current Norwegian development policy, which (for instance) involves opposing conditionalities that promote privatization, supporting only trade policies that will not prevent poorer countries from developing into ‘welfare societies’ similar to Norway’s own, and leading the search for ‘new global financing sources that can contribute to a redistribution of global wealth and the strengthening of the UN institutions’ (Government of Norway 2006). Norway is also the only country to withhold its 2007 contribution to the World Bank fund for International Development Assistance, arguing that the Bank (and the IMF) have not shown that their continuing demands for macroeconomic conditionalities are necessary, or avoid worsening conditions for the poor (Bretton Woods Project 2008). The countries involved in these initiatives are conspicuously outside today’s centers of global influence, as exemplified by the G8. A futureoriented perspective on global health requires understanding how the centers of global influence may themselves be shifting with (for instance) the rise of India, China and such emerging economies as Brazil. These developments may foster regional alliances in support of development. Conversely, they may render the global economic electorate described by Sassen more diverse in its national origins, and more transnational in its orientation, while less committed to projects of national development unless they generate returns on private investment that are attractive in the global frame of reference. Regardless, urgent needs and opportunities exist to build multinational, transdisciplinary research collaborations and communities of practice. In the academic and professional sphere, clinical disciplines and population health must be linked with fields such as international relations, development policy, political economy, health ethics and human rights law. In parallel, a

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need exists for WHO to play a more active leadership role on issues related to SDH, rooted in stronger working relationships among WHO, civil society organizations concerned with health advocacy, and a variety of agencies within the UN system concerned with social and economic policy and human rights (Labonte et al. 2007). These collaborations in themselves will not solve the problems identified in this chapter, but they constitute necessary global infrastructure for doing so.

Notes 1. For a methodologically exemplary study of structural adjustment impacts in a single country, difficult to repeat because of the resource and data requirements, see the 1998 report by Bijlmakers et al. (Bijlmakers et al. 1998). An extensive literature presents important country- or region-specific syntheses (Structural Adjustment Participatory Review International Network 2002; Sparr 2000; Schoepf et al. 2000; Kim et al. 2000; Alarcón-González and McKinley 1999). A relatively recent global overview is provided by Babb (Babb 2005). 2. For example, between 2002 and 2005 almost two-thirds of the revenue freed up by debt relief for Zambia went to pay other creditors (International Monetary Fund and World Bank 2005). 3. To which we both contributed, TS as Hub coordinator and RL as chair of the Network. 4. Most sub-Saharan African governments made a commitment to this objective in the 2001 Abuja Declaration. WHO figures show that, as of 2005, only three had lived up to it; ironically, oil-rich Nigeria was one of the lowest spenders on health (Working Group on IMF Programs and Health Spending 2007). 5. The MDG poverty reduction target involves reducing by half between 1990 and 2015 the proportion of the world’s people living below the World Bank’s contentious $1/day poverty line. Pogge (2004) has commented on the modesty of this target when viewed against a background of expanding global affluence. Another MDG target involves improving the lives of 100 million slum dwellers per year by 2020, yet it is estimated that if present trends continue, 1.4 billion people worldwide will be living in slums in that year (UN Millennium Project Task Force on Improving the Lives of Slum Dwellers 2005).

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72 Part I: The Global Health Arena Anonymous (2008) ‘Personal Communication, David Sanders to Ronald Labonté (February 2008)’. Asian Development Bank Economics and Research Department (2007) Development Indicators and Policy Research Division, Key Indicators 2007: Inequality in Asia (Manila: Asian Development Bank). Babb, S. (2005) ‘The Social Consequences of Structural Adjustment: Recent Evidence and Current Debates’, Annual Review of Sociology, 31: 199–222. Beja, E.L. (2006) ‘Was Capital Fleeing Southeast Asia? Estimates from Indonesia, Malaysia, the Philippines, and Thailand’, Asia Pacific Business Review, 12(3): 261–83. Bhutta, Z.A. et al. (2008) ‘What Works: Interventions for Maternal and Child Undernutrition and Survival’, The Lancet, 371(9610): 417–40. Bienefeld, M. (2000) ‘Structural Adjustment: Debt Collection Device or Development Policy?’, Review, 23: 533–82. Bijlmakers, L.A. et al. (1998) Socioeconomic Stress, Health and Child Nutritional Status in Zimbabwe at a Time of Economic Structural Adjustment: A Three-year Longitudinal Study, Research Report 105 (Uppsala: Nordic Africa Institute). Birdsall, N. ‘The World is Not Flat: Inequality and Injustice in our Global Economy, WIDER Annual Lecture 2005’, available at http://www.wider.unu. edu/publications/annual- lectures/en_GB/AL9/_files/78121127186268214/default/ annual-lecture-2005.pdf. Blouin, C. et al. (eds) (2008) Trade and Health: Seeking Common Ground (Montreal: McGill-Queen’s University Press). Bretton Woods Project (2008) ‘Donor Contributions to IDA Up Record Amount: Norway, Civil Society Not Satisfied’, Bretton Woods Update, 59. Camdessus, M. ‘The IMF and the Challenges of Globalization – The Fund’s Evolving Approach to its Constant Mission: The Case of Mexico (address at Zurich Economics Society)’, Washington, DC: International Monetary Fund, available at http://www.imf.org/external/np/sec/mds/1995/mds9517.htm. Cammack, P. (2004) ‘What the World Bank Means by Poverty Reduction and Why it Matters’, New Political Economy, 9: 189–211. Centro De Estudios Legales Y Sociales (2003) ‘Argentina: In the Hands of the Oligopoly of Foreign Capital’, in The Poor and the Market: Social Watch Report 2003 edited by R. Bissio et al. (Montevideo: Instituto del Tercer Mundo), pp. 82–3. Chen, L.C. et al. (2004) ‘Human Resources for Health: Overcoming the Crisis’, The Lancet, 364(9449): 1984–90. Chen, S. and M. Ravallion (2004) ‘How Have the World’s Poorest Fared since the Early 1980s?’, World Bank Research Observer, 19(2): 141–69. Cheru, F. (2001) Economic, Social and Cultural Rights: The Highly Indebted Poor Countries (HIPC) Initiative: A human rights assessment of the Poverty Reduction Strategy Papers (PRSP), E/CN.4/2001/56 (Geneva: United Nations Economic and Social Council). Cheru, F. (2006) ‘Building and Supporting PRSPs in Africa: What Has Worked Well So Far? What Needs Changing?’, Third World Quarterly, 27: 355–76. Cheru, F and C. I. Bradford, ‘The Planet at Risk: Mobilizing Resources for Global Human Security’, in Helsinki Process Papers on Global Economic Agenda, edited by Helsinki Process Secretariat (Helsinki: Foreign Ministry of Finland, 2005), pp. 9–61. Chopra, M. and I. Darnton-Hill (2004) ‘Tobacco and Obesity Epidemics: Not So Different After All?’, British Medical Journal, 328(7455): 1558–60. Collier, P. (2006) ‘Why the WTO is Deadlocked: And What Can Be Done About It’, The World Economy, 29: 1423–49.

Ted Schrecker and Ronald Labonté 73 Commission for Africa (2005) Our Common Interest: Report of the Commission for Africa (London: Commission for Africa). Cornia, G.A. et al. (eds) (1987) Adjustment with a Human Face, vol.1: Protecting the Vulnerable and Promoting Growth (Oxford: Clarendon Press). Cornia, G.A. et al. (2008) ‘Globalisation and Health: Pathway, of Transmission and evidence of Impact’, Globalization Knowledge Research Papers (Ottawa: Institution of Population Health, University of Ottawa). Available at http://www.globalhealth equity.ca/electronic%20library/Globalisation%20and%20Health%20pathway%20 of%20Transmission%20and%20evidence%20of%20Impact.pdf. Cox, R.W. (1999) ‘Civil Society at the Turn of the Millennium: Prospects for an Alternative World Order’, Review of International Studies, 25: 3–28. Cypher, J.M. (2001) ‘Developing Disarticulation Within the Mexican Economy’, Latin American Perspectives, 28(3): 1–37. Cypher, J.M. (2004) ‘Development Diverted: Socioeconomic Characteristics and Impacts of Mature Maquilization’, in The Social Costs of Industrial Growth in Northern Mexico, edited by K. Kopinak (La Jolla, CA: Centre for US-Mexican Studies, University of California – San Diego), pp. 343–82. De Ferranti, D. et al. (2004) Inequality in Latin America: Breaking with History? (Washington, DC: World Bank). Dicken, P. (2007) Global Shift: Reshaping the Global Economic Map in the 21st Century 5th edn (New York: Guilford Press). Diderichsen, F. et al. (2001) ‘The Social Basis of Disparities in Health’, in Challenging Inequities in Health. From Ethics to Action edited by T. Evans et al. (Oxford: Oxford University Press). Eide, A. (2005) ‘The Importance of Economic and Social Rights in the Age of Economic Globalisation’, in Food and Human Rights in Development, Volume I: Legal and Institutional Dimensions and Selected Topics, edited by W.B. Eide and U. Kracht (Antwerp: Intersentia), pp. 3–40. Evans, P. (2005) ‘Neoliberalism as a Political Opportunity: Constraint and Innovation in Contemporary Development Strategy’, in Putting Development First: The Importance of Policy Space in the WTO and IFIs, edited by K. Gallagher (London: Zed Books), pp. 195–215. Evans, R.G.E. and G. L. Stoddart (1990) ‘Producing Health, Consuming Health Care’, Social Science & Medicine, 31(12): 1347–63. Feachem, R.G.A. (2001) ‘Globalisation is Good for Your Health, Mostly’, British Medical Journal, 323: 504–6. Ferguson, N. and M. Schularick (2007) ‘“Chimerica” and the Global Asset Market Boom’, International Finance, 10(3): 215–39. Fröbel, F. et al. (1980) The New International Division of Labour (Cambridge: Cambridge University Press) [original German pub. 1977]. GASPP Team (2005) ‘Copenhagen Social Summit Ten Years On: The Need for Effective Social Policies Nationally, Regionally and Globally’, GASPP Globalism and Social Policy Programme Policy Brief, 6: 1–8. George, S. (1988) A Fate Worse than Debt (London: Penguin). Gereffi, G. (1999) ‘International Trade and Industrial Upgrading in the Apparel Commodity Chain’, Journal of International Economics, 48: 37–70. Gereffi, G. and M. Korzeniewicz (eds) (1994) Commodity Chains and Global Capitalism (New York: Praeger). Gore, C. (2004) ‘MDGs and PRSPs: Are Poor Countries Enmeshed in a Global–Local Double Bind?’, Global Social Policy, 4: 277–83.

74 Part I: The Global Health Arena Government of Norway (2006) The Soria Moria Declaration on International Policy, Chapter 2: International Policy (Oslo: Office of the Prime Minister). Griffith-Jones, S. and R. Gottschalk (2004) Costs of Currency Crises and Benefits of International Financial Reform (New York: Office of Development Studies, United Nations Development Programme). Griffith-Jones, S. and B. Stallings (1995) ‘New Global Financial Trends: Implications for Development’, in Global Change, Regional Response: The New International Context of Development, edited by B. Stallings (Cambridge: Cambridge University Press), pp. 143–73. Gupta, S. et al. (2002) ‘Debt Relief and Public Health Spending in Heavily Indebted Poor Countries’, Bulletin of the World Health Organization, 80: 151–7. Hanlon, J. (2000) ‘How Much Debt Must Be Cancelled?’, Journal of International Development, 12: 877–901. Harvey, D. (2005) A Brief History of Neoliberalism (Oxford: Oxford University Press). Hawkes, C. (2005) ‘The Role of Foreign Direct Investment in the Nutrition Transition’, Public Health Nutrition, 8(4): 357–65. Hawkes, C. (2006) ‘Uneven Dietary Development: Linking the Policies and Processes of Globalization with the Nutrition Transition, Obesity and Diet-related Chronic Diseases’, Globalization and Health, 2(1): 4. Hfx Foreign Exchange ‘Daily Global Foreign Exchange Turnover Rises to USD3.2 Trillion’, available at http://www.hifx.co.uk/marketwatch/market_news/headlines/uk_ Daily_Global_Foreign_Exchange_turnover_rises_to_USD_3,-d-,2%20trillion.aspx. Hogerzeil, H.V. (2006) ‘Essential Medicines and Human Rights: What Can They Learn from Each Other?’, Bulletin of the World Health Organization, 86: 371–5. Hogerzeil, H.V. et al. (2006) ‘Is Access to Essential Medicines as Part of the Fulfilment of the Right to Health Enforceable Through the Courts?’, The Lancet, 368: 305–11. Hualde, A. (2004) ‘Skills Segmentation and Social Polarization in Tijuana’s Maquiladoras’, in The Social Costs of Industrial Growth in Northern Mexico, edited by K. Kopinak (La Jolla, CA: Centre for US–Mexican Studies, University of California – San Diego). Hunt, P. (2004) Economic, Social and Cultural Rights: The Right of Everyone to the Enjoyment of the Highest Attainable Standard of Physical and Mental Health – Addendum: Mission to the World Trade Organization, E/CN.4/2004/49/Add.1 (Geneva: United Nations Economic and Social Council Commission on Human Rights). Hurley, G. (2007) Multilateral Debt: One Step Forward, How Many Back? (Brussels: European Network on Debt & Development (EURODAD)). Hutton, G. and J. Bartram (2008) ‘Global Costs of Attaining the Millennium Development Goal for Water Supply and Sanitation’, Bulletin of the World Health Organization, 86(1): 13–19. International Labour Organization Socio-Economic Security Programme (2004) Economic Security for a Better World (Geneva: International Labour Organization). International Monetary Fund and World Bank (2005) Zambia: Enhanced Initiative for Heavily Indebted Poor Countries – Completion Point Document, Country Report No 05/137 (Washington, DC: International Monetary Fund). International Monetary Fund Independent Evaluation Office (2007) The IMF and Aid to Sub Saharan Africa (Washington, DC: International Monetary Fund). James, B. and L. Ndikumana (2001) ‘Is Africa a Net Creditor? New Estimates of Capital Flight from Severely Indebted Sub-Saharan African Countries, 1970–96’, Journal of Development Studies, 38: 27–56. Jenkins, R. (2004) ‘Globalization, Production, Employment and Poverty: Debates and Evidence’, Journal of International Development, 16(1): 1–12.

Ted Schrecker and Ronald Labonté 75 Jenkins, R. (2005) ‘Globalization, Production and Poverty’ (WIDER Research Paper 2005/40). Kabeer, N. and S. Mahmud (2004) ‘Globalization, Gender and Poverty: Bangladeshi Women Workers in Export and Local Markets’, Journal of International Development, 16(1): 93–109. Kawachi, I. and S. Wamala (2007) ‘Poverty and Inequality in a Globalizing World’, in Globalisation and Health, edited by I. Kawachi and S. Wamala (Oxford: Oxford University Press), pp. 122–37. Kim, J.Y. et al. (2000) ‘Sickness Amidst Recovery: Public Debt and Private Suffering in Peru’, in Dying for Growth: Global inequality and the health of the poor edited by J. Y. Kim et al. (Monroe, Maine: Common Courage Press), pp. 127–54. King, J. et al. (2003) ‘Advancing the Odious Debt Doctrine: CISDL Working Paper’ (Montreal: Centre for International Sustainable Development Law, McGill University). Kingdon, G. and J. Knight ‘Unemployment in South Africa, 1995–2003: Causes, Problems and Policies’, Oxford: Centre for the Study of African Economies, University of Oxford, available at http://www.csae.ox.ac.uk/conferences/2006-EOIRPI/papers/csae/Kingdon.pdf. Koelble, T. and E. Lipuma (2006) ‘The Effects of Circulatory Capitalism on Democratization: Observations from South Africa and Brazil’, Democratization, 13: 605–31. Kopinak, K. (2002) ‘Environmental Implications of New Mexican Industrial Investment: The Rise of Asian Origin Maquiladoras As Generators of Hazardous Waste’, Asian Journal of Latin American Studies, 15(1): 91–120. Kopinak, K. and M.D.R. Barajas (2002) ‘Too Close for Comfort? The Proximity of Industrial Hazardous Wastes to Local Populations in Tijuana, Baja California’, The Journal of Environment Development, 11(3): 215–46. Krugman, P. (1995) ‘Growing World Trade: Causes and Consequences’, Brookings Papers on Economic Activity, 1995(1): 327–77. Labonte, R. et al. (2007) Towards Health-Equitable Globalization: Rights, Regulation and Redistribution, Globalization Knowledge Network Final Report to the Commission on Social Determinants of Health (Ottawa: Institute of Population Health, University of Ottawa). Labonte, R. and T. Schrecker (2004) ‘Committed to Health for All? How the G7/G8 rate’, Social Science & Medicine, 59(8): 1661–76. Labonte, R. and T. Schrecker (2007a) ‘Foreign Policy Matters: a Normative View of the G8 and Population Health’, Bulletin of the World Health Organization, 85: 185–91. Labonte, R. and T. Schrecker (2007b) ‘Globalization and Social Determinants of Health: The Role of the Global Marketplace (Part 2 of 3)’, Globalization and Health, 3(1): 6. Lever, H. and C. Huhne (1985) Debt and Danger: The World Financial Crisis (London: Penguin). Luke, N. (2005) ‘Confronting the “Sugar Daddy” Stereotype: Age and Economic Asymmetries and Risky Sexual Behavior in Urban Kenya’, International Family Planning Perspectives, 31(1): 6–14. Mandel, S. (2006a) Debt Relief as if People Mattered: A Rights-based Approach to Debt Sustainability (London: New Economics Foundation). Mandel, S. (2006b) Odious Lending: Debt Relief as if Morals Mattered (London: New Economics Foundation). Marmot, M. (2005) ‘Social Determinants of Health Inequalities’, The Lancet, 365(9464): 1099–104. Marmot, M. and R. Wilkinson (eds) (2006) Social Determinants of Health, 2nd edn (Oxford: Oxford University Press).

76 Part I: The Global Health Arena Martin, M. (2004) ‘Assessing the HIPC Initiative: The Key Policy Debates’, in HIPC Debt Relief: Myths and Realities, edited by J. Teunissen and A. Akkerman (The Hague: Forum on Debt and Development (FONDAD)), pp. 11–47. Mead, W.R. (1992) ‘Bushism, Found: A Second-term Agenda Hidden in Trade Agreements’, Harper’s, September: 37–45. Mehta, L. (2003) ‘Problems of Publicness and Access Rights: Perspectives from the Water Domain’, in Providing Global Public Goods: Managing Globalization, edited by Inge Kaul et al. (New York: Oxford University Press), pp. 556–76. Mehta, L. (2005) ‘Unpacking Rights and Wrongs: Do Human Rights Make a Difference? The Case of Water Rights in India and South Africa’, IDS Working Paper 260 (Brighton: Institute of Development Studies). Milberg, W. (2004) ‘The Changing Structure of Trade Linked to Global Production Systems: What Are the Policy Implications?’, International Labour Review, 143: 45–90. Milward, B. (2000) ‘What is Structural Adjustment?’, in Structural Adjustment: Theory, Practice and Impacts, edited by G. Mohan, et al. (London: Routledge). Mishra, V. et al. (2007) ‘A Study of the Association of HIV Infection with Wealth in Sub-Saharan Africa’, DHS Working Papers No. 31 (Calverton: Macro International). Moellendorf, D. (2002) Cosmopolitan Justice (Boulder: Westview). Mosley, L. (2003) Global Capital and National Governments (Cambridge: Cambridge University Press). Mosley, L. (2006) ‘Constraints, Opportunities, and Information: Financial Market – Government Relations around the World’, in Globalization and Egalitarian Redistribution, edited by P. Bardhan, et al. (New York and Princeton: Russell Sage Foundation and Princeton University Press), pp. 87–119. Nadvi, K. (2004) ‘Globalization and Poverty: How can Global Value Chain Research Inform the Policy Debate?’, IDS Bulletin, 35(1): 20–30. Naylor, T.R. (1987) Hot Money: Peekaboo Finance and the Politics of Debt (Toronto: McClelland & Stewart). Nickell, S. and B. Bell (1995) ‘The Collapse in Demand for the Unskilled and Unemployment Across the OECD’, Oxford Review of Economic Policy, 11(1): 40–62. Ooms, G. et al. (2006) ‘Do We Need a World Health Insurance to Realise the Right to Health?’, PLoS Medicine, 3(12): e530. Organization for Economic Co-operation and Development (2007) ‘Development Aid from OECD Countries Fell 5.1% in 2006’, available at http://www.oecd.org/document/ 17/0,2340,en_2649_201185_38341265_1_1_1_1,00.html. Oyefara, J.L. (2007) ‘Food Insecurity, HIV/AIDS Pandemic and Sexual Behaviour of Female Commercial Sex Workers in Lagos Metropolis, Nigeria’, Journal of Social Aspects of HIV/AIDS, 4: 626–35. Paes De Barros, R. et al. (2002) Meeting the Millennium Poverty Reduction Targets in Latin America and the Caribbean (Santiago: United Nations Economic Commission for Latin America and the Caribbean). Paluzzi, J.E. and P.E. Farmer (2005) ‘The Wrong Question’, Development, 48: 12–18. Pogge, T. (2002) World Poverty and Human Rights: Cosmopolitan Responsibilities and Reforms (Cambridge: Polity Press). Pogge, T. (2005) ‘The First United Nations Millennium Development Goal: a Cause for Celebration?’, Journal of Human Development, 5: 377–97. Pogge, T. (2005) ‘World Poverty and Human Rights’, Ethics and International Affairs, 19(1): 1–7.

Ted Schrecker and Ronald Labonté 77 Popkin, B. (2006) ‘Global Nutrition Dynamics: the World is Shifting Rapidly Toward a Diet Linked with Noncommunicable Diseases’, American Journal of Clinical Nutrition, 84: 289–98. Quinlan, M. et al. (2001a) ‘The Global Expansion of Precarious Employment, Work Disorganization, and Consequences for Occupational Health: A Review of Recent Research’, International Journal of Health Services, 31(2): 335–414. Quinlan, M. et al. (2001b) ‘The Global Expansion of Precarious Employment, Work Disorganization, and Consequences for Occupational Health: Placing the Debate in a Comparative Historical Context’, International Journal of Health Services, 31(3): 507–36. Rayner, G. et al. (2006) ‘Trade Liberalization and the Diet Transition: a Public Health Response’, Health Promotion International, 21, no. suppl. 1: 67–74. Rodrik, D. ‘How to Save Globalization from its Cheerleaders’, Cambridge, MA: John F. Kennedy School of Government, Harvard University, available at http://ksghome.harvard.edu/∼drodrik/Saving%20globalization.pdf. Ruger, J.P. (2006) ‘Ethics and Governance of Global Health Inequalities’, Journal of Epidemiology and Community Health, 60(11): 998–1002. Sassen, S. (1996) Losing Control? Sovereignty in an Age of Globalization (New York: Columbia University Press). Schoepf, B.G. (2001) ‘AIDS in Africa: Structure, Agency, and Risk’, in HIV & AIDS in Africa: Beyond Epidemiology, edited by E. Kalipeni, et al. (Oxford: Blackwell, 2004), pp. 121–32. Schoepf, B.G. et al. (2000) ‘Theoretical Therapies, Remote Remedies: SAPs and the Political Ecology of Poverty and Health in Africa’, in Dying for Growth: Global Inequality and the Health of the Poor, edited by J.Y. Kim et al. (Monroe, ME: Common Courage Press), pp. 91–126. Scott Frey, R. (2003) ‘The Transfer of Core-based Hazardous Production Processes to the Export Processing Zones of the Periphery: the Maquiladora Centers of Northern Mexico’, Journal of World-Systems Research, 9: 317–54. Smith, D.J. (2000) ‘“These Girls Today Na War-O”: Premarital Sexuality and Modern Identity in Southeastern Nigeria’, Africa Today, 47(3/4): 99–120. Solar, O. and A. Irwin (2007) A Conceptual Framework for Action on the Social Determinants of Health (Geneva: Commission on Social Determinants of Health, World Health Organization). Sparr, P. (ed.) (2000) Mortgaging Women’s Lives: Feminist Critiques of Structural Adjustment (London: Zed Books). Ståhl, T. et al. (eds) (2006) Health in All Policies: Prospects and Potentials (Helsinki: Ministry of Social Affairs and Health). Stillwaggon, E. (2006) AIDS and the Ecology of Poverty (Oxford: Oxford University Press). Stoebenau, K. (2006) ‘From Those Who “Have to Carry Men” to Those Who “Look to Marry Men”: The Social Organization of Women’s Sex Work in Antanarivo, Madagascar’ (PhD dissertation: Johns Hopkins University School of Public Health). Strange, S. (1998) ‘The New World of Debt’, New Left Review, (230): 91–114. Streak, J.C. (2004) ‘The Gear Legacy: Did Gear Fail or Move South Africa Forward in Development?’, Development Southern Africa, 21: 271–88. Structural Adjustment Participatory Review International Network (2002) The Policy Roots of Economic Crisis and Poverty: A Multi-Country Participatory Assessment of Structural Adjustment (Washington, DC: Structural Participatory Review International Network (SAPRIN)). Tawfik, L. and S. Cotts Watkins (2007) ‘Sex in Geneva, Sex in Lilongwe, and Sex in Balaka’, Social Science and Medicine, 64: 1090–101.

78 Part I: The Global Health Arena UN Millennium Project (2005) Investing in Development: A Practical Plan to Achieve the Millennium Development Goals (London: Earthscan). UN Millennium Project Task Force on Improving the Lives of Slum Dwellers (2005) A Home in the City (London: Earthscan). UNAIDS (2007) Towards Universal Access: Scaling up priority HIV/AIDS interventions (Progress Report) (Geneva: World Health Organization). United Nations Conference on Trade and Development (2007) ‘Foreign Direct Investment Surged Again in 2006’, UNCTAD Investment Brief, 1: 1–2. United Nations Country Team Viet Nam (2003) Health Care Financing for Viet Nam (Discussion Paper No. 2) (Ha Noi: United Nations Viet Nam). United Nations Department of Economic and Social Affairs (2005) World Economic and Social Survey 2005: Financing for Development, ST/ESA/298 (New York: United Nations). United Nations Development Programme (2006) Human Development Report 2006: Beyond Scarcity – Power, Poverty and the Global Water Crisis (New York: Palgrave Macmillan). United Nations Economic Commission for Latin America and the Caribbean (2000) Social Panorama of Latin America 1999–2000 (Santiago: ECLAC). Van Der Hoeven, R. and M. Lübker (2006) ‘Financial Openness and Employment: A Challenge for International and National Institutions (Global Development Network 2006 Meeting)’, Geneva: International Policy Group, International Labour Office, 2006, available at http://ctool.gdnet.org/conf_docs/Hoeven_Paper_Lunch% 20Time%20Session_ILO.pdf. Wakabi, W. (2008) ‘Low ART Adherence in Africa’, The Lancet Infectious Diseases, 8: 94. Williamson, J. ‘The Washington Consensus as Policy Prescription for Development (World Bank Practitioners for Development Lecture)’, Washington, DC: Institute for International Economics, available at http://www.iie.com/publications/papers/ williamson0204.pdf. Wojcicki, J.M. (2002) ‘“She Drank His Money”: Survival Sex and the Problem of Violence in Taverns in Gauteng Province, South Africa’, Medical Anthropology Quarterly, 16(3): 267–93. Wojcicki, J.M. and J. Malala (2001) ‘Condom Use, Power and HIV/AIDS Risk: Sexworkers Bargain for Survival in Hillbrow/Joubert Park/Berea, Johannesburg’, Social Science and Medicine, 53: 99–121. Woodall, P. ‘The New Titans: a Survey of the World Economy’, The Economist, September 16. Woods, N. (2006) The Globalizers: The IMF, the World Bank, and Their Borrowers (Ithaca, NY: Cornell University Press). Woodward, D. and A. Simms (2006) Growth is Failing the Poor: The Unbalanced Distribution of the Benefits and Costs of Global Economic Growth, ST/ESA/2006/DWP/20 (New York: United Nations Department of Economic and Social Affairs). Working Group on IMF Programs and Health Spending (2007) Does the IMF Constrain Health Spending in Poor Countries? Evidence and an Agenda for Action (Washington, DC: Center for Global Development). World Bank (1995) World Development Report 1995: Workers in an Integrating World (New York: Oxford University Press). World Bank (2007) Global Economic Prospects 2007: Managing the Next Wave of Globalization (Washington, DC: World Bank).

4 Research and Innovation in Health and Development Stephen A. Matlin

The last two decades have seen a profound change in our understanding of the relationship between health and development. This has involved a shift from the view that good health will be achieved as an outcome of development to a perspective that regards improving health as an indispensable contributor to development. The change in viewpoint was punctuated by series of international conferences (including the UN International Conference on Population and Development held in Cairo in 1994 and the Fourth World Conference on Women held Beijing in 1995) that culminated in the MDGs in 2000 and the case was cogently presented in the report of the Commission on Macroeconomics and Health in 2001 (World Health Organization 2001). A second change in perspective is now also being seen, involving a widening of approach to the areas of health requiring attention. The traditional view has been that the health problems of low- and middle-income countries (LMICs) are predominantly due to communicable diseases – especially a range of tropical parasitic diseases such as malaria, African and South American forms of trypanosomiasis, leishmaniasis, schistosomiasis and filariasis, as well as TB and, more recently, HIV/AIDS – and to maternal and perinatal conditions and nutritional deficiencies. While this remains true in Africa, where over 60 per cent of the deaths in 2002 were due to infectious diseases (World Health Organization 2004b), it is not the case in the rest of LMICs. In every WHO region except AFRO, noncommunicable diseases now account for the majority of deaths (Figure 4.1) (World Health Organization 2004a). In China, in 2002 noncommunicable diseases accounted for 77 per cent of the deaths and 66 per cent of the burden of disease (BoD) as measured in Disability Adjusted Life Years (DALYs); in India, infectious diseases accounted for 31 per cent of deaths and 41 per cent of DALYs, while non communicable diseases accounted for 49 per cent of the BoD. In these and other LMICs, the explosive growth in noncommunicable diseases such as cerebrovascular disease, heart disease, diabetes and cancer has been driven by changes in diet, physical activity and tobacco use. 79

80 Part I: The Global Health Arena 100 90 80

Percentage

70 60 50 40 30 20 10 0 AFRO

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Figure 4.1 Deaths by cause and WHO region, 2002 [Group 1: Communicable diseases and maternal, perinatal and nutritional conditions; Group 2: Noncommunicable diseases; Group 3: Injuries] Source: World Health Organization (2004, #266).

Thus, while the MDGs focus attention on efforts to reduce maternal and child mortality, malnutrition and deaths due to killer diseases such as HIV/AIDS, TB and malaria, it has become increasingly clear that the wider goals of poverty reduction and better health demand attention to a broader range of factors, including sexual and reproductive health, chronic diseases and ageing. This will require provision of much more comprehensive health services than those needed to prevent or treat infections and to ensure emergency obstetric and perinatal care. Furthermore, the need to manage HIV/AIDS as a chronic infectious disease, with lifelong provision of antiretroviral drugs and treatment of associated opportunistic infections and cancers, has also highlighted the importance of strengthening health systems. Noting that noncommunicable diseases are currently responsible for 56 percent of all deaths in low- and middle-income countries and are projected to continue increasing in prevalence due to ageing populations, a recent report from the World Bank (World Bank 2007) argues the need for new public policies to address both how to avoid the burden of noncommunicable diseases as much as possible and how to prepare for the consequences of more noncommunicable diseases associated with demographic change. As well as the widening scope of health conditions that are recognized as relevant, there has been growing appreciation that, beyond biological causes,

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ltural and env ic, cu iron m o me n o c Living and working nta e conditions io l c o Work Unemployment environment ommunity n nd c etw a l a o i c Water & al lifestyle fa u sanitation d c i t iv

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Stephen A. Matlin 81

Health care services

Agriculture and food production

Age, sex and constitutional factors

Housing

Figure 4.2 Factors affecting health Source: Dahlgren and Whitehead (1991).

there is a broad array of other factors – including economic, environmental, political and social – that act as determinants of health (Figure 4.2). It is increasingly understood that these are among the ‘causes of the causes’ of ill-health and that improving health will require giving them much greater attention (Dahlgren and Whitehead 1991). Health research has been one of the major driving forces behind the improvements in health and dramatic increases in life expectancy seen in high income countries (HICs) during the last century. Research has contributed many new drugs, vaccines, diagnostics and medical procedures and appliances and has improved understanding of how factors such as diet, physical activity and smoking affect health. It has helped to demonstrate the effectiveness and efficiency of interventions and to inform the development of good policies and practices in the organization and delivery of health services. But many LMICs have not experienced similar improvements in health and life expectancy. The 1990 report of the Commission on Health Research for Development concluded that insufficient resources were being spent on health research for the needs of developing countries, that few LMICs were investing enough of their own resources on health research and that they lacked sufficient capacity to conduct essential health research relevant to their national needs (Commission on Health Research for

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Development 1990). The Commission estimated that global expenditure on health R&D was approximately US$30 billion in 1986, but that only around US$1.6 billion (5 per cent) of this was directed to the health problems of developing countries where 90 per cent of world’s burden of avoidable ill-health was to be found. Key recommendations made by the Commission to address this gross imbalance (which has subsequently become known as the ‘10/90 gap’) were that developing countries should increase their own health research capacities, that they should strive to spend at least 2 per cent of the government health budget on essential health research and that this should be complemented by 5 per cent of donor health spending being allocated for health research and research capacity strengthening. One outcome of the Commission’s report was the establishment, in 1993, of the Council on Health Research for Development (COHRED), which in its early years championed the development of essential national health research in LMICs. Following the report of the Ad Hoc Committee on Health Research for Future Intervention Options in 1996, the Global Forum for Health Research was established in 1998 with a mission to help focus research efforts on the health problems of the poor (Ad Hoc Committee on Health Research Relating to Future Intervention Options 1996).

The changing scene A recent review by the Global Forum for Health Research summarizes the extent to which the global scene of health research for development has changed during the last two decades (Matlin 2006). At the time of the report of Commission on Health Research for Development at the beginning of the 1990s, there were very few resources devoted to the field and very few actors engaged. Two cosponsored programs – the UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR) and the UNDP/UNFPA/WHO/World Bank Special Programme for Research, Development and Research Training in Human Reproduction (HRP) – had been established at WHO in the 1970s to tackle problems recognized to be of vital importance for developing countries. The work of TDR was being complemented by research in several centers in HICs, including the National Institutes of Health and Walter Reed Army Institute for Research in the USA, the Wellcome Trust and several national laboratories researching tropical diseases in Europe. Similarly, HRP’s research was complemented by the Program for the Introduction and Adaptation of Contraceptive Technology/Program for Appropriate Technology in Health (PIACT/PATH) and research programs and institutes working on reproduction and contraception in a few countries. This small collection of national and international efforts was funded mainly by multilateral organizations, the governments of a number of OECD countries and a few philanthropic foundations. There was little interest on

Stephen A. Matlin 83

the part of the private sector in becoming involved in new research in areas such as reproductive health and tropical (or other neglected) diseases. A major exception was Merck’s donation of ivermectin for the treatment of river blindness, which began in the late 1980s (Sturchio 2001). However, in the last ten to 15 years, the landscape of health research for development has changed substantially, with large numbers of new actors appearing on the scene. These include organizations such as COHRED and the Global Forum for Health Research that have helped to make the case for supporting research for health and development (IJsselmuiden and Matlin 2006); a greatly increased number of health product development partnerships such as the International AIDS Vaccine Initiative, the TB Alliance and Medicines for Malaria Venture; more bilateral agencies and other international partners in development assistance supporting health and development; several pharmaceutical giants engaging in drug donation programs; and new philanthropic actors – in particular, the Bill & Melinda Gates Foundation – contributing very large resources to tackling global health challenges. Since its establishment in 2000 up to 2007, the Bill & Melinda Gates Foundation has provided over US$ 6.5 billion support for global health. Alongside global initiatives to tackle a range of health problems, there has also been a new impetus given to financing health research for the needs of developing countries. The Commission on Macroeconomics and Health recommended the establishment of a Global Health Research Fund (GHRF) able to disburse US$1.5 billion a year, with a further US$1.5 billion a year of R&D support being funded through existing channels. Although the GHRF proposal has not been implemented as a single initiative, in the last decade a number of separate channels have been created that are providing substantial funds for research related to product development for tropical and other neglected diseases and for vaccines to prevent some of the commonest causes of mortality in LMICs. Furthermore, some national institutions in HICs, such as research councils and institutes of health, are giving increased attention to basic research on priority health problems of LMICs. The main sources of the increased investments in research for health and development have been philanthropic foundations and the public sector in developed countries. These have, to varying degrees, initiated or supported a range of global initiatives and public–private partnerships (PPPs) for product development and clinical trials, as well as funding programs for strengthening and using research capacity in developing countries. Overall, several hundred new actors have appeared in recent years, one notable group being the roughly one hundred public–private partnerships for health, which includes partnerships focusing on product development (PDPs), on clinical trials and on access issues. A review published in 2005 showed that total allocations and commitments to the drug PDPs amounted to about US$255 million, with almost four-fifths of this coming from philanthropic foundations and only about 16 per cent from governments (Moran et al. 2005).

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The PDPs are not only new entities, but also represent a new mechanism for the creation of drugs, vaccines, diagnostics and microbicides for diseases predominantly affecting developing countries, involving a combination of mainly public funding with private sector expertise and the use of portfolio management approaches to develop a pipeline of potential products (Widdus and White 2004). Almost half of the total global expenditure on R&D for health takes place in the private sector (Global Forum for Health Research 2001), but there has been little commercial incentive for this sector to invest in diseases predominantly or exclusively found in poor countries. The size of the market failure is illustrated by the fact that in the last quarter of the twentieth century, only around one per cent of newly registered drugs were for the treatment of tropical infectious diseases (Pecoul et al. 1999). However, in the last decade the pharmaceutical industry has been giving more attention to health products for developing countries, both through its involvement in drug donation programs and, especially, through a range of partnerships that have encompassed research to develop new drugs and programs to enhance their availability, accessibility and affordability in developing countries (International Federation of Pharmaceutical Manufacturers & Associations 2005, 2006b). A survey reported that, over a period of five years following the setting of the MDGs, 126 health partnerships created by the R&D pharmaceutical industry provided health interventions to help up to 539 million people (International Federation of Pharmaceutical Manufacturers & Associations 2006a; Kanavos et al. 2006). In the process, the industry made available medicines, vaccines, equipment, health education and manpower worth US$4.38 billion, with the cost of donated medicines valued conservatively at their wholesale price. A number of industry research institutes have been created that focus on neglected diseases and in some cases draw on public as well as private sources of support, including research centers for GlaxoSmithKline at Tres Cantos in Spain, for Novartis in Singapore and for AstraZeneca in Bangalore, India. Over the course of the last decade, global efforts to stimulate R&D for neglected diseases have mainly focused on ‘push’ mechanisms involving direct investments by the public and philanthropic sectors to overcome the market failure. Recently, however, attention has turned to ‘pull’ mechanisms that are intended to encourage investments by guaranteeing a market or a reward mechanism for those developing a new product. The Advance Market Commitment, through which governments guarantee a viable market by means of a binding contract to purchase a product such as a new vaccine if it is developed and meets predetermined criteria, has received support from several countries (Center for Global Development 2005) and, in a pilot case announced in February 2007, is being applied to a new pneumococcal vaccine (Advance market commitments for vaccines 2007). Several new funding mechanisms have been established in the last few years to support the purchase of available medicines for neglected diseases,

Stephen A. Matlin 85

including the Global Fund to fight AIDS, Tuberculosis and Malaria, the GAVI Alliance, UNITAID and the International Financing Facility for Immunization. While not funding drug research themselves, the existence of these funds, which assure large-scale finances for the purchase of needed products for a number of years to come, may also stimulate greater investment in R&D to create new products. The Commission on Intellectual Property Rights, Innovation and Public Health and its successor, the Inter-Governmental Working Group on Public Health, Innovation and Intellectual Property, have attracted attention to a range of proposals for alternative systems to standard patents, which aim to lower barriers to innovation by creating patent pools and to reward innovation itself by offering prizes or compensation based on disease averted (Love 2006). Overall, these variants of the traditional patent approach, some of which effectively de-couple the rewards for invention from the subsequent pricing of the products, provide a further ‘twist’ to supplement the ‘push’ and ‘pull’ mechanisms which work within the existing regime of intellectual property protection. The increases in funding of R&D to address the health problems of developing countries must be viewed in the context of overall global spending on health research. Studies by the Global Forum for Health Research show that investments in global health R&D rose to nearly US$ 126 billion by 2003 – over four times the amount estimated for 1986 by the Commission on Heath Research for Development (Figure 4.3) (De Francisco and Matlin 2006). With 140 120

US$ millions

100 80 60 40 20 0 1986

1992

1998 Year

Figure 4.3 Global expenditures on health R&D, 1986–2003 Source: De Francisco and Matlin (2006).

2001

2003

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the profusion of new actors and new financial mechanisms, it has become important to track resource flows, make sense of the patterns and identify remaining major gaps and needs.

New perspectives The linkages between poverty and ill-health have become increasingly well established over the last decade and have led to widespread acknowledgement that improving health must be tackled at least in parallel with, if not in advance of, economic development. However, as the World Bank’s studies on ‘Reaching the Poor’ demonstrated, much still has to be learned about how to effectively target the poor in ways that have the intended impact (Gwatkin et al. 2005). There is increasing recognition that the health of individuals is a product not just of biology but also of their relationships with their surrounding environments, developed directly and through their communities, values, practices and institutions and the conditions of their environments. Beyond biological causes, many health problems are rooted in or exacerbated by conditions in society, and these may be the deeper underlying root problems that prevent people from creating and sustaining their own health and that of their families and communities. The prevalence of ill-health and disease can be symptoms of these deeper, underlying structural problems and research is needed into how to go beyond treating these symptoms in order to tackle the underlying issues – which may require, for example, broad system and structural changes across sectors to address human rights, equity and social justice. The WHO Commission on Social Determinants of Health was created in March 2005 to draw the attention of governments, civil society, international organizations, and donors to pragmatic ways of creating better social conditions for health. It brings together leading scientists and practitioners to provide evidence on policies that improve health by addressing the social conditions in which people live and work. The Commission’s main goals are: to support policy change in countries by promoting models and practices that effectively address underlying social inequities, human rights and the broad social determinants of health; to support countries in placing health as a shared goal to which many government departments and sectors of society contribute; and to help build a sustainable global movement for action on social inequities, human rights, and the other broad social determinants necessary to achieve health equity, linking governments, international organizations, research institutions, civil society and communities. The Commission is working through a series of knowledge networks to build a detailed picture of the linkages between health and the social determinants. It is likely to uncover a wide ranging new agenda of research for health that will need to be addressed if the Commission’s goals are to be realized.

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The greater attention now being given to health research for development is also signaled by the fact that WHO has been making efforts to consolidate and clarify its own role and responsibilities in health research and to develop its strategy. A paper on this subject has worked its way through the 2006 World Health Assembly and 2006, the January 2007 Executive Boards and the 2007 World Health Assembly (World Health Organization 2006a). This sets the framework for an overall policy on health research that, if approved, would come into effect in 2009. With the widening perspective on the range of issues that need to be addressed, there has been an increasing tendency to move from using the term ‘health research’ to speaking about ‘research for health’. This has been reflected in publications and in the choice of title for the meeting of Ministers of Health and other stakeholders taking place in Bamako, Mali in November 2008 – the Global Ministerial Forum on Research for Health (Bamako Secretariat 2008, Global Forum for Health Research 2004a).

Innovation Many LMICs are now showing greater commitment to investing in research for health and to developing systematic and equitable approaches to the creation and use of knowledge and innovation. When the Global Forum published its first edition of Monitoring Financial Flows for Health Research in 2001 (Global Forum for Health Research 2001), the 1998 data on which it was based did not include any example of a country that had reached a level of spending on health research equivalent to 2 per cent of its government health budget. Three years later, the second edition found four countries that had achieved this level (Global Forum for Health Research 2004b). Subsequently, the 2004 Ministerial Summit on Health Research in Mexico advocated the two per cent target (World Health Organization 2005); the meeting of Health Ministers of 14 African countries in Accra in 2006 to discuss health research committed themselves to the target in their declaration (World Health Organization 2006b, c); and, it was also further endorsed in the research resolution in the 2005 World Health Assembly (World Health Organization 2006a). Alongside these financial commitments, there has been growing attention to research capacity building and to the utilization of research capacity to support interventions and of research results to inform policy change. Examples include Mexico’s health sector reform, drawing on evidence from communities (Frenk et al. 2004; Nigenda and González-Robledo 2005); substantial improvements in health resulting from policy changes linked to the TEHIP project in Tanzania (International Development Research Center 2007); and the creation of National Health Research Forums in some developing countries, such as Argentina and Zambia. Attention to research capacity strengthening has increasingly evolved into an interest in the structure

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and functioning of national health research systems, with COHRED having played an important role in developing and encouraging this field (Kennedy and IJsselmuiden 2007). In recent years a number of developing countries have begun to demonstrate strengthening performance in innovation, characterized by a growing capacity to conduct research, generate intellectual property in the form of patents and translate the inventions into manufactured products that are accessible to the public. These ‘innovative developing countries’ (Morel 2005), which include Brazil, China, India, Malaysia, South Africa and Thailand, have the potential to contribute significantly to the production of health-related products for low-income countries (Morel, Acharya et al. 2005; Morel, Broun et al. 2005). To do so, they will require policy and legal frameworks that must be set nationally and globally – in effect, pointing to the need for attention to the ‘global health innovation system’ (Mahoney and Morel 2006), as well as significant levels of public sector investment to ensure that the system delivers products that are accessible and affordable for the poor and contribute to a reduction in social inequities. One of roles that the innovative developing countries can play is in South – South cooperation, exemplified by the project that Brazil has launched to boost public health research in Portuguese-speaking countries in Africa (Esteves 2006).

Future needs With the multiplication of funding sources and initiatives during recent years, a number of issues have emerged as being of vital importance in research for health and development. It is clear that the complexity of the system itself has become a factor that may hinder the optimum delivery and use of resources, highlighting the need for continual and systematic tracking of R&D resources at both global and national levels, so that inequities, gaps and needs can be clearly identified and mechanisms adopted that lead to coherent and comprehensive funding approaches. Efforts by the OECD to promote greater policy coherence in generating and delivering drugs for neglected diseases through the Noordwijk Medicines Agenda (Organization for Economic Co-operation and Development 2007) are one important step in this direction, in line with the Paris Declaration (Organization for Economic Co-operation and Development 2005). While increasing, research resources to address the health problems of the poor remain relatively scarce and require the use of rational, equitable and inclusive mechanisms for setting priorities, so that the available resources can be mobilized in the most effective ways. Experience in recent years suggests that inclusive priority-setting processes that bring stakeholders together and tools such as the Combined Approach Matrix that map the available knowledge, needs and opportunities can be used effectively to generate priorities for the most relevant and essential research (Ghaffar et al. 2004).

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While the lack of research funds has been the most crucial limiting factor in the application of R&D to neglected diseases at the global level, at the national level the major bottleneck in developing countries has been the shortage of sufficient numbers of adequately trained health researchers. This human resource gap mirrors the shortage in overall human resources in health in developing countries and shares many factors in common – including the problems of brain drain and inadequate financing, as well as pathways for career progression for researchers working on essential local problems rather than fashionable and ‘cutting-edge’ areas. There has also been a lack of systematic organizational mechanisms in developing countries to harness available research capacities, to promote utilization of research findings to inform policy making and to build capacity among marginalized populations that historically have been underrepresented within the research community (Council on Health Research for Development 2006). The progress currently being made in efforts to increase and to harmonize global resources to tackle some of the major global health challenges and to reduce health inequities within and between countries has generated a new sense of optimism. However, achieving the full potential that health research can and must make to improving the health of populations in all countries will require even more resources and more coherent efforts on the part of a wide range of policy makers, funders and researchers, bridging across the public, private and philanthropic sectors and encompassing new modalities and partnerships for concerted action (Donaldson and Banatvala 2007; Kickbusch 2006). The required increases in resources for health research for development will need to expand to a scale providing adequate financing not just for product R&D but also for research at the country level to improve services; research to help reduce health inequities, including research that will elucidate social inequities and human rights violations, elucidate the social determinants of health and provide evidence-based pathways to better health for all. Rather than remaining concentrated on a few high-profile diseases and conditions, the range of health problems addressed by research will need to expand take account of the changing epidemiological and demographic profiles of developing countries, with attention being given to how to adapt, apply and go beyond the solutions developed in HICs for prevention and treatment of non communicable diseases and how to respond to the age-specific needs of large cohorts of adolescents and ageing populations. It is important that LMICs continue to develop their own capacities and resources to conduct research that is relevant to their own needs, taking up the challenge of building and resourcing national health research systems to ensure that they create and systematically utilize research capacities as an integral part of their efforts to improve health. A number of countries are now advancing rapidly and developing their innovation capacities, becoming increasingly significant sources of health knowledge and products, including

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vaccines, drugs and diagnostics. These will require incentives if they are not only to supply the highly profitable markets in HICs but also to serve the needs of their own poor populations. Encouraging the development of both health research systems and innovation systems will require effective action by the public sector, with governments working to create ethical and legal frameworks and practical environments, including pump-priming with public resources where necessary, to ensure that innovation works to benefit the health of the poorest populations.

References Ad Hoc Committee on Health Research Relating to Future Intervention Options (1996) Investing in Health Research and Development (Geneva: World Health Organization). Advance Market Commitments for Vaccines (2007), ‘Five Nations and the Bill & Melinda Gates Foundation Launch Advance Market Commitment for Vaccines to Combat Deadly Disease in Poor Nations (Press Release)’, available at http://www.vaccineamc.org/media/launch_event_01.html. Bamako Secretariat (2008) ‘2008 Global Ministerial Forum on Research for Health (Press Release)’, available at http://www.dcp2.org/events/48. Center for Global Development (2005) G7 To Pilot Advance Market Commitments (Washington, DC: Center for Global Development). Commission on Health Research for Development (1990) Health Research: Essential Link to Equity in Development (New York: Oxford University Press). Council on Health Research for Development (2006) Human Resources for Health Research: an African Perspective (Geneva: Council on Health Research for Development). Dahlgren, G. and M. Whitehead (1991) Policies and Strategies to Promote Social Equity in Health (Stockholm: Institute of Futures Studies). De Francisco, A. and S.A. Matlin (eds) (2006) Monitoring Financial Flows for Health Research 2006: The Changing Landscape of Health Research for Development (Geneva: Global Forum for Health Research). Donaldson, L. and N. Banatvala (2007) ‘Health is Global: Proposals for a UK Government-wide Strategy’, The Lancet, 369(9564): 857–61. Esteves, B. ‘Brazil to Boost Health Research Capacity in Angola (7 August 2006)’, available at http://www.scidev.net/News/index.cfm?fuseaction=readNews&itemid= 3028&language=1. Frenk, J. et al. (2004) ‘Closing the Relevance–Excellence Gap in Health Research: the Use of Evidence in Mexican Health Reform’, in Global Forum Update on Research for Health (London: Pro-Brook Publishing, 2004), pp. 48–53. Ghaffar, A. et al. (eds) (2004) The Combined Approach Matrix: A Priority-setting Tool for Health Research (Geneva: Global Forum for Health Research). Global Forum for Health Research (2001) Monitoring Financial Flows for Health Research: Volume 1 (Geneva: Global Forum for Health Research). Global Forum for Health Research (2004a) Global Forum Update on Research for Health Volume 4. Equitable Access: Research Challenges for Health in Developing Countries (Geneva: Global Forum for Health Research). Global Forum for Health Research (2004b) Monitoring Financial Flows for Health Research: Volume 2 (Geneva: Global Forum for Health Research).

