Fundamentals of Global Health (GHP 557)

Session 3: Global Health and Evolving Global Health

Architecture
September 3, 2021
Professor Rifat Atun MBBS MBA DIC FRCGP FFPH FRCP
Professor of Global Health Systems
© Prof. Rifat Atun, Harvard University, 2015
Harvard University
 Session Objectives

1. Briefly explore major challenges in global health

2. Examine the global health architecture and discuss how

its changing

3. Assess the implications of the emergence of proto

institutions

© Prof. Rifat Atun, Harvard University, 2021 2

1. Global Health Challenges

2. Global Health Architecture

3. Proto institutions in global health

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© Prof. Rifat Atun, Harvard University, 2019
 Key challenges in global health
1. Demographic, epidemiological and nutritional transitions
• Epidemiological confluence and polarization – widening inequities
• Large scale migration

2. Destruction of human and animal ecosystems

• Zoonoses (pandemics)
3. Weak health systems
4. Economic and political crisis and uncertainty
• Fiscal constraints - austerity
• Donor fatigue – declining DAH: sustainability of funding

5. Aid (in) effectiveness

• Multiple financiers and providers – conditionalities
• Governance – corruption challenge

© Prof. Rifat Atun, Harvard University, 2021 4

1. Demographic, epidemiological and nutritional
transitions: the response gap

• Epidemiological transition, confluence and

polarization*: Multimorbidity and disability*

- Future shape of the NCD and chronic disease

epidemic will be characterised by multiple and
interacting risk factors and multi-morbidity

- Yet, health systems are designed to manage

individual diseases and not chronic illness or
multi-morbidity.

- Migration – within and across countries

- Widening inequalities

*Atun R, et al . Improving responsiveness of health systems to NCDs. Lancet 2013

© Prof. Rifat Atun, Harvard University, 2021 5

 2. Tragedy of the commons: destruction of
animal and human habitats and ecosystems
1. Known knowns 1. Re-emerging infections

• Tuberculosis, dengue

2. Known unknowns 2. Emerging infections

• Zoonoses (COVID-19); AMR

3. Unknown unknowns 3. New health threats

• Unpredictable – rapid evolution

© Prof. Rifat Atun, Harvard University, 2021

3. Weak health systems – not fit for purpose

Suboptimal system capability –

adequacy and distributional
challenges:
• Inadequate human resources
• Inadequate and inefficient funding
• Ineffective supply chains
• Fragmented service provision
• Weak data systems to understand
magnitude and distribution of health
challenges, to inform planning,
resource allocation and M&E

Samb B, Evans T, Atun R. et al, An assessment of interactions between global health

initiatives and country health systems. Lancet 2009; 373: 2137-2169

© Prof. Rifat Atun, Harvard University, 2021

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4. Declining donor assistance for health: DAH by
source of funding, 1990-2019

© Prof. Rifat Atun, Harvard University, 2021 8

5. Concerns about Aid (In) Effectiveness
Empirical literature: “to the extent that
growth is good for poverty reduction, it can
reasonably be inferred that poverty would
be higher in the absence of aid flows.”

Mark McGillivray: WIDER

“Aid often demonstrably improves

lives and alleviates suffering”

But “cross country growth

regressions do not have sufficient
statistical power to tell us whether
aid leads to growth, still less to
answer the more important
question of which kinds of aid are
effective and which are not.”

Owen Barder: CGD

Methodological challenges in
establishing a relation between DAH
and health outcomes
Ataya N, Aluttis C, Flahault A, Atun R, Haines A.
Improving the assessment and attribution of impacts
of development assistance for health. Lancet 2014

© Prof. Rifat Atun, Harvard University, 2021 9

 5. Aid (In)effectiveness
Achievement against MDGs: % Reduction of
underweight children under 5 years, 1990-2015
90

80

70
Percentage reduction achieved

60

Target
50

40

30

20

10

0
Global AFR AMR SEAR EUR EMR WPR

© Prof. Rifat Atun, Harvard University, 2020

 5. Aid (In)effectiveness
Achievement against MDG targets in Africa Region
120

100
AFR Target

80

60

40

20

0
Target 1C, Target 4A, Target 4A, Target 5A, Target 5A, Target 5B, Target 5B, Target 6A, Target 6C, Target 6C,
Indicator 1 Indicator 1 Indicator 2 Indicator 1 Indicator 2 Indicator 1 Indicator 2 Indicator 1 Indicator 1 Indicator 2

© Prof. Rifat Atun, Harvard University, 2015

 Class discussion

• What will be the effect of migration on health in (a) the

Americas (b) Asia (c) Africa (d) Europe?

• What strategies do you propose to alleviate the adverse

consequences of migration?

© Prof. Rifat Atun, Harvard University, 2021

1. Global Health Challenges

2. Global Health Architecture

3. Proto institutions in global health

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© Prof. Rifat Atun, Harvard University, 2019
 Architecture for Global Health: an
organizing framework for analysis

Providers/
Sources Intermediaries
Recipients

© Prof. Rifat Atun, Harvard University, 2021

 Global health architecture: flow of funds

Recipient
Donor country Philanthropic
country Private firms Individuals
Sources governments foundations
governments

International
Recipient Multilateral Bilateral Private
Intermediaries Foundations Financing
governments Agencies Agencies firms
Institutions

Providers/
Public Community
Recipients NGOs Households Private firms
institutions organisations

© Prof. Rifat Atun, Harvard University, 2021 15

 Sources of Financing for ODA (1)

