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Financing Global Health 2010

Speakers: Christopher Murray, Director, Institute for Health Metrics and Evaluation (IHME), and Alexander S. Preker, Head Health Industry and Investment Policy Analysis-Investment Climate Department, World Bank Group
Presider: Laurie Garrett, Senior Fellow for Global Health, Council on Foreign Relations
November 30, 2010
Council on Foreign Relations

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LAURIE GARRETT:  I see mostly familiar faces here, but some fresh faces as well.  So for those of you that may not have joined us here before for one of our global health sessions, my name is Laurie Garrett.  I run the Global Health Program here at the council.  

And you are in the Rockefeller Room.  The Rockefeller family were among the original founders of the Council on Foreign Relations in 1921.  And to reinforce, we do not accept money from the United States government.  So we are unlike most other think tanks you may have encountered, in that we are not even allowed to be Beltway bandits, even if we want to.  And we are strictly nonpartisan and both a membership and organization as well as a studies think tank organization.

We run very strictly according to our timetable, and we never deviate, so we'll be doing our best to be on schedule both for start and stop times.

Today's discussion is unusual is that in it is on the record -- no limitations on your ability to walk out of this room and tell everybody you know what you heard this morning.  That is not usually the case with our meetings, so you're rather fortunate.

I also would remind you that just outside the door, if you didn't get one, are both the key report we'll be discussing, some ancillary material and a jump drive that contains the PowerPoints you're going to be trying to see.  

The one downside of being in this gorgeous Rockefeller Room is that we don't have a full screen in this room.  So we have two plasma TVs for you to try and keep your eye on.  Those of you that have your backs to the TVs may want to turn your chair around, so that you can fully appreciate the details.  I know that Chris is going to be giving you a very data-driven presentation.  You'll want to see the numbers.

And the bios for both of our speakers are in your kits, so I'll not dwell on that, only to say that the IHME in Washington has -- and that's the state of Washington, mind you -- has really pioneered new ways of trying to look at what we're calling the numbers, whether we're calling it the numbers of people with polio or the numbers of people working in development or the numbers of organizations on the playing field or, as we're going to focus on today, the numbers of dollars, euros, yens and so on flowing into this exercise that we vaguely term "global health."

And what makes the IHME important in this picture is that they are truly independent, so you're not getting a sort of breakdown of the numbers from an organization that is dependent on that same flow of numbers and dollars.  And that should provide us with some greater sense of the credibility of the information we're receiving.

After Chris Murray gives his presentation, I'll turn immediately to Alex Preker from the World Bank.  Those of you not familiar with his work and what his group at the Bank is dealing with, I would just simply say this much:  It -- if you are interested in anything to do with analyzing how money flows, what it gets put to, where it may work and where it may not work, you're just going to have to deal with Alex.  That's all there is to it.

When we hit the question-answer period, it's necessary with these microphones to press the button and it turns red.  I would only ask this:  Don't press your button until you're actually called upon and then unpress it when you've finished, so that we don't hear your paper rustling for another half hour.

Thank you very much.  Chris, you're on.

CHRISTOPHER MURRAY:  Thank you, Laurie, and for that kind introduction.

So what I'll try to in the next 20 or so minutes is give a broad overview of what's in this year's Financing Global Health report.  But let me start with a little bit of framing as to why are we at the Institute for Health Metrics and Evaluation tracking development assistance for health and also public and private spending.

So we're trying to address three questions, and we see this, financing global health, as a component of one of these three key questions.  

The first question I think we all want to know in global health is, what are actually people's health problems, what are the trends in maternal mortality or child mortality, or what are the causes of ill health or mortality?  Those are all types of studies that we're engaged in.  

The second, equally important question is not what people's health problems are, but how well are we as societies addressing those health problems?  And I think that's where we take a sort of classical -- money goes into public health and medical care, things come out -- activities, various interventions -- and that has some impact, we hope, on population health.  

And so we see the tracking of the money flows as critical to understanding performance of social response to health problems.  And so I think it -- money isn't an end in itself; it's obviously a driver of what it's possible to deliver with current technologies and intervention strategies.

And the third aspect that we work on, which we won't really talk about here, but again, that financial information flows into, it's just this sort of more forward-looking assessment of the costs and consequences of different policy options.

So more specifically, on the financing area, last year, in 2009, we published the first of these annual reports, Finance and Global Health 2009, where we focused on the scale-up of development assistance for health from 1990 to 2007 as a pretty dramatic event of the last two decades.