Stephen A. Matlin 91 Gwatkin, D.R. et al. (2005) Reaching the Poor with Health, Nutrition and Population Services. What Works, What Doesn’t and Why (Washington, DC: World Bank). IJsselmuiden, C. and S.A. Matlin (2006) Why Health Research. Research for Health: Policy Briefings No. 1 (Geneva: Council on Health Research for Development and Global Forum for Health Research). International Development Research Center (2007) TEHIP & Tanzania’s Health Reforms (Ottawa: International Development Research Center). International Federation of Pharmaceutical Manufacturers & Associations (2005) Building Healthier Societies through Partnerships (Geneva: International Federation of Pharmaceutical Manufacturers & Associations). International Federation of Pharmaceutical Manufacturers & Associations ‘IFPMA Survey of Pharmaceutical Sector’s Contribution to Developing World is Conservative, Experts Say (Press Release)’, available at http://www.ifpma.org/News/NewsReleases. aspx?nID=446. International Federation of Pharmaceutical Manufacturers & Associations (2006b) Partnerships to Build Healthier Societies in the Developing World (Geneva: International Federation of Pharmaceutical Manufacturers & Associations). Kanavos, P. et al. (2006) The IFPMA Health Partnerships Survey: A Critical Appraisal. Report Commissioned by the IFPMA (Geneva: International Federation of Pharmaceutical Manufacturers & Associations and London School of Economics). Kennedy, A. and C. IJsselmuiden (2007) Why Support National Health Research Systems Development? Good Research Requires Good Research Systems (Geneva: Council on Health Research for Development). Kickbusch, I. ‘The Need for a European Strategy on Global Health’, Scandinavian Journal of Public Health, 34(6): 561–5. Love, J. ‘Submission of CPTech to IGWG’, available at http://www.who.int/phi/public_ hearings/first/15Nov06JamesLoveCPTech.pdf. Mahoney, R.T. and C.M. Morel (2006) ‘A Global Health Innovation System (GHIS)’, Innovation Strategy Today, 2(1): 1–12. Matlin, S.A. (2006) ‘The Changing Scene’, in Monitoring Financial Flows for Health Research 2006: The Changing Landscape of Health Research for Development, edited by A. de Francisco and S.A. Matlin (Geneva: Global Forum for Health Research). Moran, M. et al. (2005) The New Landscape of Neglected Disease Drug Development (London: The Wellcome Trust). Morel, C.M. (2005) Policies to Build Innovative Capacity: Presentation to the WHO–CIPIH Open Forum, Geneva, 1 June 2005 (Geneva: World Health Organization). Morel, C.M., Acharya et al. (2005) ‘Health Innovation Networks to Help Developing Countries Address Neglected Diseases’, Science, 309(5733): 401–4. Morel, C.M., Broun et al. (2005) ‘Health Innovation in Developing Countries to Address Diseases of the Poor’, Innovation Strategy Today, 1(1): 1–15. Nigenda, G. and L.M. González-Robledo (2005) Lessons Offered by Latin American Cash Transfer Programmes, Mexico’s Oportunidades and Nicaragua’s SPN. Implications for African countries (London: DFID Health Systems Resource Centre). Organization for Economic Co-Operation and Development ‘Paris Declaration on Aid Effectiveness. Ownership, Harmonisation, Alignment, Reults and Mutual Accountability’, available at http://www.oecd.org/dataoecd/11/41/34428351.pdf. Organization for Economic Co-Operation and Development ‘The Noordwijk Medicines Agenda, Noordwijk-aan-Zee, Netherlands, 21 June 2007’, available at http://www.oecd.org/dataoecd/62/11/38845838.pdf.

92 Part I: The Global Health Arena Pecoul, B. et al. (1999) ‘Access to Essential Drugs in Poor Countries: A Lost Battle?’, Journal of the American Medical Association, 281(4): 361–7. Sturchio, J.L. (2001) ‘The Case of Ivermectin: Lessons and Implications for Improving Access to Care and Treatment in Developing Countries’, Community Eye Health Journal, 14(38): 22–3. Widdus, R. and K. White (2004) Combating Diseases Associated with Poverty. Financing Strategies for Product Development and the Potential Role of Public–Private Partnerships (Geneva: The Initiative on Public-Private Partnerships for Health, Global Forum for Health Research). World Bank (2007) Public Policy and the Challenge of Chronic Noncommunicable Diseases (Washington, DC: World Bank, 2007). World Health Organization (2001) Macroeconomics and Health: Investing in Health for Economic Development. Report of the Commission on Macroeconomics and Health (Geneva: World Health Organization). World Health Organization (2002) ‘Revised Global Burden of Disease (GBD) 2002 Estimates: Mortality Estimates by WHO Region’, available at http://www.who.int/ entity/ healthinfo/statistics/gbdwhoregionmortality2002.xls. World Health Organization (2004) World Health Report 2004 – Changing History (Geneva: World Health Organization). World Health Organization (2005) Report from the Ministerial Summit on Health Research, Mexico City, 16–20 November 2004 (Geneva: World Health Organization). World Health Organization (2006a) 117th Session of WHO Executive Board, Agenda item 4.12, Document EB117.R6, WHO’s role and responsibilities in health research. World Health Organization ‘High Level Ministerial Meeting on Health Research for Developing Countries, Accra, from 14–17 June 2006, Health Ministers from Developing Countries Call for More Support for Health Research (Press Release)’, available at http://cdrwww.who.int/countries/gha/news/2006/health_research/en/ index.html. World Health Organization ‘High Level Ministerial Meetings on Health Research for Disease Control and Development (Communiqué)’, available at http://www.who. int/tdr/publications/tdrnews/special_jcb/ministerial_meetings.htm.

Part II Health and Development: Perspectives and Experiences

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5 Health and Evolution Francesco Cavalli-Sforza1

If we are trying to account for the evolution of human health, we must consider its development over the course of the history of the human species. In doing so, we have to try to make the best of the knowledge acquired so far concerning our past, covering a time span of some 6,000 generations – or more than 100,000 generations if we consider the human genus in its entirety – under changing environmental and cultural conditions. In this chapter, I argue that health is the product of evolution, and that success in evolutionary strategies explains much of the present state of global health. Throughout human history, and most markedly with respect to modern humans and since the inception of history proper, cultural evolution has increasingly gained the edge over biological evolution, to the extent that life expectancy and the unequal distribution of disease burden largely depend upon unbalances in the development of different regions of the world, rather than upon any lack of medical knowledge or healing skills. Finally, I conclude that universal health education, imparted from a very early age, and an awareness of the need to control births, are key policy objectives in any attempt to improve the general state of human health.

Lifespan and the dietary habits of early humans, of their predecessors, and of their closest living relatives The genus Homo is today reckoned to be about 2.7 million years old. Early humans (Homo habilis) appeared in Eastern Africa. They had inherited an upright posture from their australopithecine predecessors: this made them into much faster runners, enabling them to live in a largely savannah environment, and freed their hands from the requirements of locomotion. The creative interaction between hand and brain must have been the decisive factor in promoting human cultural evolution to the unique extent which it was to reach in our species. The appearance of early humans and of the first, coarsely worked, stone tools is roughly simultaneous in the archeological record. 95

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Fossil remains suggest that our earliest human ancestors were likely to live some 20 to 30 years, as compared to the 15 to 20 years typical of their australopithecine predecessors. This is close to the estimated mean lifespan of today’s chimpanzees, our closest cousins on the evolutionary tree. Like present-day primates, early humans were gatherers, feeding on fruits, leaves, herbs, seeds, and roots. They also engaged in scavenging: by using their crude stone tools to crack bones, they could feed on bone marrow. By digging holes in the ground, they could reach for tubers. Having access to food sources that were unavailable to the teeth and claws of other mammals, early humans gained a further, exclusive ecological niche, and a survival advantage. If we check on the dietary habits and lifestyle of chimpanzees, we see that they spend about 70 per cent of their waking time foraging (around 56 per cent plucking and eating food and another 14 per cent moving in search of it, according to observations). Most of their diet (around 70–80 per cent) is made of fruits, the rest of leaves, with a very small percentage (2–4 per cent, sometimes more) of animal food, mostly ants and other insects, but also small birds, their eggs, and small mammals (Consiglio and Siani 2003). In modern tribes of human hunter-gatherers, as observed in the twentieth century, the time devoted to obtaining food is definitely lower, thanks to the development of appropriate technologies, and its consumption does not necessarily occur on the spot: foodstuffs are generally collected or killed on gathering and hunting expeditions, and only later will they be consumed collectively at the group’s camp. Not surprisingly, the varieties of vegetal and animal foodstuffs consumed by chimpanzees and modern hunter-gatherers have been found to be generally similar (in the case of Gombe chimpanzees and of !Kung bushmen, for instance). On the basis of the analyses performed on the available remains, our earliest human ancestors seem to have subsisted on a mostly vegetarian diet, supplemented by scavenging the carcasses of animals killed by carnivores. The large quantity of bones found at archeological sites may be misleading from this point of view, since bones may survive for millions of years, while the remains of vegetables will perish. Things kept changing, as humans evolved. The volume of our brains increased steadily from the age of Homo habilis onwards, and intelligence must have been developing side by side with human technological capabilities in the manufacturing of tools. The scavenger slowly turned into a hunter, and the percentage of animal food in its diet increased. The control of fire, which has been documented in Kenya as long ago as 1.6 million years, made meat and other foodstuffs more digestible and tasty, and also killed the parasites in the flesh. The appearance of long wooden spears with points sharpened in the fire (the earliest find comes from Germany and has been dated to around 400,000 years ago) is testimony to hunting capabilities that were far superior to those of early humans. It has been suggested that the Neanderthals, who populated Europe and Western Asia from around 350,000

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years ago, had a mainly carnivorous diet. They must certainly have developed first-rate hunting skills, their preys being mostly horses, ibexes, and bovids, along with smaller (and sometimes larger) mammals, even mammoths. The limited amount of fossil remains of ancient human species is insufficient to provide us with a clear picture of their state of health. The impact of natural selection is such that every living organism is basically healthy: proof is the fact itself of its being alive and giving birth to offspring. Primates living in the wild, as well as modern human populations, such as Pygmies, who live by hunting and gathering in the tropical forest, exhibit excellent states of health. Pygmies have been found to be immune to the cardiovascular diseases that are a leading cause of death in contemporary industrial societies; however, they are exposed to the attack of all sorts of parasites, and in the absence of targeted remedies they have to live with them.

Success and spread of modern humans If reproductive success can be a measure of the state of health, the propagation of early humans is a testimony to the vitality of a successive human species. Homo erectus, the immediate successor of Homo habilis, also first appeared in Eastern Africa, but over the course of the following million years it spread to most of Eurasia. (A more complex taxonomy has now evolved, distinguishing descendants of habilis in Africa and Asia, but this need not concern us here.) The control of fire must have played a key role in the expansion. We do not know when and how humans lost their original coat of body hair, but it is likely to have happened in close connection with the use of fire, which made fur both inconvenient and potentially dangerous. The invention of clothing, which probably came later, contributed further to this development. Hunter-gatherers require a wide searching area to procure the food they need: accordingly, their groups can never become too large (hunting bands typically consist of several dozen individuals), so that demographic growth necessarily entails geographic expansion to further areas. As humans spread across the landmass of the Old Continent, in groups that may have had little or no connection with each other for hundreds of thousands of years, they slowly began to differentiate. Fossil remains of different human types are found in Africa, Asia and Europe, in the past two million years. However, it is believed that at no given time in the Lower Paleolithic did the total human population on the planet ever exceed a few hundred thousand. The situation began to change roughly between 150,000 and 100,000 years ago. One of the existing African strains had developed into a human type whose skeletal remains are undistinguishable from those our present-day species. We call it Homo sapiens sapiens. This tribe of modern humans, which originated in Eastern Africa and might have numbered in the thousands when it began to expand, experienced a demographic growth that led it to people

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Africa and to spread to the rest of the world, replacing, in the course of time, other existing human types, such as the Neanderthals. By 11,000 years ago, the southernmost tip of South America had been reached. It is believed that between one and 15 million individuals lived on the planet at this time. Some definite adaptive advantage must have enabled the success of modern humans, as testified by many factors: their geographic diffusion; a thousandfold growth in numbers over a span of 100,000 years (from thousands to millions, until the development of agriculture and animal breeding, ca. 10,000 years ago); the disappearance of other contemporary human strains; the appearance of new tools, in stone, wood, bone and other materials, along with original inventions, such as the spear-thrower, the bow and arrows, the sewing needle, elaborate dwellings, and forms of art. Most of this took place within some 40,000–50,000 years (beginning approximately 60,000 years ago), after almost three million years of very slow, though steady, development of human groups and technologies. The crucial adaptive factor may well have been the development of a sophisticated language, such as is spoken today by any human population on Earth, no matter how developed technologically or economically. Around 10,000 years ago, the inventiveness of modern humans was challenged by their very reproductive success. Their lifestyle as hunter-gatherers was approaching the environment’s carrying capacity: the food required to support the burgeoning human communities was becoming scarce. Agriculture and livestock farming – that is, production and control of one’s own food – were the human answer to environmental strain. It became possible to feed greater numbers, and it became an advantage to have many children, who would work more land and produce more food. The first-known example of cultivation of local grains and vegetables and of breeding of locally available animals is found at Abu Hureyra, in Mesopotamia, some 11,500 years ago (Ammerman and Biagi 2003). In the following millennia agriculture and farming appear – seemingly independently – in China, New Guinea, Central America, and in the Andes. Wherever they start, they spread fast. Farmers themselves carry the new practices with them, as they grow in numbers and expand to new lands in a scarcely inhabited world. Former hunter-gatherers adopt them, recognizing their advantages, and mix with peasants. Women, in particular, were likely to be taken as wives by the farmers, and polygyny may have been common in most places. As of the present time, farmers have replaced almost every population of hunter-gatherers on Earth: the only surviving tribes are on the verge of extinction, and the world’s population has meanwhile grown a thousandfold in some 10,000 years, from a few million to a few billion individuals. Human cultural innovations have also contributed to the shaping of our present metabolic structures: for instance, the introduction of agriculture and of animal farming promoted the diffusion of mutations enabling us to digest the gluten found in many cereals, or the lactose in milk after weaning.

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These mutations have spread with the populations where they took place, reaching different regions of the world and gaining ground over the course of time. The spread of other mutations, too, has been fostered by the transition to agriculture. By resorting to a small range of staple crops (those which could be grown with greater ease, among the ones available in the wild), farmers limited the variety of their own nutrition, as compared to that of their hunting-gathering predecessors. Grain was the main food in the diet of the European Neolithic farmers: this promoted the diffusion of a white skin color, which came to characterize all Europeans over the course of time. Grain lacks vitamin D, which is fundamental to body growth and will cause rickets when absent from the diet, but contains ergosterol, which will turn into vitamin D under the action of ultraviolet rays. As the penetration of sunlight under the skin will allow this to happen, a whiter shade of skin was favored by natural selection among farmers at northern latitudes.

Cultural evolution takes the lead The coming of the age of agriculture was to have a substantial impact on the following development of human evolution, as well as on human health. Life expectancy at birth had supposedly remained unchanged through the Paleolithic. In the absence of a sufficient amount of data, and in view of the high death rate before the reproductive age (two or three children out of a total of five), it is reckoned that life expectancy at birth must have rarely been greater than 20 years until about 200 years ago. Once humans reached adulthood, their life expectancy might have increased to some 30–40 years by the end of the Paleolithic, around 10,000 years ago (Consiglio and Siani 2003). Such a mean lifespan would be similar, or perhaps somewhat higher than that of today’s chimpanzees in the wild. The average life expectancy of adults – that is to say, of individuals who had reached reproductive maturity – had probably never exceeded 40 years of age throughout recorded history, until around one hundred years ago. Humans could live longer than that, and be very active well on in years. At the time of the Roman Republic, a male citizen was required to serve in the army for twenty years, and could sign in for five more years as a veteran, before being discharged. History bears witness to individuals who remained healthy and strong into their old age: the Venetian doge Enrico Dandolo was 97 years old, and blind, when he led the Crusader fleet to attack and conquer Constantinople, in 1204. Even in prehistory, already among Neanderthals, bones of individuals in their sixties are found, sometimes showing the traces of traumas implying that they could live to an old age only thanks to the help they received from their kin. Helping the weak and disadvantaged is obviously a cultural trait, but it is not one that is exclusive to our species: a similar behavior is also observed, for instance, among chimpanzees and many marine mammals (Waal 1996). From their very origins, humans have been a very social species.

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The dynamics of natural selection is such that it will promote the conservation of the species above and beyond that of the individual. This is clearly seen, for instance, in the wide diffusion of the sickle cell trait in populations traditionally exposed to malaria. While sickle cell heterozygotes (individuals receiving the gene from one parent only) survive malaria better than the normal type homozygotes, and enjoy therefore a reproductive advantage, so that their numbers grow in succeeding generations, marriage between sickle cell heterozygotes is bound to generate a progeny with a statistical ratio of one sickle cell homozygote (receiving the gene from both parents) out of every four children, and sickle cell homozygotes are bound to die of sickle cell anemia before the age of reproduction, in the absence of advanced medical treatment. The impact of fundamental biological evolution factors such as mutation and natural selection will therefore help the overall adaptation of a population to a specific environment, but individual survival may largely depend upon cultural developments, such as targeted medical remedies. Long before the onset of agriculture, our ancestors must have been aware of herbal remedies for their ailments, and may have practiced primitive forms of surgery. The remains of the human communities of the Upper Paleolithic, after the ice of the last glaciation began receding, bear testimony to societies of well-organized, technologically proficient and highly skilled hunters and gatherers, living in regions that were rich in plants and wild animals. Human traditions and myths, and the Bible itself, pay homage to a time when Man did not have to toil at the earth to make a living, but abundant fruit and game were readily available in the environment. In the legends of the Garden of Eden or of the Golden Age, the free life of the hunter-gatherer, or later on of the nomadic shepherd, is contrasted with the ungrateful life of the peasant. Even in our own times, the few extant tribes of hunter-gatherers refuse to settle and live in the way of farmers, as long as they can carry on their traditional way of life. Agriculture and animal husbandry brought food and wealth, but also brought new diseases. The practice of irrigating fields fostered good harvests, but the resulting expanses of still water attracted mosquitoes, and malaria became more dangerous with them, turning for millennia into one of the greatest killers of humanity. Granaries and stores provided stocks, but also brought rats to the homes of farmers, and rats were vehicles of germs, such as the plague. It would seem that most infectious diseases, from flu to smallpox, came to humans as a result of close contact with farm animals. In the course of time, this turned into a selective advantage for populations that, through prolonged exposure to the relevant infective agents, had developed an immunity of sorts. When Europeans occupied the Americas, they brought diseases which were largely responsible for the ensuing extermination of Amerinds, as the locals had had no previous exposure to the germs introduced by Europeans (Diamond 1999).

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Along with the spread of infectious diseases came poorer nutrition, resulting from a decrease in the variety of available food. The emergence of large human concentrations in cities, following the demographic expansion coupled with sedentariness, both made possible by agriculture, also contributed to a decline in the general state of health, as a consequence of overpopulation, of poor hygienic conditions (the first sewers in history appear in cities of the Indus Valley civilization, between 5,000 and 4,000 years ago), and of other factors, such as the diffusion of slave labor and of highly hierarchical social structures, showing little concern for human lives. Life expectancy is generally assumed to have fallen during the Neolithic and Bronze Age periods, perhaps below 20 years at birth.

The development of medicine With the accumulation of goods in the top classes in highly centralized urban societies, writing appears, and recorded history follows. The development of the medical profession begins, based on repeated experience and on the systematic transmission of information to fellow practitioners. The shaman slowly gives way to the doctor. An early form of dentistry, with the trepanation of the tooth, has recently been reported from the early Neolithic. Among the Babylonians and the Egyptians, orthopedics and trepanation became standard practices. The Greek Hippocrates (fifth century BC) is considered the father of scientific medicine. We find that surgery and dentistry are already well developed among the Romans, who had a wide range of tools at their command. The work of Galen (second century AD) lays the foundation for the systematic study of anatomy and physiology. Medical science progresses with the Arabs, in the Middle Ages. In the meantime, different civilizations, such as the Chinese and the Indian, have been independently developing their own systems of diagnosis and treatment, since the remotest times of antiquity. Many staple remedies of today were discovered by aboriginal peoples (quinine by Amerinds, for instance). The origins of modern western medicine lie in the Renaissance, with the development of surgical techniques, based on anatomical research. In the sixteenth century, Vesalius provides a detailed description of the body’s organization, and Paré starts on the road that will lead to modern surgery. In the following century, Harvey describes the blood circulation, Leeuwenhoek discovers micro-organisms using a microscope, while Malpighi, working with the same tool, establishes comparative anatomy by observing tissues. However, the birth of experimental science and the progress in medical research cannot be said to influence the general state of human health until the nineteenth century, when some major developments take place: the introduction of fundamental rules of hygiene, of the practice of anesthesia (with ether and chloroform at the beginning), of asepsis in surgery (Semmelweis, Lister), along with the invention of vaccines ( Jenner, Pasteur). In

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1805, Napoleon introduces mass vaccination of his troops against smallpox, extending it to the whole French population in the following year. In 1854, one of the recurrent outbreaks of cholera in London is prevented from spreading further, through the recognition that a contaminated well was the source of the infection and should be closed. In 1876, Koch establishes that microbes can cause disease. By the end of the nineteenth century, the importance of asepsis and of vaccination had been recognized universally, but few actual remedies were yet available for the sick, and no medications existed to fight the most common contagious diseases, some of which, such as pneumonia, kill about 50 per cent of those affected. The discovery of effective drugs was characteristic of the twentieth century. The first chemotherapeutic (salvarsan, against syphilis) appears in 1910; the first antibiotic is penicillin (1928), which, during World War II, was developed to become splendidly effective against pneumonia and many common infections. The number of drugs, ever more specific, multiplies in the following decades, and before the end of the century many of the infectious diseases that have been major killers of humanity for millennia are no longer as dangerous. At the outset of the twenty-first century, the scanning of the genome brings hope of a new kind of medicine – genomics – which is meant to deal with hereditary defects and to tailor prevention and treatment on the genetic make-up of the individual. Its benefits, however, may take longer than desired to turn out.

Rising life expectancies The steady improvement of the general state of health over the course of the past 200 years is shown by the exponential growth of world population, reaching from an estimated 700 millions in 1750 to more than 6.6 billion today, and by the parallel growth in life expectancy at birth, increasing from around 20–35 years mean around 1750 to today’s top ratings of almost 79 for males and more than 85 years for females in Japan, with a minimum slightly above 40 for both sexes in Sierra Leone and other African countries (United Nations Development Programme 2007) and below 40 for both sexes in Swaziland (United Nations Department of Economic and Social Affaris Population Division 2007). Population growth has occurred on different timescales in different regions of the world, but it has affected almost all peoples on the planet, the main exception being the populations of huntergatherers, which have been dwindling to extinction, with little hope of a future for the few surviving ones. As people lived longer, families grew larger. When conditions are favorable, human populations may double within one or two generations, and high figures are soon reached by the sheer force of numbers in reproduction. The decisive factors allowing for this unprecedented increase have been: the growing availability of food, following the Industrial Revolution; the

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dissemination of elementary rules of hygiene; the introduction of basic drugs, taking care of diseases that used to represent the main source of death; and, along with these, the development of an ever more artificial environment, shaped by human technologies with the intent to foster human life. The overall benefit can be seen in statistics, but cannot hide the remarkable inequalities in the distribution of health, which runs in parallel with the distribution of wealth, across the planet. Malnutrition affects one in three people worldwide, with almost one billion living on the brink of starvation. Millions are killed by diseases which could be treated by existing drugs, if only they were available locally. At the same time, the impact of some older and newer diseases is rising, defying available remedies: drug-resistant strains of malaria have appeared in Africa and Asia; tuberculosis is reintroduced by immigrants to countries that had cleared themselves of it; many antibiotics are losing their effectiveness (World Health Organization 2008); AIDS, which is highly contagious but by far not as easily transmissible as airborne diseases, affects an estimated 33 million worldwide (The Global Fund to Fight AIDS TB and Malaria 2008). It is feared, furthermore, that fast-mutating viruses affecting other species, such as the one causing the avian flu, might spread to humans, starting catastrophic epidemics (World Health Organization 2006). The actual state of health and the life expectancy of the individual vary dramatically in different regions of the world, depending largely on the history of unequal development in different countries. To find remedies, we should start by considering on which grounds a sound state of health is established.

Nutrition as the basic health requirement Appropriate nutrition is the first basic health requirement: a balanced intake of nutrients, coming from sound sources, along with clean, safe drinking water. The amount of calories required by an individual varies with age, sex, and activity performed. Whatever the required energy input, it has to be apportioned among the main nutrients to obtain a suitable diet, in percentages that have been defined by WHO as approximately around 15–25 per cent of calories from fats, 12 per cent from proteins, and from carbohydrates for the remaining, along with a high consumption of vegetable fibers and an adequate supply of vitamins and mineral salts. WHO actually recommends that attention should be paid to the kind of food one eats, more than to its caloric content (it recommends, for instance, to eat at least 400 grams of fruits and vegetables a day, to help prevent chronic diseases) (World Health Organization 1996, 2003, 2004). The human diet varies deeply in different regions of the world, as every population has to rely on the available food sources. Animal food (even freshly drawn bovine blood) is a staple in some populations of herders and fishermen. Some populations of farmers have lived mostly on grains and vegetables. Over the course of evolution, the human organism has become adapted to a variety of food sources: this omnivorous capacity is a feature of

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great survival value. The shape of our head, with teeth set below the skull (as in the australopithecines, but opposite to other primates, whose teeth protrude from the skull), as well as the rather thick coat of enamel covering our teeth, make us suited to the chewing of hard foods, such as seeds, beans, and roots. Our foreteeth are apt to bite on leaves and fruits. The design of our digestive tract shows us to be intermediate between herbivores and carnivores. It is safe to assume that the human diet slowly began to include larger amounts of meat, as we differentiated from our prehuman ancestors. If we consider the diet of a modern population of hunter-gatherers, such as the Hadza of Tanzania (who highly prize hunting and meat, and used to have no lack of wild game), we find it to be around 80 per cent vegetables and 20 per cent meat, in weight (Consiglio and Siani 2003). In animal food we find the essential amino acids we require to build the proteins that make up our own body. Since feeding on meat is something of a metabolic shortcut, it is not surprising that humans have profited from it whenever it was available. When meat became widely accessible in industrial countries, for instance, in the decades following World War II, its consumption rocketed everywhere. The pattern of reference recommended by WHO for a healthy human nutrition is the traditional diet of Mediterranean farmers, as well as the equivalent Asian diets, with plenty of wholegrains, fresh vegetables and fruit, some fats, such as olive oil and cheese, and a small amount of meat. The quality of foodstuffs is also of primary importance. The overabundance of highly processed and refined foods, often lacking in essential nutrients, in contemporary ‘globalized’ societies, has been repeatedly condemned by nutritionists, as well as the overconsumption of canned and variously preserved food in place of fresh produce. In addition, as everything circulates in the ecosystem, just as we are bound to breathe any polluted air, we are bound to ingest any pollutant that has been absorbed previously by whatever we feed on, be it heavy metals or hormones, pesticides or preservatives, substances in chemical fertilizers or in industrial waste. Along with the poorer quality of food, its excessive consumption, too, has become a major threat to health in rich countries, with obesity, and other diseases linked to an excessive intake of nutrients, affecting a high percentage of their citizens.

Physical exercise as part of our evolutionary background The regular practice of physical activities, in the form of sports or exercise, is constantly recommended by doctors, as a high road to good health. The preeminence of sedentary jobs in today’s advanced societies runs contrary to our evolutionary history, which made us adapted to an active life, of movement and physical exertion. The backaches and neck pains afflicting desk workers remind us of the million years our distant ancestors spent living on trees.

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Since humankind has appeared, for well over 99 per cent of our evolutionary history we have been hunting and gathering, walking and running for hours on most days, depending on our prowess for survival. Since the introduction of agriculture, the amount of labor expended by humans has even increased, as required by working the land, building constructions, and engaging in warfare. In the past two to three centuries, machines have been doing increasing amounts of this work for us. Yet up to a few generations ago people still moved on foot or on horseback. Although surviving through a lifetime spent in a sitting position may become in itself a selective factor in the course of time, it is important to exercise in order to keep one’s body healthy.

Facing diseases The prevention and treatment of diseases are a third fundamental requisite of healthy living. However, when a disabling disease is genetic in origin, prevention is today limited to prenatal diagnosis and pregnancy termination, when possible. For a few of the most common genetic diseases, such as cystic fibrosis, contemporary medicine offers cures that may alleviate the symptoms and extend life expectancy. Genomic medicine, tailoring the medical approach to the individual’s genetic make-up, is on the horizon of today’s research, but still far away. On the other hand, when illnesses are not hereditary, they usually arise either as a result of the attacks brought by viruses, bacteria, or other parasites, or as a consequence of chronic noncommunicable sicknesses, such as cancer, obesity, diabetes, and cardiovascular diseases. The interest of the individual is in preventing the onset of diseases, and in receiving appropriate medical care when necessary. The body tends to heal itself, and a healthy diet and proper exercise go a long way toward building a strong immune system, able to cope with most parasites and environmental threats. A scrupulous hygiene is a must, and the psychological condition of the person is also of great importance, since motivation, enthusiasm for one’s work, and interest in the surrounding world, are likely to enhance good health, and be enhanced by it. The success obtained by contemporary drugs in fighting infective and other diseases, along with the development of advanced medical treatments, of surgery, and of high-tech diagnostic tools, has spurred the growth of a huge medical and pharmaceutical industry. Of the ever-widening variety of drugs available on the marketplace, only a fraction is known to be actually effective or even life saving. Many are useless, and most of those that work, up to the most effective, are known to possibly induce undesired side effects, or damage. The high degree of individual variation, which is characteristic of every living organism, furthers such impact, as a drug may help one person, be noxious to another, not effective to a third. Iatrogenic diseases, arising

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from the undesired consequences of medical and surgical procedures of hospitalization, or from adverse reactions to drugs or their side effects, have been pointed at as the third leading cause of death in the US, after heart disease and cancer (Starfield 2000). If we add to iatrogenic diseases the sum of nutritional disorders resulting from unhealthy diets, of diseases directly induced by environmental pollutants, and of those contributed by unhealthy lifestyles (as in the case of smoking, or of the sweatshop factory worker rather than of the all too sedentary clerk), the grand total may lead us to feel that the undesired side effects of human efforts can be overwhelming. There is an open conflict here. The interest of the individual, as well as that of the state, is in keeping healthy and avoiding disease. By contrast, the economic interest of large parts of the industry is rather in keeping people unhealthy, in need of drugs and treatments, or in producing foodstuffs with an eye to profit rather than to nutritional adequacy. The consequences of a profit-centered approach in matters of health are perhaps nowhere more dismaying than in the increase of antibiotic resistance due to the widespread use of small amounts of antibiotics in animal feed, for rapid weight gain, in the absence of disease. This practice, protracted for decades, has fired back, decreasing the effectiveness of most antibiotics, which are the most powerful weapons that humankind has so far developed to fight germs. Investing adequate sums in the prevention of diseases, by disseminating basic hygienic, sanitary, and medical awareness, tailored to the recipients’ learning capabilities, beginning from preschool age onwards, would go a long way toward achieving a better state of health in the population at large. Although this is quite obvious insofar as the least developed countries are concerned (where low-cost media, such as the radio, may be used to reach areas lacking a school system), it would bring no lesser advantage to developed nations, where young and adult alike are widely defenseless against environmental pollution, poor nutritional habits, and medication abuse. It is said that in ancient China doctors were paid on a regular basis as long as their patients stayed healthy, and stopped receiving payment when the patient was sick. In the contemporary world, every effort and expense incurred in promoting the prevention of diseases is bound to bring a manifold return to the societies that engage in it: an economic return in terms of savings and of increased productivity, and a social return in terms of general wellbeing and public happiness.

Beyond carrying capacity Humankind has seldom given much thought to the medium- and long-term consequences of its own actions, and when we try to evaluate them, our efforts are hampered by the limitations of our knowledge, or by the drive of consolidated interests. When the first farmers, over 10,000 years ago,

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began reaping the benefits of agriculture and animal breeding, they could not envisage that their activities would, in the long run, pave the way to environmental degradation, the desertification of whole regions, and new and deadly diseases. The growth in numbers of human communities has long been seen as a bounty prize, a divine gift, or the tool to conquer one’s neighbors, and has therefore been traditionally promoted by religions and governments alike. Today, it may be argued that the human population has outgrown, on a global scale, the carrying capacity of its environment. More food may be produced than needed to feed the world, but the surplus does not reach the hungry, nor is it likely to do so in any foreseeable future: it is rather the hungry who reach out for wealthier countries. The high degree of consumption and of waste linked to industrialized societies clashes with the limits of mineral resources and fossil fuels. The impact of human activities on the planetary environment is jeopardizing the environmental balance itself, as shown by climate alterations, while an alternate model of development is nowhere in sight. Reproduction is what makes life possible, and every single living being would reproduce indefinitely, if it didn’t meet with environmental constraints, first and foremost the availability of food. In the case of the human species, nature has three ways to check overpopulation: famines, epidemics, and wars. We are bound to see them all making progress in the coming years.

Education is the key In western industrialized countries, the demographic transition began a couple of centuries ago – starting in England, the very country that had heralded the Industrial Revolution – and has come to completion in the past decades. As people lived longer, and the population continued to grow, the number of children per couple diminished steadily, until it reached the present zero growth balance. In emerging countries, the same phenomenon has been occurring in the past half-century: the mean number of children per woman has been declining from four in the 1970s to three today on a global scale, making demographers predict that a zero growth balance may be reached worldwide between 2040 and 2050. Nevertheless, the interplay between ecological and economical imbalances, on the one side, and a world population growing by over 75 million units every year, on the other, is bound to make the transition rather more painful than smooth (Harrison and Pearce 2000; US Census Bureau Population Division 2007). A policy thoughtful of the dire consequences of excessive population growth would try to encourage a declining birthrate worldwide, for instance by offering special support and assistance to the states and nations that agree on promoting population control. Birth control, however, just like the enforcement of healthy hygienic practices, should take the form of persuasion, rather than coercion, since it

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is as much in the interest of the citizen as it is in that of the state to prevent the damages of demographic pressure and to raise a new generation that will match, rather than exceed, the available resources. This also means healthier children. A wide array of contraceptives exists: they have to be made commonly available. Education is the key to healthy lifestyles and nutritional habits, as well as to population control. Health education should be considered as basic as the learning of the mother tongue, and it should be imparted, in the appropriate forms, starting from the very first classes that children attend. Teaching the value of different foods, the importance of clean drinking water, the sources of disease and the basics of prevention and cure, is to provide new human beings with the motivation and the tools to check the safety of what they eat and drink, to encourage them to choose their own lifestyles within the given environmental constraints, and to acquire an awareness of their own health, as of the threat of diseases and of available remedies. Education is among the most inexpensive activities in which a state, a community, or any international organization, may engage. A vast body of scientific knowledge is available, along with all sorts of both simple and sophisticated technologies: such competence has to be transferred to forthcoming generations, to help them learn how to interact with their environment and grow up as healthy human beings.

Note 1. This chapter is a general treatment of a very wide subject. Within the text, references have been given only for very specific items. The books and articles listed as references are the source of the information. Some are encyclopedic collections of what we have come to know so far on a specific subject. Such is the case of Cavalli-Sforza, Menozzi, and Piazza (Cavalli-Sforza et al. 1994), for what concerns the diffusion of Homo sapiens sapiens to the planet; of Consiglio and Siani (Consiglio and Siani 2003) for research on the nutritional habits of australopithecines, ancient human species, and today’s primates; of Klein (Klein 1999) for human paleonthology; also, to some extent, of Ammerman and Biagi (Ammerman and Biagi 2003), for the emergence of agriculture; and of Kunstler (Kunstler 2005) for societies born of fossil fuel based economy.

References Ammerman, A.J. and P. Biagi (eds) (2003) The Widening Harvest, the Neolithic Transition in Europe: Looking Back, Looking Forward (Archaeological Institute of America Colloquia & Conference Papers vol. 6) (Boston, MA: Archaeological Institute of America). Cavalli-Sforza, L.L. et al. (1994) The History and Geography of Human Genes (Princeton, NJ: Princeton University Press).

Francesco Cavalli-Sforza 109 Consiglio, C. and V. Siani (2003) Evoluzione e alimentazione. Il cammino dell’uomo (Torino: Bollati Boringhieri). Diamond, J. (1999) Guns, Germs, and Steel: the Fates of Human Societies (New York, NY: W.W. Norton & Co.). Economic and Social Affaris Population Division 2007) World Population Prospects: The 2006 Revision. Available at http://www.un.org/esa/population/publications/WPP 2006/WPP 2006_Highlightrev.pdf. Harrison, P. and F. Pearce (2000) AAAS Atlas of Population and Environment (Berkeley, CA: University of California Press). Klein, R.G. (1999) The Human Career: Human Biological and Cultural Origins (Chicago: University of Chicago Press). Kunstler, J.H. (2005) The Long Emergency: Surviving the End of Oil, Climate Change, and Other Converging Catastrophes of the Twenty-first Century (New York: Grove Press). Starfield, B. (2000) ‘Is US Health Really the Best in the World?’, Journal of the American Medical Association, 284(4): 483–5. The Global Fund to Fight Aids TB and Malaria ‘Fighting AIDS’, available at http://www.theglobalfund.org/en/about/aids/default.asp. US Census Bureau Population Division ‘Annual World Population Change: 1950– 2050’, available at http://www.census2010.gov/ipc/www/img/worldpch.gif. United Nations Development Programme (2007) Human Development Report 2007/2008. Fighting Climate Change: Human Solidarity in a Divided World, 01Human Development Index, Life Expectancy at Birth, Annual Estimates (Years) (New York: United Nations Development Programme). Waal, F.B.M. Good Natured: the Origins of Right and Wrong in Humans and Other Animals (Cambridge, MA: Harvard University Press). World Health Organization (1996) Preparation and Use of Food-based Dietary Guidelines: Report of a Joint FAO/WHO Consultation – WHO Technical Report Series, No.880 (Geneva: World Health Organization, 1996). World Health Organization (2003) Diet, Nutrition, and the Prevention of Chronic Diseases: Report of a Joint WHO/FAO Expert Consultation (Geneva: World Health Organization). World Health Organization (2004) Global Strategy on Diet, Physical Activity and Health (Geneva: World Health Organization). World Health Organization ‘Avian Influenza (“Bird Flu”) – Fact sheet’, available at http://www.who.int/mediacentre/factsheets/avian_influenza/en/. World Health Organization (2008) Global Tuberculosis Control – Surveillance, Planning, Financing (Geneva: World Health Organization).

6 Health and Development: an Economic Perspective David B. Evans1

Public health specialists often think that economists perceive development solely in terms of increases in income over time, or increases in the consumption of goods and services allowed by the rises in income. This is only partially true. Certainly, economists believe that rising income levels contribute importantly to human development, but economics has long been concerned with many other dimensions of development as well (Adelman and Morris 1967; Hicks and Streeten 1979; Streeten et al. 1981). For example, considerable attention has been paid to questions of income distribution, particularly the extent of poverty, how it affects social welfare, and what can be done to reduce it (Atkinson 1970, 2003; Ravallion 1994; Sen 1974, 1977). In addition, economists recognize the direct and indirect links between health and human development. People value health for its own sake. Health improvements contribute directly to human welfare and development, to the extent that people are even willing to give up substantial parts of their income in order to improve or maintain their health (Bleichrodt and Quiggin 1999; Maiwenn et al. 2005; Viscusi and Evans 1990). That being said, gains in health also offer individuals and society the opportunity to increase income and consumption, thereby also making an indirect contribution to development (Bloom and Canning 2000; Nordhaus 2003). One implication is that improving health can be an important way of helping the poor escape from poverty (Hulme and Shepherd 2003; Sachs and Malaney 2002). From an economic perspective, therefore, health affects human welfare and development in at least two ways. It is valued for its own sake and it is valued for its potential to increase income and consumption opportunities. This chapter discusses these two components in turn, at the same time describing some of the gaps in the available evidence. The implications for international organizations seeking to work with countries to improve human development are then considered.

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Health as a direct goal of development The belief that improving health is one of the fundamental goals of development drives the large and growing literature on cost effectiveness analysis (CEA), examining how health sector resources can be deployed to achieve the greatest possible health benefits. The objective is simply to improve health. Sometimes this is seen as a goal independent from any impact of the health improvement on income, and sometimes the indirect effects on income are built into the analysis, but the literature starts from the premise that health is worth improving for its own sake (Gold et al. 2006; Krol et al. 2006; Meltzer and Johannesson 1999; Nyman 2004; Olsen and Richardson 1999). The analysis can be undertaken from the perspective of an individual, a payer for services such as a government or a health insurance agency, or society as a whole. CEA measures the impact of alternative ways of using resources, here called interventions, in terms of physical units of health improvement. Health improvement is most commonly expressed in terms of either quality adjusted life years (QALYs) or disability adjusted life years (DALYs), and interventions are essentially compared in terms of their efficiency, the costs per unit of health outcome achieved. The mechanics of the calculations of health effects at the population level are identical for both QALYs and DALYs – the years of life gained by an intervention are multiplied by a weight, usually between zero and one, with zero representing the lowest, and one the highest, valued health state. Methods of eliciting weights can vary, however, as do their interpretation. One strand of CEA using QALYs as the outcome indicator interprets the weights as expressions of each individual’s ‘utility’ – the word economists use to describe individuals’ valuations of their own welfare – associated with alternative states of health (Lyttkens 2003; Robberstad 2005). The average value (a weighted average could be used if the analyst was concerned about health inequalities) across individuals of the benefits they would personally derive from an intervention is taken to be the social value. This is why CEA using QALYs is sometimes called cost utility analysis. On the other hand, another part of the CEA literature (some of the work using QALYs as the outcome, and all of the work based on DALYs) interprets the weights as expressions of the individual’s perception of the relative social value of the health improvements that would result from the alternative ways of using resources rather than an expression of the benefit to the individual personally (Murray and Acharya 1997). For the purposes of this chapter, the distinction is relatively unimportant. The main point is that the CEA analysis is based on the understanding that improving health is an important goal of development and is valuable for its own sake. This literature has grown substantially over the last two decades with the largest part focusing on comparing alternative ways of reducing the

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burden associated with specific diseases or health problems – tuberculosis, cardiovascular disease, or maternal mortality for example – as a way of providing guidance to managers of these programs on how best to use their resources (Adam et al. 2005; Baltussen et al. 2006; Murray et al. 2003). In addition, there have been a few attempts to draw this literature together to provide guidance to a broader set of health sector policy makers, in the form of ‘sectoral analysis’ where the costs and effectiveness of a wide range of interventions across a broad range of conditions are assessed and compared. The most comprehensive have been the two Disease Control Priority exercises and the WHO-CHOICE (Choosing Interventions that are Cost-Effective) project, which can be used to identify which interventions offer good value for money in terms of improving health, and which ones do not (Evans et al. 2006, 2005; Jamison et al. 2006; Tan-Torres et al. 2003). Despite the sheer number of studies, CEA has been adopted as a formal decision-making criterion in relatively few countries, often limited to the evaluation of pharmaceutical agents for public subsidy (Bloom,Canning and Sevilla 2004; Bloom et al. 2005; Drummond et al. 1997; Duthie et al. 1999; Gonzalez-Pier et al. 2006; Hoffman et al. 2002; Iglesias et al. 2005). One of the few formalized uses which take a more sectoral approach is found in the national health system of England and Wales, where decisions about allocating resources to new technologies, techniques and pharmaceuticals are based on reviews by the National Institute for Health and Clinical Excellence (NICE) that include considerations of cost effectiveness (National Centre for Health and Clinical Excellence 2005). One of the explanations for the limited formal use of CEA in practice is that most analysts use methods or approaches that limit the usefulness of the results to decision makers (Chisholm and Evans 2007). For example, cost effectiveness analysis rarely considers if the current mix of interventions is appropriate, preferring to focus on what should be done if new resources become available. Or analysts ask if a new technique or product is cost effective, without considering where the additional funds to pay for them will be found. A second issue is that the cost and the health impact of many interventions depend critically on what other interventions are being undertaken at the same time. For example, the change in population health that would be expected from a program involving active case finding and treatment for tuberculosis will depend on whether effective programs to reduce HIV transmission exist. These interactions are rarely considered, so policy makers cannot really be sure that the results are very meaningful. WHO’s CHOICE project was established specifically to provide decision makers with information on the costs and effectiveness of a very wide range of interventions – currently over 800 are included in the data base – taking into account interactions between interventions on costs and effects (Evans et al. 2006; Murray et al. 2000). It also allows both costs and effects to vary with the scale of the intervention, recognizing that they can be quite different

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at coverage of 50 per cent compared to 80 per cent coverage. Again, this is something that is rarely considered in cost effectiveness studies but which is important to practical decision making. Even though CEA is based on the belief that health is an important dimension of human development and is worth improving for its own sake, it is also recognized that cost effectiveness is only one of the factors that do, and should, influence the final choice about how to allocate health resources. For example, policy makers will usually also consider the impact of interventions on health inequalities when deciding how to use their resources, not just the impact on the overall level of population health. In response, some cost effectiveness analysts have begun to explore if the impact of interventions on inequality can be addressed explicitly as part of the analysis (Baltussen et al. 2006, 2007; Dolan and Robinson 2001; Schwappach 2002). That being said, economists have also tried to value the health improvements associated with interventions in money terms rather than in the physical units of health expressed in QALYs and DALYs. This is partly because many believe that neither QALYs nor DALYs are derived in a way that is not totally consistent with economic theory, whereas a monetary valuation of benefit can be so derived (Gafni and Birch 1997; Meherz and Gafni 1993). Putting a money value on the health benefits of an intervention is a different concept, in principle, to the link between health and income-earning opportunities that was described earlier, and which will be discussed further in the next section. It is simply a way of measuring the value to individuals of the health improvement itself, or in some cases, the value of the reduction in the risk of mortality (Viscusi and Aldy 2003). The most common way of doing this has been to examine differences in wages between risky and less risky forms of employment, although there has also been some analysis of people’s willingness to pay for safety devices such as those in automobiles, or fire alarms. The former reveals how much money people are willing to accept to work in an occupation with an increased risk of death, while the latter shows how much they are willing to pay to reduce their risk of death (Viscusi and Aldy 2003). Adapting an example from Kenkel (Kenkel 2001), assume that the annual risk of death in a specific occupation is 0.00001 higher than average. Assume further that each worker in this occupation is paid US$50 per year higher than average. A group of 100,000 workers employed in this occupation reveal that they are willing to accept the increased risk of death for a total payment of $5 million (100,000 multiplied by US$50). On average, we can expect one additional death per year among these workers, so implicitly the workers are valuing this ‘statistical life’ at $5 million. The $5 million is interpreted as the value of a statistical life (VSL) rather than the value of the life of each individual worker. Estimates for the US suggest median values of a statistical life of around $7 million (in year 2000 values), and these numbers are used by the US administration to guide decisions on whether different forms of public policy should

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be implemented, particularly those linked to reducing environmental risks to health and improving road safety (Viscusi and Aldy 2003). As long as the costs are lower than the overall value of the benefits – measured as lives potentially saved multiplied by the VSL – the policy is deemed acceptable from a cost/benefit perspective. Although these calculations are increasingly being applied to many types of health interventions, they are fraught with problems. For example, the VSL has been shown to vary with many individual characteristics, including age, income and education, so the results derived from the behavior of one sample of workers should not be extrapolated to the benefits of reducing health risks in a different group of people with a different set of characteristics (Aldy and Viscusi 2007; Kenkel 2001). This is compounded by the fact that the willingness to accept a given increase in the risk of death depends on the initial level of risk – people are more likely to accept the increased probability of death when the initial risk is very low than when it is high (Viscusi and Aldy 2003). If VSL is used for policy purposes, a different value should be used depending on who will benefit and the underlying level of risk, something that is not currently done in practice. In addition to these problems, VSL calculations cover only the mortality component of health increments or decrements. In order to capture other dimensions of health, some economists use what is called ‘contingent valuation’ where people are asked to express their willingness to pay (WTP) for a given change in risk or a given health improvement (Alberini et al. 2006; Amin and Khondoker 2004; Gyrd-Hansen 2005; Olsen 1997; Shiell and Gold 2002; Smith 2002). Although WTP questions could, in theory, capture people’s valuations of the impact of an intervention on mortality, morbidity, duration, the process of care, and even effects beyond those experienced by the individual patient (externalities), in practice questions rarely explore these issues (Olsen and Smith 2001). In fact, Olsen and Smith (Olsen and Smith 2001) found that most contingent valuation studies have not provided enough detail of the options that they wanted respondents to value to enable standard QALY calculations to be made. If it is not possible for an analyst familiar with the health sector to sort out the likely impact of the described interventions in terms of mortality, morbidity, and duration, it is unlikely the scenarios provide enough information to allow informed responses from the general public about their willingness to pay. Contingent valuation also entails a ‘sub-additivity’ problem – the expressed WTP for a health intervention is greater when each component is evaluated separately than when the overall intervention is evaluated in its entirety (Klose 1999). Following this logic, the sum of the WTP of people evaluating many different health interventions individually is likely to be greater than their true willingness to pay for improvements in the health system as a whole and probably greater than society’s ability to pay.

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A final problem with all the possible ways of valuing the benefits of health improvements in money terms, but particularly with contingent valuation, is that responses are income-related. The expressed WTP of a rich person for a given health improvement will be higher, other things being equal, than that of a poor person. This raises considerable ethical issues in their use for priority setting across interventions and population groups, something relevant at the national and international levels. International comparisons show that the VSL varies across countries roughly proportionally to national income per capita. If, therefore, we were to measure the benefits of a health intervention as the number of lives saved multiplied by the VSL appropriate to each country (or DALYs averted multiplied by the equivalent money value of a DALY), the implication is that international donor funds should be invested in relatively richer countries. For this reason many public health professionals are more comfortable with an analysis conducted in terms of physical units of health improvement than some money valuation of this improvement.

Health as an indirect contributor to development The potential impact of ill health on income at the individual or household level has long been a focus of attention in economics (Brunello and d’Hombres 2005; Evans and Jamison 1994; Strauss and Thomas 1998; Suhrcke, McKeeb et al. 2006; Suhrcke, Nugent et al. 2006; Suhrcke and Urban 2006a, b; World Health Organization 2001). Where households must meet some of the costs of accessing or obtaining care out of pocket, their present and/or future consumption possibilities will be restricted (through a reduction in savings or an increase in borrowing). At the extreme, these costs can push households under the poverty line (Xu et al. 2007, 2006, 2002). At the same time, illness can reduce an individual’s ability to work, which will result in lost earnings except in countries with generous forms of social security (Siddiqui 1997). Productivity (output per hour) can also fall (Chirikos and Nestel 1985; Pelkowski and Berger 2004). Many other consequences have been noted in the literature, all impinging on the present or future income of the individual. These include the need to switch from more productive to less productive pursuits or crops, inappropriate timing of agricultural activities that reduce production, and reduced capital inputs (Conley 1975; Evans and Jamison 1994; Suhrcke, McKeeb et al. 2006; Suhrcke, Nugent et al. 2006; Suhrcke and Urban 2006a, b). Beyond that, it has been argued that different types of illness have a direct impact on the cognitive development of children and perhaps their overall educational attainment levels, or their physical growth, thereby reducing future earnings (Belli et al. 2005; Cawley 2000). In some cases, children are taken out of school to substitute for parents or siblings who are too ill to work.

