Who Safeguards Global Public Health?
As citizens in a democracy, we all face periodic calls to support one health-related cause or another, advocate for specific government initiatives or oppose them, or change spending levels on foreign and domestic programs.
Once we know how the world's major public health institutions are organized and interrelated, we can make better-informed use of our time, talents, and money.
At the core of the global health system are the major programs and specialized agencies established under the banner of the United Nations in the aftermath of World War II. The mandate of these institutions has evolved during the last half century, and other key institutions have been added, but the UN and its specialized agencies remain at the center of all global public health efforts.
Along with the UN, thousands of public and private organizations are active as well, each with its own structure, governance, budget, and mission. But all fall within a few major types.
The United Nations and Global Health
Member nations fund (and govern) ten UN programs and five allied agencies active in public health, including the World Health Organization and World Bank.
Other Multilateral Organizations
Regional development banks also finance health programs, while many independent, non-governmental groups like Doctors Without Borders rely on broad popular support to sustain their work.
Bilateral Aid Agencies
Some governments prefer to channel aid directly to other nations, managing development assistance as an instrument of foreign policy.
Philanthropic foundations are at liberty to devise and fund health initiatives that might be politically unachievable.
The fact that so many different organizations are active in global health all at once suggests that much is being done. At the same time, so many varied agendas, strategies, governance structures, and accountability procedures can be confusing not only to the public, but to professionals, including those in the world's poorer nations who are attempting to understand where they can best turn for assistance.
That so many organizations operate simultaneously also raises the specter that global response to rapidly unfolding problems like HIV/AIDS, multidrug-resistant tuberculosis (MDR-TB), or avian flu may be compromised due to fragmentation, bureaucracy, competition over scarce resources, or duplication of efforts.
It's a hopeful sign, therefore, that new public-private partnerships are emerging to combine resources from a number of government, corporate, nonprofit, and philanthropic organizations. Their potential lies in the shared mission of the partners and a division of roles according to capability. Such alignments can arrive at a more streamlined approach to handling each specific challenge.
In 2000, the notion of a shared mission took on a new, global dimension with the United Nations Millennium Summit, at which world leaders agreed to a set of measurable goals that each of the 191 members of the UN would pledge to meet by 2015. These Millennium Development Goals (MDGs) have provided the entire international health community with a collective mission that knits together each organization's individual aims and interests. Industrialized nations have integrated the MDGs into their foreign aid agendas while developing countries have aligned their national planning targets with them. Four of the eight major goals are specifically health-related: to eradicate extreme poverty and hunger; to reduce child mortality; to improve maternal health; and to combat HIV/AIDS, malaria, and other diseases. (For more on the Millennium Development Goals, see www.un.org/millenniumgoals.)
The opportunity to make further strides against such health threats is enormous, but the cost of meeting them also remains high. According to UNAIDS, $12 billion are needed annually to combat AIDS alone, and this figure does not include research -- just prevention, treatment, and support services. Recent worldwide spending on HIV/AIDS is estimated at half that or less -- somewhere between $3 billion and $6 billion in 2004. Meanwhile, worldwide military expenditures stood at $950 billion that same year. The question must be asked: Are the relative expenditures directed at these two different types of threats proportional to the relative risks?
The World Health Organization estimates that if donor countries (i.e., industrialized nations) contribute 0.1 percent of their gross national product (GNP) each year to global public health -- one penny for every $10 of income -- it would be possible to avert eight million deaths per year by 2010. Donor contributions would then total $27 billion per year, roughly four times the current amount, but the estimated worldwide economic gains would be well worth it, according to the same estimates: as much as $360 billion per year from 2015 to 2020.
In channeling resources towards the Millennium Development Goals, the five largest annual donors in dollar amounts are now the United States, Japan, France, Germany, and the United Kingdom. But Denmark, Luxembourg, the Netherlands, Norway, and Sweden are the only countries who currently meet the UN's target of 0.7 percent of GNP for foreign aid. The United States may the world's top donor of aid in raw dollars, but, as yet, it ranks last among the world's wealthiest countries in terms of percentage donated: only 0.16 percent of its GNP. Progress toward the Millennium Goals has not been uniform on many fronts in the years since the summit. Unforeseen conflicts have siphoned away some resources and political will, yet the conviction persists among many world leaders, and many ordinary citizens, too, that greater global prosperity and security are inextricably tied to economic aid and better worldwide health. As a result, political commitment has been building again. In his address to the UN General Assembly in September 2005, despite the catastrophic impact of the hurricane that had just ravaged the Gulf Coast of the United States, President Bush held to the long view once more, and reaffirmed America's commitment to the Millennium Development Program.