This year, we've expanded the scope to not only the flows from high-income to low- and middle-income countries, but also what governments spend of their own resources and how those change in response to development assistance for health.  And what we plan -- and this is actually pretty long-term work, as it turns out, harder than, perhaps, one might think -- is to expand this to include out-of-pocket and household expenditure on health.  And the reason that that's quite time-consuming is that to do that, one needs to take a systematic approach to all the available measurements of household expenditure, including catastrophic expenditure.  That's coming probably in 2012.

So what's new about the way we track development assistance and government expenditure?  So last year we introduced this nomenclature, which I will just go through again in case you're not familiar with last year's assessment, which is, we distinguish funding sources, the sort of original source of dollars -- national treasuries, private philanthropy, corporate donations -- from the channel through which those monies flow.  And the channel is the organization that actually ultimately transfers resources to a final recipient, usually in a developing country, or perhaps in a research institution doing research that supports development assistance.

So those channels -- bilateral development agencies, the U.N. family, the World Bank, the Global Fund and others -- there's a lot of complexity in doing this, because there's a lot of double-counting that goes on.  Money flows from one source, the Gates Foundation, to the World Bank, but then flows back to Gavi (ph), and then Gavi (ph) pays perhaps a university to do a study, and they subcontract somebody else.  So there's this incredibly interconnected set of flows that makes this tracking work complex, because you need to, in a non-glamorous, nit-picky way, trace each of these double-countings and try to have a systematic approach.

And our systematic approach is to track the penultimate organization that transfers the money to a final recipient, which is what we call the channel of assistance.   So when I show you tables by channel, that's counting the monies that flow through that organization, not necessarily that come from that source.  We have alternative tables in the report by source as well.

Now, last year we published the first of these reports, and we had a table in there about NGOs, the top 20 NGOs, tracked by their tax returns that they file with the U.S. government.  And most -- even international NGOs have a U.S. office, they file U.S. tax returns.  And so that covers most of the universe of NGOs, but not all.

We received, after the publication of the report, a lot of correspondence from different NGOs telling us that the figures, counting the corporate donations to NGOs, were in some cases dramatically larger than the value of that donation to the recipient country, because, while the corporate donators have to follow very strict rules on how they can value the corporate donation, the NGO recipients are allowed to file on their tax returns the wholesale value.  And it turns out that we did, then, a systematic analysis of about 5,000 products of the wholesale value in the U.S. versus the international price that you can buy if you're a recipient country.  And they range from about one-quarter to one-fifth the price, the actual value.

So we have done some extensive econometric analysis of this, and we correct down these corporate donations.  And so that's a major change from last year, driven by correspondence we received from a number of the larger NGOs.

The second thing we've done is we published last year results on development assistance for health through 2007, and many people came and said, well, that's really interesting.  That's sort of -- sort of global health paleontology.  What we want to know is what's happening now, because really, the issue is the trends on financing for global health today.  

So the reason this has taken us quite a long time to do this revision is that we developed and wanted to figure out is there a way to get more timely information, even though audited financial statements tend to come out with a two-year time lag.  And so what we did is we studied agency-by-agency, donor-by-donor, the historic relationship between approved budgets and historical expenditures and estimated for each organization that relationship, then used budgeting information available for 2009 and 2010 and that historic relationship between expenditure and budgets to produce preliminary estimates for 2009 and 2010.

We've done a similar sort of modeling exercise or econometric exercise for tracking NGOs and foundations through 2010.  

Okay.  So that's a little bit around the method side, what's new, and let's focus now on what are the key findings, particularly on the development assistance side.  And I will briefly talk about the recipient government responses, which some of the science around that was published earlier in the year and is also included in this report.

So by channels of assistance, I think the thing that's most surprising to us given the discussion around the economic crisis in 2008 and the fear at the time that there would be an almost immediate downturn in global health spending is that, in fact, the total of development assistance for health has continued to grow from 2007 at $20.4 billion to $26.9 billion in 2010, at least based on the preliminary estimates.

Now, the composition, the broad trends there that we've been observing especially since 2000 continue, which is that there's a very large component of this that's direct bilateral assistance, PEPFAR, particularly.  U.K. DFID is another major component.  The U.N. as a group has actually grown over the last 10 years, but their share of the total expenditure keeps dropping.  So their sort of dominance which they had back in 1990 tends to be going down over time.  So they're below about 13 percent now of the total expenditure.  And of course, Global Fund and GAVI continue to increase, both in absolute terms and in terms of their share of the total expenditure.