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Most of these pathways are well established, although there remain critical gaps in the empirical evidence. For example, the links between years of schooling and earnings are well established. The links between some forms of cognitive development, and sometimes school absenteeism, with illness have also been established. While it is highly likely that these illnesses also reduce a child’s final level of educational attainment, this link has yet to be widely documented. However, overall it is clear that ill-health can have a substantial impact on the income-earning potential of individuals and households, not just in the current time period, but for many years into the future. Conversely, improvements in health have the potential to increase household income, not just now but for many years into the future. Health, while being valued for its own sake, also contributes to development through its impact on income and consumption. These undoubted effects at the microeconomic level must also influence the economy as a whole, although there are some problems in quantifying the impact. The most common method of estimating the macroeconomic impact of illness, most often used in the US and commonly reported in biomedical rather than economics journals, has been called the ‘cost of illness’ approach (Akobundu et al. 2006; Johnson and Bootman 1995; Kortt et al. 1998; Rice 1967; Rice et al. 1985; Sohn et al. 2006). It essentially aggregates the losses to individuals in a country and interprets them as the overall loss to the economy. This is not correct for many reasons which are well documented in the literature (Byford et al. 2000; Drummond 1992; Koopmanschap et al. 1995; Shiell et al. 1987). The total out of pocket expenses to households are not, for example, a loss in terms of Gross Domestic Product (GDP) or any other indicator of national income – health expenditures comprise part of GDP. At best they can be interpreted as losses in ‘non-health’ consumption that households would probably have preferred. Moreover, in countries with considerable unemployment and underemployment, the overall loss to the economy from illness will be lower than the aggregation of individual losses because other people replace sick or incapacitated workers. Although this method produces estimates of the macroeconomic burden of disease that are large, they cannot really be interpreted in any meaningful way and certainly cannot be interpreted as a loss of GDP. Two other methods of establishing the consequences of disease on GDP or GDP per capita – and, conversely, the potential macroeconomic benefits of improved health – have, therefore, been developed. The first involves regression analysis comparing national income (or its growth) in countries with varying levels of health, mostly over several years. This form of analysis has been undertaken for specific conditions such as malaria and cardiovascular disease, or for health in general using a proxy such as life expectancy at birth (Arora 2001; Bhargava et al. 2001; Bloom, Canning and Jamison 2004; Bloom, Canning and Sevilla 2004; Sachs and Malaney 2002; Suhrcke, McKeeb et al. 2006; Suhrcke, Nugent et al. 2006; Suhrcke and Urban 2006a;

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Weil 2007). There are a number of technical issues with these calculations, particularly the fact that the relationship between health and GDP is not one way. Health contributes to income but income also contributes to our ability to maintain or improve health. Many of the cross-country regressions have not adequately controlled for this type of endogeneity. That being said, the literature is quite convincing that national income per capita, certainly for lower-income countries, has grown faster in countries with higher levels of health, even after controlling for other determinants and allowing for the endogeneity of health and income. It has been less easy to show the impact of individual diseases on national income using this type of approach, with the notable exception of malaria. The reasons for this are not clear. This is one of the reasons why the third approach has assumed recent importance, based on computerized general equilibrium (CGE) models of varying complexity (Abegunde et al. 2007; Barlow 1967; Bell et al. 2006; Bloom et al. 2005; Cuddington 1993; Kambou et al. 1993; Robalino et al. 2002; Smith et al. 2005). They are economic models of how the economy as a whole works, and the determinants of economic growth. Health can be introduced in a number of ways, most commonly through its impact on total labor supply and the proportion of health costs that are covered from savings (which influences investment and future income). However, more complex models also exist in which health might impact on the marginal productivity of labor, or school attendance and through this, income in future years and in subsequent generations. CGE models have been developed for a variety of specific conditions ranging from HIV/AIDS, malaria and cardiovascular diseases, to avian flu and SARS, to antimicrobial resistance and air pollution. The results, however, are somewhat sensitive to the types of economic relationships that are included and the parameters used. This is partly because the inputs and model parameters are either measured, estimated or assumed, to be fed into the computer model that simulates the growth of national income and population under different scenarios. Typical inputs are the size of the labor force and the capital stock, while typical parameters are the marginal productivity of labor and capital, and the proportion of health expenditure provided by savings. The more complex the model, the more likely it is to describe the variety of interactions in an economy, but the more difficult it is to find parameter estimates specific to the country. Many models are forced to take their parameters from other countries, or simply make assumptions about their values. To illustrate, CGE models specific to HIV/AIDS always show that as prevalence increases, national income will fall. Most suggest that increasing prevalence will reduce national income per capita as well – although some scenarios show that the population might fall more rapidly than GDP resulting in an increase in GDP per capita. This is not to suggest that this outcome is either desirable or likely – it is not. It only illustrates that the results of CGE

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models remain sensitive to the model specification and the parameters used. More work needs to be done to standardize the structure of the models, and more effort needs to be devoted to estimating key parameters. As a postscript, it is possible to combine estimates of the economic consequences of ill health described in this section, with the money value of the health losses described in the last section. This has been called the ‘full income’ approach, and emerged from the debate around whether indicators of national income such as GDP truly capture the comparative wealth of nations (Becker et al. 2005). Recognizing that health is valued for its own sake, Bloom et al. (2004), for example, used the value of a statistical life to translate increases in longevity into money terms, and added this to the measured changes in GDP. They then compared the changes in the ‘full income’ of different countries, noting substantially more inequality that reflected in GDP estimates. The approach is now starting to find its way into the literature dealing with the economic consequences of specific diseases. It certainly provides a very large estimate of the economic consequences of disease, with the money value attributed to the changes in health dominating the estimates of changes in GDP – not surprising when each statistical life is valued at between 100 and 200 times the value of GDP per capita. Whether this work provides any greater impetus for the purposes of advocacy, or whether it leads to different conclusions than valuations of disease burden in terms of DALYs, remains to be seen.

Conclusions Economics sees development as multidimensional. Income is one, but only one key dimension. Another is the level of health, as are concerns with inequalities in both income and health. Health contributes to development directly – it is valued for its own sake – but also indirectly through its impact on income. This chapter has described the directions economists have been taking in understanding these pathways. While the effect of ill-health on income can be substantial at the individual and society levels, an important implication is that investment in health does not require an economic justification in the sense that investment in agriculture or infrastructure might. In the non-social sectors, investment is warranted as long as the economic benefits exceed the costs. In health, people and societies are willing to give up or forego income to maintain and improve health, that is to say they are willing to invest in health even if there is no economic return in the traditional sense. International agencies and health policy makers at all levels should not be required, nor should they seek, to justify health investments purely in terms of the economic benefits that will accrue. Individuals do not think only of economic investments when protecting their health, and governments should not either.

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There are two caveats. First, showing the economic benefits of improving health can be a useful advocacy tool, and this chapter has provided a brief review of some of the relevant literature that suggests that economic benefits can be real and substantial. However, it is important not to lose sight of the fact that health is valuable for its own sake, and that investment in the health of the elderly, for example, contributes to development even if there is no direct economic benefit. Secondly, economic considerations are important even when the goal is simply to improve health for its own sake. Resources will always be scarce relative to perceived health needs and demands, and ensuring that the resources achieve the greatest possible benefit is critical. This will remain one of the most important contributions of economists in the foreseeable future.

Note 1. The opinions expressed in this chapter are those of the author and not necessarily of the organization he represents.

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120 Part II: Perspectives and Experiences Barlow, R. (1967) ‘The Economic Effects of Malaria Eradication’, The American Economic Review, 57(2): 130–48. Becker, G.S. et al. (2005) ‘The Quantity and Quality of Life and the Evolution of World Inequality’, The American Economic Review, 95: 277–91. Bell, C. et al. (2006) ‘The Long-Run Economic Costs of AIDS: A Model with an Application to South Africa’, World Bank Economic Review, 20(1): 55–89. Belli, P.C. et al. (2005) ‘Investing in Children’s Health: What are the Economic Benefits?’, Bulletin of the World Health Organization, 83(10): 777–83. Bhargava, A. et al. (2001) ‘Modeling the Effects of Health on Economic Growth’, Journal of Health Economics, 20: 423–40. Bleichrodt, H. and J. Quiggin (1999) ‘Life-cycle Preferences Over Consumption and Health: When is Cost-effectiveness Analysis Equivalent to Cost–benefit Analysis?’, Journal of Health Economics, 18(6): 681–708. Bloom, B.S. (2004) ‘Use of Formal Benefit/Cost Evaluations in Health System Decision Making’, American Journal of Managed Care, 10(5): 329–35. Bloom, D.E. and D. Canning (2000) ‘The Health and Wealth of Nations’, Science, 287(5456): 1207–9. Bloom, D.E. et al. (2004a) ‘Health, Wealth and Welfare’, Finance and Development, 31: 10–15. Bloom, D.E. et al. (2004b) ‘The Effect of Health on Economic Growth: A Production Function Approach’, World Development, 32(1): 1–13. Bloom, E. et al. (2005) Potential Economic Impact of an Avian Flu Pandemic on Asia (Manila: Asian Development Bank). Brunello, G. and B. d’Hombres (2005) ‘Does Obesity Hurt Your Wages More in Dublin Than in Madrid? Evidence from ECHP’ (IZA Discussion Papers, Institute for the Study of Labor). Byford, S. et al. (2000) ‘Cost of Illness Studies’, British Medical Journal, 320(7245): 1335. Cawley, J. (2000) ‘Body Weight and Women’s Labor Market Outcomes’ (NBER Working paper No. 7481, National Bureau of Economic Research). Chirikos, T.N. and G. Nestel (1985) ‘Further Evidence on the Economic Effects of Poor Health’, The Review of Economics and Statistics, 67(1): 61–9. Chisholm, D. and D.B. Evans (2007) ‘Economic Evaluation in Health: Saving Money or Improving Care?’, Journal of Medical Economics, 10(3): 325–37. Conley, G.N. (1975) ‘The Impact of Malaria on Economic Development’ (Scientific Publication No. 297, Pan American Health Organization). Cuddington, J.T. (1993) ‘Modeling the Macroeconomic Effects of AIDS, with an Application to Tanzania’, World Bank Economic Review, 7(2): 173–89. Dolan, P. and A. Robinson (2001) ‘The Measurement of Preferences over the Distribution of Benefits: The Importance of the Reference Point’, European Economic Review, 45(9): 1697–709. Drummond, M. (1992) ‘Cost-of-illness Studies: a Major Headache?’, Pharmacoeconomics, 2(1): 1–4. Drummond, M. et al. (1997) ‘The Role of Economic Evaluation in the Pricing and Reimbursement of Medicines’, Health Policy, 40: 199–215. Duthie, T. et al. (1999) ‘Research into the Use of Health Economics in Decision Making in the United Kingdom. Phase II – Is Health Economics “For Good or Evil”?’, Health Policy, 46: 143–57. Evans, D.B. et al. (2006) ‘Generalized Cost-effectiveness Analysis’, in The Elgar Companion To Health Economics, edited by A. Jones (Cheltenham: Edward Elgar Press).

David B. Evans 121 Evans, D.B. et al. (2005) ‘Methods to Assess the Costs and Health Effects of Interventions for Improving Health in Developing Countries’, British Medical Journal, 331(7525): 1137–40. Evans, D.B. and D.T. Jamison (1994) ‘Economics and the Argument for Parasitic Disease Control’, Science, 264(5167): 1866–7. Gafni, A. and S. Birch (1997) ‘QALYs and HYEs: Spotting the Differences’, Journal of Health Economics, 16(5): 601–8. Gold, M.R. et al. (eds) (2006) Cost-Effectiveness in Health and Medicine (New York: Oxford University Press). Gonzalez-Pier, E. et al. (2006) ‘Priority Setting for Health Interventions in Mexico’s System of Social Protection in Health’, The Lancet, 368(9547): 1608–18. Gyrd-Hansen, D. (2005) ‘Willingness to Pay for a QALY: Theoretical and Methodological Issues. Current Opinion’, Pharmacoeconomics, 23(5): 423–32. Hicks, N. and P. Streeten (1979) ‘Indicators of Development: the Search for a Basic Needs Yardstick’, World Development, 7: 567–80. Hoffman, C. et al. (2002) ‘Do Health-care Decision Makers Find Economic Evaluations Useful? The Findings of Focus Group Research in UK Health Authorities’, Value in Health, 5: 71–8. Hulme, D. and A. Shepherd (2003) ‘Conceptualizing Chronic Poverty’, World Development, 31(3): 403–23. Iglesias, C.P. et al. (2005) ‘Health-care Decision-making Processes in Latin America: Problems and Prospects for the Use of Economic Evaluation’, International Journal of Technology Assessment in Health Care, 21(1): 1–14. Jamison, D.T. et al. (eds) (2006) Disease Control Priorities in Developing Countries, 2nd edn (New York: Oxford University Press). Johnson, J.A. and J.L. Bootman (1995) ‘Drug-related Morbidity and Mortality. A Cost-of-illness Model’, Archives of Internal Medicine, 155(18): 1949–56. Kambou, G. et al. (1993) ‘The Economic Effects of the AIDS Epidemic in Sub-Saharan Africa: a General Equilibrium Analysis’, Revue d’Economie du Developpement, 1: 37–62. Kenkel, D. (2001) ‘Using Estimates of the Value of a Statistical Life in Evaluating Regulatory Effects’, in Valuing the Health Benefits of Food Safety: A Proceedings, edited by F. Kuchler (Washington, DC: US Department of Agriculture, Miscellaneous Publication No. 1570). Klose, T. (1999) ‘The Contingent Valuation Method in Health Care’, Health Policy, 47(2): 97–123. Koopmanschap, M.A. et al. (1995) ‘The Friction Cost Method for Measuring Indirect Costs of Disease’, Journal of Health Economics, 14: 171–89. Kortt, M.A. et al. (1998) ‘A Review of Cost-of-illness Studies on Obesity’, Clinical Therapeutics, 20(4): 772–9. Krol, M. et al. (2006) ‘Productivity Costs in Health-state Valuations – Does Explicit Instruction Matter?’, Pharmacoeconomics, 24(4): 410–14. Lyttkens, C.H. (2003) ‘Time to Disable DALYs? On the Use of Disability-Adjusted Life Years in Health Policy’, The European Journal of Health Economics, 4(3): 195–202. Maiwenn, J.A. et al. (2005) ‘Optimal Allocation of Resources Over Health Care Programmes: Dealing with Decreasing Marginal Utility and Uncertainty’, Health Economics, 14(7): 655–67. Meherz, H. and A. Gafni (1993) ‘Healthy-years Equivalents Versus Quality-adjusted life years: in Pursuit of Progress’, Medical Decision Making, 13(4): 287–92.

122 Part II: Perspectives and Experiences Meltzer, D. and M. Johannesson (1999) ‘Inconsistencies in the “Societal Perspective” on Costs of the Panel on Cost-Effectiveness in Health and Medicine’, Medical Decision Making, 19(4): 371–7. Murray, C.J.L. and A.K. Acharya (1997) ‘Understanding DALYs’, Journal of Health Economics, 16(6): 703–30. Murray, C.J.L. et al. (2000) ‘Development of WHO Guidelines on Generalized Cost-effectiveness Analysis’, Health Economics, 9(3): 235–51. Murray, C.J.L. et al. (2003) ‘Effectiveness and Costs of Interventions to Lower Systolic Blood Pressure and Cholesterol: a Global and Regional Analysis on Reduction of Cardiovascular-disease Risk’, The Lancet, 361(9359): 717–25. National Centre for Health and Clinical Excellence (2005) A Guide to NICE (London: National Centre for Health and Clinical Excellence). Nordhaus, W. (2003) ‘The Health of Nations: the Contribution of Improved Health to Living Standards’, in The Measurement of Economic and Social Performance, edited by M. Moss (New York: Columbia University Press for National Bureau of Economic Research). Nyman, A.J. (2004) ‘Should the Consumption of Survivors be Included as a Cost in Cost-utility Analysis?’, Health Economics, 13(5): 417–27. Olsen, J.A. (1997) ‘Aiding Priority Setting in Health Care: Is There a Role for the Contingent Valuation Method?’, Health Economics, 6(6): 603–12. Olsen, J.A. and J. Richardson (1999) ‘Production Gains from Health Care: What Should be Included in Cost-effectiveness Analyses?’, Social Science & Medicine, 49(1): 17–26. Olsen, J.A. and R.D. Smith (2001) ‘Theory Versus Practice: a Review of Willingness-topay in Health and Health Care’, Health Economics, 10(1): 39–52. Pelkowski, J.M. and M.C. Berger (2004) ‘The Impact of Health on Employment, Wages, and Hours Worked Over the Life Cycle’, The Quarterly Review of Economics and Finance, 44(1): 102–21. Ravallion, M. (1994) ‘Measuring Social Welfare With and Without Poverty Lines’, The American Economic Review, 84(2): 359–64. Rice, D.P. (1967) ‘Estimating the Cost of Illness’, American Journal of Public Health, 57(3): 424–40. Rice, D.P. et al. (1985) ‘The Economic Costs of Illness: a Replication and Update’, Health Care Financing Review, 7(1): 61–80. Robalino, D.A. et al. (2002) ‘Risks and Macroeconomic Impacts of HIV/AIDS in the Middle East and North Africa: Why Waiting to Intervene Can Be Costly’ (World Bank Policy Research Working Paper 2874). Robberstad, B. (2005) ‘QALYs vs DALYs vs LYs Gained: What are the Differences, and What Difference do They Make for Health Care Priority Setting’, Norsk Epidemiologi, 15(2): 183–91. Sachs, J. and P. Malaney (2002) ’The Economic and Social Burden of Malaria’, Nature, 415(6872): 680–5. Schwappach, D.L.B. (2002) ‘Resource Allocation, Social Values and the QALY: a Review of the Debate and Empirical Evidence’, Health Expectations, 5(3): 210–22. Sen, A. (1974) ‘Informational Bases of Alternative Welfare Approaches: Aggregation and Income Distribution’, Journal of Public Economics, 3(4): 387–403. Sen, A. (1977) ‘On Weights and Measures: Informational Constraints in Social Welfare Analysis’, Econometrica, 45(7): 1539–72. Shiell, A. et al. (1987) ‘Cost of Illness Studies: an Aid to Decision-making?’, Health Policy, 8(3): 317–23.

David B. Evans 123 Shiell, A. and L. Gold (2002) ‘Contingent Valuation in Health Care and the Persistence of Embedding Effects Without the Warm Glow’, Journal of Economic Psychology, 23(2): 251–62. Siddiqui, S. ‘The Impact of Health on Retirement Behaviour: Empirical Evidence from West Germany’, Health Economics, 6(4): 425–38. Smith, R.D. (2002) ‘Construction of the Contingent Valuation Market in Health Care: a Critical Assessment’, Health Economics, 12(8): 609–28. Smith, R.D. et al. (2005) ‘Assessing the Macroeconomic Impact of a Healthcare Problem: the Application of Computable General Equilibrium Analysis to Antimicrobial Resistance’, Journal of Health Economics, 24(6): 1055–75. Sohn, S. et al. (2006) ‘Cost of Moderate to Severe Plaque Psoriasis in Germany: A Multicenter Cost-of-Illness Study’, Dermatology, 212(2): 137–44. Strauss, J. and D. Thomas (1998) ‘Health, Nutrition, and Economic Development’, Journal of Economic Literature, 36(2): 766–817. Streeten, P. et al. (1981) First Things First: Meeting Basic Needs in Developing Countries (New York: Oxford University Press). Suhrcke, M. et al. (2006) ‘The Contribution of Health to the Economy in the European Union’, Public Health, 120(11): 994–1001. Suhrcke, M. et al. (2006) Chronic Diseases: an Economic Perspective (London: OxHA Public Health and Economics Working Group). Suhrcke, M. and D.M. Urban (2006a) ‘Are Cardiovascular Diseases Bad for Economic Growth?’ (CESifo Working Paper Series). Suhrcke, M. et al. (2006b) Is Cardiovascular Disease Bad for Economic Growth? (Venice: WHO European Office for Investment for Health and Development). Tan-Torres, T.E. et al. (2003) Making Choices in Health: WHO Guide to Cost Effectiveness Analysis (Geneva: World Health Organization). Viscusi, W.K. and J.E. Aldy (2003) ‘’The Value of a Statistical Life: A Critical Review of Market Estimates Throughout the World’, Journal of Risk and Uncertainty, 27: 5–76. Viscusi, W.K. and W.N. Evans (1990) ‘Utility Functions That Depend on Health Status: Estimates and Economic Implications’, The American Economic Review, 80(3): 353–74. Weil, D.N. (2007) ‘Accounting for the Effect of Health on Economic Growth’, Quarterly Journal of Economics, 122(3): 1265–306. World Health Organization (2001) Macroeconomics and Health: Investing in Health for Economic Development. Report of the Commission on Macroeconomics and Health (Geneva: World Health Organization). Xu, K. et al. (2007) ‘Protecting Households from Catastrophic Health Expenditures’, Health Affairs, 26(4): 972–83. Xu, K. et al. (2006) ‘Understanding the Impact of the Elimination of User Fees: Utilization and Catastrophic Health Expenditures in Uganda’, Social Science and Medicine, 62(4): 866–76. Xu, K. et al. (2002) ‘Understanding Household Catastrophic Health Expenditures: a Multi-country Analysis’, The Lancet, 362(9388): 996.

7 Health, Development, and Human Rights1 Stephen Marks

The purpose of this chapter is to explore how the three concepts of human rights, health and human development have been defined and linked and what implications these linkages have for the policies and practices of international organizations. At the conceptual level, the definitions of development, health and human rights are virtually identical and widely accepted in the abstract. WHO defines health as ‘a state of complete physical, mental and social wellbeing and not merely the absence of disease or infirmity’ (World Health Organization 1946). Such a broad definition – which some consider too broad to be meaningful (Burci and Vignes 2004, p. 109) – embraces virtually the same content as development and human rights since all three deal with the improvement of the human condition and the fulfillment of the human potential. Human rights are about creating an environment in which people can develop their full potential and lead creative lives by assuring ‘the dignity and worth of the human person’ and promoting ‘social progress and better standards of life in larger freedom,’ in the words of the Universal Declaration of Human Rights. For development, UNDP uses the concept of human development, which is ‘about creating an environment in which people can develop their full potential and lead productive, creative lives in accord with their needs and interests [and] thus about expanding the choices people have to lead lives that they value’ (United Nations Development Programme 2002). However, even at such a high level of abstraction, distinctions can be made. The goals of health concentrate on the requirements of physical, mental and social dimensions of human existence, whereas development goals tend to focus on the material conditions that allow people to benefit from economic processes in ways that improve their condition; and human rights goals tend to deal with normative constraints on power relations to ensure human dignity and the elimination of repressive and oppressive processes. Thus, health, development and human rights have in common human wellbeing – or, as philosophers would say, ‘flourishing,’ or the ‘good life’ – but approach 124

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this meta-goal through physical, mental and social wellbeing; economic processes; and normative constraints respectively. I will explore the role of international actors with respect to human rights, health and human development by highlighting theoretical approaches (conceptual frameworks) through which human rights thinking is applied to development, focusing particularly on health and by exploring some examples of the practices of human rights in health and development. Scholars, policy makers and practitioners have been using a common vocabulary in recent years with respect to each of the approaches in question. Some involve the overlapping of all three concepts; some emerge from human rights thinking; some are more common to development and health thinking. My purpose in grouping them here is to show how each one offers a way of understanding how human rights, health and development are related in theory and practice.

Human rights-based approaches to health and development in theory Building on the abstract definitions quoted above, we can provide a more complete picture of how health, development, and human rights are related by examining those theoretical approaches that are the most relevant to understanding the interconnections between the three, namely, the social justice approach, the holistic approach, and the capabilities approach. The relevance of each of these approaches to health, development, and human rights will be outlined in this section, leaving the more practical dimensions to the section that follows.

The social justice approach Many in the public health field attach primary importance to eliminating social disparities and inequalities in access to health. Their agenda is common to many in the food security, adequate housing, environment and globalization fields, and is often expressed through the concept of social justice. ‘Human rights’ sometimes becomes a surrogate for social justice, the assumption being that what contributes to social justice in the context of development is also a contribution to human rights. However, there are differences between human rights and social justice, which will be explained below. Thomas Pogge understands social justice as the justice of social institutions or a criterion ‘which assesses the degree to which the institutions of a social system are treating the persons and groups they affect in a morally appropriate and, in particularly, evenhanded way’ (Pogge 2002). The relation between social justice and human rights is explained in this way: ‘A complex and internationally acceptable core criterion of basic justice might best be formulated, I believe, in the language of human rights [understood]

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primarily as claims on coercive social institutions and secondarily as claims against those who uphold such institutions’ (Pogge 2002). Paul Farmer, coming from public health and social medicine, is another voice for social justice who uses human rights as a privileged normative instrument. Drawing on the insights of liberation theology, which ‘argues that genuine change will be most often rooted in small communities of poor people,’ he uses the methodology ‘observe, judge, act’ to challenge unjust structures and understand how a social justice approach can be used to address disease and suffering (Farmer 2003). He explains, ‘For me, applying an option for the poor has never implied advancing a particular strategy for a national economy. It does not imply preferring one form of development, or social system, over another. . . A truly committed quest for high-quality care for the destitute sick starts from the perspective that health is a fundamental human right’ (Farmer 2003). He is critical of ‘liberal’ development theory and practice based on ideas of reformism that seek to bring the technological advances of modernity to the poor (‘developmentalism’). He is also critical of the human rights movement for failing to attach sufficient importance to economic, social and cultural rights. He warns, ‘As international health experts come under the sway of the bankers and their curiously bounded utilitarianism, we can expect more and more of our services to be declared “cost-ineffective” and more of our patients to be erased. In declaring health and health care to be a human right, we join forces with those who have long labored to protect the rights and dignity of the poor’ (Farmer 2003). This approach is put into practice, among others, by Partners in Health (PIH), which works directly with the destitute sick in Haiti, Peru, Russia and other locations and defines its mission as providing ‘a preferential option for the poor in health care’ and its advocacy goal as ‘helping to build a movement to fight for health and social justice’ (Partners in Health 2007). Similarly, Oxfam International explains that its ‘policies and practices will place the rights and interests of poor people at the center of the agendas of international bodies, governments and of the powerful corporate sector – which increasingly dominates the global economic and social landscape’ (Oxfam International 2005). Its strategic plan, called ‘Toward Global Equity,’ enumerates ‘five rights-based aims’ directed towards making globalization work for poor and excluded people by establishing and implementing new ‘fair rules for the global economy’ (Oxfam International 2005). Social justice captures an important feature of the human rights framework for development, namely, the emphasis on the moral imperative of eliminating glaring social inequality within societies and structurally-imbedded patterns of international support for those inequalities (Kim et al. 2000). However, the human rights framework goes beyond a commitment to social justice in that it supports other dimensions of a life people value that are not focused entirely on reducing the suffering of the poor and vulnerable. It is also different from social justice insofar as it does not rely on a subjective

Stephen Marks 127 Table 7.1

Human rights and social justice approaches compared

Features

Social justice

Human rights

Sources of authority

Moral commitment to fairness; solidarity with oppressed

Human rights law; theories of justice based on equal rights and dignity

Priority groups

Poor and marginalized communities

All individuals and certain groups

Modes of action

Primarily social mobilization; secondarily legal and administrative redress

Primarily legal and administrative redress; secondarily social mobilization

Relation to established order

Primarily questioning of unjust structures (capitalism, patriarchy, ethnic stratification); sometimes using established institutions to advance equality

Primarily working within existing structures; exceptionally questioning them (apartheid, non-democratic government)

sense of outrage at the suffering of the poor and excluded within society – however admirable such sentiments may be – but rather on a set of agreed standards that limit what governments can do that may contribute to social injustice and defines what they must do to redress such injustice. Table 7.1 lists some of the distinguishing features between human rights and social justice approaches of development. Applied to the field of public health, the social justice approach is illustrated by the focus on inequalities by scholars such as Norman Daniels (Daniels 2005; Daniels et al. 2000, 2005) and Nancy Krieger (Krieger 2000, 2001), as well as the extensive research on health equity (Global Equity Gauge Alliance 2003). These studies base the concept of health equity on theories of social justice and draw attention to the failure of improvement in overall health status in terms of decline in mortality and morbidity to reach some social groups, denying them equality of opportunity (Anand et al. 2002).

The holistic approach Many approaches to development, human rights and health have in common an awareness of the interrelationships among complex social processes. The World Bank’s ‘Comprehensive Development Framework,’ for example, refers to the ‘interdependence of all elements of development – social, structural, human, governance, environmental, macroeconomic, and financial’ (World Bank 2007) and the OECD’s ‘Strategy for Sustainable Development’ is defined as a ‘co-ordinated set of participatory and continuously improving processes of analysis, debate, capacity-strengthening, planning and investment, which integrates the economic, social and environmental objectives of society, seeking tradeoffs where this is not possible’ (Organization for Economic Co-operation and Development 2001).

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The holistic approach to human rights is reflected in Article 28 of the Universal Declaration of Human Rights (1948), which refers to the right to ‘a social and international order in which the rights and freedoms set forth in this Declaration can be fully realized.’ Such an order can only be conceived on the basis of social structures conducive to the realization of rights that cover the civil, cultural, economic, political, and social domains. It implies a holistic framework in which the cumulative effect of realizing all types of human rights is a structural change in both national societies and international society. Typical of numerous UN pronouncements on the subject, the Vienna Declaration and Programme of Action (June 1993) affirms in paragraph 5: ‘All human rights are universal, indivisible and interdependent and interrelated. The international community must treat human rights globally in a fair and equal manner, on the same footing, and with the same emphasis. While the significance of national and regional particularities and various historical, cultural and religious backgrounds must be borne in mind, it is the duty of States, regardless of their political, economic and cultural systems, to promote and protect all human rights and fundamental freedoms’ (United Nations 1986, 1993). The first implication for health of this holistic approach to human rights is that it challenges the separation of between civil and political rights, on the one hand, and economic, social, and cultural rights, on the other. Traditionally, the former are supposed to be absolute or of immediate applicability, whereas the latter are relative or for progressive realization. The former are characterized by violations that must be redressed regardless of resources, while the latter are programmatic, calling for cooperation and utilization of resources. These neat distinctions, which developed throughout the Cold War, are disappearing in theory and practice. The holistic approach connects all human rights, dispensing with many of the traditional distinctions between categories of rights, although the two covenants, each one devoted to one of the traditional categories (United Nations General Assembly 1966b, a), remain the standard reference documents. In the context of development, the holistic approach means that all human rights, not just the right that appears most relevant to the task at hand, must be considered. In health, for example, it is not enough to consider that the allocation of resources to affordable health care contributes to the right to health; the public health decision maker must ask what determinants of health will be positively affected by the promotion and protection of rights to housing, food, education, information, nondiscrimination, work, and effective remedies, to mention only the most obvious ones.

The capabilities approach The Nobel Prize-winning economist Amartya Sen has articulated an approach to human rights and development that is widely endorsed by United Nations institutions and of particular relevance to health. In his chapter called ‘Poverty as Capability Deprivation’ in Development as Freedom (Sen 1999b), he

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argues that development is not the acquisition of more goods and services but the enhanced freedom to choose, to lead the kind of life one values. These enhanced choices are called capabilities. Poverty, he explains, is the deprivation of basic capabilities, and he urges that attention be focused on aspects of life other than income to understand what poverty is and how to respond to it. He uses three focal features of deprivation of basic capability – premature mortality, undernourishment, and illiteracy – which are also the basis for the Human Development Index of UNDP. In the capabilities discourse, ‘capability’ is the option available to the individual to partake of some valued dimension of life; ‘functioning’ is the exercise of that option (Nussbaum 1988, 1999; Sen 1999a; Crocker 1992). Public policy tends to focus on functioning, food consumption or healthcare delivery, for example. Sen and Nussbaum propose that public policy should instead focus on capability. Capabilities in relation to food (land, seed, water) refer to the conditions that make it possible for a farmer to produce adequate food or a worker to purchase it (wages, availability in markets) and for the entire population to have adequate nourishment. Similarly, health is the capability of leading a healthy life in terms of accessibility, affordability, appropriateness and of quality of care. Because the capability approach links development concerns to freedom, and because freedom implies the widening of choices in the civil, political, social, economic, and cultural spheres, each of the capabilities may be contemplated as a starting point for a human rights understanding of the development process. This approach has become official policy of UNDP, as reflected in the assertion ‘. . .human development shares a common vision with human rights. The goal is human freedom. And in pursuing capabilities and realizing rights, this freedom is vital. People must be free to exercise their choices and to participate in decision making that affects their lives. Human development and human rights are mutually reinforcing, helping to secure the wellbeing and dignity of all people, building self-respect and the respect of others’ (United Nations Development Programme 2001). Using Sen’s capability perspective to support the claim that poverty is a violation of human rights, Polly Vizard has reviewed Sen’s contributions to ethics and economics and developed numerous insights into the relevance of this contribution to a framework for combating poverty as part of a human rights agenda (Vizard 2006). She explores the ways in which Sen’s capability approach could be supported through international human rights law (Vizard 2006). She extends the capability approach to the international human rights protection mechanisms, considered as a ‘“working model” of international accountability and responsibility in the field of global poverty and human rights’ (Vizard 2006). Jennifer Ruger has systematically explored the capabilities approach to the right to health (Ruger 2006). In her analysis, capabilities are clarified by reference to a social choice paradigm known as ‘incompletely theorized agreements’ (ITA), which allow the capability approach to resolve divergent

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views on health capability (Sen’s ‘dominance partial ordering’). In this view, it is not necessary to determine a comparative value for various health outcomes (freedom from violence vs. freedom from infectious disease, for example) although it may be useful to distinguish between ‘central’ and ‘non-central’ health capabilities (such as freedom from extreme poverty, which is a prerequisite for other capabilities, such as prevention of a specific disease) (Ruger 2006). The value of Ruger’s analysis for the functioning of international institutions lies in the applications of the ITA framework to complement the capability approach where different people or countries have different and sometimes conflicting views on health policy or priorities, as is often the case in the international policy setting. This framework would enhance the potential for reasoned public policy decision making in particular situations, or on central aspects of health and capabilities, while disagreement may persist on non-central aspects. As Ruger says, ‘It also allows for different paths to the same conclusion’ (Ruger 2006). These recent efforts to expand the theoretical understanding of capability reinforce the trend of international institutions, especially UNDP, to introduce the capability approach to development thinking and practice. The grounding of the approach in development economics and its ever more meaningful linkages to developments in human rights make it the most appealing theoretical framework for a human rights based approach to health and development, and one which can help move from theory to practice.

Human rights-based approaches to health and development in practice Perhaps the most frequent linking of human rights, health and human development in policy has been the so called ‘rights-based’ approach to development, affirming that development should be pursued in a ‘human rights way’ or that human rights must ‘be integrated into sustainable human development.’ The ‘rights way to development’ is the shorthand expression for ‘the human rights approach to development assistance,’ as articulated in the 1990s by André Frankovits of the Human Rights Council of Australia. The essential definition of this approach is ‘that a body of international human rights law is the only agreed international framework which offers a coherent body of principles and practical meaning for development cooperation, [which] provides a comprehensive guide for appropriate official development assistance, for the manner in which it should be delivered, for the priorities that it should address, for the obligations of both donor and recipient governments and for the way that official development assistance is evaluated’ (Human Rights Council of Australia 1995). Frankovits is echoed by NGO advocates of a human rights-based approach (Häusermann 1998). This section describes the policy of the principal human rights unit of the UN and related policies adopted by several other UN agencies having responsibilities in the areas of health and development.

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Policies and practices of international organizations The sub-section will examine experiences at the global, bilateral and local levels, beginning with the Office of the High Commissioner for Human Rights (OHCHR). The OHCHR defines ‘rights-based approach to development’ as: A rights-based approach to development is a conceptual framework for the process of human development that is normatively based on international human rights standards and operationally directed to promoting and protecting human rights. (United Nations Commissioner for Human Rights 2008) Essentially, a rights-based approach integrates the norms, standards and principles of the international human rights system into the plans, policies and processes of development. The norms and standards are those contained in the wealth of international treaties and declarations. The principles of a rights-based approach to development generally include the following: express linkage to rights; accountability; empowerment; participation; and, nondiscrimination and attention to vulnerable groups (United Nations High Commissioner for Human Rights 2008). UNICEF contributed to the translation of the ideas of rights-based development into development practice through its human rights-based approach to programming (HRBAP) (Jonsson 2003). UNDP adopted a policy in 1998 of integrating human rights into sustainable human development (United Nations Development Programme 1998) and currently applies a rights-based approach to programming, supports national human rights action plans, and provides assistance for human rights initiatives involving civic educations, awareness-raising campaigns, strengthening or creation of ombudsman offices and extension of human rights institutions to the sub-national level.’ (United Nations Development Programme 2008). These definitions have now been merged into the current strategy for cooperation among UN agencies in implementing a human rights approach is found in Action 2. The ‘Action 2 Initiative’ is part of the Secretary-General’s 2002 reform proposals (United Nations General Assembly 2002) and calls for joint UN action to strengthen human rights related actions at the country level. The Action 2 interagency Task Force, consisting of OHCHR, UNDP, UNFPA, UNICEF, and UNIFEM, has pursued the clarification and training of staff in this approach, including an Action 2 Global Programme and a common learning package. In 2007, the Working Group on Training, in collaboration with the UN System Staff College, issued The UN Common Learning Package on Human Rights-Based Approach (HRBA), building on the experience of all agencies (United Nations Development Group 2007). The Programme became fully operational in 2006 (Action 2 Global Programme 2007). The growing trend among scholars, development NGOs and international institutions is to integrate into the human rights-based approach to development both concepts that already had currency in development theory – such as accountability and transparency as part of good governance – and new a

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dimensions with which development practitioners were less familiar – especially the explicit reference to government obligations deriving from international human rights law and procedures. For the development practitioner in the field of public health, four guiding principles for action steps may be considered to move from human rights theory to development practice.

Define socioeconomic issues in terms of rights Issues of health, education, food, shelter, labor, vulnerability, marginalization, equity, gender, and similar matters are constant concerns of the development practitioner. The International Covenant on Economic, Social and Cultural Rights has formulated them all in normative terms. The challenge is to learn the similarities and differences in the understanding of these concepts in the contexts of development planning and implementation, on the one hand, and human rights, on the other.

Refer to obligations of the main human rights treaties The seven main human rights treaties contain commitments that States parties have made in areas directly affecting development. It is appropriate – and even mandated by the Memorandum of Understanding between the High Commissioner for Human Rights and the Administrator in the case of UNDP of March 4, 1998 – to draw on these obligations in discussion with governments regarding their development plans and priorities. One need not consider it too political or controversial, for example, to draw a government’s attention to a project that acquiesces to or results in some form of discrimination in access to health care. In that case, explicit reference to that government’s obligations under the Covenant should be part of the discussion. The treaty monitoring committees, especially the Committee on Economic, Social and Cultural Rights, have issued thoughtful interpretations of the content of specific rights, with examples of what they expect States parties to do to fulfill their obligations with respect to those rights. The public health practitioner would benefit from a careful reading of General Comment 14 on the right to health and other General Comments of direct relevance to health, such as General Comments 18, 19, and 24 of the Committee on the Elimination of discrimination Against Women (dealing respectively with disabled women, violence against women and women and health) or General Comment 3 of the Committee on the Rights of the Child (dealing with HIV/AIDS and the rights of the child). It is especially important to reflect on the concepts of ‘core minimum obligations’ (Committee on Economic Social and Cultural Rights 1900).

Apply the participatory method Participation is part of most development strategies. The human rights framework enhances this dimension of development and surrounds it with certain guarantees, such as freedom of association and expression, the right to information, and protection from arbitrary treatment of persons who express

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critical views. The right to development provides a normative basis for making participation an essential dimension of development planning, and community-based action using human rights learning offers an in depth model for ensuring effective participation at the local level. The Declaration on Human Rights Defenders, the resolutions on the UN Decade for Human Rights Education, and the Declaration on the Right to Development provide useful reference points for advocating participation.

Balance cooperative and accusatory modes Development practitioners tend to shy away from human rights because the human rights approach conjures up a confrontational ‘naming and shaming’ approach used by organizations like Amnesty International and Human Rights Watch. While these organizations do use pressure on states by calling attention to their shortcomings, human rights advocacy is not at all limited to that mode of interaction. The cooperative mode, often readily observed in the practice of the treaty monitoring bodies, offers ample opportunity for both foreign development partners (bilateral and multilateral) and domestic civil society organizations to interact productively with ministerial officials and other government agents of development. Explanations, information, indications of best practices, and the like are often more effective than threats of publicity or prosecution. Understanding the nature of government responsibilities, as well as those of individuals and non state actors, is essential to knowing when and how to shift from the cooperation to the accountability mode.

Policies and practices of bilateral donors and NGOs Many bilateral donors have explicit mandates for human rights in development. Their experience can be valuable in developing the skills needed for human rights monitoring of development projects. This trend has been particularly noticeable in setting the policy of donor countries. A recent study by OECD on the approaches of its member states drew the lesson that ‘human rights offer a coherent normative framework which can guide development assistance’ (Organization for Economic Co-operation and Development 2006). The advantages identified by OECD relate to adaptability to difference political and cultural environments, the potential for operationalizing human rights principles, relevance to good governance and meaningful participation, poverty reduction and aid effectiveness (Organization for Economic Co-operation and Development 2006). In February 2007, the OECD adopted its Action - Oriented Policy Paper on Human Rights and Development (Organization for Economic Co-operation and Development 2007). Other governments have adopted human rights-based approaches to development and even compared experiences among bilateral donors (Frankovits and Earle 2000; Piron and O’Neil 2005). Extensive analysis and elaborate policy papers have been drawn up by the major European and Canadian funding agencies, incorporating a human rights approach, most notably by the

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British Department for International Development and the Swedish International Development Agency. Several major development NGOs, such as Oxfam, CARE, Save the Children and Médècins sans frontières (MSF) have similarly embraced a human rights framework for their operations (Nelson and Dorsey 2003; Sano 2000). Physicians for Human Rights (PHR), conducts investigations and denounces behavior that violates internationally recognized human rights (Sirkin et al. 1999). Habits of local NGOs and other elements of civil society, such as traditional practices harmful to heath or contrary to equity, may impede or help with integrating human rights into sustainable human development. The development practitioner should identify the human rights constituency within the civil society that can take the lead in dealing with traditional practices. Most intractable among these is entrenched corruption in government and civil society, which runs directly counter to equity concerns and participatory aspects of the human rights approach.

The human rights learning at the community level A third application of human rights in the practice of development of value for health promotion is that of human rights education and learning (HRL). As understood here, HRL is close to the concept of community-based development work or participatory action research (PAR). The essence of these ideas is that the most effective means of enhancing people’s capabilities is to facilitate their own social transformation through participation in the decisions that affect development. When the United Nations General Assembly proclaimed the UN Decade for Human Rights Education (1995–2004) in 1994, it gave an acceptable definition of human rights education in acknowledging that it ‘involves more than providing information but rather is a comprehensive life long process by which people at all levels of development and in all strata of society learn respect for the dignity of others and the means and methods of ensuring that respect within a democratic society’ (United Nations General Assembly 1993). Government acceptance of HRL is further reflected in the Declaration on Human Rights Defenders (officially known as the ‘Declaration on the Right and Responsibility of Individuals, Groups and Organs of Society to Promote and Protect Universally Recognized Human Rights and Fundamental Freedoms’), which was adopted on the occasion of the 50th anniversary of the Universal Declaration of Human Rights (United Nations General Assembly 1998). That Declaration covers human rights training and education, including the duty to facilitate human rights education at all levels of schooling, and in particular in the training of lawyers, law enforcement officials, members of armed forces, and public officials (United Nations General Assembly 1998). The Declaration recalls various human rights treaties establishing the duty of States parties to adopt measures to promote human rights through teaching, education, and training; to ensure the widespread dissemination of information about national and international human rights laws; to report

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to UN treaty bodies; and to encourage states to support the establishment of independent human rights institutions, such as human rights commissions and ombudspersons. These are useful commitments on which development practitioners can build when working with governments on integrating the HRL approach into their human rights agenda. The most salient feature of HRL is the concept and practice of a transformative pedagogy of human rights, which holds the potential for altering the power structure behind most forms of oppression and repression. Indeed, if people everywhere commit to building a political culture based on the right and responsibility of everyone to respect, ensure, and fulfill human rights for all, the space for abuse of public trust, violence against the physical and mental integrity of others, and exploitation of the vulnerable will contract. Clarence Dias has listed five ways in which HRL contributes to development: by helping monitor development activities; by mobilizing support for victims’ struggles for rehabilitation, redress, and justice; by promoting understanding of the rationale for development; by securing more effective participation in the development process; and by securing accountability for those responsible for misuse of public resources (Dias 1997). Human rights learning, as defined here, is promoted by NGOs such as PDHRE, People’s Movement for Human Rights Learning and Human Rights Education Associates (HREA), and has been adopted in part by the Office of the High Commission for Human Rights (United Nations General Assembly 1997) and by the World Health Organization in the area of reproductive health and rights (World Health Organization 2001). Moreover, support by international agencies like UNDP for international and local NGO projects based on such an approach is consistent with the resolutions and plan of action of the UN Decade for Human Rights Education and the world Programme for Human Rights Education. The technical approach of those agencies reassures governments while dealing with issues that are fundamentally political. Extensive information is available on the various approaches to conducting HRL activities in a wide range of settings (Andreopoulos and Claude 1997; People’s Movement for Human Rights Learning 2006) and on resources and contacts (Elbers 2000). The basic precepts of HRL give content to the participation concept in development. In practical terms, HRL as a development strategy focuses on non-formal human rights education in which the human rights educator’s role is that of ‘facilitator’ rather than ‘teacher.’ More specifically, it is ‘goaloriented non-formal education,’ that is, organized, systematic educational activity outside the school system that is designed to reach any of the following six goals – as articulated by Richard Claude (Claude 2007): enhance knowledge; develop critical understanding; clarify values; change attitudes; promote solidarity; and, alter behavior or practice. When all six are met, the most important goal can be achieved: empowerment, which Richard Claude defines as ‘a process through which people and/or communities increase their control or mastery over their own lives and the decisions that affect their

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lives’ (Claude 2000). A constant concern of the human rights educator is to make the learners aware of their right to know their rights and especially their right to claim them. It is in this sense that we refer to human rights education as ‘transforming beggars into claimants,’ that is, shifting from development as charity to development as the realization of capabilities. It is therefore essential that HRL apply ‘participatory methodologies’ to provide an experiential foundation for learning. The learning process, according to this methodology, is not memorization of information communicated by the instructor, but an experience through which learners acquire understanding by engaging in social change directly related to development. The HRL approach can take many forms, from small group community taskforces to the creation of human rights cities or communities. The concept of human rights communities, as promoted by PDHRE, is based on the idea of members of a community accepting human rights obligations in all aspects of community life, whether in the family (for example, agreeing to respect the rights of women and children as defined in CEDAW and CRC regardless of contrary traditional practices), in professional life (for example, judges agreeing to apply national and international human rights law in their courts), and in sum in all the contexts of social life. The idea has been implemented in several cities in different parts of the world (Rosario, Argentina; Graz, Austria; Bihac, Bosmia; Porto Alegre, Brazil; Edmonton, Canada; Temuco, Valparaiso, Chile; Bonyo, Newton, Wa, Nimamobi and Walewale, Ehana; Korogocho, Kenya; Timbuktu, Kayes, Sikasso, Konna, Gao, Bara Sara and the 5th District of Bamako; Musha Rwanda; Mogale, South Africa; Washington, DC, USA; and other information) and is being expanded with the assistance of UNPD. Improving access to and quality of health is central to this process (People’s Movement for Human Rights Learning 2007).

Conclusion The theoretical links between development, human rights and health are best understood in terms of social justice, a holistic understanding of social process, and capabilities. These approaches are not exhaustive or mutually exclusive but cover the main ways in which human rights can be understood as integrally linked to human development, with special reference to health. The practice of international agencies, national governments, and civil society is instructive on the transformation of these theoretical constructs into policies, resource allocation and programs. The setting in which a health policy may be modified to respond to human rights concerns varies considerably from one situation to another. The range of approaches surveyed here illustrates some of those settings. The health practitioner, whether holding positions of responsibility in government, working for an NGO, or representing and international agency, stands at the front lines of the effort to transform the human rights framework from the theory of academics or the rhetoric of resolutions adopted in New York and Geneva into practice that affects people’s lives and health.

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Notes 1. This chapter draws in part on the author’s chapter on ‘Human Rights in Development: The Significance for Health’, in S. Gruskin et al. (eds), Perspectives on Health and Human Rights (New York: Taylor and Francis, 2005) pp. 95–116. 2. The concept of capabilities has also been articulated by Martha Nussbaum, who collaborated with Sen, in numerous writings. See, for example, Crocker (1992), Nussbaum (1988, 1993). 3. In 2007, the Working Group on Training, in collaboration with the UN System Staff College, issued The UN Common Learning Package on Human Rights-Based Approach (HRBA), building on the experience of all agencies (United Nations Development Group 2007).

References Action 2 Global Programme (2007) 2006 Annual Report (New York, NY: Action 2 Global Programme). Anand, S. et al. (eds) (2002) Public Health, Ethics, and Equity (Oxford: Oxford University Press). Andreopoulos, G.J. and R.P. Claude (eds) (1997) Human Rights Education for the TwentyFirst Century (Philadelphia, PA: University of Pennsylvania Press). Burci, G.L. and C.-H. Vignes (2004) World Health Organization (Aspen, CO: Aspen Publishers, Inc.). Claude, R.P. (2000) Popular Education for Human Rights: 24 Participatory Exercises for Facilitators and Teachers (Amsterdam and Cambridge, MA: Human Rights Education Associates). Claude, R.P. (2007) Methodologies for Human Rights Education. A project of the Independent Commission on Human Rights Education (New York: People’s Movement for Human Rights Learning). Committee on Economic Social and Cultural Rights (1990) General Comment No. 3, UN Doc. E/1991/23, Annex III, para. 10. Crocker, D.A. (1992) ‘Functioning and Capability: The Foundations of Sen’s and Nussbaum’s Development Ethic’, Political Theory, 20(4): 584–612. Daniels, N. (2005) ‘Fair Process in Patient Selection for Antiretroviral Treatment in WHO’s Goal of 3 by 5’, The Lancet, 366(9480): 169–71. Daniels, N. et al. (2000) ‘Benchmarks of Fairness for Healthcare Reform: a Policy Tool for Developing Countries’, Bulletin of the World Health Organization: the International Journal of Public Health, 78(6): 740–50. Daniels, N. et al. (2005) ‘An Evidence-based Approach to Benchmarking the Fairness of Health-sector Reform in Developing Countries’, Bulletin of the World Health Organization : the International Journal of Public Health, 83(7): 534–41. Dias, C.J. (1997) ‘Human Rights Education as a Strategy for Development’, in Human Rights Education for the Twenty-First Century, edited by G.J. Andreopoulos and R.P. Claude (Philadelphia: University of Pennsylvania Press), pp. 52–3. Elbers, F. (ed.) (2000) Human Rights Education Resourcebook (Cambridge, MA: Human Rights Education Associates). Farmer, P. (2003) Pathologies of Power. Health, Human Rights and the New War on the Poor (Berkeley: University of California Press).

138 Part II: Perspectives and Experiences Frankovits, A. and P. Earle (2000) ‘Report of the Donor Workshop 2000, The Stockholm Workshop on the Human Rights Approach to Development Cooperation’, available at http://www.sida.se/shared/jsp/download.jsp?f=hr_2.pdf&a=16375. Global Equity Gauge Alliance (2003) ‘The Equity Gauge: Concepts, Principles, and Guidelines. A Guide for Social and Policy Change in Health’, available at http://www.gega.org.za/download/gega_guide.pdf. Häusermann, J. (1998) A Human Rights Approach to Development (London: Rights and Humanity). Human Rights Council of Australia (1995) The Rights Way to Development: A Human Rights Approach to Development Assistance (Sydney: Human Rights Council of Australia). Jonsson, U. (2003) Human Rights Approach to Development Programming (New York: United Nations International Children’s Emergency Fund). Kim, J.Y. et al. (eds) (2000) Dying for Growth: Global Inequality and the Health of the Poor (Monroe, ME: Common Courage Press). Krieger, N. (2000) ‘Discrimination and Health’, in Social Epidemiology, edited by L.F. Berkman and I. Kawuchi (New York: Oxford University Press), pp. 36–75. Krieger, N. (2001) ‘Commentary: Society, Biology and the Logic of Social Epidemiology’, International Journal of Epidemiology, 30(1): 44–6. Nelson, P.J. and E. Dorsey (2003) ‘At the Nexus of Human Rights and Development: New Methods and Strategies of Global NGOs’, World Development, 31(12): 2013–26. Nussbaum, M. (1988) ‘Nature, Function, and Capability: Aristotle on Political Distribution’, Oxford Studies in Ancient Philosophy, Supplement: 145–84. Nussbaum, M. (1993) ‘Non-Relative Virtues: An Aristotelian Approach’, in The Quality of Life, edited by M. Nussbaum and A. Sen (Oxford: Clarendon Press), pp. 1–6 Nussbaum, M. (1999) ‘Capabilities, Human Right, and the Universal Declaration’, in The Future of International Human Rights, edited by B.H. Weston and S.P. Marks (Ardsley, NY: Transnational Publishers Inc.). Organization for Economic Co-operation and Development (2001) Strategies for Sustainable Development: Practical Guidance for Development Co-operatioon, DCD/ DAC(2001)9 (Paris: Organization for Economic Co-operation and Development). Organization for Economic Co-operation and Development (2006) Integrating Human Rights into Development: Donor Approaches, Experiences and Challenges (Paris: Organization for Economic Co-operation and Development). Organization for Economic Co-operation and Development (2007) Action-Oriented Policy Paper on Human Rights and Development, DCD/DAC/15/FINAL (Paris: Organization for Economic Co-operation and Development). Oxfam International (2005) ‘Oxfam International’s Mission Statement’, available at http://www.oxfam.org/en/about/mission. Partners in Health (2007) ‘Advocacy’, available at http://www.pih.org/what/advocacy. html. People’s Movement for Human Rights Learning (2006) Human Rights Learning: A Peoples’ Report (New York: People’s Movement for Human Rights Learning). People’s Movement for Human Rights Learning (2007) ‘Human Right Cities – a Practical Way to Learn and Chart the Future of Humanity’, available at http://www. pdhre.org/projects/hrcommun.html. Piron, L.-H. and T. O’Neil (2005) Integrating Human Rights into Development: A Synthesis of Donor Approaches and Experiences (Paris: Organization for Economic Co-Operation and Development). Pogge, T. (2002) World Poverty and Human Rights: Cosmopolitan Responsibilities and Reforms (Cambridge: Polity Press).

