The largest multilateral organization of all is the United Nations, formed in 1945 with 50 founding member states and now consisting of 191 nations. Headquartered in New York City, the UN is governed by its General Assembly, composed of representatives of all member states, each of which has one vote. (For a list of members, see www.un.org/Overview/unmember.html).
While much of the authority in the UN is concentrated in its Security Council, the only UN body with power to impose decisions that other member states must carry out, 10 UN programs and funds engage in significant public health-related activities. All fall under the aegis of the Economic and Social Council, which coordinates several programs, funds, and agencies.
In 2000, a significant shift occurred, however: health moved for the first time onto the agenda of the UN Security Council, whose main responsibility is the maintenance of international peace and security. At the instigation of then-U.S. Ambassador Richard Holbrooke, the Security Council met to debate the impact of AIDS on peace and security in Africa. This meeting resulted in the Security Council's commitment to train peacekeeping forces in AIDS prevention, and in a Security Council resolution calling for member nations to develop strategies to roll back the epidemic, particularly in the military.
How extensive are the global health programs of the UN overall? One way to measure their scope is to look at their cost. All ongoing UN activities are paid for primarily through the biennial budget, which is funded by dues assessed from all 191 General Assembly members on a sliding scale that takes into account the size of each nation's economy. To pass, the biennial budget must be approved by two-thirds of the General Assembly members after a legislative process that involves several committees. Where health programs are concerned, ancillary funding outside the budget can also come into play.
To provide a sense of overall scale, the entire biennial regular budget for the UN during 2004-2005 was $3.6 billion. UN special agencies and funds and its peacekeeping operations during the same period added another $2.8 billion, for a total of $6.4 billion. This is $1 billion less than the budget of Panama during the same period. By comparison, U.S. federal expenditures during 2004 alone were on the order of $2.34 trillion.
Each of the 10 UN programs and funds with health-related activities has its own governing body, budget, standards, and guidelines; and each relies on a combination of contributions from the UN regular budget and voluntary support from governments, organizations, and individuals. The family of programs and funds includes the following:
Several other autonomous organizations, joined to the UN through special agreements, play a very significant in global public health. These have their own separate governing bodies and budgets, and each has its own community of member states, ranging in number from 160 to 191. All are financed partially through government contributions from member states, based on their ability to pay, and partially through contributions from foundations and non-governmental organizations. (See Private Foundations and NGOs below.) One representative from each member state sits on the governing board of each agency. Agencies with significant health-related activities include the following:
The World Health Organization (WHO): Established in 1948 solely to coordinate activities that prevent the spread of diseases across national borders, the WHO now has a broad mandate to promote attainment of "the highest possible level of health" by all people. Headquartered in Geneva, Switzerland, the WHO operates many of its programs from six regional offices, including the Pan-American Health Organization (PAHO). The WHO's annual budget is about $900 million, slightly more than the annual budget of the island of Barbados and slightly less than the annual budgets of Burkina Faso and Chad.
Increasingly, the WHO is collaborating with non-governmental organizations and foundations in formal private-public partnerships. (See Global Funds and Alliances below.)
The World Bank: The International Bank for Reconstruction and Development (IBRD) and the International Development Association (IDA) are two of five institutions that make up the World Bank Group, which is headquartered in Washington, D.C. All five provide finance to countries for the purpose of development and poverty reduction, and to safeguard international investment, which often includes financing for health programs.
The goal of the IBRD, established at the end of World War II, is to reduce poverty in middle- and low-income countries through loans, guarantees, and advisory services. The IDA, established in 1960, provides interest-free credits, grants, and low-interest loans to the world's poorest countries as a means of supporting poverty reduction.
Each institution is owned by its member governments, who are, in effect, its shareholders. Because voting rights are proportional to the level of financial contribution, the governments making the largest investment (of which the United States is one) always exert strong influence over World Bank policies. Recipient nations are usually required to undertake certain political measures as a condition of the assistance they receive. Promoting democracy and limiting corruption are often among these measures, as can be more controversial ones, such as reducing social expenditures to improve fiscal stability.
In addition to the contributions from its members, the World Bank Group also raises funds in the world's financial markets by issuing bonds. The group's total annual budget is $20 billion, about six times that of the UN. In 2004, 15 percent of this amount, or $3 billion, went toward health, nutrition, and population programs.
The International Monetary Fund (IMF): Also headquartered in Washington, D.C., the IMF provides its member countries, including low-income nations, with financial support, policy advice, and technical assistance to help with balance-of-payment problems, which occur when the flow of money out of a country exceeds the flow of money coming in.
While the IMF does not make loans for specific projects, it does run poverty reduction and growth support programs, through which it makes loans to help develop and implement policies that can improve health and education, safeguard the environment, and combat diseases such as HIV/AIDS and malaria.
The IMF is governed by a Board of Governors, which includes one representative from each of its 184 member nations. Each member nation is assigned a quota proportional to the relative size of its economy. This determines the amount it pays in subscription, the weight of its vote in shaping policy, and its access to IMF funding to meet its own needs. The organization relies on these member payments to fund its programs, and each member nation must pay its subscription in full upon joining the Fund.
IMF loans to help manage fiscal problems usually come with requirements to launch specific economic reforms, some of them controversial, such as privatization of state-run companies and currency devaluation.
The Food and Agriculture Organization (FAO): The FAO works to improve agricultural productivity, food security, and the living standards of rural populations. The organization serves as a network to collect and disseminate agriculture- and nutrition-related knowledge and a forum for discussion and policymaking. The FAO, whose 2004-2005 budget was $749 million, is headquartered in Rome.
The International Fund for Agricultural Development (IFAD): IFAD grew out of the 1974 World Food Conference and, like the FAO, has its headquarters in Rome. Its mandate is to combat hunger and rural poverty in developing countries through agricultural projects. With an annual budget around $400 million, IFAD provides direct funds (loans and grants) and helps mobilize additional resources to raise food production and nutrition levels among the poor in developing countries, especially by promoting and enhancing agricultural productivity.