Traditional Donors Innovative Financing New Institutions

• OECD DAC* • Private Foundations *

• G7 • Corporate Initiatives
• European Union
• G20

New Bilateral Donors

• China
• Russia

* see additional slides

© Prof. Rifat Atun, Harvard University, 2021 16

 Channels of Assistance (1)
Bretton Woods Institutions UN Specialised Agencies (19)
• World Bank – IBRD; IDA; IFC • IMF
• WHO
• ILO
• FAO

Regional Development Banks UN Training institutions (10)

• European Investment Bank
• UNITAR
• European Bank for Reconstruction
and Development • UNU
• Inter-American Development Bank
• Asian Development Bank UN Funds and Programs
• African Development Bank • UNICEF
• Asian Infrastructure Investment Bank • UNDP
• UNFPA
© Prof. Rifat Atun, Harvard University, 2021 17
 Channels of Assistance (2)

Bilateral Agencies Other Agencies

• USAID • European Commission
(EuropeAid)
• UKAID
• Organisation of Islamic Countries
• JICA
• OPEC
• CIDA
• SIDA
• AUSAID
• NORAID

© Prof. Rifat Atun, Harvard University, 2019 18

 Channels of Assistance (3)
A: Global Health Initiatives C: Partnerships
• PEPFAR
Global Partnerships
• The Global Fund to Fight AIDS,
Tuberculosis and Malaria • STOP TB Partnership
• GAVI • Roll Back Malaria
• UNITAID • Partnership for Maternal, Neonatal
and Child Health (PMNCH)

B: International NGOs
• International Red Cross and Red Smaller non-state entities/foundations
Crescent Society • PATH
• BRAC • FIND
• Oxfam • IAVI
• Save the Children • UN Foundation
• CARE International • COVAX
• MSF
19
© Prof. Rifat Atun, Harvard University, 2018
 Class Discussion

1. What are the strengths and weaknesses of the current

architecture and governance for global health?

2. Has the current architecture and governance been effective

in the global COVID-19 response?

3. What would you change, if anything?

© Prof. Rifat Atun, Harvard University, 2021

1. Global Health Challenges

2. Global Health Architecture

3. Proto institutions in global health

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© Prof. Rifat Atun, Harvard University, 2021
 Proto Institutions in Global Health

Post Bretton Woods era

Emergence of new institutional forms: proto institutions

Improved responsiveness and

Inclusive governance: involvement and

Society -- better outcomes

1 embeddedness of non-state actors

accountability to civil
2 Shared responsibility

3 Joint solution generation and implementation

© Prof. Rifat Atun, Harvard University, 2021

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 Global Fund case study: partnerships at all
levels
Global Fund contribution
Examples

Impact e.g. declining mortality from HIV,

TB and malaria

e.g. sustainability and partner

System effects systems

Grant performance e.g. coverage, people reached

by services

Operational performance e.g. funding, disbursement

© Prof. Rifat Atun, Harvard University, 2021 23

Global Fund governance: inclusive coalitions

Public Sector Civil

(Governments Society
and Agencies)

Technical
Private Agencies
Sector
and
Partnerships

© Prof. Rifat Atun, Harvard University, 2021 24

 The Global Fund Board: Composition
20 voting members
• Equal representation by implementers and donors.
• Non-governmental organizations, communities affected by HIV, TB
and malaria, the private sector, and private foundations are also
represented as voting members.

8 non-voting members
• The Board Chair and Vice-Chair;
• Representatives of partner organizations including the World Health
Organization and World Bank; as well as the Additional Public
Donors constituency

© Prof. Rifat Atun, Harvard University, 2021 25

Country Level governance: Country Coordinating
Mechanisms

National committees in each country

• Include representatives from government, the private sector,

technical partners, civil society and communities living with
the diseases

• Function: coordinate the development and submission of

funding applications to the Global Fund on behalf of the entire
country.

© Prof. Rifat Atun, Harvard University, 2021 26

Implementation of Global Fund financed
programs

• Principal Recipients and Sub-recipients

• Include: country ministries and public bodies, civil society,

technical support providers, implementers of programs,
donors and others

© Prof. Rifat Atun, Harvard University, 2021 27

 Class discussion

1. What are the implications of proto institutions in global health?

• A: Pros

• B: Cons

© Prof. Rifat Atun, Harvard University, 2015

 Class Debate: Poll 1
The mandate of the World Health Organization should be:

1. Reduced so that it can better focus on priorities and be more

effective

2. Reduced with delegation to new regional institutions

3. Stay the same

4. Enhanced with the same governance arrangements

5. Enhanced with an international treaty that provides an

obligation for countries to take certain actions for major
health threats.
© Prof. Rifat Atun, Harvard University, 2021
 Class Debate
1. What is the future of the World Health Organization and
should its mandate change?

• Reduced

• Stay the same

• Enhanced

© Prof. Rifat Atun, Harvard University, 2015

Thank you

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Sources of Financing: OECD Development
Assistance Committee

Australia Germany New Zealand

Austria Greece Norway

Belgium Ireland Portugal

Canada Italy Spain

Denmark Japan Sweden

European Union Korea Switzerland

Finland Luxembourg United Kingdom

France The Netherlands United States

© Prof. Rifat Atun, Harvard University, 2021 32

 Private Initiatives: Foundations

• Bill and Melinda Gates Foundation

• The Wellcome Trust
• Ford Foundation
• Rockefeller Foundation
• Howard Hughes Medical Instituite
• Children’s Investment Fund Foundation
• Fondation Mérieux
• Merck for Mothers
• Medtronic Foundation
• Novartis Foundation

© Prof. Rifat Atun, Harvard University, 2021