Stephen Marks 139 Ruger, J.P. (2006) ‘Toward a Theory of a Right to Health: Capability and Incompletely Theorized Agreements’, Yale Journal of Law & Humanities, 17(2): 273–326. Sano, H.-O. (2000) ‘Development and Human Rights: The Necessary, but Partial Integration of Human Rights and Human Development’, Human Rights Quarterly, 22: 734–52. Sen, A. (1999a) Commodities and Capabilities (Oxford: Oxford University Press). Sen, A. (1999b) Development as Freedom (Oxford: Oxford University Press). Sirkin, S. et al. (1999) ‘The Role of Health Professional in Protecting and Promoting Human Rights’, in The Universal Declaration of Human Rights: Fifty Years and Beyond, edited by Y. Danieli et al. (New York: United Nations). United Nations (1986) Declaration on the Right to Development, Adopted by General Assembly resolution 41/128 of 4 December 1986. United Nations (1993) Vienna Declaration and Programme of Action, Adopted by General Assembly resolution 41/128 of 4 December 1986. United Nations Development Group (2007) ‘UN Common Learning Package on Human Rights-Based Approach (HRBA)’, available at http://www.undg.org/index. cfm?P=531. United Nations Development Programme (1998) Integrating Human Rights with Sustainable Human Development: a UNDP Policy Document (New York: United Nations Development Programme). United Nations Development Programme (2001) Human Development Report 2001 (New York: United Nations Development Programme). United Nations Development Programme (2002) Human Development Report 2002 (New York: United Nations Development Programme). United Nations Development Programme (2008) ‘Protecting and Promoting the Universal Values of Human Rights and Rule of Law, available at http://www.undp.org/governance/sl-justice.htm. United Nations General Assembly (1966a) International Covenant on Civil and Political Rights, Adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI) of 16 December 1966. United Nations General Assembly (1966b) International Covenant on Economic, Social and Cultural Rights, Adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI) of 16 December 1966. United Nations General Assembly (1993) GA Res. 48/127, 48th Sess. Supp No. 49 at 246 UN Doc. A/48/49 (vol. 1). United Nations General Assembly (1997) Report of the Secretary General, Guidelines for National Plans of Action for Human Rights Education, UN doc. A/52/469/Add.1. United Nations General Assembly (1998) GA Res. 53/144, Adopted on 9 December 1998. United Nations General Assembly (2002) Strengthening of the United Nations: an Agenda for Further Change, UN Doc. A/57/387 of 9 September 2002. United Nations High Commissioner for Human Rights (2007), ‘Rights-based Approaches’, available at http://www.unhchr.ch/development/approaches-04.html. Vizard, P. (2006) Poverty and Human Rights: Sen’s Capability Perspective Explored (Oxford: Oxford University Press). World Bank ‘Comprehensive Development Framework. Questions and Answers’, available at http://go.worldbank.org/CXLO25YMM0. World Health Organization (1946) Constitution (preamble). World Health Organization (2001) Transforming Health Systems: Gender and Rights in Reproductive Health: a Training Curriculum for Health Programme Managers (Geneva: World Health Organization).

8 Health and Development: an Ethics Perspective Andrea Boggio

If commissioned to depict on the canvas the status of global health, a Dutch painter from the sixteenth century would likely draw a wide open landscape with incumbent dark clouds. Although in the past century human health has collectively improved ‘more than during the entire previous span of human history’ (World Bank 1995), major challenges darken the picture. At the end of 2003, the late Director-General of WHO Lee Jong-wook noted that: Although aggregate global health indicators have improved substantially since the middle of the past century, the gross health inequalities highlighted in the Alma-Ata Declaration persist. Indeed, the gaps are widening between the world’s poorest people and those better placed to benefit from economic development and public health progress. (Jong-wook 2003) Data show that life expectancy varies drastically across the globe to the point that the lifespan of people in several less developed countries is no more than half that of many developed countries. Communicable diseases that had been eradicated in many regions of the world are re-emerging in ‘new clothes,’ now often resistant to existing drugs. Members of vulnerable communities are often exposed to greater health risks than the rest of the population. Every day, wars and severe poverty cause preventable deaths of countless individuals. All humans have a fundamental right to enjoy a meaningful life, and good health is an essential condition for enjoying a meaningful life. Yet many humans around the globe do not get a chance to enjoy a life free from suffering. It is hard to disagree with the view that there is something wrong with this picture. What should we do to improve this situation? How should we go about improving people’s life? Why? These questions are fundamentally moral ones. Is the present state of affairs of global health wrong? Should we do more to improve the life conditions of other humans? Are health inequalities acceptable? In this chapter, I explore these questions from the perspective of international organizations working on global health. I argue that 140

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international organizations have a moral obligation to redress the present state of affairs of global health and that this moral duty can be discharged if international organizations adhere to the principles of beneficence and justice. Finally, I will examine some of the implications for policymakers involved with addressing the challenges posed by global health.

Ethics as the foundation for international organizations’ actions International organizations as moral actors Underdevelopment and poor health conditions prevent people from enjoying ‘a good life’ – or wellbeing, in the economists’ and philosophers’ jargon. Living ‘a good life’ is a concept used in ethics to describe a non-instrumental good for a person – a good that is intrinsically valuable – that is, not merely by virtue of being instrumental to the acquisition of other goods (Kraut 2007). It is a concept so crucial to ethics that moral philosophers often evaluate whether or not an action is good or bad depending on its ability to respectively increase or decrease a person’s wellbeing. In many ways, international organizations’ health and development policies and programs are also about maximizing the wellbeing of the recipients by removing barriers that prevent people from enjoying ‘a good life’. The institutional mission of the UN, its bodies, and its specialized agencies umbrella is therefore ‘ethical’ in the sense that its actions matter morally. Should they also be judged in ethical terms? My argument is that international organizations are moral actors that owe certain duties to the recipients of the actions and that their policies and program should aim to discharge these duties. Ethics involves systematizing, defending, and recommending concepts of right and wrong behavior. If applied to the health and development problems discussed, ethical analysis turns to questions of the duty to redress underdevelopment so that individuals can achieve higher levels of wellbeing, and, in particular, on the foundations of such duty and on the principles that ought to govern the actions, policies, and programs aiming to discharge such duty to redress underdevelopment. Unfortunately, these questions are only rarely incorporated in the design of policies and programs, which rely almost exclusively on other analytical tools – primarily empirical evidence from various disciplines and political analysis. Throughout the chapter, I shall outline the foundations, principles, and processes that international organizations ought to consider in designing and implementing policies and programs. Before turning to the analysis, I shall stress a methodological point. While ethics commonly contemplates the actions of individuals, I focus exclusively on international organizations as collective moral actors, and not on the individuals who are a part of these institutions. Individuals may in fact contribute either directly (by personally taking part in development programs) or indirectly (for instance, by giving money to charities involved

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in humanitarian and development projects) to health development. However, analyzing actions and decision of individuals rather than organizations – what they ought to do – is beyond the scope of the chapter.

Beyond human rights Although accurate and tempting, framing the institutional aim of international organizations in terms of realization of human rights is insufficient. The idea that people starve, suffer from preventable diseases, and die prematurely is morally problematic. However, that international organizations owe a moral duty to redress underdevelopment is not the paradigmatic framework in which we think about health and underdevelopment. This role is increasingly played by the human rights framework. In recent years, the right to development has received international recognition as an ‘inalienable right of all human beings and peoples to participate in, contribute to, and enjoy economic, social, cultural, and political development, in which all human rights and fundamental freedoms can be fully recognized’ (United Nations 1986). Moreover, health is referred to as a basic human right (Lie 2004). The human rights approach has been particularly influential with regard to the United Nations and its agencies. In the years following the adoption of the Universal Declaration of Human Rights, several UN bodies have, in fact, reiterated the principle that health is a fundamental human right. Among them, the 1978 WHO Declaration of Alma Ata, the 1986 UN Declaration on the Right to Development, the 2002 ILO Resolution concerning healthcare as a basic human right, and the Human Development Report 2000 acknowledge the key role that human rights ought to play in the shaping health and development policies. Historical, legal, and theoretical reasons have all contributed to the rise of the human rights paradigm. Historically, the UN system was born as a reaction to the extreme violation of human rights and therefore the adoption on the part of the UN and its bodies of the human rights framework is in recognition of its origins and its mission. Legally, the UN, its bodies, and the member states are also bound to respect the human rights recognized under international law. ‘Human rights are international norms that help to protect all people everywhere from severe political, legal, and social abuses’ (Nickel 2006). Indeed, severe poverty and underdevelopment are increasingly argued to qualify as violations of basic human rights. Finally, the human rights approach is also very attractive from a theoretical perspective because of its undeniable strength in being perceived as a set of principles shared by humanity above the cultural and political context in which they are recognized. Although helpful and potentially transformative of the health and development thinking, the human rights framework alone is insufficient. Several critiques may be raised to challenge the human rights approach. However, for brevity, I will focus exclusively on two: their progressive realization

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argument and the ‘short-circuit’ argument. Firstly, human rights are rights to be progressively realized. Article 2.1 of the International Covenant on Economic, Social, and Cultural Rights sets out what the parties commit themselves to do about this list, namely to ‘take steps, individually and through international assistance and co-operation . . . to the maximum of its available resources, with a view to achieving progressively the full realization of the rights recognized in the present Covenant’ (United Nations General Assembly 1966). The legal instruments, and the case law setting forth human rights law, are often overly broad. Furthermore, extensive interpretation is needed to derive compelling practical implications from these broad, legal statements. This interpretative process is usually more uncertain and demanding than is conceded by many human rights lawyers. It is very difficult to arrive at a definition of what we really mean by a human right to health. How should policy makers realize these progressive rights? The answer to this question lies outside the human rights framework. Implementing human rights requires further deliberation. Thus, if it is agreed that human rights are to be progressively realized and that some form of reasoning ought to guide this process. Moral reasoning – reasoning about human wellbeing based on the impartial assessment of claims and the justification of proposed courses of action – is, in my judgment, the best candidate. Secondly, the language of rights may lead to a clash of competing rightsbased claims (the ‘short-circuit’ argument). A multitude of human rights coexists, which can be used as basis for a multitude of claims, which may compete one against the other. If we consider the scenario of the allocation in sub-Saharan Africa of a scarce amount of drugs protecting the recipient from a deadly, contagious disease, then the resident of a remote village in an isolated region has a human right-based claim to access the drug that is of equal strength to the inhabitant of a large urban area. Whose human rights ought to be realized? By framing all issues in terms of individual rights, the analysis is confined to narrow legal questions, often leading to incompatible claims. Moreover, human rights language, especially in the light of progressive realizability, does not provide a specific way to resolve disputes about competing claims that may arise. An excessive reliance on the right language in reasoning about health and development is not sufficiently conducive when analyzing complex questions.

The duty to redress underdevelopment International organizations are moral actors that have an obligation to redress underdevelopment and to favor human wellbeing and flourishing. Starting from the publication of Peter Singer’s path-breaking essay on ‘Famine, Affluence, and Morality’ (Singer 1972), moral philosophers have increasingly argued that institutions play a crucial role in shaping the wellbeing of individuals around the world – and especially the most vulnerable – and

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that therefore they ought to be aware of their responsibilities and to discharge in the best possible way their duty toward the underdeveloped. Based on the principle of the ‘Greater Moral Evil Principle’, Singer argues that there is a moral duty to prevent the suffering caused by poverty and deprivation whenever we can do it without sacrificing anything of comparable moral worth: ‘. . . if it is in our power to prevent something very bad from happening, without thereby sacrificing anything else morally significant, we ought, morally, to do it’ (Singer 1972). Since it is in our power to prevent suffering and death from lack of food, shelter, and medical care without sacrificing anything of comparable moral importance, it is the moral duty of the wealthier to prevent suffering and death from these causes. Although in 1972 Singer was mostly concerned with duties owed by individuals, in recent writings, the Australian philosopher has expanded the argument to incorporate the collective dimension of the duty to redress underdevelopment. In particular, noting that ‘more and more issues increasingly demand global solutions . . ., we need to strengthen institutions for global decision-making and make them more responsible to the people they affect’ (Singer 2002). Philosophers with approaches different from Singer’s utilitarianism agree with the conclusion that institutions play a crucial role in shaping the wellbeing of individuals around the world. Building upon the idea that unequal living conditions of people around the world cannot be justified and that poverty is an ongoing harm affluent countries inflict on vulnerable individuals, Thomas Pogge argues that a ‘just’ global order comprised of international institutions ought to be established (Pogge 2002): There is a shared institutional order that is shaped by the better-off and imposed on the worse-off [, which] is implicated in the reproductions of radical inequality in that there is a feasible institutional alternative under which severe and extensive poverty would not persist. (Pogge 2005) In sum, moral philosophers have offered persuasive arguments that affluent countries ought to remove any source of inequality (by reshaping the global institutional order) and any source of harm (by eradicating poverty). International organizations that are created and funded by governments to redress underdevelopment also possess the traits of moral actors: they are created with the purpose of ‘doing good’; they are capable of deciding the preferable course of action; they can take actions based upon their decisions. It follows that international organizations can be seen as moral actors owing certain duties to the underdeveloped, that they should activate themselves so that moral duties and discharged, and that they should be held morally accountable as any other moral actor, whether individual or a collective one. The remaining of the chapter discusses how to translate these moral requirements into actions.

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Discharging the duty to the underdeveloped A neutral approach to the ethics of underdevelopment There are several approaches that provide a basis for a moral obligation to design and implement policies and programs addressing health and development concerns. None of these approaches has been able to win universal assent for various reasons. Because of the diversity of views that are represented in international institutions, it is reasonable to analyze the ethical issues of health and development by presenting a series of principles that are potentially shared among competing moral theories rather than supporting a particular moral approach. Therefore, I propose a framework based on a limited set of substantive and procedural principles that should guide actors and institution engaged in redressing underdevelopment in discharging their duty to redress underdevelopment. Traditionally, political scientists analyse political decisions in terms of authority (who decides?) and legitimacy (under what conditions?). Often in concert with national government, international organizations’ funding bodies are entrusted with the authority to design and implement health and development policies and programs. Thus, in health development, questions of authority are less pressing than questions of legitimacy. There is growing agreement that international organizations’ policies and programs earn legitimacy, but not that they are efficient and fair. In moral terms, efficiency and fairness translate in the principles of beneficence and justice, which ought to be the primary principles guiding international organizations in designing and implementing health and development policies and programs.

Beneficence Economists consider a policy or a program to be efficient when the unit of desired improvement is produced at the lowest possible cost. Ethicists consider the problem of the efficiency in broader terms, considering as a basis for the scrutiny the capacity of people to enjoy wellbeing and to live a life worth living. Actions contributing to increasing the opportunities for wellbeing are considered to be morally justifiable and sometimes even required. ‘Beneficence’ is used in philosophy to refer to the principle that imposes on moral actors the duty to act so that the wellbeing of human beings is expanded. In fact, few would disagree that, to discharge their duty to the underdeveloped, international organization ought to adopt and implement policies and programs that improve the living conditions of those living under conditions of poverty and health deprivation. The principle of beneficence embodies the duty to help others further their important and legitimate interests. John Stuart Mill argues that actions are to be judged according to ‘utility in the largest sense, grounded on the permanent interest of man as a progressive being’ (Mill 1869). Undeniably, wellbeing is a legitimate

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interest of humanity, even for thinkers with political or philosophical views different from Mill’s. What does ‘making things better’ entail in the context of health and development? What measures should the international community and international organizations implement to discharge their obligations? To adhere with the principle of beneficence, international organizations’ policies and program must: (1) not harm the recipients but remove or reform policies and arrangements that create barriers to development and improving poor health conditions; (2) address the ultimate determinants of poverty and health deprivation such as the social determinants of health, preventing conflict, reducing corruption, and establishing local conditions of good governance; and (3) respect recipients’ autonomy and values. Firstly, beneficence requires ‘not harming.’1 People living under conditions of poverty and health deprivation are already the worse off globally. Dale Jamieson persuasively argues that, ‘[r]ather than advocating ambitious agendas to remake the world, we should focus first and primarily on challenging those structures that bring about and maintain global poverty’ (Jamieson 2005). Therefore, the minimal content of the moral duty owed to them substantiates in not increasing the present burdens affecting the lives of those living in conditions of extreme poverty. These burdens include shorter life expectancy, diseases that disproportionately affect less developed countries, wars, famine, and violations of human rights. ‘Not harming’ requires the implementation of health programs that do not increase the rate of preventable diseases, do not lead to creating an environment of poverty and exploitation, do not focus on a limited set of variables but scrutinize and incorporate various determinants of poor health into the policy framework, to name a few. International organizations must also remove or reform policy frameworks and arrangements that create barriers to development and improving poor health conditions. Trade barriers and the appropriation of the global commons by the rich nations through IPRs are clear examples of regulatory arrangements that act as obstacles to health development. Thomas Pogge proposes a reform of the system oriented towards favoring health development: The rules should be redesigned so that the development of any new essential drug is rewarded in proportion to its impact on the global disease burden (not through monopoly rents). This reform would bring down drug prices worldwide close to their marginal cost of production and would powerfully stimulate pharmaceutical research into currently neglected diseases concentrated among the poor. Its feasibility shows that the existing medical-patent regime (TRIPS as supplemented by bilateral agreements) is severely unjust – and its imposition a human rights violation on account of the avoidable mortality and morbidity it foreseeably produces. (Pogge 2006)

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Secondly, beneficence requires thinking about the ultimate causes of poverty and health deprivation. ‘Not harming’ is a demanding, yet insufficient goal of programs and policies redressing health underdevelopment. Beneficence also requires interventions that go beyond removing the immediate determinants of poverty and health deprivation and remove the ultimate causes of health deprivation. Wellbeing is a multidimensional goal, and development policies must be multidimensional and consider the complex range of factors that determine poverty and health deprivation – security, governance, and sustainability, to name a few. For instance, armed conflicts are a primary cause of poverty and health deprivation. Poverty is at the root of many conflicts around the world, and conflicts foster living in conditions of poverty and are detrimental to health and health systems (Collier and Dollar 2004). Good governance is certainly another precondition of development. Corruption practices – involving officials working for international organizations, local governments, or other bodies operating in the field of human development – subtract money and other resources. Globally, as much as 25 per cent of procured medicines can be lost to fraud, bribery and other corrupt practices (Ensor and Duran-Moreno 2002). Governance and accountability rules are therefore essential in any effort to redress underdevelopment. Thus, the mechanisms of allocation of development aid must be set up in such a way that the various agencies engaged in fighting underdevelopment should prevent development funds from being managed by corrupt officials at the local level (United Nations 2006). Thirdly, beneficence requires that autonomy and values are respected. Policies and programs cannot be said to truly maximize the wellbeing of the recipients if they disregard their preferences and values. The ability to choose the life that is good for oneself is the cardinal way to achieve wellbeing because each individual is the best judge of his or her own interests. Protecting autonomy and diversity of views and values must be central to development policies. Amartya Sen has elegantly summarized this idea by stating that ‘[d]evelopment can be seen . . . as a process of expanding the real freedoms that people enjoy’ (Sen 1999). If development is based on freedom, freedom can only be a realistic option in a political and institutional environment that recognizes and preserves fundamental rights and liberties. And it is the duty of international organizations, among others, to create such an environment and to respect different values.

Justice There are many different conceptions of, spheres in, and levels at which justice operates. In this chapter, I will consider the sphere of international justice and its implications for international organizations in deciding and implementing health and development policies and programs. In this context, justice operates primarily as a normative principle that international organizations ought to adhere to in making decisions from a procedural point of

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view (how decisions are made) and from a substantive one (what outcomes are reached). From a procedural standpoint, the principle of justice is often seen as a leading principle in making choices and as ‘the first virtue of social institution’ (Rawls 1971). Therefore, decisions should be reached fairly, simply in order for them to be ethical. From this general principle of justice, we ought to derive secondary principles that, once followed, lead to the shaping of a decision-making framework that is fundamentally ‘just’. There is some agreement among political philosophers that these secondary principles or conditions comprise publicity, relevance, and revisability – as proposed and defended by Normal Daniels and Jim Sabin (Daniels and Sabin 2002) – and name the resulting process a ‘deliberative framework’ (Cohen 1996; Cooke 2000). Emphasizing a shared process of discussion, following rules of rational argument and non-coercive exchange of views, Joshua Cohen, a prominent deliberative democracy scholar, argues that ‘to justify the exercise of collective political power is to proceed on the basis of a free public reasoning among equals’ (Cohen 1996). The first of the conditions that must be met to have a ‘just’ deliberative framework is publicity. Publicity requires that the process is reasonably transparent, that the rationale of decisions is comprehensible and made public, and that reasonable arguments and evidence are adhered to. The relevance condition requires that institutions are arranged by their member states so that they are entrusted by the recipients of their policies and programs, that promote a wide participation in the debate, and that the outcomes take into consideration the needs, values, and aspirations of the program recipients. Stakeholder involvement may also offer an opportunity to protect the rights of those affected by health and development policies. The relevance condition is, therefore, a means to include and mediate between diverse, culturally and value-based points of view. Although apparently not efficient, this condition is ethically required, because respect for different value systems is an important part of implementing policies and programs at an international level. Finally, the revisability condition requires that policies and programs can be challenged and improved over time, and that the personnel responsible for them be accountable in instances of discriminatory conduct, the disregard of prevailing evidence and best practices, unreasonableness or non-cooperation. In addition to imposing procedural requirements, the principle of justice requires that the outcome of the deliberative process respects a minimum, substantive standard of fairness. A crucial aspect of substantive justice concerns priority setting and the allocation of scarce resources. The resources (funding, instruments, and human capital) available for designing and implementing health and development programs are limited, and often insufficient to address all of the needs of those who live in conditions of underdevelopment. How can policy makers and program directors set priorities and allocate development resources without offending the sense of

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justice that program recipients expect from international organizations? As with most of the issues in the field of applied ethics, the answer to this question is a difficult one indeed. The starting point of a justice-based analysis is to recognize that all human individuals, simply by virtue of their status as human, are entitled to equal moral consideration. On a very general level, this principle entails that the interests of an individual living under conditions of poverty and health deprivation must be considered to be equal to those of any other individual, whether living in similar conditions or in a developed nation. The body in charge of deciding or implementing a program must define and articulate the subjective scope of its obligation – whose interests ought to be given consideration – which is in part defined by the nature of the policies and programs that must be adopted. For instance, a policy discussion on the legality of limitations of IPRs affects subjects in both developed countries (pharmaceutical companies holding IPRs) and in less developed countries (communities in need of affordable drugs); a policy discussion on the allocation of affordable drugs among people affected by a specific condition will have a narrower scope – limited to those in need of the drugs. In all cases, however, equal consideration of interest must not be designed discriminatorily. Once agreed that equal moral consideration is a fundamental trait of a justice-based approach in priority setting and the allocation of scarce resources, listing which characteristics ought to be taken into consideration in defying equal moral consideration is a difficult task. Unfortunately, there is no fixed set of principles or rules that can be invariably applied by policy makers and development actors. The variability of the factual contexts in which priorities are set and allocations are made prevents ethicists from recommending a set of principles that can be universally applied. If a distributive justice checklist is not realistic, each decision to exclude potential recipients from enjoying health and development programs must be justified any time it is made. To justify these decisions, an ethically-informed deliberative process that follows the condition analyzed above (publicity, relevance, and revisability) will lead to the ethically preferable decision, which will enable international organizations to discharge their moral duty toward the underdeveloped.

Ethics as an ideal framework for reasoned policy decisions International organizations are moral actors that have specific moral obligations that consist in maximizing the wellbeing primarily (but not exclusively) of those living in conditions of poverty and health deprivations. Two moral principles – beneficence and justice – ought to guide international organizations in discharging their moral duty. To adhere to the principle of beneficence, international organizations’ policies and program must: (1) not harm the recipients and remove or reform those policies and arrangements

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that create barriers to development and improving poor health conditions; (2) address the ultimate determinants of poverty and health deprivation such as the social determinants of health, preventing conflict, reducing corruption, and establishing local conditions of good governance; and (3) respect recipients’ autonomy and values. In order to adhere to the principle of justice, international organizations’ policies and programs in health and development must be the outcome of a deliberative process meeting certain conditions (publicity, relevance, and revisability) and must satisfy minimal requirements of justice by assuring the equal moral consideration of all potential recipients. In sum, ethics require an understanding of the proper role that international organizations ought to play as moral actors and a deliberative framework that leads to choices that adhere to the greatest possible extent of moral principles. Consequently, ethics require that ‘there is a space for deliberation in which reasonable people will disagree about what is ethically required, either from a human rights perspective or from other ethical conceptions’ (Daniels 2004). This deliberative space differs from existing decision-making arrangements, which are predominantly either technical, and rely exclusively on empirical evidence, or are political, and rely exclusively on power balances and political constraints. An ethically based deliberative space is inherently different because it expands the policy horizon by considering value judgments that lie underneath technical and political choices. Judgments based exclusively on technical efficiency or political opportunity are incomplete, and values – whether based on culture, beliefs, ideologies, or interests – must not be not submerged within technical conclusions. Value judgments about the importance of the interests at stake are of primary importance, because they speak to what people hold as being important to them, and thus what is instrumental to achieve their wellbeing. An ethically grounded approach brings values to the surface and enables decision makers to assess empirical evidence, to distinguish empirical from normative issues, to manage competing values, and to achieve consistent policy outcomes that are based on a homogenous set of values. International organizations must address their moral leadership in resolving poverty and health deprivation, and ethics is the ideal, intellectual and political, space for deliberating and justifying actions that ultimately lead to improving the wellbeing of those who need it the most.

Note 1. Sometimes for ethicists the requirement not to harm is construed separately from beneficence and called the ‘principle of non maleficence.’ Although the subtleties of conceptual categorizations are at the core of ‘doing philosophy’ – and the distinction between ‘doing good’ and ‘not doing harm’ ought to be carefully

Andrea Boggio 151 investigated – the scope and purpose of this chapter does not require such an effort. What is important is that those engaged in designing and implementing programs aiming to redress underdevelopment are conscious that ‘doing good’ requires first of all not to harm the beneficiaries of such programs.

References Cohen, J. (1996) ‘Procedure and Substance in Deliberative Democracy’, in Democracy and Difference: Contesting the Boundaries of the Political, edited by S. Benhabib (Princeton, NJ: Princeton University Press, 1996), pp. 95–119. Collier, P. and D. Dollar (2004) ‘Development Effectiveness: What Have We Learnt?’, The Economic Journal, 114(496): F244–F271. Cooke, M. (2000) ‘Five Arguments for Deliberative Democracy’, Political Studies, 48(5): 947–69. Daniels, N. (2004) ‘How to Achieve Fair Distribution of ARTs in “3 by 5”: Fair Process and Legitimacy in Patient Selection’ (Prepared for WHO consultation, Geneva). Daniels, N. and J.E. Sabin (2002) Setting Limits Fairly: Can We Learn to Share Medical Resources? (New York: Oxford University Press). Ensor, T. and A. Duran-Moreno (2002) ‘Corruption as a Challenge to Effective Regulation in the Health Sector’, in Regulating Entrepreneurial Behaviour in European Health Care Systems (European Observatory on Health Care Systems), edited by R.B. Saltman et al. (Maidenhead: Open University Press), pp. 106–24. Jamieson, D. (2005) ‘Duties to the Distant: Aid, Assistance and Intervention in the Developing World’, The Journal of Ethics, 2: 151–70. Jong-Wook, L. (2003) ‘Global Health Improvement and WHO: Shaping the Future’, The Lancet, 362(9401): 2083–8. Kraut, R. (2007) What is Good and Why: the Ethics of Well-being (Cambridge, MA: Harvard University Press). Lie, R. (2004) ‘Health, Human Rights and Mobilization of Resources for Health’, BMC International Health and Human Rights, 4(1): 4. Mill, J.S. (1869) On Liberty (London: Longman, Roberts & Green). Nickel, J. (2006) ‘Human Rights’, Stanford Encyclopedia of Philosophy. Available at http://plato.stanford.edu/entries/rights-human. Pogge, T. (2002) World Poverty and Human Rights: Cosmopolitan Responsibilities and Reforms (Cambridge: Polity Press). Pogge, T. (2005) ‘World Poverty and Human Rights’, Ethics and International Affairs, 19(1): 1–7. Pogge, T. (2006) ‘Human Rights and Global Health: a Research Program’, in Ethics and Infectious Disease, edited by M. Selgelid et al. (Oxford: Blackwell), pp. 285–314. Rawls, J. (1971) A Theory of Justice (Cambridge, MA: Harvard University Press). Sen, A. (1999) Development as Freedom (Oxford: Oxford University Press). Singer, P. (1972) ‘Famine, Affluence and Morality’, Philosophy and Public Affairs, 1(1): 229–43. Singer, P. (2002) One World: The Ethics of Globalisation (New Haven, CT: Yale University Press). United Nations (1986) Declaration on the Right to Development, Adopted by General Assembly resolution 41/128 of 4 December 1986.

152 Part II: Perspectives and Experiences United Nations ‘UN Health Agency Launches Attack on Multi-billion-dollar Counterfeit Medicine Market’, available at http://www.un.org/apps/news/story.asp? NewsID=20462&Cr=who&Cr1. United Nations General Assembly (1966) International Covenant on Economic, Social and Cultural Rights, Adopted and opened for signature, ratification and accession by General Assembly resolution 2200A (XXI) of 16 December 1966. World Bank (1995)World Development Report 1995: Workers in an Integrating World (New York: Oxford University Press).

Part III The Global Health and Vulnerability

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9 Health and Development: the Role of International Organizations in Population Ageing Chris Phillipson, Carroll Estes, and Elena Portacolone1

Doña Barbara never had a chance to save for old age. She and her husband are subsistence farmers living in the high plains of Bolivia. Doña Barbara is entitled to a small annual pension, but she has no birth certificate, so has not been able to make a claim. Doña Barbara and her husband have stomach pains because of their poor diet. Health is a constant worry. They are entitled to free healthcare but there are no doctors within reach. Their daughters help when they can, but they live far away from them (HelpAge International 2006). Wilson’s four nieces and nephews have lived in his home in Juba, Sudan since his wife’s sister and then her husband died. Wilson had five children but they are all dead. ‘There is nobody who can help us now. I used to work as a builder but I’m not strong enough anymore’. Wilson still finds it hard to come to terms with the death of his last daughter. ‘I’ve been trying to find the money to go to Khartoum so that I can see her grave, so I can believe she is really gone’ (HelpAge International 2006). John Riukaamya is a 73-year-old from Kampala, Uganda. Seven of his children have died of AIDS. He and his wife care for more than 20 orphans, as well as five of their own school-age children. As a former civil servant John receives a pension of 110,000 Ugandan shillings (US$63.7) a month. ‘With this pension I have to buy school books, clothes and food and look after the house.’ ‘When the children are sick we have to buy their medicines.’ ‘My wife and I also have to buy our own medicines. These should be available free in the health centre, but are often not stocked there because they are special to older people.’ Three of the orphans in his care are HIV-positive. ‘I try to provide potatoes, cassava and millet every day for all of the children. Am always worrying about how I am going to find enough money. It’s a big responsibility with nobody to help me’ (HelpAge International 2007).

Ageing, development, and international organizations The ageing of populations is now a significant dimension of global society. In the developed world, and many parts of the developing world, the share 155

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of older persons is increasing at a rapid rate. On the one side, this can been seen as a major achievement and milestone in human development; on the other side, important challenges need to be considered, notably in respect of creating viable healthcare and pension systems to support older people (United Nations 2007). WHO argues that ageing can be managed and sustained with perspectives which ‘enact “active ageing” policies and programs that enhance the health, participation and security of older citizens’ (World Health Organization 2002). These, it is argued, should be based on the rights, needs, preferences and capacities of older people. They also need, it is further suggested, to embrace a ‘life course perspective that recognizes the important influence of earlier life experiences on the way individual’s age’ (World Health Organization 2002). As the case studies cited indicate, however, the experiences of older people may be at odds with the goals and aspirations identified by international governmental organizations. This is especially the case in respect of older people living in developing countries, where discussions about the relationship between ageing and development remain at an early stage (Lloyd-Sherlock 2004). At the same time, important contributions have begun to emerge, arising from the 2002 World Assembly on Ageing and the resulting Madrid International Plan of Action on Ageing (MIPAA) (Sidorenko and Walker 2004). Alongside this, critical perspectives on aging have identified the crisis for older people generated by increasing inequality and uneven development, this reflecting the intensification of globalization as an economic and social process (Estes and Phillipson 2002). Given the above context, this chapter focuses on three main areas for discussion: first, the population characteristics of global ageing; secondly, the challenges facing older people across global society; thirdly, the role of international governmental organizations in responding to population ageing. In the conclusion, the case of an ‘age-sensitive’ globalization will be developed, alongside a number of policy proposals.

The development of global ageing Population ageing is driven by the move from a demographic regime of high fertility and high mortality to one of low fertility and relatively low mortality. The former is associated with fast-growing young populations; the latter with more stable populations, including a larger proportion of people in the older age groups. No part of the world has been left untouched by this demographic revolution and the evidence suggests that a return to patterns of high fertility and mortality is highly unlikely. The proportion of the world’s population over 60 years is now increasing more rapidly than in any previous era. In 1950 there were around 200 million people over 60 throughout the world; this had increased to around 550 million by 2000; by 2025 their number is expected to reach 1.2 billion (United Nations 2007).

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The pace of demographic ageing is increasing fastest in the developing world. It is most noticeable in countries such as China where fertility is well below replacement levels and life expectancy greater than 71 years (Peng and Phillips 2007). Projections suggest that by 2025 China alone will contain a larger number of older people than Europe, with the proportion aged 65 and over doubling – from 6.9 per cent to 13.2 per cent – over the period 2000–25. In Asia, which contains the bulk of the world’s population, median age will increase between 2000 and 2050 from 26.1 to 38.7. Europe will age at a slower rate but from an older starting point, with the median age over the same period rising from 37.7 to 47.7 years; Oceania and North America following a similar pattern. The situation in the countries comprising sub-Saharan Africa is more complex, given the continuation of high fertility alongside the impact of HIV/AIDS and the high rate of mortality among younger age groups. Two consequences follow: firstly, that with rapid population growth the absolute numbers of older people will increase; secondly, that high mortality among younger people is likely to increase the proportion of older people in the population of many African countries. The number of people aged 65 and over is projected to increase by about ten million in sub-Saharan Africa between 1999 and 2015. While the overall population size will increase by 47 per cent during this period, the growth in the number of people of 65 years or older is set to rise by 57 per cent. Population ageing will have a substantial impact on the less economically developed countries. Already, the majority (61 per cent or 355 million) of the world’s population of people aged 60 and over live in poorer countries. This proportion will increase to nearly 70 per cent by 2025 and 79 per cent by 2050 (amounting to nearly 1.6 billion people) (United Nations 2007). For many countries, however, population ageing has been accompanied by reductions in per capita income and declining living standards. In the case of sub-Saharan Africa, 23 out of the 43 countries are now poorer than they were in 1975, with the great majority of inhabitants living on less than US$2 per day (Commission for Africa 2005). Aboderin highlights the extent to which the combination of poverty with HIV/AIDS has halted or even reversed improvements in health across the sub-Saharan African countries. In 26 countries, life expectancy at birth is lower than it was in 1980; the life expectancy of a child born today is under 50 years in 30 countries and under 40 in eight countries (Aboderin 2005). Despite the problems facing older people in developing countries, these individuals play a crucial role in providing care and support within their family and the wider community. This is clearly illustrated in the increasing role of grandparents providing care to children orphaned by HIV/AIDS. Over 60 per cent of orphaned children live in grandparent-headed households in Namibia, South Africa and Zimbabwe, and over 50 per cent in Botswana, Malawi and Tanzania. Around eleven million children have been orphaned

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by HIV/AIDS in sub-Saharan Africa, with data from 27 countries in the region showing that the extended family takes care for nine out of ten of these orphans. In most cases, responsibility for care falls upon grandparents, usually the grandmother (Knodel et al. 2002; Monasch and Clark 2004). Given that older people are already one of the poorest groups within developing countries, the impact of HIV/AIDS may further exacerbate the problems they face in managing both their own old age and their caring role within the family, as John Riukaamya’s words at the beginning of this chapter poignantly illustrated.

Challenges facing older people The reality of global ageing has to be set within a context of institutional ageism – defined as stereotyping and discrimination against people on the basis of age – in both developed and less developed countries. In America, the taskforce led by Robert Butler at the International Longevity Center identified the extent of age-related discrimination (Butler 2006). Health-related forms of discrimination included: one to three million Americans over 65 subjected to abuse by someone on whom they depended for care and attention; nine out of ten nursing homes lacking adequate staff; just 10 per cent of people aged 65 and over receiving appropriate screening tests for bone density, colorectal and prostate cancer. In developed countries, older people are less likely to receive recommendations for cancer treatments that could extend their lives than younger people, even when there is no medical reason to avoid those treatments. The pattern of under-treatment is exacerbated by the underrepresentation of older people in most clinical trials (Muss 2001). Some even suggest that older people, such as those over age 80, should receive no curative treatments, regardless of their prognosis, because they have lived out their ‘natural lives’ (Callahan 1987). Furthermore, a technology-intensive medical care system is increasingly inappropriate for the chronic disease challenges of older people, including hearing problems, falls, incontinence, and social isolation, as well as poly-pharmacy and the need for end-of-life care. These challenges do not usually require expensive tests, surgical interventions, or state-of-the-art technology (Hanlon et al. 2001; Miller et al. 2002; Tinetti et al. 1995). In developing countries, Paalman et al. highlight the fact that the main cost-effectiveness tool used by the World Bank in allocating healthcare resources gives a lower social value to health improvements for older as compared with younger age groups (Paalman et al. 1998). Lloyd-Sherlock notes that the Bank justifies this policy on the grounds of young people’s productivity in contrast with that of older people and that this ‘represents a blatant form of discrimination’ (Lloyd-Sherlock 2004). The association between health and poverty has an especially strong impact on older people – women in particular. The poor have reduced life expectancy,

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lower self-rated health status, increased morbidity and disability, and worse functional status (Verbrugge 1989). Socioeconomic status, whether defined by income, education, employment, poverty or wealth, is inversely associated with mortality in virtually all countries studied (Crystal 1982). In addition, socioeconomic inequality, independent of economic status, is related to health status (Crystal and Shea 1990). Developing countries, particularly low-income ones, tend to spend a much lower share of their national income on healthcare in comparison with developed countries. Per capita health expenditure in sub-Saharan Africa is over 50 times less than the average of such expenditure in the developed world. A report by the United Nations Department of Economic and Social Affairs notes that: ‘The lower public share of total health spending not only implies a heavier financial burden at the personal level, but also reflects the relatively lower revenue-raising capacity of poor countries and the lower level of the Government’s health interventions to mitigate market failures in healthcare and health insurance markets’ (United Nations 2007). Health is a life course phenomenon. There is a crucial connection between health at late and early life and events across the lifespan. Thus, where social injustice early in life affects one’s health, healthcare, and life chances, it is likely to be mirrored at later stages. Three types of resources convert early life inequities into late life inequities in health: a. Human capital – knowledge and skills that influence employment, job satisfaction and income; b. Social capital – the types and density of ties that enhance social integration and support; and c. Personal capital – sense of efficacy, and personal control, which mainly develops during younger adult years (O’Rand 2002). Health is influenced on the above three levels by the interactive effects of racism, sexism, social class and ageism (Robert 1999; Dressel et al. 1997; Williams et al. 1994; Folbre 2001). These inequalities are significantly influenced by the institutional effects of race, government, the market, gender, and family structures (Dressel et al. 1997; Estes 2001). In less developed countries, most people will enter old age after a lifetime of poverty and deprivation, poor access to healthcare and an inadequate diet. Malnutrition is far more common as compared with Europe and North America, with prevalence figures of between 30 and 48 per cent cited for older adults (60 plus) in some parts of sub-Saharan Africa. Emergency situations caused by war and famine pose particular problems; for instance, data from Sierra Leone reported that three quarters of adults sampled were underweight (HelpAge International African Regional Development Centre 2004). Health problems are often reinforced through poor access to hospitals and primary healthcare, limited understanding among healthcare professionals about older people’s health needs, as well as the high costs of medication

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(McIntyre 2004). Such problems have themselves been exacerbated by the migration of skilled nursing labor from the global south to richer countries such as the UK and USA. In the UK, to take one example, over the period 2000–04 countries such as India, Nigeria, Ghana and South Africa contributed nearly half of the annual number of new entrants to nursing (Buchan et al. 2005; Phillipson 2006). Buchan makes the point that the demographics of many developed countries – an ageing population and an ageing healthcare workforce – mean that many governments will continue to be active in encouraging the inflow of healthcare providers from less developed countries (Buchan 2001). In developed countries, in the last half-century, old age has usually been equated with specific diseases or a general pathological state. The cultural aversion to ageing and veneration of youth have spawned negative attitudes toward older people that may be internalized and manifested in personal low self-esteem, low self-efficacy, and low sense of control – all of which are risk factors for dependency, depression and illness (Rodin and Langer 1977). The response to this trend has been to define the problems that face older people as rooted in biology and to place the treatment of these problems in the realm of medicine. The biomedicalization of ageing has facilitated the ‘commodification’ of the needs of older people, which has, in turn, produced a costly and highly profitable ‘aging enterprise’ and enlarged the medicalindustrial complex (Estes and Binney 1989; Estes 1979; Estes et al. 2001). As a result, the goal of producing medical goods and services has shifted from fulfilling human needs such as basic shelter and nutrition to monetary exchange and private profit – and with it, increasing social inequality. The biomedicalization of ageing obscures the extent to which the health of older people can be improved by modifying social, economic, political and environmental factors. Biological and genetic factors account for only 30 per cent of successful ageing, while behavioral, social and environmental factors account for 70 per cent (Rowe and Khan 1998). Non-biomedical approaches to improving the health of older persons include: (a) targeting wealth inequalities; (b) increasing education opportunities; (c) providing adequate housing for all; (d) enhancing the opportunities for meaningful human connections; (e) offering public guarantees of universal access to health care, including long term care and rehabilitation; (f) expanding the reach of primary care and prevention endeavors and (g) creating policies and community environments that promote healthful behaviors, such as smoking cessation, diet and exercise (Poland et al. 1998).

The role of international governmental organizations Transnational bodies of different kinds are of increasing importance in shaping policy debates in the field of ageing. Of particular relevance is the way in which globalization as a social and economic process has created restrictions

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on the development of social welfare, a significant byproduct of the influence of transnational organizations. Financial globalization, to take one illustration, while not a direct cause of the erosion of welfare states, nonetheless sets significant boundaries around their development. A distinctive feature of the present period, as identified by David Held et al., is the extent to which financial globalization has imposed an external financial discipline on governments that has contributed to both the emergence of a more market friendly state and a shift in the balance of power between financial markets (Held et al. 1999). In this respect the political agenda of advanced capitalist states increasingly reflects the constraints of global finance, even though the specific impact of financial globalization varies greatly among nation-states. A significant aspect of global ageing has been the way in which international governmental organizations feed into what has been termed as the ‘crisis construction and crisis management’ of policies for older people (Estes 2001). A discourse has emerged among leading global actors about the future of social policy, most notably in areas such as pensions, health, and social services (Estes 1991). Agencies such as the World Bank and IMF have been at the forefront of attempts to foster a political climate conducive to limiting the scope of state welfare promoting in its place private and voluntary initiatives. The report of the World Bank Averting the Old Age Crisis was influential in promoting the virtues of multi-pillar pension systems, and, in particular, the case for a second pillar built around private, non-redistributive, defined pension contribution plans (World Bank 1994). The World Bank has also argued the case for reducing state pay-as-you-go (PAYG) schemes to a minimal role for basic pension provision. This position has influenced both national governments and transnational bodies such as ILO, with the latter now conceding to the World Bank’s position with their advocacy of a means-tested first pension, the promotion of an extended role for individualized and capitalized private pensions, and the call for OECD member countries to raise the age of retirement (now being put into effect in many European countries). This debate amounts to a significant global discourse about privatized pension provision and benefit cuts (via higher retirement ages), but one which has largely excluded perspectives that might suggest an enlarged role for the state, as well as those which question the stability and cost-effectiveness of private pension schemes (Blackburn 2006). International governmental organizations have also begun to exert an influential role in relation to health and social care services. Increasingly, the social infrastructure of welfare states is being targeted as a major area of opportunity for global investors. In the provision of health services WTO has promoted a restricted role for the state and an enlarged role for the private (commercial) sector as well as equal treatment for domestic and foreign health providers. WTO enforces more than twenty separate international agreements, using international trade tribunals that adjudicate disputes. Such agreements include the General Agreement on Trade in Services (GATS), the

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first multilateral legally enforceable agreement covering banking, insurance, financial services and related areas. WTO has itself called upon member governments to reconsider the breadth and depth of their commitments on health and social services. This is placing enormous pressure on countries to move further in the opening up of public services to competition from global (and especially North American) corporate providers and private insurers. In many instances, policies pursued by international governmental organizations operate directly against the interests of older people. The World Bank, for example, has been a staunch advocate of user fees as a means of revenue generation for healthcare. McIntyre, however, notes that: ‘Substantial evidence existed from an early stage that user fees adversely affect health service utilization, particularly for the poorest groups [which] include a large share of the elderly population’ (McIntyre 2004). In another area of policy, the Bank has been accused of distorting the research evidence on the side of advocating pension privatization for developing countries. Banerjee et al., in their evaluation of World Bank research, question the usefulness of the Bank’s pension reform work in light of the ‘bias and analytical errors’ on which it has been based, concluding that: ‘Overselling first the value of privately managed individual accounts and then of non-financial defined contribution systems does not serve the Bank’s central role in broadening the understanding of development policy’ (Banerji et al. 2006).

Developing an ‘age-sensitive globalization’ Taking a global perspective on the lives of older people will be of increasing importance over the course of this century. Dannefer (2003) has suggested that a new ‘global geography’ of the life course has begun to emerge, with contrasting experiences in the less developed as opposed to more developed regions of the world. The ‘typical’ life course pattern associated with western industrialized countries (the so-called three boxes of education, work and retirement) is in fact ‘atypical’ for much of the world. A global perspective on the life course underlines the importance of encompassing a fuller range of human diversity and variation. In particular, we need to understand the factors that contribute to the differential shape of the life course, with factors such as transnational flows of capital, the role of multinational organizations, and labor market opportunities, being among the key elements. Thus far, older people and their representative organizations can claim only limited influence on the debates and policies about population ageing launched by key international governmental organizations. The case that needs to be made is for an ‘age-sensitive’ globalization in which older people have greater influence in key international fora. Relevant components are: a. Auditing the activities of key international governmental organizations in respect of their activities on ageing issues;

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b. Building an age dimension into development policies and strategies; c. Promoting ageing organizations as major players alongside existing multilateral agencies; d. Strengthening the age dimension in human rights legislation; e. Encouraging older people’s organizations to play a prominent role in the network of groups and fora which comprise global civil society. This is an important agenda, but one that is being only partially addressed in the UN, WHO and related bodies. This is illustrated by MIPAA, which arose from the Second World Assembly on Ageing in 2002. The ultimate goal of MIPAA is to improve the quality of life of older people on the basis of security, dignity and participation, while at the same time promoting measures to reconcile ageing and development, and sustaining supportive formal and informal systems of individual wellbeing. Sidorenko and Walker note that the idea of a ‘Society for All Ages’ is a guiding theme in the Plan, and that this is seen to embrace: . . . human rights; a secure old age (including the eradication of poverty); the empowerment of older people; individual development, selffulfillment and well-being throughout life; gender equality among older people; inter-generational inter-dependence, solidarity and reciprocity; health care, support and social protection for older people; partnership between all major stakeholders in the implementation process; scientific research and expertise; and the situation of ageing indigenous people and migrants. (Sidorenko and Walker 2004). The authors further suggest that the ultimate goal of MIPAA is to ‘improve the quality of life of older people on the basis of security, dignity and participation, while at the same time promoting measures to reconcile ageing and development, and sustaining supportive formal. . . and informal. . . systems of individual well-being’ (Sidorenko and Walker 2004). Implementing such objectives will, however, require major policy initiatives. Five areas in particular may be highlighted. First, rights for older people must be defined as basic human rights. Social justice for older people must begin with the assertion of the human right to health, as established in the Universal Declaration of Human Rights and the United Nations Principles for Older Persons. This includes the human rights of older people as a group, as well as subgroups of older people who have suffered lifelong injustice. Working to reduce the socioeconomic–health gradient at all ages promotes justice for both current and future cohorts of older people (World Health Organization 2008). Promoting public health approaches to aging will reduce the biomedicalization of old age. Secondly, the growing inequality between developed and less developed countries must be reversed. Wade suggests that globalization as it currently operates is

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increasing inequality within as well as between countries (Wade 2001). This is creates new forms of exclusion, notably for women, the working class, and minority ethnic groups. Growing inequality requires positive action from bodies such as the United Nations and the WHO. The concern of these bodies to encourage the empowerment of older people will surely fail unless national and global inequalities are tackled in a systematic way – notably those which reduce the life chance of those older people living in less developed countries and the poorer communities of the developed world. Thirdly, NGOs and international governmental organizations must further collaborate with and strengthen organizations representing older people. Formulating policies that can have an impact on key transnational bodies is set to be a major task over the next few years. Groups representing older people must become connected with larger organizations and forums that are attempting to formulate a global agenda on social issues. The recent upsurge of political activity among pensioners in a number of countries offers a potentially important platform upon which to build age-integrated movements for social change. The joining of the movements of opposition to the worst abuses of globalization is essential and the role of older people’s organizations will be pivotal in challenging attempts at widespread privatization of public health and retirement programs. Fourthly, the needs of older people in crisis and emergency situations require urgent attention. The onset of global warming, the acceleration of military conflict, and the recurrence of famine and disease in less developed countries place older people at particular risk. Older people are especially vulnerable in periods of social and economic crisis, with displacement from their home, separation from relatives, and disruption in supplies of food and healthcare. Notwithstanding this, HelpAge International argue that: . . . donor agencies do not currently consider older people to be a high risk group, to be targeted for food aid, in emergency situations. . . A greater awareness relating to the health and nutrition needs of older people in emergency areas is required among community-based organizations and local and international NGOs involved in relief programmes. (HelpAge International African Regional Development Centre 2004). This point applies equally to developed and developing countries, as demonstrated in crises such as Hurricane Katrina in the USA (Bytheway 2006), and the 2003 heatwave in France (Ogg 2005). In both cases, elderly people were disproportionately affected compared with other age groups, but failed to receive the specialist help required. Fifthly, the international community must take a stronger stand in monitoring and evaluating policies affecting older people. Ageing units in international governmental organizations are often understaffed or not existent. The small United Nations Aging Group in New York, for instance, could be

Chris Phillipson, Carroll Estes, and Elena Portacolone 165

strengthened in order to play a major role in monitoring, coordinating and consulting with international governmental organizations and NGOs in initiatives affecting older people. Along those lines, NGOs and international governmental organizations should collaborate to implement programs designed to develop and widely disseminate best practices following the example of the WHO ‘International Mental Health Collaborating Network’. At the same time, bodies such as the UN and WHO will need to confront the power of international governmental organizations such as the IMF and World Bank to impose social policies which result in cuts in expenditure on services for groups such as older people (Estes and Phillipson 2002). This has been a particular feature of economic programs directed at Latin American and East European countries and is in conflict with the aspirations of the Madrid Plan to build a secure and dignified old age across the global community.

Conclusions Ageing must now be viewed as a global phenomenon, one transforming developing as much as developed countries. A focus on global ageing issues should be at the center of social and health policy. Much work must be done to achieve this goal: publicly funded healthcare appropriate for older people remains an elusive goal in many countries; only a minority of the world’s elderly has access to a pension scheme; discrimination and abuse of the old appears to be institutionalized across many cultures. Set against this, elders themselves may be a crucial source of wisdom, care and strength in a divided world. Working toward a cohesive intergenerational society, underpinned by social security and health care, remains a central goal for the international community in the twenty-first century.

Note 1. Parts of this chapter were adapted from C. Estes et al., ‘Ageing and Globalization’, in Social Theory, Social Policy and Ageing, edited by S. Biggs et al. (Maidenhead: Open University Press, 2003); C. Estes and S. Wallace, ‘Older People’, in Social Injustice and Public Health, edited by B. Levy and V. Sidel (Oxford: Oxford University Press, 2006); and C. Phillipson, ‘Ageing and Globalization: Issues for Critical Gerontology and Political Economy’, in Ageing, Globalization and Inequality, J. Baars et al. (Amityville, New York; Baywood Publishing Company, 2006).

References Aboderin, A. (2005) Understanding and Responding to Ageing, Health, Poverty and Social Change in Sub-Saharan Africa: A Strategic Framework and Plan for Research (Oxford: The Oxford Institute for Ageing).

166 Part III: Global Health and Vulnerability Banerji, A. et al. (2006) ‘An Evaluation of World Bank Research’ (mimeo). Blackburn, R. (2006) Age Shock: How Finance is Failing Us (London: Verso Books). Buchan, J. (2001) ‘Nurse Migration and International Recruitment’, Nursing Inquiry, 8(4): 203–4. Buchan, J. et al. (2005) International Migration of Nurses: Trends and Policy Implications (Geneva: International Council of Nurses). Butler, R.N. (2006) Ageism in America (New York: International Longevity Center-USA). Bytheway, B. (2006) ‘The Evacuation of Older People: The Case of Hurricane Katrina. Paper at the Annual Conference of the Royal Geographical Society and the Institute of Geography’. Callahan, D. (1987) Setting Limits: Medical Goals in an Aging Society (New York: Simon & Schuster, 1987). Commission for Africa (2005) Our Common Interest: Report of the Commission for Africa (London: Commission for Africa Secretariat). Crystal, S. (1982) America’s Old Age Crisis (New York: Basic Books). Crystal, S. and D. Shea (1990) ‘Cumulative Advantage, Cumulative Disadvantage and Inequality Among Elderly People’, Gerontologist, 30: 437–43. Dannefer, D. (2003) ‘Toward a Global Geography of the Life Course’, in Handbook of the Life Course, edited by J. Mortimer and M. Shanahan (New York: Kluwer Academic/Plenum Publishers, 2003), pp. 647–59. Dressel, P. et al. (1997) ‘Gender, Race, Class, and Aging: Advances and Opportunities’, International Journal of Health Services, 27: 579–600. Estes, C.L. (1979) The Aging Enterprise (San Francisco, CA: Jossey-Bass). Estes, C.L. (1991) ‘The Reagan Legacy: Privatization, the Welfare State and Aging’, in States, Labor, Markets and the Future of Old Age Policy, edited by J. Miles and J. Quadagno (Philadelphia, PA: Temple University Press). Estes, C.L. (2001) ‘From Gender to the Political Economy of Ageing’, European Journal of Social Quality, 2(1): 28–46. Estes, C.L. and E.A. Binney (1989) ‘The Biomedicalization of Aging’, Gerontologist, 29: 587–96. Estes, C.L. et al. (2001) ‘The Medical–Industrial Complex and the Aging Enterprise’, in Social Policy and Aging, edited by C. L. Estes (Thousand Oaks, CA: Sage). Estes, C.L. and C. Phillipson (2002) ‘The Globalization of Capital, the Welfare State and Old Age Policy’, International Journal of Health Services, 32(2): 279–97. Folbre, N. (2001) The Invisible Heart: Economics and Family Values (New York: The New Press). Hanlon, J.T. et al. (2001) ‘Suboptimal Prescribing in Older Inpatients and Outpatients’, Journal of the American Geriatrics Society, 49(2): 200–9. Held, D. et al. (1999) Global Transformations (Oxford: Polity Press). Helpage International (2006) Annual Review (London: HelpAge International). Helpage International (2007) ‘Preparing for an Ageing World’, Ageing and Development, 21: 6. Helpage International African Regional Development Centre (2004) Summary of Research Findings on the Nutritional Status and Risk Factors for Vulnerability for Older People in Africa (Westlands, Nairobi: HelpAge International). Knodel, J. et al. (2002) AIDS and Older Persons: an International Perspective, PSC Research Report No. 02–495 (Ann Arbor: Population Studies Center, University of Michigan). Lloyd-Sherlock, P. (ed.) (2004) Living Longer: Ageing, Development and Social Protection (London: Zed Books).

Chris Phillipson, Carroll Estes, and Elena Portacolone 167 Mcintyre, D. (2004) ‘Health Policy and Older People in Africa’, in Living Longer: Ageing, Development and Social Protection, edited by P. Lloyd-Sherlock (London: Zed Books). Miller, S.C. et al. (2002) ‘Does Receipt of Hospice Care in Nursing Homes Improve the Management of Pain at the End of Life?’, Journal of the American Geriatrics Society, 50(3): 507–15. Monasch, R. and F. Clark (2004) ‘Grandparents’ Growing Role as Carers’, Ageing and Development, 16: 6–7. Muss, H.B. (2001) ‘Older Age – Not a Barrier to Cancer Treatment’, New England Journal of Medicine, 345(15): 1128–9. O’Rand, A.M. (2002) ‘Cumulative Advantage Theory in Life Course Research’, Annual Review of Gerontology and Geriatrics, 22: 14–30. Ogg, J. (2005) Heat Wave (London: The Young Foundation). Paalman, M. et al. (1998) ‘A Critical Review of Priority Setting in the Health Sector: the Methodology of the 1993 World Development Report’, Health Policy Planning, 13(1): 13–31. Peng, D. and D.R. Phillips (2007) ‘Potential Consequences of Population Ageing for Social Development in China’, in Living Longer: Ageing, Development and Social Protection, edited by P. Lloyd-Sherlock (London: Zed Books), pp. 97–116. Phillipson, C. (2006) ‘Migration and Health Care for Older People: Developing a Global Perspective (Commentary)’, in Social Structures: Demographic Changes and the WellBeing of Older Persons, edited by K. Warner Schaie and P. Uhlenberg (New York: Springer Publishing), pp. 158–69. Poland, B. et al. (1998) ‘Wealth, Equity and Health Care: a Critique of a “Population Health” Perspective on the Determinants of Health’, Social Science and Medicine, 46: 785–98. Robert, S.A. (1999) ‘Neighborhood Socioeconomic Context and Adult Health: The Mediating Role of Individual Health Behaviors and Psychosocial Factors’, Annals of the New York Academy of Sciences, 896(1): 465–8. Rodin, J. and E.J. Langer (1977) ‘Long-term Effects of a Control-relevant Intervention with the Institutionalized Aged’, Journal of Personality and Social Psychology, 35(12): 897–902. Rowe, J.W. and R.L. Khan (1998) Successful Aging (New York: Pantheon Books). Sidorenko, A. and A. Walker (2004) ‘The Madrid International Plan of Action on Ageing: From Conception to Implementation’, Ageing & Society, 24: 147–65. Tinetti, M.E. et al. (1995) ‘Shared Risk Factors for Falls, Incontinence, and Functional Dependence: Unifying the Approach to Geriatric Syndromes’, Journal of the American Medical Association, 273(17): 1348–53. United Nations (2007) World Economic Survey 2007: Development in an Ageing World (New York: United Nations). Verbrugge, L.M. (1989) ‘The Dynamics of Population Aging and Health’, in Aging and Health: Linking Research and Public Policy, edited by S. J. Lewis (Chelsea, MI: Lewis). Wade, R. (2001) ‘Winners and Losers’, The Economist, April 28: 93–7. Williams, D.R. et al. (1994) ‘The Concept of Race and Health Status in America’, Public Health Reports, 109(1): 26–41. World Bank (1994) Averting the Old Age Crisis (Oxford: Oxford University Press). World Health Organization (2002) Active Ageing: A Policy Framework (Geneva: World Health Organization). World Health Organization (2008) Closing the Gap in a Generation: Health Equity through Action on the Social Determinants on Health (Geneva: World Health Organization).

10 Child Health and Development Linda Richter and Chris Desmond

The links between health and development are strongly manifest among children. A child born in Sierra Leone is more than 90 times more likely to die before they reach five years of age than a child born in Singapore (World Health Organization 2005). A substantial part of this difference relates to access to health services, but the most important single cause of child mortality in the world is undernutrition (Victora et al. 2000). Children die because they don’t have enough quality food. Malnutrition is estimated to be the underlying cause of 53 per cent of child deaths (Black et al. 2003; Fishman et al. 2004). Figure 10.1 gives a breakdown of the causes of death for children under five years of age. Moreover, it is estimated that more than 200 million children who survive the neonatal period, malnutrition and childhood illnesses nonetheless suffer impairments to their growth and cognitive development (GranthamMcGregor et al. 2007; Rivera et al. 1995; Thomas and Strauss 1997). This, combined with less, and delayed access to, as well as poorer quality of, formal education for poor children plays a major role in the intergenerational transmission of the world’s greatest illness – poverty (Brown and Pollitt 1996). Undernutrition among poor children is not only about lack of access to food. Rather, it is embedded in a context of poverty, which affects maternal growth and health (Walker et al. 2007), parental mental and motivational state (Rahman et al. 2007), the authority of female caregivers to access and use resources for the wellbeing of children (Engle et al. 1996), and family capacity to actively feed children and provide environmental and interpersonal stimulation for cognitive and language development (Richter 2004). Maternal depression, for example, has been linked to infant diarrheal illness (Rahman et al. 2007), malnutrition (Salt et al. 1988) and broader outcomes such as conduct disorder and psychological distress (Leschied et al. 2005). Lack of socioeconomic development, inequalities and resultant poverty are what lie at the root of most of child ill-health (Victora et al. 2001). This assertion is particularly applicable to children under five and to mortality, but the 168

Linda Richter and Chris Desmond 169 Measles 4%

Malaria 8%

Diarrhoea 17% Pneumonia 19% HIV/AIDS 3% Injuries 3%

Others 10% Neonatal 36% Malaria Pneumonia

Injuries Others

Neonatal HIV/AIDS

Diarrhoea Measles

Figure 10.1 Major causes of death among children under five years of age and neonates in the world, 2000–2003 Source: Bryce et al. (2005).

situation is similar for older children as well as for other areas of health such as emotional regulation and social adjustment (Barbarin and Richter 2001). While socioeconomic development, via its impact on poverty and inequality, plays a central role in the determination of child health, the relationship is not unidirectional because the health of children also has a direct link to a society’s socioeconomic development. As mentioned, poor health is likely to be linked to lower educational outcomes and can leave children without the competencies and skills to lift themselves out of poverty, leaving the next generation of children to face the same risks they did (Harper et al. 2003). The situations faced by many poor children are clearly serious and the need for support is obvious, particularly given the preventable nature of most deaths, disability, and loss of potential. The HIV/AIDS epidemic has made the situation even more difficult with large increases in mortality in highly affected regions (UNAIDS 2006). Prevention of mother to child transmission interventions are still slow to roll out and treatment for children has not yet picked up (World Health Organization 2007). In addition, risks to children’s health and development, including their care, increase when their mothers are HIV positive (Richter and Foster 2006).

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Simple interventions are known to be effective. These include clean water and sanitation, oral rehydration for diarrhea and impregnated bed nets to prevent malaria ( Jones et al. 2003). Vaccination coverage can be increased, food security can be improved, and health and education services and programs can be extended. Most importantly, poverty can be alleviated (Victora et al. 2000). All of these actions have the potential to dramatically improve the growth and health of children, as well as their chances for educational achievement, earnings and productive lives (Engle et al. 2007; Grantham-McGregor et al. 2007). What role international organizations have in responding to the needs of children by supporting such actions is an important question. There are, however, a few factors which should be noted before trying to respond to it. First, there is a considerable distance between poor children and international organizations; an obvious point, but one which is sometimes overlooked in considering responses. Efforts to improve child health can miss the most important context for children – a family and household, and the care environment of neighborhoods and communities (Lanata 2001). Failure to acknowledge this can undermine rather than strengthen efforts to improve children health and development. Most children die at home, rather than in a health facility. Interventions which acknowledge the central role of the family and community context, such as community-based Integrated Management of Childhood Illness, are often highly successful (Hill et al. 2004). Secondly, children will always need to be supported and efforts to provide for them will always be necessary. Children may, at times, be in crisis, but children themselves are not a crisis. Interventions to support children must thus comprise long-term systems of support not ad hoc programs or projects. Short-term, circumscribed efforts have their place in response to a particular situation; but, importantly, they are a response to that situation, not to children. This point has also been made with respect to children affected by HIV/AIDS (Richter et al. 2006). The family, variable as it might be, is the only institution which can provide care uniquely responsive to a child’s health and development, especially young children. This we know from decades of studies of the impact of residential care on children (Frank et al. 1996; Richter 2004). Families are the only social institutions that can provide care on the scale necessary to reach vulnerable children. Other institutions, organizations and interventions can and should support families to provide such care, not aspire to provide care directly to children. In the latter eventuality, children can be separated further from endogenous social systems which increases, rather than decreases, their vulnerability. Although many actors have important parts to play in ensuring the health and wellbeing of children, the state is the only institution with the legitimacy, responsibility, coverage and longevity to support families on an indefinite basis.

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It is against this backdrop that the role of international organizations should be considered. There are numerous interventions which can benefit children’s health and development. Many of these consist of extended or improved health care services – vaccines are an example, as are health education and family practice interventions such as promoting breastfeeding. Others are public health interventions such as the provision of clean water and the distribution of anti-malarial impregnated bed nets. These key interventions are clearly important, but this chapter will focus on one somewhat different type of intervention. The possibility of initiating or expanding income transfers to families or households is currently receiving a great deal of attention in the development field. This form of social protection raises, in a very pointed way, issues which are relevant for other interventions. This chapter will focus on the success of cash transfers to families in benefiting children’s health and education. The latter is included because education links with long-term individual health and social development more broadly. A number of international organizations have been significantly involved in the development and expansion of cash transfers programs, including the World Bank, ILO (Pal et al. 2005), UNICEF (UNICEF 2007), UNDP, and DFID (Department for International Development 2005). This involvement and the stances taken by them raise points relating to the appropriate role of international organizations in country, their relationship to the state, and the state’s relationship to its citizens. This chapter will argue that the interventions have been, in the main, successful and that international organizations have played a supporting role with generally positive outcomes. The interventions are large scale, long term and appreciate the role of the family in children’s health and development. Social transfer programs also have broader developmental outcomes and, in some instances, have served to strengthen the accountability of governments, not to international organizations but to the most appropriate monitoring and evaluation groups, their own people.

Health impacts of cash transfer interventions An increasing number of developing countries are implementing cash transfer programs as part of their social protection agenda. These include conditional cash transfer programs such as Brazil’s Bolsa Familia and Mexico’s Oportunidades, as well as programs in Nicaragua, Chile, Bangladesh and Turkey. Conditional programs, with payment dependent on use of services to support children’s health and development, are relatively recent. Ten years ago they were implemented in only three countries; now, including pilots, there are programs in over twenty countries (World Bank 2007). There are also a number of unconditional transfer programs such as South Africa’s

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Child Support Grant and non-contributory pensions in Brazil, South Africa, Namibia, Botswana, Senegal and Lesotho, among others. Income transfers are large-scale interventions. For example, Bolsa Familia reaches 11 million families (close to 45 million people), Oportunidades five million households and South Africa’s Child Support Grant has around eight million beneficiaries. The majority of these programs in developing countries are relatively new, having been started in the 1990s or later. The exception is South Africa’s system which is somewhat older but which, prior to 1994, had a strong racial bias and associated limited coverage. All of these programs involve the provision of cash to beneficiaries. For a number of programs this cash payment is subject to conditions, although some programs, such as Ecuador’s Bono de Desarrollo Humano, combine conditional and unconditional elements. There is also a continuum of soft (monitoring at a group level) to hard conditionality (individual monitoring and consequences), although no programs seem to exclude families without providing significant assistance to meet conditions. The conditions typically relate to healthcare visits for pregnant and lactating mothers and for children, as well as participation in preschool programs, and school enrolment and attendance for older children. While it is clear that those conditional cash programs that have been rigorously evaluated, have been successful in improving health, and especially educational, outcomes, it is as yet unclear whether their effects occur as a result of the cash, the conditions, the monitoring, the integration of and expanded access to services or the sense of empowerment among caregivers and families that accompanies entitlement (Hoddinott et al. 2001). There is also evidence, discussed later, that unconditional interventions, such as the South African Child Support Grant, also have a positive impact on health. Further, the data indicate that old age pensions, which are not even targeted at children, have had positive outcomes for children’s health (Duflo 2000). The conditional versus unconditional debate is an important one and more research is needed on the practical implications of applying and monitoring conditionality, the cost effectiveness, as well as the unintended negative effects and ethics of potentially excluding the most incapacitated families. While the debate is important and will be referenced where relevant, the focus of this chapter is on the health benefits of cash paid directly to households, whether conditional or not. As indicated earlier, the majority of young children die because they lack access to the appropriate quantity and quality of food and/or because they live in an environment which is not conducive to them benefiting from what food is available. A strong argument can be made that, more often than not, this lack of access to basic nutrition is not a result of unwillingness among those caring for children to provide for their charges’ needs, but rather their inability to do so because of poverty (Smith and Haddad 2000). Directly alleviating poverty through predictable, if relatively small, income transfers

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to households addresses the basis of children’s ill-health via nutrition, as well as providing households with the resources to cover user costs of accessing clean water, health care, and education. The design of the roll out and expansion of the Mexican cash transfer program, Oportunidades, allowed for a rigorous evaluation of its impact, comparing communities where the intervention had begun with those where it had not yet started. The randomized selection of communities in planning the intervention made a number of studies possible and as a result there is a wealth of data on the impacts of Oportunidades, and it is worth examining the program in more detail (Newman et al. 1994). As mentioned, the Mexican intervention involves a conditional cash transfer. The grant is paid subject to conditions which include the provision of nutritional supplements for children under two years of age, growth monitoring for children under five years of age, participation in prenatal care, well baby care and immunization programs as well as adult preventative visits and participation in health education programs (Gertler 2000). There are also school attendance requirements for older children. One evaluation of Oportunidades found that health service utilization increased in households receiving the grant (Gertler 2000) as did availability of food (Hoddinott et al. 2001). It was estimated that Oportunidades recipient households went twice as often to clinics than non-recipient households (Gertler 2000). The grant also appeared to reduce the probability of reporting illness among children. Oportunidades households reported a 12 per cent lower incidence of illness over the period of recall. The health benefits, seemingly, were not restricted to children; there was also a significant reduction in the number of days in bed or with mobility difficulties reported among adults (Gertler 2000). Much of the health benefit was likely due to increased food consumption. In Oportunidades households, average consumption increased 14.5 per cent and food consumption 10.6 per cent. These increases were more pronounced in poorer households. As a result of greater spending on food, caloric intake increased by close to 8 per cent although the impact on food quality was not statistically significant (Hoddinott and Skoufias 2000). Similar positive impacts on health and the health behavior of conditional transfers have been observed elsewhere. For example, in a Columbian program, a reduction of ten percentage points was recorded in the incidence of acute diarrhea in young children and in Nicaragua, timely immunization rates rose significantly (Rawlings 2004). The success in improving health outcomes is not only limited to conditional cash transfers. The South African Child Support Grant is a means-tested unconditional transfer to caregivers of children up to the age of 14 years. Unlike Oportunidades, the concurrent national roll out of the grant did not allow for rigorous community-level evaluation. Nonetheless, analysis of the

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available data indicates that children in households receiving the grant are taller than children in eligible but non-recipient households, particularly those children whose caregivers had received the grant from when the child was at a young age (Aguero et al. 2006). Height is an important long-term indicator of child nutrition and health. Putting aside the possibility that eligible households receiving the grant may be different from non-recipient households in ways that affect child growth and health, the results suggest that the income transfer had a significant impact on children. In most developing countries, households with higher incomes provide a healthier diet for their children and have more access to healthcare and to better-quality services (Victora et al. 2000). The goals of conditional cash transfer programs may be to generate an impact on child health and education outcomes over and above those that are normally associated with a rise in income and/or to change the values driving consumption/expenditure choices in poorer households. What is clear, however, is that increases in household income benefit children. The benefits are observed under conditional and unconditional grants systems, and even when transfers are not targeted at children, such as old age pensions in South Africa (Case 2001), Namibia and Brazil (Barrientos and DeJong 2004; Devereux 2002). More research is needed to ascertain if, and in what contexts, targeting and conditionality increase the impact of income transfers on child health. The benefits of transfer programs have been observed not only under customary conditions in developing countries, but have also been documented to be protective during emergencies. In Nicaragua during the coffee crisis, for instance, consumption dropped dramatically in both coffee-producing and non-coffee-producing areas. However, among beneficiaries of income transfers, there was no reduction in consumption in non-coffee areas and while there were reductions in coffee-producing areas these were nine fold smaller than those observed among coffee-producing households (Maluccio 2005). There is thus strong evidence that cash transfers to poor households have health benefits for children. To date, however, the evidence has been accumulated within a narrow definition of health (for example, height, food consumption, and attendance at health facilities for prevention services). Research in the field of cash transfers has not yet examined their long-term connection with development, although they have been linked with educational outcomes which, as mentioned, are themselves linked to long term development. In a range of countries cash transfer programs have been shown to have a strong association with improved school enrolment and attendance (Department for International Development 2005). Education has obvious long-term links with both individual health and socioeconomic development. The connection with education, realization of individual potential and, via these, with longer-term socioeconomic development is one of the

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major distinguishing factors of cash transfer programs to improve health as compared to typical, generally much narrower, health interventions. Oportunidades households in Mexico had higher educational enrolment rates for both boys and girls. The impact for girls was particularly marked for the age range 12–17 years. Girls from recipient households reported enrolment close to 20 per cent higher than girls from non-recipient households (Schulz 2000). Associations between income transfer programs and reduced child labor have also been found in some contexts (Rawlings 2004), as have reductions in equality (Soares et al. 2006) and improved economic development (Devereux 2002), all of which have long-term health impacts. The emerging evidence is that income transfers, both conditional and unconditional, have positive impacts on children’s health, education and on the economic environment in which they live. It is difficult to compare such programs to other interventions, but efforts have been made to compare cash to in-kind transfers. The results have generally suggested that cash transfers have a lower delivery cost, although there are strengths and weaknesses to both approaches depending on the context (Barrientos and DeJong 2004). Crudely speaking, if markets exist and goods are available, cash tends to be more efficient; if not, in-kind transfers may be the better option. For example, when there are food shortages in the broader environment, in-kind transfers may be beneficial. This is often not the case, however, because even under drought conditions, while food may be in short supply it is available, just at a higher price. When there are functioning markets and what is wanted are available, goods provided by in-kind transfers may be sold and very inefficiently transformed into cash; the latter having the flexibility that poor families require to meet their needs. The problem of comparison is, however, more complicated because cash transfer programs have multiple impacts, which makes comparisons with focused health interventions difficult. While comparisons are difficult, what is clear is the growing interest in cash transfer programs, not only in response to poverty but also as a response to the diverse impacts of, for example, HIV/AIDS on children (Green 2005). Given this context – of growing interest in what has been demonstrated to be an effective approach to children’s health and wellbeing in developing country contexts – it is important to interrogate the appropriate role for international organizations in this field, and what their role here suggests for other areas of intervention.

The role of international organizations to date A number of international organizations have been involved in one way or the other in the initiation, implementation, reform, or funding of cash transfer interventions in developing countries. The World Bank, for example, has

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been involved in training, analytical work and lending in 85, 84 and 62 countries, respectively, regarding safety net issues, which increasingly include cash transfers (World Bank 2007). The UK Department for International Development (DFID) and Germany’s Gesellschaft für Technische Zusammenarbeit (GTZ) have played a leading role in funding programs, particularly in subSaharan Africa (World Bank 2007). Other organizations have focused on facilitation and technical support. UNICEF, for example, has been providing technical and other support to understand and pilot the adaptation of income transfer programs to support children affected by HIV/AIDS (Green 2005), and the International Poverty Centre of the United Nations’ Development Programme has provided technical assistance to countries in the design phases. Given the current involvement of international organization in income transfer programs, one may ask what their most appropriate role might be. DFID identifies a number of roles which international organizations can play. Increases in foreign aid can make programs affordable via budgetary support for poverty reduction. Countries with existing systems may benefit form the provision of technical support. Both for these countries and those considering their options to support human capital development or address crises, and going beyond the individual country level, international organizations can play a strong role in developing an evidence base on income transfers in order to facilitate decision making. At the country level, international organizations can support governments to develop evidence-based social protection, with an appropriate role identified for cash transfers (Department for International Development 2005). DFID is a supporter of cash transfers and their careful identification of the appropriate roles for international organizations confirms their long-term vision. Cash transfers are, however, not universally supported. There are governments that provide foreign aid, and international agencies who give technical and financial assistance for child health and other programs, who oppose direct income transfers, particularly without conditions. The international community is often mobilized to directly help ‘children’ rather than to support the local socioecological systems that support children on an ongoing and sustainable basis – most particularly families, but ultimately, also community- and faith-based organizations, health and education services and even developing country governments (Richter and Foster 2006; Richter et al. 2006). One reason for this is that children are easily configured to be innocent victims of forces beyond their control and it is difficult to deny responsibility to help them, based on common humanity. From this point of view, children may also be seen to be the innocent victims of irresponsible parents, uncaring and abusive families, exploitative community groups, underfinanced essential services and corrupt governments. None of the latter is readily perceived to require, or even deserve,

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direct financial or other assistance. In fact, one can sometimes discern active antagonism to the local context of poor children; international organizations, and/or the local agencies they support and whose agendas they influence, sometimes act as if they are the only groups capable of providing responsible care for vulnerable children in poverty settings, or in crisis conditions such as those occasioned by HIV/AIDS. This binary is not dissimilar in its form, or its consequences, from the age-old debate in welfare about the ‘deserving’ and ‘undeserving’ poor (Goldson 2002). Two principles are critical in informing how international organizations, and their local agencies, position themselves to provide assistance to support child health and development. The first is acknowledgement of the characteristics of environments essential for child growth, health and development. The second is apprehending the scale of need and required action on behalf of poor children in developing countries, and how the requisite response to the magnitude of the problems simultaneously fulfils the rights-based commitments made by all but one donor country, and most international organizations (United Nations 1989). Realistically, such scale can only be achieved and maintained by state provision or coordination. Caregivers and families, in a variety of permutations, provide care for children. A century of child development research demonstrates that children, especially young children, grow and develop best within a network of consistent, emotionally involved adults (Richter 2004). Where such networks have been destroyed or dissipated – and this is less frequent than often assumed by outsiders (International Social Service and UNICEF 2004) – it is the responsibility of states, as well as international and local agencies, to promote stable alternative family care for children (United Nations 1989). External actors cannot replace the care of children by families in their customary contexts. Rather, their duty is to support that care. Income transfers are one obvious example of such support for caregivers and families in poverty, where other conditions are conducive. The need for assistance to assure the growth, health and development of poor children in developing countries is very great. This requires that international agencies take a leading role in committing to actions that are scalable to all vulnerable children. For decades, time- and budget-bound projects have been provided to small numbers of vulnerable children in demonstration, pilot and other exemplary efforts in developing countries. Most of them have been supported by international agencies of one kind or another. There is a time and place for good exploratory pilots and for rigorously evaluated demonstration projects of a size that encompasses the implementation challenges of national coverage. From the start, however, they need to be conceptualized, planned and funded to respond to the long-term challenge of expanding to national coverage. Working in this framework is consistent with, and manifests, a child rights approach. Projects that reach only a few vulnerable children – and these are

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usually in urban centers, along main roads, and in serendipitously selected rural areas – increase inequality. Resources get distributed in ways that result in fewer children getting more services, leaving hard-to-reach children without even basic provisions for survival (Victora et al. 2000). Income transfer programs are a means to support large numbers of children, and this provides a channel to respond nationally with an intervention which complements health and education services. When combined with conditions, under appropriate circumstances they have also been shown to provide impetus for the expansion of health and education facilities into previously underserved areas (Barrientos and DeJong 2006). Cash alone is clearly not enough; the importance of complementary health, education and welfare services and programs is obvious. Complementary educational interventions assist families in appreciating the benefits of investments in children’s health and education independently of conditions which seek to enforce the ‘right decision.’ Cash without the necessary access to services such as healthcare and schooling will have limited impact beyond improved nutrition. However, in many circumstances, this is a critical first step. In order to provide in-country support it is necessary for international organizations to set priorities within a long-term perspective. No developing country can do everything at once for children. Pressure to do so can result in inaction. Decision support for the progressive realization of children’s rights by governments, through social security for families and universal access to essential services, is critical. The debate introduced here is in many ways similar to one relating to the appropriate relationship between the international community, domestic governments and citizens. There have been different and changing views on the role of funders in supplying services directly or via non-state providers to citizens, or supporting governments – again with or without conditions. A lack of trust in developing country governments, again likely linked to the allocation of fault, has historically hampered direct budgetary support and led to funders favoring direct service provision or conditionality. In the short term there may be instances where interventions should target services directly to children. However, for long-term, sustainable inputs to benefit the health of children, families must be strengthened, and this strengthening should be led by governments because it must be indefinite. Cash transfers are one part of such an approach and highlight many of the issues involved. Just as governments have a role in strengthening families and should not bypass, or skip over them, so international organizations have a role in strengthening states and it is not productive to skip over governments or families. The support provided to date by international organizations, providing technical assistance and financing, and the areas of intervention listed by DFID link in well with this argument. It is, however, important to be clear that

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strengthening families and governments is not as simple as providing additional resources. In cash transfer programs, for example, it is important who receives the grant. Oportunidades, and many of the other programs, purposely target women recipients. Changing the power balance within the home can play an important role in the realization of benefits for children. This is also true at the state level. Supporting and strengthening governments requires the strengthening of democratic processes and domestic accountability. Efforts by international funders to monitor the spending of their funds are often given unreasonable priority and so can burden governments to the point of reduced effectiveness. Strengthening domestic accountability in the long term is likely to be a far more efficient and sustainable way of ensuring good governance. Interestingly, cash transfers have helped show how communities can place pressure on policy makers to deliver. Coping with being poor and insecure is a full-time job. Without predictable income or livelihoods, poor people have to continually work for basic needs. Furthermore, linking transfers to services, possibly via conditions has been shown to increase demand for those services making them important local political issues (Victora et al. 2000). The cash transfers approach is consonant with the general need to move the debate away from short-term patchwork responses toward addressing underlying causes and strengthening domestic systems and provisions for children.

Conclusions Poverty is the root cause of the major share of child ill-health and mortality and the resultant denial of human potential. Health systems and services, as well as public health interventions, have an important role to play in improving outcomes for children. While such interventions do alleviate poverty by improving health status and reducing expenditures on health, they have a limited impact in this regard. In contrast, income transfers aim to address the underlying role of poverty in health and welfare more generally. This chapter has presented evidence as to the short-term success and the possibility of long-term improvements in the health and education of children as a result of such programs and their interaction with health and education services. A critical aspect of cash transfers is that they recognize the role of the family in the care of children. Service providers also often seek to deal directly with children and overlook the only social institution which can provide longterm support for children. If improvements are to be seen for children on an ongoing basis into the future, realizing and supporting the potential role of families is central. The response to children and families cannot be short-lived. Children will always need support and in most settings families will too. When cast in this light, the importance of long-term, large-scale responses is obvious. Cash

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transfers and the universal provision of services are obvious examples. Such large-scale responses cannot be provided on an ongoing basis by outsiders. Governments and civil society have to take on this role. It is the continuous need for support and the distance between children and international organizations which is important in determining the appropriate role for such bodies to play. Strong families and communities, efficient governments and meaningful democratic monitoring should be the longterm goals if the health of children is to improve. The role of international organizations should be to seek ways to support the realization of such goals.

References Aguero, J.M. et al. (2006) The Impact of Unconditional Cash Transfers on Nutrition: The South African Child Support Grant (Washington, DC: Center for Global Development). Barbarin, O. and L. Richter (2001) Mandela’s Children: Growing Up in Post-Apartheid South Africa (New York: Routledge). Barrientos, A. and J. Dejong (2004) Child Poverty and Cash Transfers (London: Child Poverty Research and Policy Centre). Barrientos, A. and J. Dejong (2006) ‘Reducing Child Poverty with Cash Transfers: A Sure Thing?’, Development Policy Review, 24: 537–52. Black, R.E. et al. (2003) ‘Where and Why are 10 Million Children Dying Every Year?’, The Lancet, 361(9376): 2226–34. Brown, J.L. and E. Pollitt (1996) ‘Malnutrition, Poverty and Intellectual Development’, Scientific American, 274(2): 38–43. Bryce, J. et al. (2005) ‘WHO Estimates of the Causes of Death in Children’, The Lancet, 365(9465): 1147–52. Case, A. (2001) Does Money Protect Health Status? Evidence from South African Pensions (Princeton, NJ: Princeton University, Research Program in Development Studies). Department for International Development (2005) Social Transfers and Chronic Poverty: Emerging Evidence and the Challenge Ahead (London: Department for International Development). Devereux, S. (2002) ‘Can Social Safety Nets Reduce Chronic Poverty?’, Development Policy Review, 20(5): 657–75. Duflo, E. (2000) ‘Child Health and Household Resources in South Africa: Evidence from the Old Age Pension Program’, American Economic Review, 90(2): 393–8. Engle, P.L. et al. (1996) Care and Nutrition: Concepts and Measurement (Washington, DC: International Food Policy Research Institute). Engle, P.L. et al. (2007) ‘Strategies to Avoid the Loss of Developmental Potential in more than 200 Million Children in the Developing World’, The Lancet, 369(9557): 229–42. Fishman, S.M. et al. (2004) ‘Childhood and Maternal Underweight’, in Comparative Quantification of Health Risks. Global and Regional Burden of Disease Attribution to Selected Major Risk Factors, edited by World Health Organization (Geneva: World Health Organization), pp. 39–162. Frank, D.A. et al. (1996) ‘Infants and Young Children in Orphanages: One View From Pediatrics and Child Psychiatry’, Pediatrics, 97(4): 569–78.

Linda Richter and Chris Desmond 181 Gertler, P. (2000) The Impact of PROGRESA on Health (Washington, DC: International Food Policy Research Institute). Goldson, B. (2002) ‘New Labour, Social Justice and Children: Political Calculation and the Deserving-Undeserving Schism’, British Journal of Social Work, 32(6): 683–95. Grantham-Mcgregor, S. et al. (2007) ‘Developmental Potential in the First 5 Years for Children in Developing Countries’, The Lancet, 369(9555): 60–70. Green, M. (2005) Strengthening National Responses to Children Affected by HIV/AIDS: What is the role of the State and Social Welfare in Africa (New York: United Nations Childrens Fund). Harper, C. et al. (2003) ‘Enduring Poverty and the Conditions of Childhood: Lifecourse and Intergenerational Poverty Transmissions’, World Development, 31(3): 535–54. Hill, Z. et al. (2004) Family and Community Practices that Promote Child Survival, Growth and Development: A Review of the Evidence (Geneva: World Health Organization). Hoddinott, J. et al. (2001) Participation and Poverty Reduction: Issues, Theory, and New Evidence from South Africa (Washington, DC: International Food Policy Research Institute). Hoddinott, J. and E. Skoufias (2000) The Impact of PROGRESA on Consumption (Washington, DC: International Food Policy Research Institute). International Social Service and UNICEF (2004) Improving Protection for Children without Parental Care: Care for Children Affected by HIV/AIDS the Urgent Need for International Standards (New York: International Social Service and UNICEF). Jones, G. et al. (2003) ‘The Bellagio Child Survival Study Group’, The Lancet, 362(9380): 323–7. Lanata, C.F. (2001) ‘Children’s Health in Developing Countries’, in Poverty, Inequality and Health: An International Perspective, edited by D. Leon and G. Walt (Oxford: Oxford University Press). Leschied, A.W. et al. (2005) ‘The Relationship Between Maternal Depression and Child Outcomes in a Child Welfare Sample: Implications for Treatment and Policy’, Child & Family Social Work, 10(4): 281–91. Maluccio, J. (2005) Coping with the ‘Coffee Crisis’ in Central America: The Role of the Nicaraguan Red de Proteccion Social (Washington, DC: International Food Policy Research Institute). Newman, J. et al. (1994) ‘Using Randomized Control Designs in Evaluating Social Sector Programs in Developing Countries’, World Bank Research Observer, 9(2): 181–201. Pal, K. et al. (2005) Can Low Income Countries Afford Basic Social Protection? (Geneva: International Labour Organization). Rahman, A. et al. (2007) ‘Maternal Depression Increases Infant Risk of Diarrhoeal Illness: a Cohort Study’, Archives of Disease in Childhood, 92(1): 24–8. Rawlings, L. (2004) A New Approach to Social Assistance: Latin America’s Experience with Conditional Cash Transfers Programs (Washington, DC: World Bank). Richter, L. (2004) The Importance of Caregiver–Child Interactions for the Survival and Healthy Development of Young Children (Geneva: World Health Organization). Richter, L. and G. Foster (2006) Strengthening Systems to Support Children’s Healthy Development in Communities Affected by HIV/AIDS: a Review (Geneva: World Health Organization). Richter, L. et al. (2006) Where the Heart Is? Meeting the Psychosocial Needs of Young Children in the Contexts of HIV/AIDS (The Hague: Bernard van Leer Foundation, 2006).

182 Part III: Global Health and Vulnerability Rivera, J.A. et al. (1995) ‘Nutritional Supplementation during the Preschool Years Influences Body Size and Composition of Guatemalan Adolescents’, The Journal of Nutrition, 125(4) Supplement: 1068S–1077S. Salt, P. et al. (1988) ‘The Influence of Early Malnutrition on Subsequent Behavioral Development. VII. The Effects on Maternal Depressive Symptoms’, Journal of Developmental & Behavioral Pediatrics, 9: 1–5. Schulz, P. (2000) The Impact of Progressa on School Enrollment (Washington, DC: International Food Policy Research Institute). Smith, L. and L. Haddad (2000) Explaining Child Malnutrition in Developing Countries: a Cross-Country Analysis (Washington, DC: International Food Policy Research Institute). Soares, F.V. et al. (2006) Cash Transfer Programmes in Brazil: Impacts on Inequality and Poverty, Working Paper 21 (Brasilia: United Nations Development Program – International Poverty Centre). Thomas, D. and J. Strauss (1997) ‘Health and Wages: Evidence on Men and Women in Urban Brazil’, Journal of Econometrics, 77: 159–85. UNAIDS (2006) 2006 Report on the Global AIDS Epidemic (Geneva: World Health Organization). UNICEF (2007) Enhanced Protection for Children Affected by AIDS: A Companion Paper to The Framework for the Protection, Care and Support of Orphans and Vulnerable Children Living in a World with HIV/AIDS (New York: United Nations Children’s Fund). United Nations (1989) Convention on the Rights of the Child (Geneva: United Nations). Victora, C.G. et al. (2000) ‘Explaining Trends in Inequities: Evidence from Brazilian Child Health Studies’, The Lancet, 356(9235): 1093–8. Victora, C.G. et al. (2001) ‘The Impact of Health Interventions on Inequalities: Infant and Child Health in Brazil’, in Poverty, Inequality and Health: An International Perspective, edited by D. Leon and G. Walt (Oxford: Oxford University Press). Walker, S.P. et al. (2007) ‘Child Development: Risk Factors for Adverse Outcomes in Developing Countries’, The Lancet, 369(9556): 145–57. World Bank (2007) Social Protection for the Poorest: The Position and Experience of the World Bank. Policy Note Prepared by the Social Protection and Labour Department (Washington, DC: World Bank). World Health Organization (2005) The World Health Report 2005 – Make Every Mother Count (Geneva: World Health Organization). World Health Organization (2007) Towards Universal Access: Scaling Up Priority HIV/AIDS Interventions in the Health Sector: Progress Report (Geneva: World Health Organization).

11 Women, Health, and Development Lenore Manderson

Health and economic development are interdependent. Health outcomes improve with development, infant mortality and maternal mortality rates drop, and life expectancy increases. Increased health and increased life expectancy lead to increased productivity and increased consumption, leading (depending on the development theorist) to increased wealth (World Bank 1993). Increased wealth allows for increases in health expenditure at individual, household and government levels; concurrently, the proportionate expenditure on emergency health measures is lower relative to expenditure on and investment in health promotion and prevention of illness. And so on. The reality is more complicated. Development efforts take advantage of an increasingly healthy population to maximize and build economic capital, but the extent to which this is true in relation to cultural, intellectual and social capital varies. Structural and political factors intrude and lead to very different outcomes for people. The relationship of health and development for women is often especially variable. As I illustrate in this chapter, women’s health may be compromised in various ways as a result of development, a term I use here loosely to refer both to specific local policies and to wider shifts in the global economy that reverberate in local economies and societies. In the next section of this chapter, I identify seven distinct ways in which women’s health has been affected negatively by the processes and structures of development. In the third section, I turn to the role of international organizations; using case studies, I highlight the critical role they have played in drawing attention to, disrupting and preventing the compromises to women’s health and wellbeing.

Linking health, gender and development Development programs create or entrench women’s subordination Woman’s Role in Economic Development (Boserup 1970) was a landmark publication that first drew attention to the systematic ways in which women’s 183

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health and wellbeing were compromised as economic development programs were rolled out. As she documented, national governments and aid agencies presumed, and so introduced or buttressed, a gendered division of labor that aligned women with reproduction and domestic life, and men with production and the public sector. In practical terms, as Boserup illustrates, in agricultural development programs, men were provided with training, resources, funds and technical support even when, as in much of Africa, they had no prior experience of or in connection to farming. The results are well documented: in some instances, interventions simply failed as the farmers, that is, the women who had been excluded from outreach and ignored by extension workers, remained unconvinced of new technologies and approaches. In other cases, development programs strengthened gender divisions: men who farmed drove tractors, produced cash crops, and spent profits on technologies to enhance production (fertilizers, pesticides, etc.) and to meet their own needs; women who farmed continue to use traditional labor-intensive technologies, with the little cash they generated being used for domestic purposes and their own and their children’s health. In other cases, women did worse still, as they lost title to land that, through customary inheritance law, had been their own, as they were relegated from public to private life, and as they lost, with their land, independence, autonomy and security. The attention to men also reinforced prevailing gender relations, depriving women of opportunities to loosen the conventional constraints of marriage and kinship. Women’s explicit exclusion from development programs and changes in relations of production further influenced their access to resources, and it eroded their autonomy in health seeking, entrenching or creating dependence of women on men to present for care and advice. Importantly, this influenced reproductive decision making and sexual health care as well as advice and treatment for acute conditions (Basu 1995; Benería 2003; Benería and Feldman 1992; Blumberg et al. 1995; Boserup 1970; Buvinic et al. 1983; Dixon-Mueller 1993; Elson 1995; Safa and Leacock 1986; Visvanathan et al. 1997; Young et al. 1981).

Women’s health is compromised as women are incorporated into development While women were often marginalized in development outreach and extension programs in the primary sector, this was not true for the secondary sector. An important continuing trend in economic development has been the recruitment of women, often very young, into industries producing goods for a global market – perhaps more precisely, for the industrialized world. The reasons for doing so have been well analysed (Benería 2003; Elson 1995, 1996; Elson and Pearson 1981; Kabeer and Mahmud 2004). Young women especially are regarded as passive and pliable workers, reluctant to challenge the conditions of labor or the exercise of authority by employers, particularly where their employment is unstable and unemployment is endemic (Young

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et al. 1981). They are willing therefore to be employed at low rates in lowlevel positions. Young women are regarded as especially dexterous, making them ideal for the repetitive work that was instantiated by their employment in the nascent electronics industry in the 1970s. Today the ideas relate equally to women’s work in export-oriented food industries, the garment industry, the manufacture of surgical and other precision instruments, and costume jewelry. Their health is compromised by multiple factors associated with the conditions of labor. As Pun Ngai illustrates of China (Pun 2005), women factory workers often work at low wages in substandard physical conditions, working 12-hour shifts, with very limited time off for food and toilet needs. They typically live in crowded factory dormitories. The health conditions are predictable: backaches, headaches, vaginal and urinary tract infections, chronic pelvic pain, eye strain and damage, hearing damage, respiratory problems, and cumulative trauma disorders to hands and arms. Where women like men have been incorporated into primary industry as wage laborers, they are exposed to pesticides, insecticides, fungicides and other toxins at a cost to their own health, including to their reproductive health and outcomes (Garcia 2003; Hippert 2002).

Women’s health is compromised by the double day Women must often balance domestic and market work with working long hours at low wages in poor conditions in industry. This is referred to as the double day – paid work supplemented by the work involved in the purchase and preparation of food, cleaning the house, washing clothing, child care and child rearing, and often other tasks associated with self care, care of husband and, depending on cultural setting, the care of members of the extended family. Research on the double day illustrates that, even in industrialized settings, women take on the disproportionate burden of domestic work and also undertake a range of community and service activities. Increased life expectancy has resulted in a greater need for home-based care for elders in developing (and highly industrialized) countries, and, for the most part, the physical and emotional labor involved in such care falls to women. Tiredness is a major health cost of the double day, but women’s nutritional status and mental health may also be compromised. Further, while writing of a double (or triple) day suggests some spatial differentiation of the two, this is not necessarily the case. Often women’s participation in the labor force is through casualized outwork at piece rates; concurrently women care for infants and small children, older family members and others who are sick or infirm and require care, and undertake household tasks. Where women’s work is outside the home, they may similarly combine their tasks, taking infants and young children with them while they undertake agricultural labor, work in a market, wash clothes or clean others’ houses, and cook food for the family concurrently with other tasks (Buvinic et al. 1983; Karlekar 1982; Nussbaum

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2000). In this process, women may further compromise their own health and that of their children.

Women’s health is compromised by differential access to education In general, there is a flow on from economic to social development. Aspects of social development, such as education, flow first to boys. Literacy and numeracy provide the basic tools to negotiate contemporary life: to trade, travel, negotiate favorable conditions of work, borrow money. Boys’ opportunities to formal education, relative to girls, provide them with greater skills that lead to increased opportunities in employment and civic and political life. Low literacy and limited access to formal education conversely limit women’s opportunities in the public sector and further limit the opportunities for empowerment. This has direct effects on health. Through formal learning and a greater general ability to take up new ideas, education enhances people’s knowledge about health, the risks of infection or disease, the ability to adopt interventions for prevention, recognize signs and symptoms of illness, and act promptly to reduce severe morbidity and mortality. With education, women are empowered with respect to their own and their children’s health. The dual commitments of UNICEF to school and basic health care reflect the synergy of the two.

Medical treatment and health programs are often gender blind, with negative outcomes for women Women play multiple roles in maintaining health through their roles in biological reproduction, in childcare, the nutrition and management of health and illness of children, in feeding other householders, caring for the sick, frail and elderly, and arranging for medical care, concomitant with work in domestic production and increasingly in the paid workforce (Doyal 1995; Nussbaum 2000; Sen et al. 2002; Sweetman 2001). Insofar as women almost everywhere have primary responsibility for infants and small children, then women’s poor health status also compromises children’s health – and that of entire households. Within international organizations and in developing countries, in consequence, there has been growing concern on the impact of gender-based inequality on women’s health. This initially focused on reproductive health, including access to antenatal care, safe motherhood, freely available contraception, and, subsequently, health prevention advice, screening and support for women with regard to cancers, sexually transmissible and reproductive tract infections, and HIV. More recently, there has been increased awareness that gender potentially shapes the health risks, presentation and progression, survival rates, and treatment options and prognosis, of all diseases. This includes infectious diseases, where gender influences apparent differences in prevalence and incidence as a result of differences in exposure, home diagnosis and presentation for care. However, biology also

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influences the course of disease, as severity of malaria in pregnant women demonstrates (Brabin and Brabin 1992). Health services and public health interventions, as well as clinical and epidemiological understandings of disease, have often been gender blind. Clinics are not always accessible to women. In much of the world, women are reluctant to present for care to a male health professional, and they may indeed be prevented from doing so by their husbands or mothers-inlaw. Women may present for certain health problems, but may not report signs and symptoms that might be misinterpreted. For example, women may not report signs of genital schistosomiasis, onchocerciasis or filiariasis infection with vulval or breast swelling or itchiness out of embarrassment, because of fear that they have a sexually transmitted infection or will be considered, regardless, as promiscuous (Poggensee et al. 1999; Ramaiah et al. 2000; Vlassoff et al. 2000). Public health programs have frequently ignored local gendered sensitivities, or worked around them in ways that render the interventions ineffective (not spraying insecticide in women’s houses, for instance). Behavioral changes often require women’s additional labor: household and peridomestic work, involving the removal and safe disposal of hard waste to prevent mosquito breeding, and therefore to reduce the transmission of dengue, is a case in point (Winch et al. 1994). Similarly, the recruitment of women as volunteers in multiple primary health care programs rarely takes into account that women are time-poor. Programs are often also introduced without forethought of the negative impact they might have on women’s lives. El Katsh and Watts describes in Egypt women’s refusal to use water pumps and washing machines and so avoid the river and the risk of schistosomiasis infection, when to do so was to accept isolation from other women and to miss the opportunities for their children to play with others, and the practical support and information that meeting other women by the water’s edge provided (El Katsha and Watts 2003).

Social disruption associated with rapid economic development has further negative effects on women’s health and wellbeing Economic development has everywhere been accompanied by urbanization, as a result of the concentration of manufacturing and service industries, and increased access to goods and services, including health and education. It has also been accompanied by increased migration not only to cities, but also to other rural areas intermittently when work is more readily available on a continuing basis, as occurs with the transport of raw materials and manufactured products between the periphery and center and between countries. Labor migration has also increased with men and women travelling to other countries in search of better paid work (Ferguson and Morris 2007; Mercer et al. 2007; Pallikadavath et al. 2005). Often population movement and resettlement results in the fragmentation of families, and while historically men have migrated and women have stayed at home, increasingly women migrate

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too, leaving children with grandparents or older siblings. In cities, people often live in extremely crowded and poorly serviced settings, without the support of other family members and where alcohol and other substance abuse, and property crime, are prevalent. In these contexts, women are especially vulnerable to sexual violence and other intimate partner violence (Dinnen 1993; Jewkes et al. 2002; Jewkes et al. 2003; Kalichman et al. 2007).

The focus on political development may lead to resistance to international efforts to enhance women’s health The above points highlight the need for extensive action by communities, governments and international agencies in order to address gender inequality, ensure appropriate treatment for women, and reduce their risks of infectious disease and the multiple health problems that are socially produced. This is not necessarily straightforward. Certain interventions, including those that support women to control their fertility and the timing of conception, prevent women from sexually transmitted infections and HIV, provide services to support women who are survivors of violence, and enable women to participate in screening and receive regular care, may be opposed at multiple levels. Such opposition may occur not only by other household members but also by community, national and transnational institutions (such as churches), reflecting national and subregional tensions. In certain cases, too, there is resistance to interventions because of perceptions of cultural imperialism and practical interference. Local responses to international efforts, through human rights legislation and advocacy to eliminate female genital mutilation (FGM), highlight the sensitivities involved (Manderson 2004). Resistance is primarily local, constellating around arguments of the rights of people to maintain traditional cultural practice, but with wider repercussions. In 1994, for instance, in response to a television program on FGM broadcast to coincide with the International Conference on Population and Development, the then Minister of Health in Egypt decreed that the procedure should be performed only in government facilities by trained medical personnel. Although continued advocacy against FGM lead to the decree being rescinded two years later, it took over a decade of sustained public education and advocacy before the procedure was finally banned in 2007.

International efforts In recognizing the links between gender, health and development, international organizations have been major players advocating for and providing practical solutions to enhance women’s health. In this section, I discuss how they have worked toward global agendas to establish gender equity, often supporting local networks and coalitions to effect social change. For the purpose of illustration, I focus on a subset of health issues that impact on women in resource-poor settings and a selection of organizations. I first discuss gender

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in relation to infectious disease and specifically neglected diseases of poverty. I then describe the collaborations between individual scholars and activists, NGOs and international organizations to initiate and sustain a global network to promote research on sexual violence in order to ensure that this is recognized as a priority public health problem.

Mapping the players in women’s health Worldwide, international agencies and multilateral organizations are involved directly and indirectly in defining and redefining what are desirable and achievable development policies and programs, and in taking practical action, to enhance and protect women’s health. The complex relations between and absolute numbers of players, the variety of organizations, policies, conventions and programs, all point to the pernicious ways in which social structures and systems, economic, political and cultural organizations, subordinate women and affect them both physically and mentally, and highlight the difficulties that individuals, governments and community-based organizations face in redressing gender bias and improving women’s health. Boserup’s 1970 book stimulated extraordinary scholarship, advocacy and reflection in international organizations. 1975 was declared International Women’s Year. The first world conference held as part of the year’s activities in Mexico City, focused on a trio of themes – equality, development and peace – but in this context also attended to the ways in which women were disadvantaged in health services, housing, nutrition and family planning. In responding to the Conference Plan of Action, negotiated in committees at the conference, the UN General Assembly proclaimed a first Decade for Women (1976–1985), with guidelines, goals and targets related to health and development. As a direct outcome of IWY, new international organizations were established to supplement the work of the Commission on the Status of Women (established in 1946) and the Branch on the Advancement of Women: an International Research and Training Institute for the Advancement of Women (INSTRAW) was established to generate, through close collaboration with the UN Statistical Division and ILO, an evidence base to make women and their roles in social and economic development visible. The work of the Institute, located in the Dominican Republic since 1983, has extended beyond questions of measurement alone, to attend to questions of women’s household production, women’s access to credit and water, the gendered effects of structural adjustment and globalization, women’s access to work, health and education, and gender-based violence. In 1976, also as an outcome of the conference, UNIFEM was established to provide the institutional framework for research, training and operational activities in the area of women and development, and provide financial and technical assistance to promote women’s human rights, political participation and economic security, so indirectly also addressing questions of health and personal

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security; in recent years it has specifically taken up questions of sexual health, human rights and gender-based violence. Multiple other members of the UN system are concerned explicitly with women’s health and development. UNICEF was established in 1946 to provide humanitarian and development assistance, including through policy advice and program assistance to national governments for the benefit of children and mothers in developing countries; since 1969, UNFPA has supported programs to help women (and men) plan families and avoid unwanted pregnancies, ensure safe pregnancy and childbirth, avoid sexually transmitted infections, combat gender-based violence, and promote gender equality. Other organizations, such as FAO, ILO and the UNHCR, through their own mandates routinely address matters that directly affect health and wellbeing, and, by implication, gender. The primary organization concerned with women’s health and development, WHO, provides global policy advice at national, regional and global levels to work toward the attainment by all peoples of the highest possible level of health. In 2007, WHO’s mission was refined in terms of its role in providing leadership on global health matters and shaping the health research agenda, with its performance measured by the impact of its work on women’s health and on health in Africa. To the extent that indicators for health, such as morbidity and poverty, are poorer for women than men in Africa as elsewhere, then performance focuses on women both regionally and globally. This attention to gender, and its articulation with health and development outcomes, reflects decades of work within WHO and in other agencies to address gender differences in health. At its headquarters in Geneva, the Department of Gender, Women and Health (GWH) has advocated the inclusion of a gender perspective, emphasized the health consequences of discrimination against women, and is currently taking a lead within the organization to mainstream gender. This is translated and disseminated at regional levels. The unit of Women and Health Development at the WHO Regional Office for the Eastern Mediterranean (WHO/EMRO), for instance, emphasizes the need for gender-based analysis to identify, and so taked account of, the social and biological differences of men and women in health outcomes and risks. A number of affiliated centers also have strong programs on gender and the resultant differences in health status, attainment and vulnerability. The WHO Centre for Health Development in Kobe, Japan – established in 1995 and focusing specifically on the urban environment – developed the Kobe Plan of Action for Women and Health and practical indicators on the gender sensitivity of health systems and health promotion partnerships with cities, and promotes leadership in women’s health. For almost two decades, the UNICEF/UNDP/World Bank/WHO Special Programme on Research and Training in Tropical Diseases (WHO/TDR) has supported research, training strategies and the development of interventions to reduce gender bias in risks,

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treatment and outcomes of infectious diseases of poverty, as I discuss further below. UNAIDS has necessarily always attended to gender, as a key factor influencing risks of infection of HIV and access to treatment. The inequalities of relationships between men and women, the pervasiveness of violence against women, women’s and girls’ biologically vulnerabilities, and the links between gender and poverty, all mean that increasingly HIV infection and AIDS are women’s health problems (Farmer et al. 1996). Supplimenting these organizations are conventions, plans of actions and consensus statements that inform government policies and programs. The global statements that inform such shifts include the Program for Action of the International Conference on Population and Development (ICPD) held in Cairo in 1994, the Beijing Platform of the Fourth International Conference on Women (ICW) (1995), Beijing Plus Five, as well as the Convention on the Elimination of Discrimination against Women (1979) and the Convention on the Rights of the Child (1990). The statements provide a mandate for much of the work of international agencies and sovereign states to address the social, cultural and economic barriers that impact upon women’s health.

Gender and neglected tropical diseases As illustrated in the first part of this chapter, inequalities in health outcomes reflect a combination of biological, social and economic vulnerabilities. These are, in many cases, poorly understood. An examination of the biology, epidemiology, prevention and treatment of neglected tropical diseases illustrates the ways in which this occurs, and consequently, why gender matters in the distribution and control of these diseases of poverty. A first step was to examine the links between gender and the nature of infection, the incidence and prevalence of tropical disease, and the development, implementation and success of control programs. Two diseases that are still, at the time of writing, part of WHO/TDR’s mandate – malaria and tuberculosis – are no longer classified as ‘neglected infectious diseases,’ particularly as a result of international investment, although even for these diseases, the literature on sex and gender is limited. Sex is relevant for malaria, because women lose semi-immunity with pregnancy and malaria increases the risks of miscarriage, premature labor and stillbirth (Helitzer-Allen et al. 1993; Reuben 1993). Gender is relevant to the extent that risk factors of infection vary according to behavior and exposure. In Hainan, China, for instance, men who work in the forest are at greater risk of infection than women (Tang et al. 1995). Subsequent research highlights the relevance of gender in the uptake of preventive measures and the sustainability of interventions and has furthered understanding of how hormonal factors affect immunity and fetal and maternal outcomes. Information on the links between gender and tuberculosis has been enhanced by a multicountry study of TB infection, with research collaboration in India, Bangladesh, Malawi and Colombia (Weiss et al. 2006). Again,

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the data point to the ways in which gender shapes the epidemiology of disease and individual outcomes, through gender-related differences in exposure to the pathogen, differences in presentation to health services for diagnosis, differences in household willingness to adhere to treatment regimes, and differences in the implications of disease. Little is known of neglected tropical diseases such as infections other than malaria and tuberculosis. From 1990, reviews of the extant medical literature conducted within WHO/TDR, an essay competition in 1991 and research projects conducted with TDR support, have all drawn attention to the significance of both sex and gender on infection and treatment. Women’s apparent lower rates of lymphatic filariasis, for example, related to their reluctance to present and be examined by male doctors, particular with breast or vulval involvement (Babu et al. 2004; Gyapong et al. 1996). The prevalence of female genital schistosomiasis similarly was underestimated because of a lack of scientific investigation (Feldmeier et al. 1993; Michelson 1993). A recent review indicates the possibility that schistosome-associated morbidity, other than schistosomiasis-related anaemia, negatively affects maternal, fetal and neonatal outcome, including birth weight, but the field is underresearched. Concurrently, review papers and new research consistently draw attention to the social impact of these infections on women, including in terms of their ability to marry and participate fully in society (Bandyopadhyay 1996; Hudelson 1996; Long et al. 2001; Rao et al. 1996; Rathgeber and Vlassoff 1993; Thorson and Johansson 2004; Vlassoff et al. 2000). Where these diseases are prevalent, the risk of infection typically depends on sharply gendered patterns of use of the environment and exposure to pathogens. The segregation and confinement of women, for example, may be protective if women are excluded from the ecological niches where the risk of infection is greatest, but they may be at increased risk of severity of disease where exposure is greater, for instance when washing clothes and bathing children in schistosome-infested water. Typically in these areas, too, depending also on age and relationship to head of household, women’s lack of mobility reduces presentation for care and their lack of personal resources reduces affordability of treatment. Women may not report conditions that embarrass them; there is a lack of integrated care so women lack opportunities to seek care for themselves when presenting with children, and inconvenient clinic hours and poor quality of care discourage attendance.

Sexual violence as a public health priority Any week provides a snapshot of the footprints that international organizations, human rights instrumentation, institutions, political systems and structures place on local soil. In any week, in widely diverse settings, a range of activities and events instantiate how the policy environment has shifted to provide the beginnings of gender equality and reproductive and sexual

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rights. By way of example, in late April 2007, members of Law and Advocacy for Women in Uganda petitioned the Constitutional Court to have FGM declared illegal. Earlier in the month, they had successfully petitioned the Court to abrogate the country’s law on adultery on the grounds that it made marital infidelity an offence when committed by women but not by men. The current petition follows a campaign of awareness of the physical and psychological costs of FGM, sponsored by the UNFPA. Three days later, UNICEF and the Inter-Parliamentary Union (IPU), at a meeting in Indonesia, launched a joint handbook for parliamentarians to introduce legislation, allocate public funds and launch the Secretary-General’s report on violence against children, including sexual violence, which highlights the underreporting, pervasiveness and physical, emotional and psychological costs of such violence. The growing attention to sexual and other interpersonal violence is very much a joint effort of international agencies, non government organizations, community groups and foundations. A range of agencies and conventions have been in place for some decades, a number preceding and others the consequence or following International Women’s Year. In particular, groups and agencies constellated around female genital cutting, stimulated by the publication of The Hosken Report (Hosken 1979) but advanced also by WHO, UNICEF and UNFPA. Other gender-based violence – rape, domestic violence, and other sexual assault and violence – has had far less support, however. This reflects in part the lack of recognition of the relationship of such violence to diverse physical and mental health problems, in the short and longer term, in part to the normalization of violence against women by doctors and lawyers, and in part through trivialization (leading to considerable debates about the importance of establishing its epidemiology before action might be taken). The WHO Multicountry Study on Women’s Health and Domestic Violence against Women (Garcia-Moreno et al. 2005) presents data from interviews with an extraordinary 24,000 women from ten countries, and highlights the prevalence of intimate partner violence, its association with women’s physical, mental, sexual and reproductive health, and the extensiveness and impact of non partner violence, sexual abuse during childhood and forced first sexual experience. In 2000, on the initiative and with the financial support of the Global Forum for Health Research, a major consultation was held in Australia to establish an initiative on sexual violence (Bennett and Manderson 2000; Bennett et al. 2000), leading in 2002 to the Sexual Violence Research Initiative (SVRI). SVRI, with a secretariat originally based at WHO and now based in South Africa, is a network of researchers, policy makers, activists, donors and others committed to promoting research on sexual violence and generating empirical data to ensure that sexual violence, broadly defined, is recognized as a priority public health issue. The SVRI builds on and extends the work of WHO undertaken in the context of the multicountry study, and highlights the social, personal and economic pathologies that shape women’s health.

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Conclusions Gender is a means by which power and resources are divided unequally, with differential effects on health and human development. Gender-based inequality interacts with inequalities of social class, race, caste and ethnicity, so women may face additional disadvantages compared to men from the same social group. While it is difficult to examine the effect of these divisions as if independent, gender is pervasive and affects all dimensions of health and illness. Women’s poor health in turn influences the extent to which countries are able to move forward their development agendas; their poor health also undermines their participation in development and their ability to share in the benefits of development. International organizations – multilateral agencies, foundations, formal associations and informal networks – all have a role in ensuring that gender-based inequalities remain on the agenda, and in finding ways around institutional rigidities and political sensitivities to ensure that women and their health are not sacrificed for development.

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196 Part III: Global Health and Vulnerability Karlekar, M. (1982) Poverty and Women’s Work: a Study of Sweeper Women in Delhi (New Delhi: Vikas Publishing House). Long, N.H. et al. (2001) ‘Fear and Social Isolation as Consequences of Tuberculosis in VietNam: a Gender Analysis’, Health Policy, 58(1): 69–81. Manderson, L. (2004) ‘Local Rites and Body Politics: Tensions Between Cultural Diversity and Human Rights’, International Feminist Journal of Politics, 6(2): 285–307. Mercer, A. et al. (2007) ‘Sexual Risk Behavior of Married Men and Women in Bangladesh Associated With Husbands’ Work Migration and Living Apart’, Sexually Transmitted Diseases, 34(5): 265–73. Michelson, E.H. (1993) ‘Adam Rib Awry – Women and Schistosomiasis’, Social Science & Medicine, 37(4): 493–501. Nussbaum, M. (2000) Women and Human Development: The Capabilities Approach (Cambridge and New York: Cambridge University Press). Pallikadavath, S. et al. (2005) ‘HIV/AIDS in Rural India: Context and Health Care Needs’, Journal of Biosocial Science, 37(5): 641–55. Poggensee, G. et al. (1999) ‘Schistosomiasis of the Female Genital Tract: Public Health Aspects’, Parasitology Today, 15(9): 378–81. Pun, N. (2005) Made in China: Women Factory Workers in a Global Workplace (Durham, London and Hong Kong: Duke University Press and Hong Kong University Press). Ramaiah, K.D. et al. (2000) ‘The Impact of Lymphatic Filariasis on Inputs in Southern India: Results of a Multi-site Study’, Annals of Tropical Medicine and Parasitology, 94(4): 353–64. Rao, S. et al. (1996) ‘Gender Differentials in the Social Impact of Leprosy’, Leprosy Review, 67(3): 190–9. Rathgeber, E.M. and C. Vlassoff (1993) ‘Gender and Tropical Diseases – a New Research Focus’, Social Science & Medicine, 37(4): 513–20. Reuben, R. (1993) ‘Women and Malaria – Special Risks and Appropriate Control Strategy’, Social Science & Medicine, 37(4): 473–80. Safa, H. and E. Leacock (eds) (1986) Women’s Work: Development and the Division of Labor (Westport, CT: Bergin and Garvey Publishers). Sen, G. et al. (eds) (2002) Engendering International Health: the Challenge of Equity (Cambridge MA: MIT Press). Sweetman, C. (ed.) (2001) Gender, Development, and Health (Oxford: Oxfam). Tang, L.H. et al. (1995) ‘Social Aspects of Malaria in Heping, Hainan’, Acta Tropica, 59(1): 41–53. Thorson A. and E. Johansson (2004) ‘Equality or Equity in Health Care Access: a Qualitative Study of Doctors’ Explanations to a Longer Doctor’s Delay Among Female TB Patients in Vietnam’, Health Policy, 68(1): 37–46. Visvanathan, N. et al. (eds) (1997) The Women, Gender, and Development Reader (London: Zed Press). Vlassoff, C. et al. (2000) ‘Gender and the Stigma of Onchocercal Skin Disease in Africa’, Social Science & Medicine, 50(10): 1353–68. Weiss, M.G. et al. (2006) Gender and Tuberculosis: Cross-site Analysis and Implications of a Multi-country Study in Bangladesh, India, Malawi, and Colombia (Geneva: UNICEF/UNDP/World Bank/WHO Special Programme for Research and Training in Tropical Diseases (TDR)). Winch, P.J. et al. (1994) ‘Vector Control at the Household Level – an Analysis of its Impact on Women’, Acta Tropica, 56(4): 327–39. Young, K. et al. (eds) (1981) Of Marriage and the Market: Women’s Subordination in Cross-Cultural Perspective (London: CSE Books).

Part IV The Interrelation Between Specific Disease and Development

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12 Long-term Impacts of Leading Chronic Diseases in Low- and Middle-income Countries: a Comparative Analysis1 David Stuckler and Derek Yach

In 2008 more than 31 million people will die from four leading chronic diseases – heart disease, respiratory diseases, diabetes, and common cancers.2 Nearly 80 per cent of these deaths will occur in low- and middle-income countries, where these chronic diseases claim around 80 per cent more lives than the infectious causes put together.3 Over the past decade rises in chronic diseases have been most greatly concentrated in developing countries, and have outpaced some of the original Global Burden of Disease ‘pessimistic scenario’ forecasts. The future outlook is no better. Chronic diseases were responsible for 46 per cent of all deaths in developing countries in 2002 – a figure which will grow to 59 per cent by 2030, or to over 37 million lives a year. In all regions of the world, even in low-income countries, leading chronic diseases are projected to be the leading killers. This means that, globally, chronic diseases will rise as infectious diseases fall (Figure 12.1 and Table 12.1).4 Even in sub-Saharan Africa, where the HIV/AIDS crisis is at its worst, infectious disease mortality rates are expected to drop by 40 per cent over the next 20 years while chronic disease mortality rates will nearly double from 2.3 million to 4.4 million deaths a year. More generally, chronic diseases are growing at a much faster pace in low- and middle-income countries compared to high-income ones (Table 12.2). With these consequences, one might expect that key health organizations, the World Health Organization and national health ministries, and development institutions that focus on poverty, the World Bank and United Nations Development Program, would be making aggressive efforts to combat the rising tide of chronic diseases in developing countries. This is, unfortunately, not the case.5 Table 12.3 outlines some reasons why, and the rest of the chapter is devoted to understanding what the long-term impact will be if chronic diseases, and their drivers, remain unchecked – the current ‘no action’ scenario. We begin our analysis by introducing a basic model of chronic disease epidemiology, which is then tested against a series of stylized facts about chronic 199

200 Part IV: Disease and Development Table 12.1 Expected change in infectious and chronic disease mortality rates per 100,000 population from 2002 to 2030 – Data and region categories based on Mathers and Loncar projections Region World High Income Eastern Europe and Central Asia East Asia and Pacific South Asia Latin America Middle East and North Africa Sub-Saharan Africa

Infectious diseases

Chronic diseases

−99.54 −8.02 7.11 −55.17 −236.42 −55.80 −71.52 −457.11

100.74 109.29 43.62 234.16 95.10 172.71 83.11 23.82

Source: Mathers and Loncar (2006).

Table 12.2 Growth rate in infectious and chronic disease mortality rates (per cent per year), 2002 to 2030 – Data and region categories based on Mathers and Loncar 2006 projections Region World High Income East Asia and Pacific Eastern Europe and Central Asia South Asia Latin America Middle East and North Africa Sub-Saharan Africa

Infectious diseases

Chronic diseases

−1.45 −0.53 −1.91 0.35 −2.94 −1.87 −2.42 −1.76

0.61 0.50 1.37 0.15 0.67 1.24 0.68 0.24

Source: Mathers and Loncar (2006).

diseases to ascertain key drivers of chronic disease growth. In the following section, we evaluate these determinants in the context of globalization, and provide empirical tests of our hypotheses with respect to prevailing explanations. We then draw upon this evidence base to forecast some global effects of chronic disease growth on health and economic development in rich and poor countries. Finally, we conclude with some implications for global health governance and recommendations for chronic disease control.

Drivers of chronic disease risk Beneath the chronic disease trends lay a common set of risk factors: clinical risk factors – hypercholesterolemia, hypertension, and a diverse set of cardiac

Table 12.3

Sources of weak global responses to chronic diseases

Dimension

Key feature

Exposure, prevention, and treatment aspects Health Systems Historical orientation of healthcare systems towards acute care Determinants

Heterogeneity

Favors care practices focusing on “high risk” individuals rather than on population risks; Bias towards tertiary and specialist care rather than prevention

Role of macro-social and -economic forces in propelling risks

Low competence and capacity within health sector for acting upon upstream and globalized drivers of risks

Behavioral and choice aspects of chronic disease risks

Risks framed as problems of individual responsibility, emphasizing role of individual rather than socio-environmental intervention

Diversity of chronic disease inputs and end-points

Complicates prevention and treatment intervention analysis, implementation, and evaluation

Population accumulation and distribution of risks and disease Risk Accumulation Long and variable lag times between risk exposure and clinical expression as disease or disability Age Distribution

Implications for chronic disease control

Chronic diseases tend to occur in middle- to laterstages of life

Greater population dispersion and lower recognizeability make chronic diseases easier to ignore and less likely to stimulate fear or public outrage; Longer-term benefits of interventions mismatch with shorter-term political cycles; More difficult to model empirically Less political salient than conditions that afflict youth; Promoted the misconception that chronic diseases are inevitable consequences of aging; Misspecification of epidemiologic forecasts (Continued)

201

202

Table 12.3

Continued

Dimension

Key feature

Implications for chronic disease control

Social Distribution

Within countries: As countries develop, higher SES groups tend to first absorb transformed risk habits and are thus the earliest to develop chronic diseases

Promoted the notion that chronic diseases are “diseases of affluence” despite evidence that the within-population distribution of chronic disease risks undergoes a “social transition” to disproportionately afflict lower SES groups

Between Countries: Higher relative burden of chronic disease in developed countries but higher absolute burden in developing countries

Lower prioritization of chronic diseases by global actors on distributive grounds, even though chronic disease growth will be concentrated in developing countries and further widen the gap between the health of the rich and poor

Political, economic and managerial aspects Role of Markets Economic notion that markets will achieve optimal level of chronic disease control

Individual responsibility paradigm provides no legitimate role for state intervention; Does not take into account evidence for market failures

Health Sector Reform

Expanding marketization of health systems

Cost-shifting reforms have levied greater costs of chronic disease prevention and treatment onto patients

Decentralization and devolution of health authority

Policymaking capacity of national health ministries and systems circumscribed

Diffusion of governance authority to private actors

Tensions between chronic disease prevention aims and profit incentives of private actors (i.e., private-public partnerships versus public-private partnerships)

Governance Shifts

David Stuckler and Derek Yach 203 1 Prevention social determinants

Healthy population

P1

2 Prevention age, multiple risks, social determinants

Behavioral risk factor

Upstream: social, cultural and economic intervention

P2

3 Prevention age, multiple risks, health systems, social determinants

Clinical risk factor

P3

4 Prevention age, multiple morbidities, health systems, social determinants

Chronic disease morbidity

P4

Chronic disease mortality

Downstream: healthcare system intervention

Figure 12.1 Transition state model of chronic disease epidemiology

markers, and associated behavioral risk factors – tobacco, physical inactivity and unhealthy diets. A standard model of chronic disease epidemiology is depicted in Figure 12.1. Here a member of the population transitions (i) from being healthy to accumulating behavioral risk, at a probability which is modified by the effectiveness of primary prevention and a set of social determinants (P1 ); then, (ii) from behavioral risk to clinical risk at a probability modified by the effectiveness of secondary prevention as well as other modifiers such as age, co-existing risks, and social determinants (P2 ), and so forth. Exposures to risk factors act synergistically and cumulatively over the life-course for speeding up the progression from being healthy to future chronic disease morbidity and mortality. As chronic diseases move from one state to the next, the health and economic burdens increasingly grow. With extremely low probability can any of these transitions be reversed; however, with successful intervention, their progression can be stopped. What does this model tell us about chronic disease trends? We use three stylized facts about chronic diseases to shed light on what are the key drivers of chronic disease growth: 1. Persons die at younger ages from chronic diseases in poor countries than in rich countries. 2. Poor countries have higher chronic disease morbidity rates than rich countries. 3. Chronic diseases are growing faster in poor countries than in rich countries. Fact #1, depicted formally in Table 12.4, implies that people in poorer countries are either moving through the transitions from being healthy to dying more rapidly than in rich countries or accumulating behavioral risks at younger ages. There is evidence for both of these possibilities: (i) health systems in resource-poor settings are less effective at stopping chronic disease progression; and (ii) the initiation of alcohol and tobacco occurs at younger ages in poor countries, and co-existing risks, such as micronutrient

204 Part IV: Disease and Development Table 12.4 Standardized chronic disease mortality rate ratios, low versus high income countries by age group Age Group

Mortality Rate Ratio

0–14

15–29

30–44

45–59

60–69

70–79

80+

3.24

2.77

1.80

2.06

2.16

1.97

1.35

Source: WHO (2004)

deficiencies and stunting, lead to greater risks for childhood obesity and early onset diabetes.6 Taking fact #2, that poor countries have higher chronic disease morbidity rates than rich countries (about 31 per cent higher), together with fact #3, suggests that healthcare is unlikely to be a crucial driver. While healthcare can possibly account for fact #2,7 health systems alone cannot explain the rise in chronic disease incidence. Indeed, P3 , the probability of a transition from clinical risk to chronic disease morbidity, has likely been decreasing across the world as health systems have become stronger. What about population ageing? Some studies put it as a key driver of chronic disease rises (Mathers and Loncar 2006).8 However, aging cannot account for global differences in mortality rate growth: the percentage of population over 65 years is rising faster in developed than in developing countries, even though the absolute numbers of persons ageing is much higher in developing countries (Centers for Disease Control and Prevention 2003). In sub-Saharan Africa, the proportion of persons over 65 years will increase from 3.1 per cent in 2007 to 3.7 per cent in 2030 while mortality is projected to rise by 90 per cent and mortality rates are projected to grow at a rate of 0.2 per cent a year during this period. Perhaps the set of behavioral risk factors then. Together, they are estimated to account for 30 per cent to 60 per cent of chronic diseases – and their burden is growing. Tobacco is projected to be responsible for 50 per cent more deaths than HIV/AIDS in 2015, or over ten per cent of all deaths – roughly 6.4 million. Some of these risks are global bads, such as tobacco, for which risk always increases as tobacco rises. Other risks, however, can be beneficial, such as dietary intake and physical activity. What the behavioral risks have in common is that they operate at the individual level. These occupy the space in the model at P1 , or the probability that a population member starts smoking, drinking, not exercising, or eating unhealthy foods. To explain cross-national patterns of chronic disease using these individual risk factors thus begs the question: Why are people all over the world today making worse personal choices than before, and much more so in developing countries than in developed ones? Clearly this is only a partial explanation, and a large residual risk remains to be accounted for.9

David Stuckler and Derek Yach 205

To fully understand what is driving such sweeping individual changes – that is, population changes – one must look to the social forces that are transforming not just individual but societal risk distributions.

The role of globalization and some empirical tests Social epidemiology: the role of globalization Globalization provides the best theoretical framework for understanding rising chronic disease risks today and for thinking about what will happen in the future. Here we outline three structural aspects of globalization: economic flows, economic growth and technological change, which are shifting the entire healthy population’s risk distribution to the right (or increasing P1 much faster in poor than rich countries).

Economic flows Recent years have seen a rapid increase in global interconnectivity, or ‘transnationality’, that facilitates the free flow of goods, resources and services across countries. Many of these products flow from the Global North to the Global South, and in doing so tap existing local markets and often create new ones. Most of these flows as they relate to behavioral risks favor items that can be easily transported, such as processed and pre-packaged items – including fizzy drinks, cigarettes, etc. Since supply chains and technology are greater in the Global North, many of these products outcompete more expensive products generated by local suppliers. As a result of these significant market advantages that transnational companies enjoy, there has been and will continue to be large-scale entry of Western food & beverage companies into ‘emerging markets.’ Countries often wish to encourage such investment from foreign sources (foreign direct investment, or FDI) as a way to boost economic growth.10 FDI offers know-how and resources which are typically unavailable at home. In order to enhance the potential for these flows, countries seek to more fully integrate themselves into the global marketplace by liberalizing trade restrictions and transferring the ownership of large state-owned monopolies to the private sector (Hawkes 2005, 2006). Much of this is to the good. When markets work well, people are better off. More competition brings lower prices and more efficiently delivers goods to populations. From a chronic disease control perspective, strategies such as liberalizing trade restrictions breaks down for the global bads like tobacco, but could be favorable for increasing access to nutritious fruits and vegetables.11 However, many critics believe that the current market environment in poor countries privileges risky rather than healthy products (Beaglehole and Yach 2003; Hawkes 2005, 2006; Pang and Guindon 2004; Popkin 2002). How

206 Part IV: Disease and Development

this might be the case can be better understood by examining the interaction between these prevailing economic strategies and co-occurring social transformations.

Economic growth As the level of a population’s income grows, population habits and consumption patterns change. Rapid growth creates a tremendous opportunity to modify a population’s risk just as their lifestyles catch up to their newfound wealth. This is particularly the case for rapidly developing countries such as India and China, which have registered record economic growth rates of over 5 per cent on average over the past decade but have also experienced the rapid uptake of chronic disease risks. In contrast to western countries, where people buy more healthy foods and spend more time exercising as their income levels rise, in developing countries the opposite appears to be occurring (Cutler et al. 2003; Drewnowski and Darmon 2005; Popkin et al. 2001). Why might this be the case? First, transnational companies have more successfully engaged in aggressive information campaigns in developing countries using advanced marketing strategies proven in western countries. In less competitive information environments, such as those in developing countries, marketing is even more powerful than persons in the West can appreciate. One particularly effective strategy has been to confer social status or prestige on eating in restaurants, often by associating them with cosmopolitan western habits (Witkowski 2007). This, and other effective marketing strategies, raises the desirability of western imports and outside-the-home food consumption as they become more affordable – that is, as incomes grow.12

Technological change and social flows Growth is only part of the story. Technological changes driving growth are also key. As societies advance technologically, labor shifts from agrarian production to intellectual production, and workplaces become increasingly sedentary. Work becomes more centralized as tech and service industries grow (think of call centers in India), and these work opportunities in turn drive people en masse from rural to urban settings. In urban settings food production can be concentrated and can better take advantage of economies of scale, leading to lower prices and further incentivizing people to eat outside the home. Urban settings in developing countries also have fewer opportunities for physical activity. As more women begin to enter the workforce – a possibility encouraged by technological advance – they face greater time constraints for household production of food and this time poverty also acts to move food consumption away from the home. Because of the market structure and incentives described previously, the net effect on society is greater consumption of unhealthy products and increasing sedentary behavior.

David Stuckler and Derek Yach 207

In sum, economic flows have increased the accessibility of behavioral risks, social changes accompanying economic growth have encouraged their uptake, and technological change has created incentives for people to exercise less and eat out more. All these forces join to heighten population risk of chronic diseases growth in developing countries. Stated succinctly, we arrive at five conclusions which are contributing to rising chronic disease risks and mortality in the developing world:13 1. Globalization is leading to greater inter-country dietary dependence. 2. Foreign direct investment in food & beverage in developing economies has favored less healthy products in developing countries. 3. Transnational companies, via marketing, influence persons in poor countries to prefer western products as income levels rise. 4. Technological change speeds up all these processes, and 5. Technological change encourages more inactive lifestyles and shifts the locus of food consumption away from the home. In the developed world, however, these effects hold but in reverse, and thus can be expected to be associated with lower chronic disease mortality rates.14

A simple model of the effects of globalization on chronic disease mortality To more formally illustrate these effects on chronic diseases, and how they differ across rich and poor countries, we provide a simple comparative analysis using correlations and multivariate regression. First we take a set of poor, middle and rich countries, determined by the tertiles of the average gross domestic product per capita from 1960 to 2000. Using WHO Global Mortality Data, we then correlate growth with total cardiovascular and chronic disease mortality. The patterns are clear: In all cases, growth is associated with increased chronic diseases in poor countries, and the effect appears to linearly worsen for poor countries compared with middle and rich ones. For rich countries, the effect reverses such that greater income levels are associated with lower heart disease and chronic disease levels. Turning to the key aspects of economic globalization identified earlier, market integration and foreign direct investment, and the main social change discussed, urbanization, reveals similar patterns as that seen for economic growth. Urbanization is linked to greater heart disease and chronic disease mortality rates in poor countries, but lower mortality rates in middle countries and in rich ones. Market integration follows the same pattern, except it has no significant effect in middle-income countries. Foreign direct investment associates with increased cardiovascular and chronic disease mortality in poor countries but

208 Part IV: Disease and Development Heart disease mortality

Chronic disease mortality

RPoor  0.40** Growth

RPoor  0.29**

RMiddle  0.13**

Growth

RRich  0.44**

RMiddle  0.13** RRich  0.37**

Figure 12.2 Correlation of growth with total cardiovascular and chronic disease mortality Globalization

Urbanization RPoor  0.46** RPoor  0.58** RMiddle  0.15** RMiddle  0.18** RRich  0.18** RRich  0.11** Cardiovascular mortality

Chronic disease mortality

Foreign direct investment RPoor  0.48** RPoor  0.38** RMiddle  0.04 RMiddle  0.11* RRich  0.04 RRich  0.10* Cardiovascular mortality

Chronic disease mortality

Market integration RPoor  0.23* RPoor  0.42** RMiddle  0.05 RMiddle  0.02 RRich  0.21** RRich  0.24** Cardiovascular mortality

Chronic disease mortality

Note: Poor countries  $3000 US per capita income, Middle countries $3000 and $7000, and Rich countries $7000 US on average from 1972 to 2000. Mortality Data are from the WHO Global Mortality Database. Economic data are from the World Bank World Development Indicators 2005 edition and International Monetary Fund International Financial Statistics 2007 series. Cross-country data de-trended for effects of changing ICD classifications. *  p0.05, **  p0.01

Figure 12.3 Correlation of market integration, foreign direct investment, and urbanization with total cardiovascular and chronic disease mortality

has no effect on rich countries, although there is a significant adverse effect of foreign direct investment on middle-income countries. This fits with our analysis that the effects of foreign direct investment, market integration and urbanization qualitatively differ by levels of country development. What does this mean for developing countries in the future? As an indication, we present some multivariate regression models of what these effects have historically done to high-income countries, where the chronic disease burden has fully matured. More specifically, since chronic diseases have a decadal lag time between exposure to risk and the development of chronic disease, we focus on high-income countries to identify how population exposures twenty years ago have shaped their current chronic disease burden in order to understand the consequences for developing countries today.15 It is clear from Table 12.5 that, historically, greater growth, foreign direct investment, market integration and urbanization have fueled a significant

David Stuckler and Derek Yach 209 Table 12.5 Twenty-year-long difference models of chronic diseases from 1960 to 2000, high-income countries16 Covariate

Change in Heart Disease Mortality over 20 year span

Change in GDP per capita Change in FDI levels Change in Market Integration Change in Urbanization Change in Population Age Dependency Average Rate of Growth R2

0.45** (0.10) 0.03** (0.01) 0.59** (0.10) 0.01* (0.01) 0.02** (0.01) −0.00 per cent 0.31

Change in Chronic Disease Mortality over 20 year span 0.20** (0.06) 0.01 (0.01) 0.43** (0.10) 0.03** (0.01) 0.04** (0.00) 0.45 per cent 0.59

Table 12.6 Decomposition of population ageing and globalization effects on chronic diseases17 Covariate

Change in Log GDP per capita Change in Log FDI levels Change in Market Integration Change in Urbanization Change in Population Age Dependency

Average Change

1.225 2.534 0.080 1.862 2.383

Estimated Effect on Heart Disease Mortality over 20 year span

Estimated Effect on Chronic Disease Mortality over 20 year span

0.557 0.071 0.047 0.025 0.046

0.242 0.041 0.034 0.050 0.088

part of the rises in heart disease and chronic disease mortality. For example, each one per cent increase in the population living in urban settings has increased the long-term population total chronic disease growth rate by 3 per cent. By comparison, NCD mortality grew on average in rich OECD countries at a rate of 0.5 per cent per year. This is clearly a sizable effect. The common explanation of chronic disease growth, that population ageing is the primary driver, is supported in our model, but not nearly to the extent that has been emphasized in the literature. Population aging, as measured by population age dependency (or percentage of population over 65), was linked to increases in heart disease mortality changes and total chronic disease mortality. Compared with changes in economic growth, however, these effects had only one-third the total magnitude for chronic disease mortality changes and less than one-tenth the effect as GDP per capita changes

210 Part IV: Disease and Development

(see Table 12.6 for a decomposition of these effects). In fact, population aging was only more powerful than urbanization for heart disease and market integration for total chronic diseases. Our results here show that the notion that chronic diseases are inevitable consequences of aging is grossly overstated – and historically false.

Long-term epidemiologic and economic impacts of rising chronic diseases Now we are finally in position to clarify what will happen in the coming years. 1. Chronic diseases will further widen the health gap between rich and poor countries. Since chronic diseases are growing at a faster pace in low- and middle-income countries, their impact will widen the health gap between the global North and South. Chronic disease mortality will rise by 15 per cent in high-income countries, but by 22 per cent in low- and middle-income ones. As shown before using standardized mortality ratios, the mortality will hit working-age populations much harder in poorer countries than in richer ones. It follows that, 2. Chronic diseases are killing and disabling people at their peak productivity. It is often argued that infectious diseases in Africa have caused a ‘poverty trap’. Because so many working-age people are dying, the workforce is unable to push Africa’s economy forward. In turn, so many people are dying because there aren’t enough resources to combat the epidemic. What is so bad about diseases like AIDS in Africa for growth? First, once acquired, HIV/AIDS cannot be clinically stopped, and leads to long-term suffering on the road to a painful death. Second, it costs the health system a lot of money. Third, left unchecked, it can spread at an alarming pace as exposure to risks in the population grows. All of these burdens apply to chronic diseases. The global data show that the question is not if infectious diseases overtake chronic ones but, rather, when. The concern is that, just as AIDS is being conquered, and given the costly similarities between AIDS and chronic diseases, the AIDS poverty trap will simply morph into a chronic disease poverty trap in coming years. 3. Chronic diseases will slow countries’ economic growth rates. Consider the economic impacts of heart disease in working-age men today in OECD countries. As before, this presents an idea of what the economic impacts will be once the chronic diseases risks prevalent today in low-income settings develop into full-blown chronic disease morbidity and mortality. This can also be justified because poor countries are about a decade behind rich ones in their chronic disease burden. Table 12.7 shows the results of a neoclassical growth model, augmented with chronic disease mortality. Each one per cent increase in working-age chronic disease mortality is associated with a −0.05 per cent decline in economic growth. These results are

David Stuckler and Derek Yach 211 Table 12.7 Effect of chronic disease working-age mortality on economic growth18 Dependent variable: real GDP per capita change Covariate

Fixed Effects Model

Log Chronic Disease Working Age Mortality Log Inflation Openness Secondary Education Levels Savings Rate Number of Country-Years Number of Countries

−5.11 (1.43)** −1.73 (0.37)** 0.01 (0.02) −0.02 (0.03) 0.23 (0.07)** 532 20

consistent with previous economic models (Suhrcke and Urban 2006), and a large set of studies linking chronic diseases to high economic costs (Suhrcke et al. 2006; World Bank 2007; World Health Organization 2005). Extending this model to low-income countries suggests that a 40 per cent rise in chronic diseases – the amount expected in Latin America from 2002 to 2030 – will result in a 2 per cent slowdown in economic growth each year. This is a large effect: by comparison, the United States economy grows by about 2 per cent on average every year.19 4. Chronic diseases are contributing to North–South economic divergence. Since the rises in chronic diseases will be concentrated in poor countries, it follows that chronic diseases are contributing to North–South economic divergence.

The way forward Emerging from this analysis is a clear long-term picture of chronic disease proliferation and rising economic burdens concentrated in poor countries, and of an inadequate response to the need for control by individuals, markets and global players. The global challenge faced by WHO and major international players is how to act in concert to tackle rising chronic diseases without discouraging equitable and sustainable economic development. One obvious solution is to adopt a coordinated approach between infectious and chronic diseases – to build health system capacity while transforming health systems from acute to chronic care models. As recent studies have shown, AIDS treatment in resource-poor settings is failing due to poor adherence (Rosen et al. 2007). What is not mentioned is that AIDS is a chronic disease. That AIDS is one of the few infectious diseases that are on the rise reflects the same limitations fueling the unchecked growth of chronic diseases in poor countries today. Yet learning and sharing between AIDS-CVD-Diabetes control is not taking place, and is passing up a tremendous opportunity for enabling health systems to address long-term population healthcare problems as billions of dollars flow into AIDS and TB control.

212 Part IV: Disease and Development

A focus should also be maintained on the priorities of populations, not just the priorities of donors. National health ministries have introduced more than 40 resolutions in the past several decades within WHO to develop stronger systems for combating chronic diseases. Heeding these calls for change would bring global health closer to what it aspires to be an equitable practice, committed to the principles espoused by Health for All and the Declaration of Alma Ata (International Conference on Primary Health Care 1978). The reality is that despite the very clear economic and epidemiologic impacts, and their inequitable global distribution, little or no action will be forthcoming in the next few years. Infectious disease control will remain the priority, and, given current forecasts for global falls under the baseline scenario, probably be heralded as a great success of the global health triumvirate – WHO, the World Bank, and the Gates Foundation.20 But the die has been cast, and the patterns have been set: the overwhelming focus on infectious diseases will have low marginal impact that will be traded off for excess losses due to chronic diseases. The scenarios painted here under the ‘baseline case’ correspond to where we are today and will be tomorrow – ‘the no action case.’

What is to be done? Firstly, it is understandably very difficult for public health practitioners to engage the global drivers of chronic diseases, and, in particular, when transnational corporations play a leading role in the process. There is a critical need to engage with the private sector (as one of the authors of this chapter has done), and to overcome the ‘anti-corporate’ culture that exists in public health today (owing much to the legacy of tobacco company actions) (Wiist 2006). Public health has an important role to play in convincing corporations to expand healthy product lines, and can play a role as ‘health investment advisors’ to show the economic benefits of doing so. Likewise, public health can learn from the private sector, and collaboration can yield significant gains in public health’s effectiveness.21 Secondly, interactions with Ministers of Finance are crucial in order to align economic growth policy with health policy. Economic development need not imply a chronic disease curse. While the way forward may seem unclear and foreign for many, the analysis provided in this chapter paints a roadmap of how to proceed on this front. Model parameters, such as the one provided here for a neoclassical growth model, can be replicated in each country to identify what the effects of growing chronic diseases will be for national economies under low-, medium- and high-chronic disease growth scenarios – the strategy recommended by the Wanless report for shifting Treasury funding (Wanless 2002).22 Next, NGOs have to step up to fill the donor gap. Donors will not be interested until they are rewarded by the public for their positive involvement. This is mainly due to the political economy failures outlined in Table 12.3.

David Stuckler and Derek Yach 213

Evidence redressing pervasive chronic disease myths, such as that they are inevitable consequences of aging or that they are ‘diseases of affluence,’ must be more widely disseminated. Some groups, such as Oxford Health Alliance, are pushing in positive directions and beginning to mobilize fragmented interest groups – but clearly, much more needs to be done. While numerous cost-effective interventions for chronic diseases have been tested and are available, there remains a critical need to develop a roadmap that defines appropriate interventions based on the causes of chronic diseases at macro- and micro-levels from which a coherent prevention plan can be constructed. At the broadest level the roadmap could begin with economic, political, and social factors. At the narrowest level, it might begin with psychological and biological factors that affect eating and activity. In the case of eating, these would be taste, accessibility, convenience, cost and the amount of promotion. The factors that lie between the broad and narrow factors must be defined so that prevention can be based on estimates of the most powerful point at which to intervene in the causal chain (Yach et al. 2006). The academy can be of great help in all of these processes, but currently it is not doing enough. The case for upstream forces driving chronic diseases, as outlined here, is quite clear and robust. Genetics or biomedical factors alone cannot independently explain any of the rises in chronic diseases. Yet almost all of the scant academic resources today are being devoted to genetic research, mainly driven by the pharmaceutical sector, with hopes to develop obesity pills and other ‘cures.’ And, as a result, this paradigm is being reproduced in public health and medical classrooms worldwide. What is desperately needed – and long overdue in the academic world – is cross-disciplinary collaboration with economists, sociologists, and political scientists to understand the social transformations at the broader levels that are driving chronic diseases and to develop feasible and effective strategies to reverse them. Until then, the chronic disease prevention roadmap will implicitly remain focused on the narrow set of biomedical factors. Reversing chronic disease growth will therefore require ‘intersectoral action’ – that hot WHO buzzword, which no one knows what means or how to bring about. The way to start is to change the way we think, the way we do research, and the way we are trained in public health and medicine. Only then will the urgently needed changes be put in motion, and public health interventions lay claim to a significant cause-and-effect in its own relationship to chronic disease control.

Notes 1. A modified version of this chapter is also available as D. Stuckler, ‘Population Causes and Consequences of Leading Chronic Diseases: A Comparative Analysis of

214 Part IV: Disease and Development

2.

4.

5.

6.

7.

8.

9.

Prevailing Explanations’, Milbank Quarterly, 86, no. 2 (2008) 273–326 (Copyright Milbank Memorial Fund). Over four-fifths of all deaths and two-fifths of all disability due to chronic diseases derive from these four chronic disease sub-types. Although other important chronic disease sub-types, such as neuropsychiatric disorders and sensory organ diseases, are associated with high morbidity levels, they occur with a much lower probability and cause comparably lower mortality. Another motivation relates to their similar set of determinants; of the chronic disease sub-types, these four in particular are driven by three key risks: (i) tobacco, (ii) alcohol consumption, (iii) unhealthy diet and physical inactivity. This is not to understate the importance of the other chronic disease sub-types; however, if these risks were ameliorated, many of the high-burden, low-probability chronic diseases would also be improved. Thus, throughout this article the discussion will target these leading chronic diseases, or ‘diseases of development.’ Income categories are based on the World Bank’s ‘2003 World Development Indicators’ Report, used for Mathers and Loncar forecasts (Mathers and Loncar 2006). Countries are stratified into groups according to 2001 GNI per capita, calculated using the World Bank Atlas method: low income ($745 or less); middle income ($746–$9,205); and high income ($9,206 or more). This holds for all regions except for in Eastern Europe and Central Asia where an increase in infectious diseases will also occur, albeit at one-sixth the amount expected for chronic diseases and primarily due to the mid-1990s economic transitions in the former Soviet Union. For example, WHO spends $1 for every chronic disease death versus $7 for every HIV/AIDS death in the developing world, yet the chronic diseases are causing six times as many deaths in low- and middle-income countries. The World Bank argues that ‘any shift in attention from communicable diseases to noncommunicable ailments . . . would work to the detriment of the poor . . . [and] the shift’s primary beneficiaries would be the rich, who would therefore gain at the expense of the poor’ (Gwatkin and Guillot 2000). India, for example, has the worst iron deficiency levels in the world and the largest diabetes pool. Exposure to stressors during early life-stages increases the risk of future chronic disease development (Aboderin et al. 2001). Even this is not clear cut: poor countries have a higher P4 , which means that persons transition from morbidity to mortality much faster than in rich countries. This would compress morbidity, and further suggests that the biggest drivers are upstream. This is largely a spurious feature of the method used to decompose epidemiologic and demographic change. First, demographic change is defined by these studies as the remainder from total forecast change in deaths minus mortality changes attributable to changes in age-specific mortality rates driven. But the explanatory variables used to capture changes in age-specific mortality rates don’t include the chronic disease promoting factors identified here (only a proxy for smoking, not even tobacco), and in so doing falsely attribute these omitted variables to demographic change – a common regression misspecification issue, although the forecasts are unaffected. Moreover, the macro-stories painted about demographic change driving chronic disease growth aren’t consonant with geographic patterns of ageing, mortality and mortality rises. We show more rigorously later in this article using regression models that the impacts of aging have been grossly overstated.

David Stuckler and Derek Yach 215 10. This residual can be thought of as a ‘risk factor residual.’ 11. In fact, stimulating foreign direct investment is central to most financial ministries’ economic growth strategies in developing countries. 12. See criticisms of export dumping of sugar from the Global North to South and their implications for obesity levels for suggestions why this has not been the case either. 13. In economic parlance, marketing increases the income elasticity: ∂R/∂I, or the change in chronic disease risk with respect to a change in income, all things being equal. It appears that ∂2 R/∂I2 < 0, or that after a certain income level risk levels with changing income start diminishing – or even turning negative (the effect seen in rich countries). 14. The discussion here is hardly to suggest that globalization has not improved wellbeing in many respects – foreign direct investment for example leads to investment in rural development and can push for higher norms on food safety standards and level the playing field. We only wish that a significant caution be added so that efforts can be made to de-couple economic changes with their potentially harmful health effects. 15. Except for iv and v relating to technological change, a universal process but one with diminishing impacts for high income countries. For example, urbanization is not proceeding as rapidly in developed countries. 16. Researchers argue that a key difference is that developing countries are moving through these transitions at a much faster pace today (Popkin 2002). 17. * – p < 0.05, ** – p < 0.01. Robust standard errors in parentheses. Urbanization is the percentage of the population living in urban settings; Market integration is total capital flows/GDP; FDI is the natural log of foreign direct investment. Countries include 17 high-income OECD countries for which comparative data from WHO Global Mortality Database are available. Data de-trended using period effects to adjust for changing ICD-classifications and secular trends from 1960 to 2000. 18. Estimated effects given by MR/X *X, where X is the determinant and β = MR/X. 19. Robust standard errors in parentheses, clustered by country to reflect nonindependence of sampling and for robustness to serial correlation. Models include country and time fixed effects. Significance at * – p < 0.05, ** – p < 0.01. 20. Note that this method provides a full macroeconomic accounting for all of the microeconomic channels of chronic disease’s impact: healthcare costs, productivity costs, changes to savings, investment and consumption behavior, diminished education, likelihood of foreign direct investment, to name a few. 21. The Millennium Development Goals do not compare declines against baseline expected drops. Irrespective of any intervention, Goal 6 will be met: to halt and begin to reverse the spread of infectious diseases (HIV/AIDS, malaria and other diseases). 22. This can also go a long way to shifting global health policy from ‘health funding as charity or cost-containment’ to ‘health funding as investment.’

References Aboderin, I. et al. (2001) Life-course Perspectives on Coronary Heart Disease, Stroke and Diabetes: Key Issues and Implications for Policy and Research (Geneva: World Health Organization).

216 Part IV: Disease and Development Beaglehole, R. and D. Yach (2003) ‘Globalisation and the Prevention and Control of Non-communicable Disease: the Neglected Chronic Diseases of Adults’, The Lancet, 362(9387): 903–8. Centers for Disease Control and Prevention (2003) ‘Public Health and Aging: Trends in Aging – United States and Worldwide’, Journal of the American Medical Association, 289(11): 1371–3. Cutler, D.M. et al. (2003) ‘Why Have Americans Become More Obese?’, The Journal of Economic Perspectives, 17: 93–118. Drewnowski, A. and N. Darmon (2005) ‘The Economics of Obesity: Dietary Energy Density and Energy Cost’, American Journal of Clinical Nutrition, 82(1): 265S–73. Gwatkin, D. and M. Guillot (2000) ‘The Burden of Disease among the Global Poor: Current Sanitation, Future Trends and Implications for Strategy’ (World Bank and Global Forum for Health Research). Hawkes, C. (2005) ‘The Role of Foreign Direct Investment in the Nutrition Transition’, Public Health Nutrition, 8: 357–65. Hawkes, C. (2006) ‘Uneven Dietary Development: Linking the Policies and Processes of Globalization with the Nutrition Transition, Obesity and Diet-related Chronic Diseases’, Globalization and Health, 2(1): 4. International Conference on Primary Health Care (1978) Declaration of Alma-Ata (Copenhagen: World Health Organization Regional Office for Europe). Mathers, C.D. and D. Loncar (2006) ‘Projections of Global Mortality and Burden of Disease from 2002 to 2030’, PLoS Medicine, 3(11): e442. Pang, T. and G.E. Guindon (2004) ‘Globalization and Risks to Health’, EMBO Reports, 5: S1, S11–S16. Popkin, B. (2002) ‘Part II: What is Unique about the Experience in Lower- and Middle-income Less-industrialised Countries Compared with the Very-high-income Industrialised Countries?’, Public Health Nutrition, 5(1a): 205–14. Popkin, B. et al. (2001) ‘Trends in Diet, Nutritional Status, and Diet-related Noncommunicable Diseases in China and India: The Economic Costs of the Nutrition Transition’, Nutrition Reviews, 59(12): 179–90. Rosen, S. et al. (2007) ‘Patient Retention in Antiretroviral Therapy Programs in SubSaharan Africa: A Systematic Review’, PLoS Medicine, 4(10): e298. Suhrcke, M. et al. (2006) Chronic Diseases: An Economic Perspective (London: OxHA Public Health and Economics Working Group). Suhrcke, M. and D.M. Urban (2006) ‘Are Cardiovascular Diseases Bad for Economic Growth?’ (CESifo Working Paper Series, 2006). Wanless, D. (2002) Securing Our Future Health: Taking a Long-Term View (London: HM Treasury). Wiist, W.H. (2006) ‘Public Health and the Anticorporate Movement: Rationale and Recommendations’, American Journal of Public Health, 96(8): 1370–5. Witkowski, T.H. (20070 ‘Food Marketing and Obesity in Developing Countries: Analysis, Ethics, and Public Policy’, Journal of Macromarketing, 27(2): 126–37. World Bank (2007) Public Policy and the Challenge of Chronic Noncommunicable Diseases (Washington, DC: World Bank). World Health Organization ‘Revised Global Burden of Disease (GBD) 2002 Estimates: Mortality Estimates by WHO region’, available at http://www.who.int/entity/ healthinfo/statistics/gbdwhoregionmortality2002.xls. World Health Organization (2005) Preventing Chronic Diseases: a Vital Investment (Geneva: World Health Organization). Yach, D. et al. (2006) ‘Epidemiologic and Economic Burden of the Global Epidemics of Obesity and Diabetes’, Nature Medicine, 12(1): 62–6.

13 Strategies for Financing Universal Access to Health Care and Prevention: Lessons Learnt and Perspective for the Twenty-first Century Sergio Spinaci and Valerie Crowell1

The 2001 report of the Commission on Macroeconomics and Health (CMH) urged a heightened partnership between the world’s low- and middle-income countries and the high-income countries to scale up access of the world’s poor to essential health services (World Health Organization 2001). Its recommendations were directed to a variety of stakeholders, including developing countries, donors, the pharmaceutical industry and the international financial institutions. The responsibility for meeting the health-related MDGs to reduce poverty was thus placed squarely on both developing countries and their partners.1 The CMH found that, although on the rise, 1999 levels of funding for health were inadequate to address the costs of scaling up essential health interventions in the world’s poor countries. It recommended that, on average, an additional US$66 billion per year would be needed by 2015 to scale up essential health interventions in all low-income countries. It also urged that the donor community should aim to increase development assistance for health (DAH) from an average of about US$6.7 billion per year over the period 1997–1999 to about US$27 billion per year by 2007 and US$38 billion per year by 2015 (World Health Organization 2001). These estimates are broadly consistent with other estimates of the cost of expanding essential health interventions. The 1993 World Development Report estimated that US$62 billion would be needed to provide an essential clinical package in all developing countries (World Bank 1993). In addition to increased levels of financial assistance, there is a need for improvements in the way donor monies are managed to improve the effectiveness of DAH, especially in the context of a proliferation of new actors in global health. Among its recommendations, the CMH supported the establishment of the Global Fund to Fight AIDS, Tuberculosis and Malaria 217

218 Part IV: Disease and Development

(GFATM), to raise additional resources for the three diseases while at the same time improving recipient–donor coordination and increasing the speed with which funds are delivered. It also supported a comprehensive and resultsoriented approach to health sector development, using the framework of the Poverty Reduction Strategy Papers and balancing the need for both disease-specific interventions and systemic improvements (World Health Organization 2001). More than five years on, development assistance for health has increased substantially, and performance-based global health partnerships such as the Global Alliance for Vaccines and Immunization (GAVI) and the GFATM now channel a large portion of the funding in these areas. The development community has made strides on advancing the aid effectiveness agenda, adopting specific targets and indicators. There is also heightened emphasis on the importance of health systems strengthening in order to boost progress in disease-specific programs and ensure that health funding can be absorbed at the periphery. However, evidence suggests that large gaps still exist between pledges to increase and improve aid and actual practice. The United Nations 2007 update on progress towards the MDGs revealed that sub-Saharan Africa is not on track to meet any of the Goals (United Nations 2007). This slow progress may be due in part to lags between commitments and disbursements of aid, and the additional time needed to translate increased funding into measurably improved health outcomes. Nevertheless, it seems that new approaches to delivering aid have not completely overcome important challenges, such as how to fund countries in which policy and institutional environments are weak. Lack of health system capacity in countries has impeded progress toward disease-specific targets, and heightened donor coordination at global level has not been matched by similarly greater alignment and harmonization in countries. There continue to be tensions between the need for long term, sustainable funding that conforms to national priorities, and donor focus on demonstrating short-term impact of their investments and responding to changing domestic political agendas. After reviewing levels and trends in DAH since 2000 we use the case of malaria to examine in greater detail recent changes in aid modalities and the consequent effects on absorption of funds in countries. We conclude by considering the lessons learnt from the experiences of recent years and highlight several areas for attention towards improving current and future international health financing.

Development assistance for health: levels and trends Table 13.1 shows that significant new funding has been leveraged for global health since 2000. In 2005, total commitments to DAH stood at approximately US$13.8 billion (Michaud 2007). The World Bank, along with

Sergio Spinaci and Valerie Crowell 219 14,000 12,000 10,000 8,000 6,000 4,000 2,000 0

2000

2001

2002

2003

2004

2005

599

399

792

1,626

1,743

1,714

Multilateral agencies

3,636

3,712

3,800

4,594

5,147

5,324

Bilateral agencies

3,083

2,986

4,254

4,276

6,085

6,790

Private non profit

Figure 13.1 DAH in US$ millions Source: Michaud (2007).

the International Monetary Fund and the African Development Fund, has recently forgiven the debt of many poor countries with recommendations to allocate those resources for the social sectors. The 2005 Group of Eight (G-8) Gleneagles communiqué called for raising annual aid flows to Africa by US$ 25 billion by 2010 (The Secretary of State for Foreign and Commonwealth Affairs 2005). As seen in Figure 13.1, the share of DAH from private nonprofit organizations has increased considerably. This is due largely to the contributions of the Bill & Melinda Gates Foundation, which by July 2007 had given away just under US$ 8 billion for global health programs (of which about US$ 3.8 billion had been directed to TB, HIV/AIDS, and other infectious diseases) (Bill & Melinda Gates Foundation 2007). Despite the increases in DAH, there is evidence of a large gap between commitments and approvals of funds, and disbursements. Although set up in 2002, the GFATM did not begin to make disbursements until well into 2003, and many grant disbursements have been significantly delayed. By mid-2007, the GFATM had approved grant proposals worth US$8.35 billion, but had only disbursed US$4.15 billion, or less than half (The Global Fund to Fight AIDS Tuberculosis and Malaria 2007a). Evidence suggests that development partners are focusing their aid on the health problems that represent the greatest burden in developing countries, namely reducing child mortality, improving maternal health, and combating HIV/AIDS, tuberculosis and malaria. Funding has increased for GAVI, a public–private partnership focused on increasing access to vaccines in poor countries (Global Alliance for Vaccines and Immunization 2007). In April 2007, the Board of the GFATM agreed that the Fund should grow to some

220 Part IV: Disease and Development

$6–8 billion per year by 2010, and total pledges of US$ 9.7 billion for 2008– 2010 were secured at the GFATM Replenishment meeting in September 2007 (The Global Fund to Fight AIDS Tuberculosis and Malaria 2007c). At the June 2007 G8 summit in Germany, developed countries pledged to make available US$60 billion to combat HIV/AIDS, tuberculosis and malaria over the coming years (G8 Summit 2007; Heiligendamm 2007). In recognition of the disproportionate impact of these diseases in Africa, 61 per cent of funds approved in GFATM Round 4, and 55 per cent in Rounds 5 and 6, were allocated to sub-Saharan Africa. Nearly two-thirds of funds approved in Round 6 are for AIDS, with 24 per cent and 17 per cent for malaria and tuberculosis, respectively (The Global Fund to Fight AIDS Tuberculosis and Malaria 2007b). However, noncommunicable diseases, which are not included in the MDGs, have not seen similar increases in funding and attention, although they contribute an ever greater proportion of the global burden of disease (Leeder et al. 2004). The increases in available external resources for global health continue to be outpaced by the needs. In recent years a number of new and innovative funding mechanisms have been put forward or implemented to help accelerate resource mobilization for health and development. An example is the International Finance Facility (IFF), which would leverage immediate resources for aid by issuing bonds in the international capital markets, against donor pledges for annual payments to the IFF. This idea is being piloted in the area of immunization. Advance Market Commitments (AMC), which are financial commitments from donors to subsidize the future purchase of a vaccine or drug which is under development, thereby stimulating private sector research and development, have also been initiated. The recently launched UNITAID, financed through a tax on airline tickets, aims to generate long-term and predictable financing for drugs and diagnostic kits to fight HIV/AIDS, TB and Malaria. This kind of facility could assure the pharmaceutical industry of continuous funding and demand which could lower drug prices.

Improving aid effectiveness Increases in development assistance for health are welcome, but more aid must be accompanied by efforts to increase its effectiveness. In the past, donors have supported primarily project-oriented, disease-specific programs based on national geopolitical interests. This can result in suboptimal allocations, as well as undermining national capacity, rather than building national systems and institutions. The issue of aid effectiveness has become ever more critical due to the significant proliferation of actors in the global health space in recent years. Today it estimated that there are more than 60,000 AIDS-related NGOs alone (Garrett 2007). This situation has increased the transaction costs of aid for recipient governments.

Sergio Spinaci and Valerie Crowell 221 Table 13.1 Net aid inflows in five African countries (in per cent of GDP) 2000 Ethiopia Ghana Mozambique Tanzania Uganda

6.0 −0.3 20.4 7.5 6.8

2001

2002

2003

8.8 10.6 15.4 7.9 15.5

16.1 2.6 16.4 6.6 10.5

15.0 7.1 15.0 7.6 9.9

Source: Gupta et al. (2006).

More than half of US aid is focused on Iraq, Afghanistan, Egypt, Israel, Colombia, Jordan, and Pakistan, which, with the exception of Afghanistan and Pakistan, are middle-income, rather than low-income countries (Schieber et al. 2007). Although it has decreased, geographically tied aid still made up one fifth of total health aid in 2005 reported to the OECD, excluding US assistance which is predominantly tied (Lane and Glassman 2007). The burden on countries has been particularly pronounced in recent years with vast increases in funding for HIV/AIDS treatment programs and the pressure to achieve quick results. In Zambia, this situation resulted in the provision of antiretroviral treatment (ART) country wide in the absence of an approved national policy and before inclusion in the Basic Health Care Package, and provision of ART by the private sector without adequate quality assurance and certification/accreditation systems in place (Musumali 2007). External assistance for HIV/AIDS and other programs focused on specific health problems has often had the effect of creating parallel systems at the expense of basic public health services. In Zambia, there was a shift of staff time to ART, at the detriment of other essential services and resulting in increased staff burn out (Musumali 2007). The unpredictability of donor funds is a constraint to effective national planning and budgeting, particularly in countries that are heavily reliant on external funds, which are hesitant to make investments in the health sector that cannot be sustained if aid flows decrease. Table 13.1 shows the variability and unpredictability of the flows of development aid. One of the most visible responses to the problem of aid effectiveness in recent years has been the adoption of performance-based funding, whereby countries are asked to set clear, measurable targets and indicators for progress, against which funding is then released. The GAVI Alliance and the GFATM, through which donors have agreed to regularly pool large amounts of their health funding, both use this approach to grant funding. A concern arises, however, with regard to supporting countries with weak policy and institutional environments, as these are often the countries in which the need for aid is most urgent. These countries may have difficulty securing funding through performance-based initiatives, or may lose

222 Part IV: Disease and Development

that funding because of slower than expected progress. Implementation of GFATM grants, upon which future disbursements depend, has been shown to be strongly related to political stability (Lu et al. 2006). The Millennium Challenge Corporation is a US government program that provides assistance to countries determined to provide good governance. The agency has recently been criticized for spending only US$155 million of the US$4.8 billion it has approved for projects (Dugger 2007). The predictability and sustainability of funding through performancebased funding initiatives remains a concern. The GFATM is dependent on periodic replenishments of its funding, which determine the total size of each grant round. In November 2006, the Global Fund Board created a new mechanism termed the Rolling Continuation funding channel, for wellperforming grants to apply for continuing funding for up to an additional six years beyond the original proposal term. While this new mechanism may improve sustainability and predictability of some grants, it may also increase the divide between well- and poorly-performing countries. Through mechanisms such as the International Finance Facility for Immunization (IFFIm), which was proposed in 2005, donors are moving towards multiyear commitments which should improve the predictability of funding. By April 2007, more than US$3.2 billion had already been pledged to the IFFm, and GAVI will disburse approximately US$900 million to frontload immunization initiatives in 2007 (GAVI Alliance 2007b). GAVI also developed a framework for co-financing in 2007, to help ensure the sustainability of country programs that support the introduction of new vaccines. By focusing on narrow disease-specific targets, performance-based funding frameworks may overlook investments in health systems that are needed to ensure those targets are met. It has been estimated that sub-Saharan Africa needs approximately 700,000 additional physicians in order to meet the MDGs (Kurowski et al. 2003). The achievement of the MDGs by 2015 requires an annual training of health workers that costs from a low of US$1.6 million per country per year to almost US$ 2 billion in a large country like India. This would increase health expenditure by US$2.8 per person per year, on average (World Health Organization 2006). Investments are also needed in procurement and supply chain management systems and health information systems, which are critical to optimize and ensure the sustainability of programs. Recently, global health initiatives are intensifying efforts toward investing in health systems. In December 2005, the GAVI Alliance Board decided to invest US$500 million over a five-year period to help countries overcome health system weaknesses that impede sustainable increases in immunization coverage (GAVI Alliance 2007a). The GFATM is exploring a framework for increasing and organizing its support to national health systems. In September 2007, an International Health Partnership was launched to simplify and improve the delivery of aid to selected developing countries, while focusing efforts on strengthening health systems (Dyer 2007).

Sergio Spinaci and Valerie Crowell 223

In March 2005, more than 100 countries and donor organizations endorsed the Paris Declaration on Aid Effectiveness, which outlined specific actions for improving aid effectiveness and targets for country ownership, alignment on country development strategies and systems, harmonization, managing for results, and mutual accountability. A survey conducted in 2006 found that while the Paris Declaration has stimulated an important dialogue at country level on how to improve aid, in 2005 only 39–40 per cent of aid flows for the government sector used country public financial management and procurement systems (OECD 2007). A recent analysis of 14 countries that have developed World Bank poverty reduction strategies shows that, although budget support is increasing as a share of donor support, on average less than 20 per cent of donor disbursements are provided as general budget support (Foster 2005).

Development assistance: the case of malaria We now use the case of malaria to look more closely at the challenges and lessons learnt with respect to financing universal access to health care and prevention. Malaria represents a large portion of the global burden of disease, threatening at least 40 per cent of the world’s population (World Health Organization 2005), and has been a focus of recent heightened attention and new global health initiatives. In many African countries, more than 50 per cent of outpatients and up to 80 per cent of inpatients in health facilities have malaria (personal communication, WHO). Therefore, responding effectively to malaria requires strengthening health systems in Africa. Malaria exemplifies the challenges in coordinating the activities of numerous development partners. To accelerate visibility and resource mobilization for the disease and coordinate partner efforts to support country malaria control efforts, the Roll Back Malaria (RBM) Partnership was launched in 1998 by WHO, the World Bank, UNICEF and UNDP. The RBM Partnership includes malaria-endemic countries, their bilateral and multilateral development partners, the private sector, nongovernmental and community-based organizations, foundations and research and academic institutions. All of these constituencies are represented on the RBM Partnership Board. The RBM Partnership’s main goal is to halve malaria mortality by 2010 and to reduce it by 75 per cent by 2015. Its interim targets, established at the African Summit on Roll Back Malaria was in Abuja, Nigeria in 2000, were to ensure that by the year 2005, at least 60 per cent of populations at risk or suffering from malaria had access to effective preventive and curative interventions. In Abuja, over 20 African Heads of State pledged their commitment to malaria control and called on international aid donors to furnish resources of at least US$1 billion per year to the RBM Partnership (Roll Back Malaria Partnership 2000). Annual donor investment in malaria control has risen from approximately US$50 million in 2000 to over US$500 million in 2006. Although this amount falls short of the estimated US$4 billion per

224 Part IV: Disease and Development

year needed to effectively control malaria (Kiszewski et al. 2007), it represents major progress. This increase is due in large part to contributions from the GFATM and to several major initiatives, notably the World Bank Booster Programme and the US President’s Malaria Initiative. By late 2007, the GFATM had signed over US$1.6 billion in grant agreements for malaria, and disbursed over US$1.2 billion of that amount (The Global Fund to Fight AIDS Tuberculosis and Malaria 2007a). In September 2005, the World Bank launched the Booster Program for Malaria Control. Over the initial phase of the programmed, from 2005 to 2008, the Bank expects to commit approximately US$500 million to support the programmed in approximately 20 countries (World Bank 2007). USAID is the other major source of international funding for malaria control. In 2005, the US President’s Malaria Initiative (PMI), a five-year, US$1.2 billion commodity-based initiative to combat malaria, was launched. USAID increased its funding for malaria from US$90 million in 2005 to US$225 million in 2007 (USAID 2006). However, this funding does not appear to be completely additional since other programs (such as USAID umbrella grants for malaria) were reduced, apparently to cover first-year PMI commitments. The advent of the World Bank Booster Programme and the US PMI were both responses to scathing criticisms of previous malaria control programs. There was also realization that the heightened global momentum for malaria control generated by the RBM Partnership had failed to lead to clear strategies and guidelines and cohesive, coordinated support to malaria endemic countries. In part as a result of these deficiencies, many of the funds that were pledged for malaria control around the year 2000 failed to become available or were significantly delayed, and progress towards globally agreed targets was very slow (Anonymous 2005b). In 2006, the World Bank was accused of failing to deliver the US$300–500 million funding it pledged to Africa when the Roll Back Malaria campaign was launched, as well as lack of transparency and ‘medical malpractice,’ by allowing countries to spend its money on antimalarial drugs that were no longer effective (Attaran et al. 2006). In 2005, the ineffectiveness of USAID’s malaria assistance was widely publicized, including that less than eight per cent of the agency’s malaria budget was spent on lifesaving commodities. This led to a drastic revision of US malaria programs. In April 2005, the Eliminate Neglected Disease (END) Act introduced to Congress mandated that at least half of program budgets be used for commodity purchasing (US Congress 2005). The RBM Partnership has undergone a change process. Thanks in large part to the effective joint effort of partners through the RBM Harmonization Working Group, in the latest (7th) round of grant funding, 62 per cent of malaria proposals were successful, the highest rate for any disease in any GFATM funding round. The US PMI also represents a departure from past efforts, and in April 2007 received high marks in a donor scorecard that

Sergio Spinaci and Valerie Crowell 225

measured transparency and efforts to monitor the effectiveness of malaria spending (Africa Fighting Malaria 2007). Nevertheless, these initiatives continue to be hindered by a number of implementation challenges. A weakness in the GFATM process is the unpredictability of time lags between the submission of proposals to GFATM, approvals and disbursement of funding, which impedes country planning and contributes to market instability for malaria commodities, such as artemisin combination therapies (ACTs), currently the most effective Medicines for falciparum Malaria. In the worst-case scenario, market instability leads to price increases and a high risk of supply shortages. Some countries, such as Burundi and Liberia, were deemed to have adequately implemented their malaria treatment plans, but failed to secure further resources, particularly via GFATM Round 6, as a result of weaknesses or gaps in proposals or in implementation of activities that were not directly related to ACT scale up. Several countries, such as Nigeria and Benin, that had already received funds for ACT scale up risked having to scale down activities as a result of insufficient resources in original GFATM grants, or existing grants coming to an end or being terminated, again often as a result of weaknesses in other areas of implementation not directly related to ACT scale up. This unpredictability can lead to a serious erosion of confidence on the part of the pharmaceutical sector and consumers, further hampering efforts to improve access to lifesaving medicines. While the GFATM is meeting a large percentage of the needs for ACTs in the public sector, the majority of malaria disease episodes are treated in the private sector in most malaria endemic countries. To address this problem, the Affordable Medicines Facility for Malaria (AMFm) is a proposed new approach aiming to increase the use of eligible ACTs in malaria endemic countries and delay resistance to these drugs. This would be achieved through a buyer copayment available to both the public and private sectors, intended to decrease the end user prices of these medicines compared to other less effective anti-malarials, resulting in enhanced penetration in both public and private channels. There are a number of risks associated with implementation of the AMFm that will need to be mitigated, such as by monitoring end-user prices and patient safety, with associated costs. Finally, while malaria-specific funding has risen over the past few years, it is also focusing increasingly on funding commodities without concurrent increases in funding for technical assistance to build country capacity, and operational research to optimize interventions in the country context.

Partnerships for health: looking ahead Overall, while the outlook for global health looks much more positive than a decade ago, many challenges remain toward ensuring improved effectiveness of aid within a comprehensive development framework.

226 Part IV: Disease and Development

Fortunately, donor funding for health is evolving constantly to respond to the need for improved aid modalities. The experience described above of the US government and World Bank malaria programs of recent years suggests that donors can reorient their strategies and policies quickly when there is recognition that those policies are not achieving their intended impact. The GFATM is modifying its modus operandi to take account of the needs for health systems strengthening, and where there are gaps in the GFATM’s ability to respond to country needs, other mechanisms, such as the AMFm, have sprung up to address them. Also, there is evidence that where adequate funding, good technical assistance and effective partnerships have come together effectively at the country level, rapid and dramatic impact on the malaria burden can occur (Bhattarai et al. 2007). Countries and their partners need to continue working to strike a balance between project and program-based approaches, a challenge which major bilateral and multilateral initiatives, including the GFATM, currently do not address adequately. This is critical both for strengthening country programs and for stabilizing the markets for commodities upon which future gains depend. A clear framework for organizing the private sector involvement in health care and prevention should also be a priority. The magnitude of the recent resource mobilization effort for global health begs the question of how the gains will be sustained in the longer term. Despite progress, external funding will need to be maintained for some years in order to address malaria and other diseases. Partners need to continue to move toward multiyear commitments, while at the same time linking with trade, environment and other sectors for a comprehensive approach to development and poverty alleviation. At the same time, ministries of finance in developing countries need to be engaged and urged to increase national budget allocations for health. The experience of the last decade in financing global health has raised new questions and issues that must be addressed. It is thus critical to invest more in technical assistance and operational research to seek ways of improving the use of aid, as well as to boost monitoring and evaluation of development assistance for health, to ensure continued learning and to optimize its contribution to better health outcomes.

Note 1. The authors are grateful for the contributions of Dr Catherine Michaud, Senior Research Scientist, Harvard Initiative for Global Health, Harvard University, Cambridge, MA, who provided valuable data on development assistance for health, and Mr Ayawo Awanyo, WHO intern, who helped compile information for this chapter.

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References Africa Fighting Malaria ‘Africa Fighting Malaria: the Malaria Donor Scorecard’, available at http://www.fightingmalaria.org/pdfs/afm-scorecard.pdf. Anonymous (2005b) ‘Reversing the Failures of Roll Back Malaria’, The Lancet, 365(9469): 1439. Attaran, A. et al. (2006) ‘The World Bank: False Financial and Statistical Accounts and Medical Malpractice in Malaria Treatment’, The Lancet, 368(9531): 247–52. Bhattarai, A. et al. (2007) ‘Impact of Artemisinin-Based Combination Therapy and Insecticide-Treated Nets on Malaria Burden in Zanzibar’, PLoS Medicine, 4(11): e309. Bill & Melinda Gates Foundation ‘Global Health Grants’, available at http://www.gates foundation.org/GlobalHealth/Grants/default.htm?showYear=2007. Dugger, C. (2007) ‘US Agency’s Slow Pace Endangers Foreign Aid’, The New York Times, December 7. Dyer, O. (2007) ‘New International Health Partnership is Set Up to Improve Delivery of Aid’, British Medical Journal, 335(7619): 532. Foster, M. ‘MDG-Oriented Sector and Poverty Reduction Strategies: Lessons from Experience’, available at http://www.hlfhealthmdgs.org/Documents/ MDGorientedPRSPs-Final.pdf. G8 Summit 2007 Heiligendamm ‘Chair’s Summary’, available at http://www.g-8.de/ nsc_true/Content/EN/Artikel/__g8-summit/anlagen/chairs-summary, templateId= raw, property=publicationFile. pdf/chairs-summary. Garrett, L. (2007) ‘The Challenge of Global Health’, Foreign Affairs, 86: 1–17. Gavi Alliance ‘Health System Strengthening’, available at http://www.gavialliance.org/ resources/HSS_Background.pdf. Gavi Alliance ‘Innovative Funding’, available at http://www.gavialliance.org/about/ in_finance/index.php. Global Alliance for Vaccines and Immunization ‘Donor Contributions and Commitments’, available at http://www.gavialliance.org/support/donors/index.php. Gupta, S. et al.(2006) Macroeconomic Challenges to Scaling Up Aid in Africa: a Checklist for Practitioners (Washington, DC: International Monetary Fund). Kiszewski, A. et al. (2007) ‘Estimated Global Resources Needed to Attain International Malaria Control Goals’, Bulletin of the World Health Organization: the International Journal of Public Health, 85(8): 569–648. Kurowski, C. et al. (2003) Human Resources for Health: Requirements and Availability in the Context of Scaling Up Priority Interventions in Low-income Countries. Case Studies from Tanzania and Chad, HEFP Working Paper 01/04 (London: London School of Hygiene and Tropical Medicine). Lane, C. and A. Glassman (2007) ‘Bigger and Better? Scaling Up and Innovation in Health Aid’, Health Affairs, 26(4): 935–48. Leeder, S. et al. (2004) A Race Against Time: the Challenge of Cardiovascular Disease in Developing Economies. Heart Disease in Developing Countries. Can We Prevent a Crisis? (New York: The Earth Institute, Columbia University). Lu, C. et al. (2006) ‘Absorptive Capacity and Disbursements by the Global Fund to Fight AIDS, Tuberculosis and Malaria: Analysis of Grant Implementation’, The Lancet, 368(9534): 483–8. Michaud, C. (2007) ‘Data on Development Assistance for Health’ (Unpublished data made available by the author).

228 Part IV: Disease and Development Musumali, C.M. ‘HIV/AIDS and Health Systems. Strengthening in Zambia. A Tale of Two Initiatives (Powerpoint Presentation)’, available at www.phrplus.org/ Presentations/1_GHC_Cosmas.ppt. OECD (2006) ‘Aid Effectiveness: 2006 Survey on Monitoring the Paris Declaration’, available at http://www.oecd.org/document/20/0,3343,en_2649_3236398_ 38521876_1_1_1_1,00.html. Roll Back Malaria Partnership ‘The Abuja Declaration on Roll Back Malaria in Africa’, available at http://www.rbm.who.int/docs/abuja_declaration_final.htm. Schieber, G. J. et al. (2007) ‘Financing Global Health: Mission Unaccomplished’, Health Affairs, 26(4): 921–34. The Global Fund to Fight Aids Tuberculosis and Malaria ‘Current Grant Commitments & Disbursements’, available at http://www.theglobalfund.org/en/ funds_raised/ commitments. The Global Fund to Fight Aids Tuberculosis and Malaria ‘Distribution of Funding after 6 Rounds’, available at http://www.theglobalfund.org/en/funds_raised/distribution. The Global Fund to Fight Aids Tuberculosis and Malaria ‘Donors Provide US$9.7 Billion to the Global Fund. Initial Pledges for 2008–2010 Enable the Global Fund to Triple in Size’, available at http://www.theglobalfund.org/en/media_center/press/pr_ 070927.asp. The Secretary of State for Foreign and Commonwealth Affairs ‘G8 Gleneagles 2005, Africa’, available at http://www.fco.gov.uk/Files/kfile/PostG8_Gleneagles_ Africa,0.pdf. United Nations ‘Africa and the Millennium Development Goals: 2007 Update’, available at http://www.uneca.org/eca_resources/news/2007/Africa-MDGs07.pdf. US Congress (2005) The Eliminate Neglected Diseases (END) Act of 2005. 109th US Congress, 1st session, S. 950 (2005), available at http://frwebgate.access.gpo.gov/cgibin/getdoc.cgi?dbname=109_cong_bills&docid=f:s950is.txt.pdf USAID ‘Funding History. USAID Malaria Funding 1997–2006’, available at http://www.usaid. gov/our_work/global_health/id/malaria/funding/malfunding. html. World Bank (1993) World Development Report: Investing in Health 1993 (New York: Oxford University Press). World Bank ‘Status of Financing in the Booster Program’, available at http://go.world bank.org/6WZ5JH2CM0. World Health Organization (2001) Macroeconomics and health: investing in health for economic development. Report of the Commission on Macroeconomics and Health (Geneva: World Health Organization). World Health Organization (2005) 2005 World Malaria Report (Geneva: World Health Organization). World Health Organization (2006) ‘High Level Ministerial Meeting on Health Research for Developing Countries, Accra, from 14–17 June 2006, Health Ministers from Developing Countries Call for More Support for Health Research (Press Release)’, available at http://cdrwww.who.int/countries/gha/news/2006/health_research/en/ index.html.

14 HIV Epidemic and Response: Social, Economic and Development Impact∗ Yves Souteyrand, Dongbao Yu and Kerry Kutch

Recently much has been said about the important reduction in the estimates of the number of people living with HIV/AIDS. In 2007, UNAIDS and WHO revised their estimates downward by 16 per cent compared with the estimates published in 2006 (UNAIDS 2007a). Most of the decline was due to better methods for gathering data which have yielded a more accurate understanding of the epidemic and the numbers of people affected. But there are also encouraging indications the epidemic may be levelling off since 2001 and the number of deaths due to AIDS has declined slightly over the past two years, probably due to increased access to treatment and longer survival times. Notwithstanding these encouraging developments, HIV/AIDS remains a serious health and development challenge. In 2007, it is estimated that there were 33.2 million people-living with HIV/AIDS, 2.1 million deaths, and 2.5 million new infections. Sub-Saharan Africa, with 22.5 million people living with HIV/AIDS, is by far the most heavily affected region (UNAIDS 2007a). Between 2000 and 2020, it has been estimated that some 68 million people, including 55 million in Africa, will die prematurely due to AIDS (UNAIDS 2006). In addition to being one of the worst health crises mankind has ever faced, HIV/AIDS has also negatively affected the overall social and economic development of affected countries. The choice of how to respond to the HIV/AIDS epidemic will have important implications for social and economic development in many low- and middle-income countries.

The development impact of HIV/AIDS As a health issue, HIV/AIDS impacts on development in two ways. First, HIV/AIDS has a direct negative impact on the health sector, and affects the ∗

The author are staff members of the World Health Organization. The authors alone are responsible for the views expressed in this publication and they do not necessarily represent the decisions or policies of the World Health Organization.

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ability of health systems to deliver adequate and appropriate health services. Secondly, HIV/AIDS is a serious public health problem that affects other aspects of social and economic development.

Impact on the health sector Within the various components of the multisectoral response to HIV/AIDS, the health dimension is prominent. It can be conservatively estimated that 60 per cent to 70 per cent of resources needed to respond to the HIV/AIDS epidemic are health sector-related (UNAIDS 2007b), including interventions such as developing health service and laboratory facilities, surveillance, ensuring safe blood supplies, diagnostics and testing, antiretroviral treatment, procurement and distribution of HIV medicines, diagnostics and other commodities, control of sexually transmitted diseases, treatment of opportunistic infections, substitution therapy for injecting drug users, and critical prevention interventions such as male circumcision and prevention of mother to child transmission. Because of the importance of the health sector in addressing HIV/AIDS, well-functioning health systems are critical to an effective response to the epidemic. Unfortunately, health systems in many affected countries are not up to the task of responding to HIV/AIDS. Many health systems suffered from chronic weaknesses even before being confronted with HIV/AIDS. Now, in the face of increased pressure caused by HIV/AIDS, many of these systems are unable to provide adequate levels of service (Travis et al. 2004). HIV/AIDS itself severely compromises the ability of health systems to respond to the epidemic. HIV/AIDS reduces the supply of services due to morbidity and mortality of health professionals and other strains on health systems (Samb et al. 2007); and it increases the demand for health services due to increased morbidity from HIV/AIDS in the general population. HIV/AIDS may also shift the structure of services provided towards HIV/AIDS and away from other important health issues. In many developing countries health system personnel are greatly affected by AIDS. In Botswana, AIDS has caused the disappearance of 17 per cent of the workforce in health services between 1999 and 2005, and in Lusaka, Zambia, it has been estimated that 40 per cent of midwives are HIV positive (UNAIDS 2006). In Malawi and Zambia, the morbidity and mortality rates among these professional has been multiplied by factors of five and six respectively. In South Africa, three-quarters of nurses included an HIV-related reason among the top ten reasons for nurse resignations, and nearly half placed an HIV-related reason among their top five (Veriava 2005). To simply keep the number of doctors and nurses constant in these countries between 2000–10, it will be necessary to increase the number of doctors and nurses trained by between 24 per cent and 40 per cent (Haacker 2002). The World Bank estimates that a country in which the prevalence of HIV is 15 per cent may lose up to 3.3 per cent of its health professionals each year. Furthermore,

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many people abandon the health professions because of overwork and fear of becoming infected due to a high rate of accidental exposure to blood and the absence of effective protective procedures within the health structure (Chen et al. 2004). HIV/AIDS also directly increases the overall demand for health services. In sub-Saharan Africa, half of all hospital beds are occupied by people affected by AIDS. In the countries of East Africa, this proportion may reach 80 per cent (Haacker 2002). Increased access to antiretroviral treatment has two opposite effects on the health system: as people suffer less from opportunistic infections, the direct demand for health services, especially for hospitalizations, will decrease; at the same time, pressure will increase as more people will take lifelong complex treatment needing appropriate monitoring. The new approach of provider-initiated testing and counseling, recommended by WHO and UNAIDS, which aims to increase access to HIV testing in order to improve access to prevention and treatment services (Bass 2006), will create new demands on the health system. Prevention interventions such as male circumcision and prevention of mother to child transmission in perinatal care also increase the demand on health systems. Increased morbidity from HIV/AIDS in the general population is also a substantial source of additional demand.

Demographic impact AIDS is the primary cause of death among adults in sub-Saharan Africa, and has had significant demographic consequences in most high-prevalence countries (Pison 2002). Projections estimate that by 2025 in the 60 most affected countries the total population will be 188 million less than it would have been without AIDS (United Nations 2004). AIDS has reversed several decades of progress in terms of life expectancy at birth, in many cases taking the indicators back to the levels of the 1940s. According to UNAIDS, average life expectancy in sub-Saharan Africa is now 47 years, while it would be 62 in the absence of AIDS. Southern Africa is particularly affected. In Zimbabwe, there has been a reduction in life expectancy of 35 years (from 60 years in 1985–1990 to 35 years in 2000–2005) (UNAIDS 2006). The impact of AIDS on life expectancy in sub-Saharan Africa is due in part to infant mortality directly or indirectly linked to AIDS. Mortality among under the age of five has increased by 20 to 40 per cent because of AIDS in sub-Saharan Africa. In Botswana, mortality of infants under five years of age was 62 per 1,000 live births between 1990 and 1995, while in 2006 the figure was 106 deaths per 1,000 live births (UNAIDS 2006). The highest growth in mortality is observed among adults between 20 and 49 years of age. In East Africa, the mortality rate among 15–49 year olds will be, in 2010, between 2.4 per cent and 5 per cent, depending on the country. Without AIDS, the rate would be between 0.1 per cent and 0.6 per cent

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(US Bureau of the Census 2003). In Haiti, AIDS is the principal cause of death among adults between the ages of 15 and 44. HIV/AIDS also affects fertility rates. Efforts to prevent the transmission of HIV from mother to child focus in part on preventing pregnancy among HIV-positive women. Partly as a result of these efforts, birth rates have declined by between 15 per cent and 40 per cent depending on the country (Gray et al. 1998). According to the US Bureau for the Census, population growth rates in East Africa have been reduced by between 6 per cent and 1.5 per cent in 2000. This reduction, which could reach 3 per cent in 2010 in the most affected countries (with the negative growth rates in Botswana, South Africa and Zimbabwe), is due to the increase in the rate of mortality, as well as to the reduction in fertility rates among women living with HIV (United Nations 2004).

Social impact HIV/AIDS has a direct impact on a number of important social aspects of development such as equality, children, education and gender. With regard to children, globally the number of children living with HIV increased from 1.5 million in 2001 to 2.1 million in 2007. Deaths due to AIDS among children is estimated to be 330,000 in 2007. Nearly 90 per cent of all HIV-positive children live in sub-Saharan Africa (UNAIDS 2007a).Over and above the impact of the disease is the impact on children through the loss of their parents and parental affection and protection. More than one in nine children under age 18 in sub-Saharan Africa have lost a parent, and the HIV/AIDS pandemic is the leading cause. HIV/AIDS deaths today could have major long-term effects on economic development by affecting the human capital accumulation of the next generation (Evans and Miguel 2007). With regard to education, AIDS affects both the supply and demand for education. On the demand side, HIV/AIDS causes a reduction in the number of children who are enrolled in school due to reduced fertility rates, increased child mortality, and because HIV/AIDS makes it difficult or impossible for children in affected families to attend school. In the Kwazulu Natal region of South Africa, 275 children were enrolled in primary school in 2002 versus 370,000 in 1990 (Whiteside 2002). A study of 20,000 children in Kenya showed that the rate of school attendance fell by 5 per cent after the death of a parent, and that the decline is twice as large after the death of the mother than after the death of the father (Bicego et al. 2003). On the supply side, teachers are a particularly exposed population due to their ages and their socioeconomic status. In South Africa the prevalence of HIV among teachers is 21 per cent among teachers aged 25 to 34 and 13 per cent among teachers aged 25 to 44 (Paul 2005). The minister of education in Zambia reports that 2.2 per cent of teachers died in 1999, many more than the number of teachers trained in the same year (Grassly et al. 2003).

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With regard to gender, as the epidemic has progressed, we have witnessed an increasing proportion of women among those living with HIV/AIDS. In sub-Saharan Africa more than 60 per cent of those living with HIV/AIDS are women and the proportion of people living with HIV/AIDS who are women is increasing in every region (UNAIDS 2007a). Due to a variety of factors, women are more vulnerable to HIV/AIDS than men (Krishnan et al. 2007). In sub-Saharan Africa, women are infected by HIV more often and earlier in their lives than are men. Young women between the ages of 15 and 24 are two to six times more at risk of becoming infected than men of the same age (UNAIDS 2006).

Economic impact AIDS and economic growth The macroeconomic consequences of AIDS are evaluated in the international literature by measuring the reduction in the growth rate of Gross National Product (GNP) or per capita revenue attributable to the epidemic. Numerous studies have been carried out since the beginning of the 1990s. All of them postulate significant effects on growth, the size of the changes varying from one study to another. Overall, annual economic growth is estimated to be approximately 0.5–1.5 per cent below what would have been achieved in the absence of HIV/AIDS. A link is demonstrated, using data from 51 countries (1990–1997), between the annual per capita growth rate and the rate of prevalence (Bonnel 2000). According to this analysis the reduction in the per capita growth rate will be 0.6 per cent when the prevalence rate is 5 per cent, and 1.4 per cent when prevalence is 30 per cent. These analyses illustrate the global economic impact of HIV/AIDS. They have, however, been based on a simplified approach to the economy, which may underestimate the real effects on production. Problems associated with transmission of knowledge, which is compromised because the epidemic primarily affects young adults could also worsen HIV/AIDS impact on economic growth. Finally, they often do not integrate the long-term negative effects on savings and productive investment. Poverty contributes to HIV/AIDS epidemics and AIDS contributes to poverty, although we still do not know enough about the complex pathways of this relationship (Moatti and Ventelou 2007; Gillespie et al. 2007; Bärnighausen et al. 2007). The economic impact of HIV/AIDS results from direct and indirect costs. Direct costs are direct HIV-related expenditures made by different actors (households, enterprises, states) which shift expenditures away from meeting other needs, and which adversely affect the ability of these actors to save and invest. Indirect costs are linked to the reduction in productive capacity, economic activity, public sector revenue, and in the productivity of the individuals affected by the disease. Indirect costs may be measured by the loss of

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revenues to business, industry, governments and households that are induced by this reduction. Indirect costs may be significant in the case of AIDS, which affects primarily young adults of working age.

Impact on households AIDS has an immediate and marked effect on households. By obligating adults to leave the workforce, either partially or totally, AIDS has an impact on the amount of time worked, on professional activity and, by extension, on household income. The entire family of the infected person is directly affected because the time and energy required to care for a sick person diverts the efforts of other productive members of the family from remunerated activity. Often the woman must interrupt her paid work in order to care for her husband or other members of the family when they fall sick (Whiteside 2002; Dixon et al. 2001). The travel necessary for medical consultations, visits to or traditional practitioners or to acquire medication also diverts time and energy of other members of the family. This reduction in other productive activity on the part of families affected by AIDS (that is to say families in which at least one member is living with HIV/AIDS) has implications for household revenue, which may fall substantially. In Côte d’Ivoire the revenue of households affected by AIDS is estimated to be barely half of the revenue of households not affected (UNAIDS 2006). This reduction in financial resources reduces many families to poverty – in some cases even extreme poverty. In parallel, the structure of household expenditures is modified. Household expenditures on health may increase extraordinarily to the detriment of other subsistence expenditures. To care for the person with AIDS, not only do families allocate less money to leisure or children’s education, but most ˆ d’Ivoire, of them are forced to sell their belongings and go into debt. In Cote 70 per cent of agricultural households have used their savings to finance the provision of care for a person living with HIV/AIDS (Cogneau and Grimm 2006). Furthermore, funerals constitute a heavy financial burden for households. They require the efforts of much of the extended family for several days. In Africa, funerals are often organized in the village of origin of the deceased, which can create important transportation expenses. In total, the expenditures for funeral expenses are sometimes more than those allocated to health. All of these costs are financed by reducing savings, assuming additional debt, or by the sale of durable belongings. In South Africa, the households interviewed have used on average 21 months of savings to meet these expenses (UNAIDS 2006). Households may also seek the assistance of other households. In this way the economic impact of AIDS spreads beyond the household of the affected person and the consequences may be felt at the level of the community and the village (Bonnel 2000).

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Impact on savings, investment and productivity The reduction in disposable income caused by HIV/AIDS may result in a reduction in the size of markets and a decline in the industrial production and profitability of enterprises (Daly 2000) leading to lower levels of employment and wages. Reduced savings also reduces the availability of funds available for investment. The result of this may be a reduction in capital accumulation and a subsequent decline in labor productivity due to shifting factor ratios. In Botswana this effect has been estimated to have had a major impact on the economy (MacFarlan and Sgherri 2001).

Impact on labor and industry The HIV/AIDS pandemic affects the supply of labor due to morbidity and premature mortality among working-age adults. Key sectors in the economy are particularly concerned by the disappearance of skilled and experienced labor. This is the case in the mining sector in South Africa. Currently, about 60 per cent of miners are between 30 and 44 years of age, but in 15 years, this proportion will fall 10 per cent due to deaths linked to AIDS in the youngest age groups (Dixon et al. 2002). The long period of incapacity associated with AIDS also affects work productivity. A study carried out by three large enterprises in Côte d’Ivoire shows that, with an HIV prevalence rate among staff of 10 per cent, the costs associated with AIDS represent between seven and ten per cent of total labor costs. These costs reduce the competitiveness and profits of enterprises. The combined impact of absenteeism, reduced productivity, and social expenses linked to sickness (such as disability pensions, daily allowances and funeral expenses) and the cost of recruitment and training has been estimated to reduce profits of firms in southern Africa by 6 to 8 per cent (Bollinger and Stover 1999).

Impact on the agricultural sector The agricultural sector, particularly in developing countries, is very labor intensive. Agricultural activities require an important quantity of human resources during periods of planting and harvest, and the agricultural sector is therefore particularly affected by AIDS. FAO has estimated that between 1985 and 1987, AIDS caused the deaths of seven million agricultural workers in Africa, and that an additional 16 million could die between 2007 and 2015 (FAO/UNAIDS 1999). According to FAO (FAO 1996), the HIV/AIDS epidemic has reversed the last 40 years of progress in rural and agricultural development. The mechanisms through which HIV/AIDS can lead to a reduction in agricultural capacity are well known (Barnett 2002) and include reductions in the quantity of labor (UNAIDS 2006; Bollinger and Stover 1999), plots cultivated (FAO/UNAIDS 1999; FAO 1996), range of crops produced (FAO 1996; Barnett

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and Whiteside 2002), household resources, and intergenerational transfers of knowledge. By reducing the availability of food due to a reduction in production and restricting access to food due to falling household resources, AIDS also potentially threatens food security and nutrition (Barnett and Whiteside 2002). As outlined above, the economic impact of HIV/AIDS creates a vicious circle which compromises long-term development efforts. At the household level, a reduction in productive activity and household revenue, coupled with increased expenditures associated with HIV/AIDS leads to dissavings and indebtedness. The resulting dearth of available labor and investment funds in turn leads to the depletion of capital, reduced economic activity and productivity, declining public sector revenue, and, finally, to reduced incomes and the long-term poverty of households.

HIV/AIDS and human development The notion of human development focuses not only on productive activity and economic growth, but also takes into account the aspirations of individuals to participate effectively in the lives of their societies – longevity, good health, access to education, and a good standard of living. The human development indicator elaborated by UNDP (United Nations Development Programme 2005) synthesizes these dimensions and permits a comparison of countries and following of their evolution. The HIV/AIDS epidemic has had a major impact on human development (Barnett 2002, 2003). By affecting primarily young adults, it affects not only productive activity but also a range of nonmarketable activities which do not generate revenue, but which contribute nonetheless to the organization and development of societies: education of children, production of subsistence agriculture, and community and family life. The Human Development Report 2005 identifies AIDS as the factor that has inflicted on human development the most marked reversal in history (United Nations Development Programme 2005). Between 1990 and 2003, several countries most affected by AIDS have experienced substantial reductions in the human development index ranking. South Africa has declined by 35 positions, Zimbabwe by 13, Botswana by 21, Swaziland by 20, Kenya by 18, Zambia by 16, and Lesotho by 15.

The response to HIV/AIDS Reducing impact through an effective response An effective response to HIV/AIDS can significantly reduce or mitigate many of the negative demographic, social and economic effects described above (Veenstra and Whiteside 2005). Prevention programs which avert infections lead to lower rates of mortality and morbidity from AIDS and reduce the social and economic impact of the epidemic. Access to affordable treatment

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for HIV/AIDS can also have a beneficial impact at several different levels. Treatment can significantly prolong the productive lives of people living with HIV/AIDS. Where treatment is widely available at little (or no) cost to the end-user, morbidity and mortality from AIDS can be significantly reduced. In Africa, the estimated net financial benefits to employers of making ART available to employees are positive for many companies. There are also many other unmeasured or nonfinancial benefits of providing treatment to employees, including reducing the time managers must spend coping with employee deaths and turnover, mitigating the impact of AIDS on workforce morale, motivation, and discipline, stemming the loss of skill and experience from the workforce, and allowing a company to respond compassionately to the crisis facing its employees (Rosen et al. 2007). We can expect an effective response to HIV/AIDS to lead to a substantial improvement in human development in the most highly affected countries. Life expectancy and quality of life will improve for millions of people and demographic imbalances may begin to be adjusted. Parents who might have been infected live to support their children and provide invaluable intergenerational transfers of knowledge. Children who may have been orphaned have a supportive family and are able to go school. And schools themselves function better because teachers who might have died of AIDS live to provide an education for future generations. Effective prevention programs and access to affordable treatment also reduce the impact on households in several ways. By reducing the amount of time and household income that must be spent on caring for those living with HIV/AIDS, prevention and affordable treatment leave additional funds available to be spent on education and other items of importance to development. Households also benefit from an increased productive lifespan of key wage earners, and consequently need not suffer from a substantial reduction in income that would normally accompany morbidity and mortality from AIDS. The impact on labor, industry and economic growth and productivity is also straightforward. By preventing new infections and treating those who are already living with HIV/AIDS, countries can reverse the negative productivity effects of HIV/AIDS and begin to recover the growth in GDP previously lost to the epidemic. Impact of antiretroviral treatment on the quality of life, decreased hospitalization, increase in income and decreased on absenteeism has been documented in different countries, including Kenya, South Africa and Thailand. Household disposable income increases, leading to additional savings, investment, capital accumulation, and ultimately to increased productivity and higher wages. While the benefits of comprehensive prevention programs and affordable access to treatment are clear at the household level and for overall growth and development, the implications for national budgets are more questionable. On one hand, there is a positive impact on tax revenues due to higher levels of economic growth, productive activity and household income. On the other hand, there are substantial costs associated with providing prevention

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programs and free or low-cost access to treatment. To some extent these costs can be met through international transfers, such as grant funding through programs such as the GFATM, World Bank or PEPFAR. But some countries are concerned with the sustainability of such programs, and are reluctant to begin providing free treatment which they may not be able to sustain if international sources of funds are reduced. Innovative mechanisms for sustainable financing of HIV/AIDS programs, such as UNITAID, an international drug purchase facility to be financed with sustainable, predictable resources, through air travel tax, particularly for treatment, are therefore an essential part of an integrated response.

Developing an effective response We have argued above that HIV/AIDS is not only a public health issue, but also a serious socioeconomic problem that compromises development in many of the most severely affected countries. An effective multisectoral response to the epidemic is required to reduce the negative effects of HIV/AIDS and allow countries to achieve their development potential. The health sector is particularly important to the success of this response because HIV/AIDS is predominantly a health concern and must be addressed in the context of broader health sector issues. Recent debates have focused on the relative merits of a ‘horizontal’ as opposed to a ‘vertical’ approach to public health. General health services have the advantage of being comprehensive, flexible in adjusting to changing disease patterns, permanent and embedded in community life. On the other hand, disease-specific programs can deal effectively with ‘scourges that are so widespread, and affect so high a proportion of the population as to be a dominant factor in hindering the social and economic development of a country’ (Gonzalez 1965). This debate largely neglects to consider the significant and direct impact HIV/AIDS has on health systems and on overall levels of social and economic development. Perhaps more than any other health issue, HIV/AIDS itself directly affects the ability of health systems to respond to the epidemic and, importantly, to provide other badly needed health services. Effective, direct action on the disease can reduce many of the negative impacts on development and may well generate significant external benefits for health service delivery. Furthermore, the debate often frames the vertical and horizontal approaches as mutually exclusive. However, they can also be mutually supportive as part of an integrated approach. Where the health system is very weak, it is legitimate to start delivering some services while building up infrastructure in a second step. This is the case for countries most heavily affected by HIV/AIDS. The work of Partners in Health (PIH) in Haiti is a clear example of how the delivery of HIV services supported the delivery of other services as well (Walton et al. 2004). Other studies have demonstrated that integrated

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AIDS prevention and care, including the use of antiretroviral agents, has been feasible in resource-poor settings, and that such efforts may have favorable and readily measured impacts on a number of primary health care goals, including vaccination, family planning, tuberculosis case finding and cure, and health promotion (Mills 2005; Gonzalez 1965). Because HIV/AIDS is a complex disease that touches on numerous aspects of health service delivery, there is reason to believe that strengthening systems to deliver HIV/AIDS services can have an impact on health systems in general and can help improve access to high-quality health services (Yu 2007; El-Sadr and Abrams 2007). The experience of WHO with the ‘3 by 5’ initiative (to have three million people on treatment by the end of 2005) demonstrated that a vertical approach could succeed in delivering adequate high-quality services for HIV/AIDS, even where health systems are weak overall. On the other hand, continuing expansion of effective response to HIV/AIDS cannot occur without strengthening health systems to deliver HIV/AIDS prevention and treatment interventions. In high-burden settings existing capacity can become saturated, expansion often cannot occur without a significant strengthening of health sector capacity (World Health Organization 2006a). Based on the intrinsic importance of the disease, its constraints to social and economic development, and the availability of antiretroviral drugs and other necessary technologies (Mills 2005; Gonzalez 1965), an integrated approach, including prevention, treatment and care, to scaling up the response to HIV/AIDS would seem to be the rational choice. Not surprisingly, major Global Health Initiatives (GHIs) are taking stronger measures to further step up efforts to strengthen the health system while targeting specific diseases, including HIV/AIDS. For example, the recent GFATM Board meeting decided to expand the support for health system strengthening efforts in the coming rounds applications (The Global Fund to Fight AIDS TB and Malaria 2007). PEPFAR is to channel more resources for training and retaining more health workers (Dybul 2007). These programs are increasingly abandoning the categorically defined ‘vertical’ versus ‘horizontal’ approaches, but more with the so called ‘diagonal’ or ‘matrix’ approach (Yu 2007). WHO and partners recognize the potential synergies that exist between vertical and horizontal approaches, and the importance of ensuring that disease-specific programs also strengthen overall health systems’ capacity (World Health Organization 2007, 2006b). WHO has adopted an approach to HIV/AIDS that includes health systems strengthening as part of a comprehensive approach to HIV/AIDS. As part of this strategy, WHO has recently launched an initiative to ‘treat, train and retain’ health workers, which aims to reinforce human resource capacity of health systems in developing countries and allow them to effectively address HIV/AIDS (World Health Organization 2006c). This initiative can be expected to generate some important external benefits for strengthening human resources capacity in the overall health system.

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Conclusion HIV/AIDS has a significant impact on the development of high-prevalence developing countries. Even though HIV/AIDS is largely a health issue, the developmental impact is felt across a broad spectrum of demographic, social and economic development issues. The implications of HIV/AIDS for the health sector are particularly important, as HIV/AIDS creates an additional burden on the health sector while at the same time seriously reducing the capacity of the health sector to respond to HIV/AIDS or to provide other health services that are essential for social and economic development. The current debate between horizontal and vertical approaches to HIV/AIDS and health systems overlooks the importance of these effects. Proponents of the horizontal approach often neglect to consider the substantial impact of HIV/AIDS on health systems, and consequently fail to appreciate the benefits to the health systems of disease-specific programs to HIV/AIDS. At the same time, the response to HIV/AIDS cannot succeed without substantial strengthening of overall health systems capacity. Significant synergies exist between vertical programming and health systems strengthening. The key to a successful response is to use an effective approach that captures the momentum of the focused response to HIV/AIDS in order to strengthen overall health systems.

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Yves Souteyrand, Dongbao Yu and Kerry Kutch 241 Cogneau, D. and M. Grimm (2006)’ ‘Socioeconomic Status, Sexual Behavior, and Differential AIDS Mortality: Evidence from Côte d’Ivoire’, Population Research and Policy Review, 25: 393–407. Daly, K. (2000) The Business Response to HIV/AIDS: Impact and Lessons Learned (Geneva and London: Joint United Nations Programme on HIV/AIDS (UNAIDS), The Prince of Wales Business Leaders Forum (PWBLF) and the Global Business Council on HIV&AIDS). Dixon, S. et al. (2001) ‘AIDS and Economic Growth in Africa: a Panel Data Analysis’, Journal of International Development, 13(4): 411–26. Dixon, S. et al. (2002) ‘The Impact of HIV and AIDS on Africa’s Economic Development’, British Medical Journal, 324(7331): 232–4. Dybul, M. ‘Statement Before the Committee on Health, Education, Labor and Pensions United States Senate (Washington DC, 12 Nov. 2007)’, available at http://www.pepfar.gov/press/96710.htm. El-Sadr, W.M. and E. Abrams (2007) ‘Scale-up of HIV Care and Treatment: Can it Transform Healthcare Services in Resource-limited Settings?’, AIDS, 21(5) Suppl.: S65–S70. Evans, D.K. and E. Miguel (2007) ‘Orphans and Schooling in Africa: A Longitudinal Analysis’, Demography, 44: 35–57. FAO (1996) Effect of HIV/AIDS on Agricultural Production Systems in West Africa (Rome: Food and Agriculture Organization (FAO)). FAO/UNAIDS (1999) Sustainable Agricultural/Rural Development and Vulnerability to the AIDS Epidemic (Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS) and Food and Agriculture Organization (FAO)). Gillespie, S. et al. (2007) ‘Investigating the Empirical Evidence for Understanding Vulnerability and the Associations Between Poverty, HIV Infection and AIDS Impact’, AIDS, 21(7) Suppl.: S1–4. Gonzalez, C.L. (1965) ‘Mass Campaigns and General Health Services’ (World Health Organization, Public Health Papers 29). Grassly, N.C. et al. (2003) ‘The Economic Impact of HIV/AIDS on the Education Sector in Zambia’, AIDS, 17(7): 1039–44. Gray, R.H. et al. (1998) ‘Population-based Study of Fertility in Women with HIV-1 Infection in Uganda’, The Lancet, 351(9096): 98–103. Haacker, M. (2002) ‘The Economic Consequences of HIV/AIDS in Southern Africa’ (IMF Working Paper). Krishnan, S. et al. (2007) ‘Poverty, Gender Inequities and Women’s Risk of HIV/AIDS’, Annals of the New York Academy of Sciences, annals.1425.013. Macfarlan, M. and S. Sgherri (2001) ‘The Macroeconomic Impact of HIV/AIDS in Botswana’ (IMF Working Paper, 2001). Mills, A. (2005) ‘Mass Campaigns Versus General Health Services: What Have we Learnt in 40 Years About Vertical Versus Horizontal Approaches?’, Bulletin of the World Health Organization, 83: 315–16. Moatti, J.P. and B. Ventelou (2007) ‘The Economic Impact of HIV/AIDS in Developing Countries: An End to Systematic Under-estimation’, in HIV, Resurgent Infections and Population Change in Africa, edited by M. Caraël and J. R. Glynn (The Hague: Springer Netherlands). Paul, B. (2005) ‘The Impact of the AIDS Epidemic on Teachers in Sub-Saharan Africa’, Journal of Development Studies, 41: 440–66. Piot, S. et al. (2007) ‘AIDS, Poverty and Human Development PLOS Med., 23 October, 4.

242 Part IV: Disease and Development Pison, G. (2002) ‘Le sida va-t-il entraîner un recul de la population de l’Afrique au sud du Sahara’, Population et Sociétés, 385: 1–4. Rosen, S. et al. (2007) ‘The Private Sector and HIV/AIDS in Africa: Taking Stock of 6 Years of Applied Research’, AIDS, 21(7) Suppl.: S41–S51. Samb, B. et al. (2007) ‘Rapid Expansion of the Health Workforce in Response to the HIV Epidemic’, New England Journal of Medicine, 357(24): 2510–14. The Global Fund to Fight Aids TB and Malaria ‘16th Global Fund Board Meeting Decisions’, The Global Fund to Fight AIDS, TB and Malaria, available at http://www.theglobalfund.org/en/files/boardmeeting16/GF-BM16-Decisions.pdf. Travis, P. et al. (2004) ‘Overcoming Health-systems Constraints to Achieve the Millennium Development Goals’, The Lancet, 364(9456): 900–6. UNAIDS (2006) AIDS Epidemic Update: Special Report on HIV/AIDS: December 2006 (UNAIDS/06.29E) (Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO)). UNAIDS (2007a) AIDS Epidemic Update: December 2007 (UNAIDS/07.27E/JC1322E) (Geneva: Joint United Nations Programme on HIV/AIDS (UNAIDS) and World Health Organization (WHO)). UNAIDS (2007b) Financial Resources Required to Achieve Universal Access to HIV Prevention, Treatment, Care and Support (Geneva: Joint United Nations Programme on HIV/AIDS). United Nations (2004) World Population Prospects: The 2004 Revision Analytic Report (New York: United Nations). United Nations Development Programme (2005) Human Development Report 2005: International Cooperation at a Crossroads: Aid, Trade and Security in an Unequal World (New York: United Nations Development Programme). US Bureau of the Census (2003) World Population Profile: 2000 (Washington, DC: US Government Printing Office). Veenstra, N. and A. Whiteside (2005) ‘Economic Impact of HIV’, Best Practice & Research Clinical Obstetrics & Gynaecology, 19(2): 197–210. Veriava, Y. (2005) The Impact of HIV/AIDS on Health Service Personnel at Two Public Hospitals in Johannesburg (Johannesburg: University of Witwatersrand). Walton, D.A. et al. (2004) ‘Integrated HIV Prevention and Care Strengthens Primary Health Care: Lessons from Rural Haiti’, Journal of Public Health Policy, 25: 137–58. Whiteside, A. (2002) ‘HIV/AIDS, Health and Education’, in State of the Art, AIDS and Economics, edited by S. Forsythe et al. (Washington, DC: Futures Group International, POLICY Project, 2002), pp. 24–9. World Health Organization (2006a) Evaluation of WHO’s Contribution to ‘3 by 5’: Main Report (Geneva: World Health Organization). World Health Organization (2006b) ‘Opportunities for Global Health Initiatives in the Health System Action Agenda’ (Geneva: Making Health Systems Work series No. 4). World Health Organization ‘WHO Launches New Plan to Confront HIV-related Health Worker Shortages (Press Release)’, available at http://www.who.int/mediacentre/ news/releases/2006/pr37/en/index.html. World Health Organization (2007) Everybody’s Business: Strengthening Health Systems to Improve Health Outcomes: WHO Framework for Action (Geneva: World Health Organization). Yu, D. (2007) ‘Health Systems Strengthening in the Era of Scaling up the Response to HIV/AIDS’ (Unpublished manuscript).

15 Global TB Control: Persisting Problem, Shifting Solutions Mukund W. Uplekar and Mario C. Raviglione

Tuberculosis, popularly known as TB, is a disease that has affected mankind for millennia. Robert Koch discovered the germ that causes TB over a century ago. Largely a disease of poverty, resource-poor countries carry most of the global burden of TB today. Although present in all parts of the world, TB declined speedily as socioeconomic conditions in the industrialized countries improved – even before drugs to cure it were discovered. Investing in TB control therefore raises an important question at the outset: why spend when the problem is known to disappear with socioeconomic development? Clearly, the price of not investing is too high. In addition, the reality is more complex: the perceived disappearance of TB from rich countries can be virtual rather than real. The notorious TB bacilli remain dormant in the human host only to resurface and multiply when the surrounding environment becomes favorable to them – weakening of body defenses due to any reason and poverty-related factors in general. Moreover, the tools for tackling TB available today allow us to diagnose and treat but not prevent it effectively from occurring. A disease that thrives among poor countries, persists in poorer settings among rich countries, and flourishes when economies and social conditions deteriorate can truly be called a barometer of development. Appropriately therefore, global TB control is among the targets and indicators to measure the progress toward the MDGs of 2015 (United Nations Statistics Division 2007; Dye et al. 2006). This chapter describes the evolution of global efforts to control TB, an ancient scourge to humanity. The following section gives an account of some basic facts about TB and statistics on the worldwide burden of the disease. After this, we detail the evolution of the problem of TB compounded significantly in recent years by the HIV epidemic, the emergence of multi-drug resistance, and weak health systems. TB appeared on the international public health agenda when WHO was established in 1947 (Chisholm 1958). Sixty years later, it also remains prominently on WHO’s agenda. Even so, in retrospect, the progress in global TB control over the past decades has not always been steady or sustained. Embedded within the broader international public 243

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health development, it has followed the swings of the proverbial pendulum. The fourth section highlights these swings of the pendulum of global TB control over the past decades. The final section examines the future of TB control. The chapter concludes that meeting global TB control targets and eventual elimination of TB is indeed possible provided current efforts are pursued undiluted and in partnership, new tools of TB care and prevention are developed and deployed swiftly and, in contrast to the past, efforts to strengthen health systems are designed in such a way as to further improve and not impede TB control.

The problem and its magnitude TB is caused by Mycobacterium tuberculosis, also known as TB bacillus. It spreads through the inhalation of tiny droplets produced when a patient suffering from TB of the lungs coughs, spraying infectious particles around. The initial infection with TB bacilli, often in early childhood, usually takes place in the lungs. In many instances, the initial infection becomes quiescent and remains so to the extent that 90 per cent of people silently infected never develop TB during their lifetime. Any weakening of the body’s defenses in later life, however, may allow reactivation of the disease. A third of the world’s population is estimated to be infected with TB. A large part of it lives in poor countries. HIV is a most powerful factor known to increase the risk of developing TB. The diagnosis of pulmonary TB, the commonest and the most infectious form of the disease in developing countries, is commonly done by demonstration of TB bacilli in a microscopic examination of a sputum-smear obtained from a suspected patient – a simple but cumbersome technique that has now been in use, almost unmodified, for a century. TB patients harboring too few bacilli to demonstrate by sputum-smear examination are diagnosed on the basis of their symptoms and X-ray of the chest showing suggestive shadows. The diagnosis of TB affecting other parts of body is confirmed by bacteriological examination of the affected part. Most TB patients can be cured by prolonged treatment with a combination of four effective drugs which are now in use for a few decades. Development of new and more effective drugs for TB, though essential, has been woefully neglected for a long time with the assumption that TB was conquered after the discovery of the current drugs between 1940 and 1970. The long treatment and limited drugs have given rise to the complex problem of multi-drug-resistance TB, which is difficult to diagnose, treat, and cure. BCG, the known vaccine against TB, is only partially effective in preventing severe forms of the disease, especially among children. A vaccine that can afford complete protection against this oldest disease known to mankind is not yet available. The latest estimates of the global burden of TB disease refer to cases arising in 2006 (World Health Organization 2008). There were an estimated 9.2 million new cases of TB in 2006, of which 4.1 million were sputum

Mukund W. Uplekar and Mario C. Raviglione 245

smear-positive and 0.7 million were in HIV-infected adults. The total number of MDR-TB cases estimated to occur worldwide annually is 0.5 million (Zignol et al. 2006). An estimated 2.5 million people died from TB in 2006, including 0.2 million people co-infected with HIV. The gravity of the situation is better appreciated if one of these statistics is translated into a simple fact that in today’s world, which is continually witnessing mind-boggling technological advancements, an ancient disease like TB, which can be diagnosed, treated and cured, kills about three persons every passing minute. More important, most of its victims are adults from productive age group. Organizing health and community services to detecting, treating and ensuring the cure of TB cases while continuing to monitor the trends in the disease burden and supporting development of new tools to better facilitate control have been the essence of the current international TB control strategy that has evolved over time. The focus of international efforts for TB control from the mid-1990s, encapsulated as the ‘DOTS strategy’, has been mainly on setting up global, national and local systems to detect and cure TB cases and measuring progress. In 2006, the DOTS strategy was enhanced and expanded into a more comprehensive Stop TB Strategy (Raviglione and Uplekar 2006).

Progress, trends and challenges The targets set for measuring progress on global TB control employing the DOTS strategy included detecting at least 70 per cent of the estimated infectious TB cases and curing at least 85 per cent of them (World Health Assembly 1991; Dye et al. 2006). These targets reflected the minimum requirement to ensure a steady decline in the TB epidemic. In 1991, when WHO first established the targets for TB case detection and treatment success, there was no global monitoring system for measuring the burden of TB. Following the establishment of the global TB monitoring and surveillance system in the mid-1990s, the first results showed a case detection rate of 11 per cent and a treatment success rate of 77 per cent (Raviglione et al. 1997). The WHO global TB monitoring and surveillance project has provided the latest global estimates of progress against the targets for 2006 (World Health Organization 2008). They indicate that among patients with sputum smear-positive pulmonary TB diagnosed and treated under the DOTS strategy the case detection rate was 61 per cent and the treatment success rate was 84.7 per cent. More than 31.8 million TB patients were treated by DOTS programs over the 11 years from 1995 to 2006. The global achievement of a case detection rate of 61 per cent and a treatment success rate of 84.7 per cent (compared with the global targets of 70 per cent and 85 per cent respectively) represents tremendous progress in global TB control since 1991. Over the past decade the case detection rate has thus increased from 11 per cent to 61 per cent with an acceleration during the past five years (Figure 15.1), and the treatment

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Case detection rate, smear-positive cases (%)

80 WHO target 70%

70 60 50 40 30

DOTS begins 20 10 0 1990

1995

2000

2005

2010

2015

Year Figure 15.1 Progress toward global TB control targets from 1995 to 2005

success rate has increased from 77 per cent to 84.7 per cent (at the same time as an approximately tenfold increase in cases detected). After decades of steady increase, global per capita TB incidence appears to have stabilized, attributable in part to widespread implementation of the DOTS strategy and also to other factors including improved living conditions in many parts of the world and the peaking of the HIV epidemic, especially in Africa. In four out of six WHO regions (the Americas, Eastern Mediterranean, South East Asia, and Western Pacific), per capita TB incidence has been stable or falling over the past decade. In two regions (Africa and Europe) per capita TB incidence had been increasing for over a decade, but appears to have reached a peak (Figure 15.2). WHO’s current Stop TB Strategy (Table 15.1) is aimed at achieving the global Stop TB Partnership’s targets for 2015, which are linked to the MDGs (Dye et al. 2006). The MDGs provide a framework and opportunity for international cooperation in improving the health of the poor. As a disease of poverty, responsible for the loss of more years of healthy life than any other curable communicable disease, TB is one of the priorities to which these goals apply. The goal relevant to TB (Goal 6, Target 8) is ‘to have halted and begun to reverse incidence by 2015.’ In addition to interpreting Target 8 as an incidence rate that should be falling by 2015, the Stop TB Partnership

Mukund W. Uplekar and Mario C. Raviglione 247 450

Estimated TB incidence/100K/yr

400 350 300 250

450

AFR SEAR EMR WPR EUR AMR WORLD

400 350 300 250

200

200

150

150

100

100

50

50

0 1990

1995

2000

2005

Figure 15.2 Progress in TB control according to WHO regions (1990–2005) [AFR: Africa; SEAR; Southeast Asia; EMR: Eastern Mediterranean; WPR: Western Pacific; EUR: Europe; AME: Americas]

has endorsed international targets linked to Target 8, to decrease TB prevalence and deaths by half by 2015 (in comparison with a 1990 baseline) (Dye et al. 2006). Furthermore, the 2050 elimination target is currently out of sight without new revolutionary tools like a vaccine (Raviglione and Uplekar 2006). Notwithstanding the recent achievements in TB control, the current rates of progress are insufficient to allow the targets of halving TB mortality and prevalence by 2015 to be achieved (Raviglione and Uplekar 2006). In particular, urgent action is needed where the trend of the epidemic has been unfavorable until recently – notably in Africa and in Eastern Europe. While there has been substantial progress in extending and improving TB programs in sub-Saharan Africa, this region has to face the challenge of the rapid rise in TB cases produced by the HIV epidemic (Nunn et al. 2005), often in places where human resources in the healthcare sector are already overburdened. In Eastern Europe, the socioeconomic crisis that followed the dismantling of the Soviet Union in the early 1990s and impoverished public health systems have contributed to a major increase in the incidence and prevalence of TB, including MDR-TB. Increased and sustained efforts are also needed in Asia, which continues to bear two-thirds of the global burden of TB due to its population size and high per capita rates of the disease. An emerging HIV epidemic in Asia also threatens recent progress in TB control, and, in some parts of China, MDR-TB is a major problem (Aziz et al. 2006). In all regions, identifying and reaching all those in need of care, especially the poorest of the poor, poses a major challenge. Efforts to control TB must progress hand in

248 Table 15.1 The Stop TB Strategy at a glance The Stop TB Strategy Vision

A world free of TB

Goal

•

Objectives • • • • Targets

• •

To reduce dramatically the global burden of TB by 2015 in line with the Millennium Development Goals and the Stop TB Partnership targets To achieve universal access to high quality diagnosis and patient-centered treatment To reduce the suffering and socioeconomic burden associated with TB To protect poor and vulnerable populations from TB, TB/HIV and MDR-TB To support development of new tools and enable their timely and effective use MDG 6, Target 8 – halt and begin to reverse the incidence of TB by 2015 Targets linked to the MDGs and endorsed by the Stop TB Partnership: – by 2005, detect at least 70 per cent of new sputum smear-positive TB cases and cure at least 85 per cent of these cases – by 2015, reduce TB prevalence and death rates by 50 per cent relative to 1990 – by 2050, eliminate TB as a public health problem (less than one case per million population)

Components of the Strategy and implementation approaches 1. Pursue high quality DOTS expansion and enhancement a. Political commitment with increased and sustained financing b. Case detection through quality-assured bacteriology c. Standardized treatment with supervision and patient support d. An effective drug supply and management system e. Monitoring and evaluation system and impact measurement 2. Address TB/HIV, MDR-TB and other challenges a. Implement collaborative TB/HIV activities b. Prevent and control MDR-TB c. Address prisoners, refugees and other high risk groups, and special situations 3. Contribute to health system strengthening a. Actively participate in efforts to improve system-wide policy, human resources, financing, management, service delivery and information systems b. Share innovations that strengthen systems, including the Practical Approach to Lung Health (PAL) c. Adapt innovations from other fields 4. Engage all care providers a. Public–Public and Public–Private Mix (PPM) approaches b. International Standards for Tuberculosis Care (ISTC) 5. Empower people with TB, and communities a. Advocacy, communication and social mobilization b. Community participation in TB care c. Patients’ Charter for Tuberculosis Care 6. Enable and promote research a. Program-based operational research b. Research to develop new diagnostics, drugs and vaccines

Mukund W. Uplekar and Mario C. Raviglione 249

hand with efforts to strengthen health systems as a whole (Anonymous 2004). The ultimate goal of eliminating TB depends on new diagnostics, drugs and vaccines. New approaches to overcoming the obstacles to TB control have been developed, but greater resources are needed to allow these approaches to be widely implemented. While all this is indeed essential and desirable, the key question is: would the current efforts be augmented and sustained to achieve global TB control? Although hopes remain high, TB being just one element of increasingly demanding international public health agenda, the answer to this question could only be speculative. Then, can a peep into the history of TB control prompt predictions on its future?

The swings of the pendulum The evolution of solutions to tackling the problem of TB in the world may be characterized as swings of a pendulum that reflected historical trends in international public health over past decades. Periods of intensive efforts to address selected public health problems (such as TB) without proportionate consideration to strengthening health systems in general have been followed by periods of investments into strengthening general health systems without required attention to specific programs (such as TB). A deeper understanding of the history of TB control could help prevent past mistakes and offer lessons for the future. This section draws largely from a review by Raviglione and Pio on the evolution of WHO policies for tuberculosis control since 1947, when, soon after its establishment after the world war, a tuberculosis section was set up within the WHO secretariat (Raviglione and Pio 2002).

The first upswing After World War II, the discovery of effective treatments against communicable diseases of importance to public health such as TB, leprosy and syphilis, promoted the building of vertical programs. Each of these programs established its own structure staffed with specialized personnel from a central level through to the local level in which the technical control activities were delivered. This single purpose machinery, independent of both the general health infrastructure and the structures of other vertical programs, was set up because it had to deal with experimental treatment methods that required specialized services for delivery. Indeed, TB programs had been developed and managed in most high-income countries in line with such a vertical structure. There was a direct line of command from a central TB division or unit down to the specialized hospitals, TB clinics, X-ray mobile units, and tuberculin test and BCG teams. The central level operated through its own officers for training, supervision, logistics, and health education, and offered its own laboratory services.

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The vertical approach, backed by socioeconomic development, was successful in industrialized countries in producing acceleration of the decline in the annual risk of infection from 5 per cent yearly in the period 1910–39 up to 13 per cent following the introduction of chemotherapy from the 1940s until 1970. The same approach was proposed by subsequent WHO expert committees to less developed countries and introduced or reinforced through the establishment of ‘training and demonstration centers’ in developing countries, satellite TB clinics responsible for case finding through mass radiography and bacteriological diagnosis, and tuberculosis hospitals for segregation of patients during chemotherapy. By the late 1950s it became clear that, in contrast to industrialized countries, in most less developed countries, there was no decline in the levels of TB. The reasons were obvious. Mass case finding and specialized case management used in the more developed countries could not be transferred effectively to other parts of the world; the cost was far beyond resources of less developed countries. In particular, some of the expensive drugs, such as rifampicin, were unaffordable. Finally, the vertical program could not provide services to the whole population through its specialized structure, and, therefore, without adequate coverage, it could not bring TB under control.

The downswing The downswing began with the first wave of integration that was mainly promoted by the results of two pioneering studies, both emerging from India. The Madras Chemotherapy Centre indicated the efficacy of home treatment and suggested that hospital beds were no longer necessary to cure the disease (Fox et al. 1959). The National Tuberculosis Institute at Bangalore showed that most sources of TB infection could be diagnosed through bacteriological examination of patients with respiratory symptoms attending general health services (Banerji 1965). During the period 1964–76, the delivery of TB services through the general health infrastructure became the national policy for TB control in almost all less developed countries. However, implementation was far from satisfactory. Whereas in a few countries the transfer of responsibilities to general services was backed by increased resources, in most, dismantling of specialized services was not accompanied by infusion of any extra resources. Thus, no significant impact on TB indicators could be achieved in less developed countries. During the 1970s, strong objections were raised against the specialized management of the TB program. The prevailing view among public health experts was that integration of service delivery could not be efficient without the integration of all the managerial functions. The PHC movement with its universal declaration of Alma Ata impelled a second wave of integration (World Health Organization 1978). The rationale behind overall integration was that because all programs operated through the same type of managerial and support activities, it would

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make a more efficient use of human and financial resources, eliminate duplication of tasks, and provide more effective support to the units responsible for TB. Compounded by economic crises that caused a weakening of the public health infrastructure at that time, in general, the integration of both managerial functions and service delivery meant the deterioration of the quality of TB case finding and treatment. General health service experts without proper training were unable to provide adequate supervision and training for TB control. The integration and oversimplification of the information system did not provide basis data to monitor and evaluate case finding and treatment results, and critical TB drug shortages were frequent. During this period, WHO, other national and international agencies, and academic institutions were perceived to have lost interest in the control of TB. In 1978, the TB Unit in WHO was transformed into a TB and Respiratory Infections Unit with the added responsibility of developing a program for the control of acute respiratory infections, but without any increase in human and financial resources. With the globalization of the so-called ‘health sector reform’ process, the integration of managerial functions was further accelerated in the late 1980s. Set up to increase equity, efficiency and quality, this process had three focuses: decentralization of authority (local empowerment), managerial integration of programs, and public consultation. Speedy implementation of reforms with little participation of TB managers was destructive for the residual TB programs in many countries. Excessive integration had resulted in near disintegration and complete loss of visibility for TB control programs.

The second upswing In the late 1980s, while national TB programs existed largely on paper, it was events outside the TB control arena that helped bring the attention back to TB control with a second upswing of the pendulum. The HIV pandemic was producing sharp increases in TB notifications especially in African countries (Narain et al. 1992). The dissolution of the former Soviet Union was accompanied by a major socioeconomic crisis and the collapse of health services, which resulted in a significant increase in TB incidence in that part of the world (Raviglione et al. 1994). The declining trend in incidence in large cities reversed and notification rates increased year after year. The deterioration of socioeconomic conditions in many countries resulted in increased levels of poverty, overcrowding, and malnutrition, which are favorable for the spread of TB infection and the progression from infection to disease. In 1990, it was estimated that the global incidence of TB was eight million new cases and resulted in around three million deaths (Kochi 1991). With only a handful of exceptions, countries did not have sound TB control programs that could achieve high cure rates and monitor the progress of control efforts.

252 Part IV: Disease and Development

The worsening global TB problem could no longer be ignored. At the same time, studies led by the International Union Against TB and Lung Disease had demonstrated the feasibility of achieving high cure rates in field conditions in Africa (Styblo 1991). This uncovered the potential of achieving substantial improvements in the prevailing situation using simple interventions that exploited the available tools and technology. WHO responded by establishing the fundamentals of a new strategic approach to TB control, emphasizing specialized managerial functions at central, regional, and district levels and, therefore, making a clear retreat from the concept of managerial integration. In 1991, the 44th World Health Assembly, through its resolution, adopted the new strategy and formulated the two global targets of curing 85 per cent of infectious cases detected and detecting 70 per cent of cases (World Health Assembly 1991). The new strategy, subsequently labeled DOTS, provided a framework for effective TB control. The strategy comprised five essential elements. Two elements are technical: case finding through the bacteriological examinations of patients with respiratory symptoms attending primary healthcare units and the administration of supervised short course treatment. The other elements are managerial ones: generating greater political commitment to mobilize sufficient resources for TB control; securing a regular supply of anti-TB drugs; and establishing a reliable information system to provide data for monitoring and assessing case finding and treatment activities (World Health Organization 1994). Meanwhile, the World Bank’s World Development Report of 1993 emphasized that a sound strategy of TB control is one of the most cost-effective public health interventions available (World Bank 1993). Sound international monitoring and surveillance systems, able to measure progress toward the achievements of the global targets set by the World Health Assembly in 1991 and to monitor drug-resistance prevalence, were then established. Country support to review and revise TB control strategies was intensified by WHO. TB research, from the most basic to the more operational research on health policy, systems and services, attracted new interest both at WHO and in many public health and academic institutions. As a result, TB was back on the global public health agenda. WHO then carried out a massive advocacy campaign to make the DOTS strategy widely acceptable and to promote the adoption of clear objectives and targets by countries. In furthering the efforts, an ad hoc committee convened by WHO in 1998 recommended further strengthening of political will through social mobilization and establishing a global partnership for TB control with nongovernmental organizations and the private sector (World Health Organization 1998). The subsequent launching of the Stop TB Partnership to enhance and sustain global efforts, the inclusion of TB-related indicators in the MDGs and the establishment of the Global Fund to fight AIDS, TB and Malaria to raise and sustain much-needed resources have all helped greatly in maintaining global TB control prominently in the international public health agenda perhaps for the longest period hitherto.

Mukund W. Uplekar and Mario C. Raviglione 253

Developed as a comprehensive response taking into account challenges problems on the ground and lessons from the past, WHO’s Stop TB Strategy highlights the interdependence of strengthened health systems and successful TB control programs (Raviglione and Uplekar 2006). The pendulum should, therefore, no longer swing.

Future of TB control: due deference within stronger systems The future of TB control will depend largely on the successful implementation of the new Stop TB Strategy, with the adequate resources made available, whether human or financial, in all countries. The six components of the Stop TB Strategy represent a holistic, health system-sensitive approach to TB control based on proper TB diagnostic, treatment and monitoring activities within functioning health systems and services. Since health systems are crucial for the effective implementation of any disease-specific package such as DOTS, the Stop TB Strategy embraces those components of the health system that are relevant to TB care and control. Without, for instance, the involvement of national HIV/AIDS programs, HIV-related TB cannot be tackled successfully. Similarly, active engagement in the process of strengthening health systems, and especially the primary health services, is necessary to obtain the synergies between a categorical program such as TB and overall health system developments. Finally, the intensity of involvement of all care providers, especially those from the nonstate sector (Uplekar et al. 2001), and of communities and patients with TB themselves will determine the capacity of a national TB program to effectively control and, in the long term, eliminate TB. All this notwithstanding, developments in sectors beyond health will determine the future of TB control. As with any other disease with strong socioeconomic determinants, the removal of the upstream determinants of disease will have the potential to speed up progress in disease control. The upstream determinants (‘causes of causes’) that maintain TB, among other diseases, in a community include poverty, urbanization, housing, nutrition, and the general level of education which influences the response to any community health threat. These upstream determinants are often shaped by new socioeconomic forces that are a part of ‘globalization.’ The upstream factors pertaining to sectors beyond health generate, in turn, more downstream factors which are directly relevant to the cycle of TB transmission in a society. These factors include conditions that are normally beyond the reach of those directly involved in TB control, yet within the health system capacity to influence them, such as tobacco use, diabetes, malnutrition, indoor pollution, and, of course, HIV infection. The Stop TB Strategy does not explicitly address the more indirect causes of TB and the upstream determinants. However, those interested in the longterm goal of TB elimination must assess the importance of both the upstream

254 Part IV: Disease and Development

and the more direct determinants of TB in a community. Understanding the ‘causes of causes’ – for example, identifying the upstream determinants of TB, will enable those involved in TB control to join those interested in addressing the range of illnesses with strong socioeconomic determinants for more visible advocacy efforts to alleviate these determinants. This can contribute to better health for all societies. Addressing those more direct factors (HIV, tobacco and diabetes) that are of great relevance specifically to TB control and also to general public health implies the joint engagement of TB programs with others in the health sector concerned with these problems. Improved socioeconomic conditions in many countries are likely to facilitate, rather than impede, disease control among the most vulnerable members of society. With further understanding of the causes of TB, those responsible for national and international efforts to control TB can work together with other health sector stakeholders toward removing these causes, thereby enhancing the Stop TB Strategy’s effectiveness and the likelihood of future TB elimination.

References Anonymous (2004) ‘Report on the Meeting of the Second Ad Hoc Committee on the TB Epidemic: Recommendations to Stop TB Partners, Montreux, Switzerland, 18–19 September 2003 Consensus Statement’, The International Journal of Tuberculosis and Lung Disease, 8(2004): 1279–84. Aziz, M.A. et al. (2006) ‘Epidemiology of Antituberculosis Drug Resistance (the Global Project on Anti-tuberculosis Drug Resistance Surveillance): an Updated Analysis’, The Lancet, 368(9553): 2142–54. Banerji, D. (1965) ’Tuberculosis: a Problem of Social Planning in Developing Countries’, Medical Care, 3(3): 151–9. Chisholm, B. (1958) ‘Ten Years Ago’, in The First Ten Years of the World Health Organization (New York: Columbia University Press, 1958). Dye, C. et al. (2006) ‘Targets for Global Tuberculosis Control [Short Communication]’, The International Journal of Tuberculosis and Lung Disease, 10: 460–2. Fox, W. et al. (1959) ‘A Concurrent Comparison of Home and Sanatorium Treatment of Pulmonary Tuberculosis in South India’, Bulletin of the World Health Organization, 21: 51–144. Kochi, A. (1991) ‘The Global Tuberculosis Situation and the New Control Strategy of the World Health Organization’, Tubercle, 72(1): 1–6. Narain, J.P. et al. (1992) ‘HIV-associated Tuberculosis in Developing Countries: Epidemiology and Strategies for Prevention’, Tubercle and Lung Disease, 73(6): 311–21. Nunn, P. et al. (2005) ‘Tuberculosis Control in the Era of HIV’, Nature Review Immunology, 5(10): 819–26. Raviglione, M.C. and A. Pio (2002) ‘Evolution of WHO Policies for Tuberculosis Control, 1948–2001’ The Lancet, 359(9308): 775–80. Raviglione, M.C. and M.W. Uplekar (2006) ‘The New Stop TB Strategy of WHO’, The Lancet, 367(9514): 952–5.

Mukund W. Uplekar and Mario C. Raviglione 255 Raviglione, M.C. et al. (1994) ‘Tuberculosis Trends in Eastern Europe and the Former USSR’, Tubercle and Lung Disease, 75: 400–16. Raviglione, M.C. et al. (1997) ‘Assessment of Worldwide Tuberculosis Control’, The Lancet, 350(9087): 624–9. Styblo, K. (1991) Epidemiology of Tuberculosis (The Hague: Royal Netherlands Tuberculosis Association). United Nations Statistics Division, ‘Millennium Indicators Database’, available at http://unstats.un.org/unsd/mi/mi_goals.asp. Uplekar, M.W. et al. (2001) ‘Private Practitioners and Public Health: Weak Links in Tuberculosis Control’, The Lancet, 358(9285): 912–16. World Bank (1993) World Development Report: Investing in Health 1993 (New York: Oxford University Press). World Health Assembly (1991) Res. WHA44.8, WHA44/1991/REC/1. World Health Organization (1978) ‘Declaration of Alma-Ata International Conference on Primary Health Care, Alma-Ata, USSR, 6–12 September 1978’. World Health Organization (1994) Framework for Effective Tuberculosis control, WHO/TB/94.179. World Health Organization (1998) Report of the Ad Hoc Committee on the Tuberculosis Epidemic. London, 17–19 March 1998, WHO/TB/98.245. World Health Organization (2008) Global Tuberculosis Control: Surveillance, Planning and Financing (WHO/HTM/TB/2008.393) (Geneva: World Health Organization). Zignol, M. et al. (2006) ‘Global Incidence of Multidrug-Resistant Tuberculosis’, Journal of Infectious Disease, 194(4): 479–85.

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Index infectious disease, i, 9, 156, 170, 231, 233, 246 mortality, 4, 9, 14, 38, 58, 81, 169, 170, 221 nutrition, 68, 81, 169, 173, 206 poverty, xv, 68, 169–70, 173, 180 programs, xiv, 137, 171, 172, 174 childbirth see pregnancy Chile, 62, 172 China, 6, 59, 61, 62, 71, 81, 89, 99, 107, 158, 168, 186, 193, 208, 249 chronic (infectious) diseases, 104 chronic conditions, xi, xv, xvi, 81, 159, 201–7, 209, 210, 212–15 see also non-communicable conditions and specific chronic conditions circumcision – female see female genital mutilation circumcision – male, 231, 232 Claude, Richard, 137 climate change, 108 Clinton Global Initiative, 3 Colombia, 63, 193, 223 communicable (infectious) diseases see specific diseases community health, vi, 5, 14, 32, 161, 171 contraception, 84, 109, 187 Costa Rica, 63 Culture, 151, 166, 214

Afghanistan, 6, 221 Africa, ii, iv, 4, 5, 8, 11, 19, 37, 45, 57, 60, 61, 65, 67, 69, 80, 89, 96, 98, 104, 144, 158, 159, 160, 172, 173, 177, 185, 191, 201, 202, 206, 212, 220, 221, 222, 224, 225, 226, 227, 230, 232, 233, 235, 236, 237, 239, 243, 248, 249, 254 ageing, xiv, 81, 91, 156, 157, 159, 161–4, 166, 206, 211 agriculture, 101, 185 age of, 100 Alma-Ata, 25, 26, 27, 28, 29, 30, 33, 44, 141, 214, 252 antiretroviral drugs, 7, 59, 81, 139, 223, 231–2, 239, 241 Argentina, 67, 89, 137 Asia, 5, 6, 19, 37, 97, 98, 104, 121, 158, 202, 248, 249 Bangladesh, 137, 172, 193 Bill and Melinda Gates Foundation, 5, 13, 84, 214, 221 Bird flu, 6, 7 birth rate, 108 Bloom, David, 6, 12 Botswana, 158, 173, 231, 232, 233, 237, 238 brain drain, 8, 57, 90 Brazil, 62, 67, 71, 76, 89, 172, 175, 183 Bush Administration, 7 Cambodia, 10, 11 cancer, 6, 81, 106, 107, 159 capitalism, xii, 12, 128, 162 cardiovascular conditions, 98, 106, 112, 117–18, 209–10 CARE, 135 child abuse, 194 child growth, 116, 175, 178 child health, 6, 8, 64, 169, 172, 177, 187

DALY see Disability-Adjusted Life Year Daniels, Norman, 128, 149 death rate, xv, 4, 100, 184, 201, 206, 209, 231, 233 debt cancellation, 64, 69 debt relief, 65, 221 debt repayment, 5, 61, 63, 64 democracy, 149 diabetes, 81, 106, 201, 206, 213, 255

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258 Index diarrhea causes, 9 children, 58, 169, 174 prevention, i, 170 diet see nutrition directed donations, 84, 134, 214 Disability-Adjusted Life Year (DALY), 77, 108, 111 Doha Conference, 35 Doha Declaration, 35 donor countries, 7, 9, 134, 178 donor-driven aid, 9, 88, 131, 165, 214, 219, 222, 223 DOTS (Directly-Observed Therapy, Short-course), 247, 248, 254 drug companies, 147 drug resistance, 107, 118, 227, 246 eating disorders, 107 education, 108, 109, 116, 136, 169, 170, 171, 173, 175, 176, 179 Egypt, 188, 189, 223 endemic, 186, 225 epidemic, xvi, 18, 102, 212, 230, 231, 239 epidemiology, xv, 192, 193, 194, 207 ethics, xiv, 71, 141, 142, 146, 151 exposure, 62, 101, 188, 203, 210, 232 extinction, 99 family planning, 190 famine, 108, 160 Farmer, Paul, 126 female genital mutilation, 189 female literacy, 187 fertility, 157, 189, 233 Food and Agricultural Organization of the United Nations (FAO), 20, 191, 237, 238 food food production, 208 food security, 126, 171 Framework Convention on Tobacco Control, 22 France, 165 freedom, 125, 128, 129, 130, 134 funding, iii, iv, 4, 5, 9, 10, 90, 115, 146, 178, 179, 180, 219, 223 cash transfer programs, 172, 174

humanitarian assistance, 131, 173, 177 resource allocation, v, 221 G8, 3, 65, 71, 222 GAVI, 5, 13, 40, 41, 42, 43, 86, 220, 221, 223, 224 gender, xv, 184, 185, 187, 189, 194 General Agreement on Trade in Services (GATS), 163 General Assembly of the United Nations, 22, 27, 190 genes, 103 genetics/genetic disorders, 103, 106, 161, 215 Ghana, 9, 165 Global Fund to Fight AIDS, Tuberculosis and Malaria, iii, xvi, 5, 13, 86, 219–24, 226–8, 240, 241, 247, 248, 251, 255 global warming, 165 globalization, xii, 5, 27, 59, 60, 61, 62, 63, 67, 68, 71, 126, 127, 157, 162, 164, 165, 191, 203, 207, 209, 253, 255 health as a human right, xiv, 21, 26, 125, 126, 131, 133 health care access, xvi, 8, 30, 60, 133, 161, 219 health care costs, 11, 59 health economics, xi, 32, 57, 84, 111, 116, 119 ‘Health for All by 2000’, 25 health inequalities, 26, 58, 68, 69, 104, 113, 126, 141, 169, 192 by country, 160 by sex, 12, 195 by income level, 119, 161, 169 health inequities, xiv, xv, 90, 91, 160 health insurance, viii, 160 health policy, xi, 22 HIV/AIDS, i, iv, xi, xvi, xvii, 4, 5, 6, 7, 8, 9, 13, 14, 31, 33, 38, 57, 58, 60, 61, 80, 81, 113, 118, 133, 156, 158, 159, 170, 171, 176, 177, 178, 187, 189, 192, 197, 201, 206, 212, 221–3, 230–3, 235–42, 245–9, 253, 255–6 prevention, xvi, 8, 170, 187, 231–2, 238, 239, 241

Index 259 treatment, 8, 232, 239, 241 horizontal approach, iii, iv, v, xii, xvi, xvii, 14, 25, 29, 45, 58, 240, 241, 242 Hsiao, William, 14 human capital, xvii, 160, 177, 233 Human Development Index (HDI), 130, 238 Human Development Report (HDR), 143, 238 humanitarian aid, 3, 131, 142, 191 hunger, 143 hygiene, 102, 103, 106 immigrants, 104, 164 immune system, 106 immunization, i, 38, 40, 41, 42, 61, 102, 171, 174, 222, 224, 241 income, i, ii, xiii, xv, 6, 11, 30, 37, 57, 58, 60, 62, 63, 64, 65, 67, 69, 80, 81, 82, 89, 111, 114, 115, 116, 117, 118, 119, 130, 158, 160, 172, 173, 175, 176, 177, 180, 201, 206, 208, 209, 210, 212, 213, 219, 223, 230, 236, 237, 238, 239, 240, 251 India, 6, 11, 61, 62, 71, 81, 85, 89, 137, 161, 193, 195, 208, 224, 252 indigenous peoples, 164 infant mortality, 31, 184, 232 infection, 9, 239, 246, 252, 253 infectious diseases, 9, 14, 17, 33, 80, 81, 85, 101, 103, 187, 189, 192, 201, 202, 212, 214 influenza, 6 International Labour Organization (ILO), 21, 143, 162, 172, 190, 191 International Monetary Fund (IMF), xiii, 63, 64, 65, 66, 70, 71, 72, 162, 166, 221 Ireland, 10 Israel, 223 Joint United Nations Programme on HIV (UNAIDS), 5, 7, 13, 57, 192, 230, 232 Jong-wook, Lee, 141 Jordan, 223 Kassalow, Jordan, 12 Korea, 4

Krieger, Nancy, 128 lead, 191 leprosy (Hansen’s Disease, Mycobacterium leprae), 251 Lesotho, 173, 238 life expectancy, xiii, 4, 6, 64, 86, 100, 104, 107, 108, 110, 121, 151, 162, 164, 188, 190, 236 macroeconomic indicators, 64, 65, 71, 117, 235 malaria, i, xi, 6, 9, 14, 31, 33, 38, 41, 80, 81, 104, 117, 118, 171, 192, 193, 221–2, 225–8, 254 incidence/prevalence, 6 pregnancy, 38, 188, 193 prevention, xvi, 41–2, 167 risk factors, 100, 101 Malawi, 158, 193, 231 malnutrition, 81, 104, 160, 169 marriage/marital status, 185, 194 maternal and child health, 68, 81 maternal mortality, 6, 12, 13, 112, 184 McNamara, Robert, 4 multidrug-resistant TB (MDR-TB), 247, 249 Médecins sans frontiers (MSF), 135 mental health/mental illness, 194 Mexico, 62, 63, 89, 176, 190 micronutrient, 206 Mill, John Stuart, 146 Millennium Development Goals (MDGs), iii, 5, 24, 28, 30, 31, 32, 33, 34, 37, 39, 41, 44, 45, 65, 219, 220, 222, 224, 245, 248 morbidity, 115, 147, 160, 193, 205, 206, 231, 232, 237 mortality, 128, 157, 158, 180, 184, 187, 201, 209, 210, 211, 212, 231, 232, 237 mortality rate, 206 mortality traps, 6 Mosley, Layna, 70 mother-to-child (MTC) transmission, 170, 232, 233 Namibia, 158, 173, 177 national health systems, 24, 33, 224 natural disasters, 60, 61

260 Index neglected diseases, xiii, 33, 37, 41, 84, 85, 86, 90, 147, 190, 192, 193, 226 neoliberalism, 59, 64 Nicaragua, 172, 174, 175 Nigeria, 69, 72, 161, 225, 227 Non-governmental organizations (NGOs), 131, 134, 135, 136, 137, 165, 166, 214127, 130, 131, 132, 133, 161, 162, 210 nutrition undernutrition, 68 obesity, 105, 106, 206, 215 occupation, 27, 118 occupational health, 27 Office of the UN High Commissioner for Human Rights (OHCHR), 132 oral rehydration therapy (ORT), 58, 170 Oxfam, 127, 135 Pakistan, 223 pandemic, 3, 5, 7, 233, 237 Papua New Guinea, 8 patents, 34, 35, 37, 85 peace, ix, 190 Pogge, Thomas, 126, 145, 147 population growth, 99, 101, 103, 108, 157, 158, 233 population planning, 108 poverty and health, xv, 21, 27–8, 30, 31, 32, 33 37, 39, 45, 68, 87, 130, 141, 148, 150, 151, 159, 169, 170, 176, 180 pregnancy, 6, 100, 106, 191, 193, 233 prenatal (antenatal) care, 106, 174 productivity, 3, 107, 118, 159, 184, 212, 217, 236, 237, 238, 239, 240 public health, xi, 16, 17, 20, 25, 28, 29, 31, 35, 36, 37, 43, 44, 180, 188, 190, 194, 214, 240, 251, 252, 254 laws and regulations, 22, 33, 34, 68 public–private partnerships, 17, 21, 38–40, 44, 45, 88 Quality Adjusted Life Years (QALYs), 112, 114, 115 quarantine, 17

race, 160 Red Cross, 17 religion, 108 reproductive health, 136, 186, 187, 195 research, xii, xiii, 23, 83, 84, 88, 89, 90, 91, 109 Ruger, Jennifer, 130, 131 Rwanda, 9 Sabin, Jim, 149 sanitation, 28, 58 Save the Children, 135 secondary prevention, 205 second-hand smoke, 22 Sen, Amartya, 129, 130, 148 Senegal, 137, 173 Severe Acute Respiratory Syndrome (SARS), 6, 118 sex, 103, 185 differences in health status, 189, 193 sex abuse, 194 sexually-transmitted infections (STIs), 187, 191 Sierra Leone, 6, 107, 164, 173 Singer, Peter, 144, 145 smallpox, i, 4, 100, 102 social determinants of health, xii, 57, 58, 61, 69, 72, 88, 91, 147, 150socioeconomic status, 133, 160, 233, 249, 252, 253, 255, 256 South Africa, 67, 89, 158, 161, 169, 172, 173, 175, 195, 231, 233, 236, 237, 238, 239 standard of living, 238 standardized mortality ratio (SMR), 212 stroke (cerebrovascular accident, CVA), 6 surveillance, 22, 231, 247, 254 sustainability, xvi, 65, 70, 193, 224, 240 Sweden, i, 7 Switzerland, 10 Thailand, 89, 239 tobacco use, 22, 81, 205, 206, 255 trade agreements, 69 trade liberalization, 59, 61, 62, 63, 64 Trade-related Aspects of Intellectual Property Rights (TRIPS), 34–6, 147

Index 261 tuberculosis (TB), xi, xvi, 6, 31, 33, 37, 38, 81, 193, 213, 221, 245, 246, 247, 248, 249, 251, 252, 253, 254, 255, 256 disease (active TB), 247 HIV co-infection, 241, 255 incidence/prevalence, xvi, 248, 253 infection (latent TB), 193, 245, 253 MDR-TB, 4, 247, 249 transmission, 104, 246, 255 treatment, 113, 246, 254 vaccine, 246 Turkey, 172 UNICEF, 6, 13, 20, 40, 64, 71, 83, 132, 172, 177, 178, 187, 191, 192, 194, 225 United Kingdom (UK), 161 United Nations (UN), 25, 129, 135, 164, 165, 220 United Nations Development Programme (UNDP), 20, 83, 125, 130–3, 136, 172, 177, 192, 201, 225, 238 United Nations High Commissioner for Refugees (UNHCR), 191 United Nations Population Fund (UNFPA), 132, 191, 194 United Nations Relief and Rehabilitation Administration (UNRRA), 17–18 United States of America (USA), 83, 161, 165 Universal Declaration of Human Rights (1946), 125, 128, 134, 135, 143, 164 urbanization, 188, 209, 210, 212

vertical approach, iii, iv, v, xii, xvi, xvii, 14, 25, 29, 57, 58, 240, 241, 242, 251, 252 Vietnam, 59, 61 war, 5, 17, 21, 60, 103, 106, 141, 147, 160, 251 water, i, 7, 70, 101, 188 access, 190 filters, 14 quality, 104, 109 wealth, 11, 58, 66, 71, 104, 184, 208 Wellcome Trust, 83 World Health Organization (WHO), i, iv, v, x, xi, xii, xvi, 4, 6, 8, 10, 13, 17–45, 55, 57, 68, 72, 80, 83, 88, 104–5, 112, 113, 125, 141, 143, 157, 164, 165, 166, 191–5, 213–15, 225, 229, 230, 232, 241, 245, 247–9, 251–5 WHO Constitution (1948), 19, 20, 21 Williamson, John, 67 women’s health, xv, 6, 13, 133, 137, 184, 185, 186, 187, 188, 189, 190, 191, 192, 1940, 195, 233, 235 World Bank, xii, xiv, 4, 5, 6, 7, 13, 30, 32, 40, 41, 42, 62, 63, 64, 65, 71, 72, 82, 83, 87, 128, 141, 159, 162, 163, 166, 168, 172, 176, 184, 192, 201, 213, 214, 219, 220, 225, 226, 228, 232, 240, 254 World Development Report, 219, 254 World Health Assembly, 19, 21, 23, 24, 26–7, 33–4, 36–7, 88, 89, 254 World Trade Organization (WTO), 34–6, 62, 69, 162, 163 Zambia, 72, 89, 223, 231, 233, 238