But just by the color of these bars in 2010, the sort of reality is that we live in a much more pluralistic environment in terms of where the money flows through than we did even five years ago, and that trend continues.  

One particular thing to note is that in terms of the short-term trends, the post-economic crisis trends from the preliminary estimates, we see that GAVI, Global Fund have continued to grow, particularly Global Fund, the U.K. and the U.S. have continued to grow.  But some donors, bilateral organizations, some U.N. agencies have been flatlined in terms of growth already since 2008 and the NGO sector appears, not the government component flowing through NGOs, but from private donations to NGOs appears to be going down, both in terms of corporate donations, in terms of private giving to NGOs.

So that's what we believe, historically, is that those NGO contributions tend to track the economic cycle rather closely, whereas there's a much greater lag in what governments do after economic crises.

Now, one of the things that's sort of interesting, I think, that emerges from looking in detail at the audited financial statements from all the agencies is that the U.N. system has been building up slowly, not only in proportion to larger budgets, but as a fraction of their annual expenditure, their end of year reserves.

And so at the end of 2009, for example, there was $5.7 billion held in reserve by the U.N. agencies working on health, not counting the Bretton-Woods institutions; so WHO with about one and a half billion dollars in reserve, UNICEF with about $2.9 billion.

And if you go back a decade, what's also notable is that about 10 years ago, the agencies were holding back about 40 percent of a year's expenditure as end-of-year reserves.  They're now closer to 80 (percent) or 90 percent.

So this is seemingly a response to economic uncertainty, and if you talk to leaders of those organizations, they say, look, in a world where a much larger fraction of our budget is from voluntary contributions, not from regularly assessed contributions, we feel like we need to hold onto more funds at the end of the year, and it's also more difficult to spend those funds.  But there is $5.7 billion worth of end-of-year reserves.

Now, another way to look at the funding -- and note this chart's for 2008, because some of our analyses we can do the preliminary estimates for 2009 and 2010, but the ones that require very detailed unpacking of what the source of the funds, let's say for WHO, comes from, we can't do until they publish their audited financial statements.  So the report has some things where you'll see gray bars.  We know the total, but we don't necessarily know the breakdown.

One thing that's of note is that if you count both private and public giving and then say what countries are making the most effort on global health, this slide shows as a fraction of national income -- so 0.1 is 0.1 percent of national income, 0.5 percent, et cetera -- shows that Norway, Sweden, Luxembourg have the largest commitments measured in that way to global health; and the U.S. comes in at number four, much higher than usually we see these charts of U.S. contribution, where it's always the bottom, because if you count philanthropy and private giving to NGOs, the U.S. actually in total comes out as a pretty major contributor ahead of the U.K., Spain, France, Canada, Austria, et cetera.

Now, there's a lot of rhetoric from the different governments involved in the donor countries about favoring bilateral or multilateral channels or favoring NGOs.  And so, I think this diagram is interesting because it's the actual numbers for the global health flows from the public sector, so this is not counting Gates Foundation or other foundations or private giving to charities or corporate giving, just government flows through NGOs, bilaterals and multilateral institutions ordered on this chart by the size of the direct bilateral relationship.

So of the major donors, the U.K. has the largest fraction flowing directly through bilateral relationships even though they're a major proponent of the multilateral mechanisms, at least in public discussions.  And you'll see that they're a mix for the rest of their funds between -- this is the third bar over from the left -- a mix between NGOs, U.N., GAVI, Global Fund.

The U.S., with the big green bar, has a predominant or a larger flow through NGOs than anybody else, although Australia is very close, as is the -- Ireland also having a very dominant component due to NGOs.  And the U.S. uses a relatively small fraction of its funds flowing through the U.N. or GAVI, Global Fund mechanisms.

Noticeably, the countries with the big orange bars, which are Japan, Italy, France and to a lesser extent Germany, are the countries that favor multilateral mechanisms like GAVI -- or the new multilateral mechanisms like GAVI, Global Fund.

So there's an incredible diversity of choices by donors of how they channel funds, and that diversity actually differs a little bit with their stated public preferences.

Another way to look in the report -- and there's quite a lot of discussion of this, and I'll only touch on this briefly -- is the -- who receives the funds.  And so in the analysis, we look both by the total amount of money flowing to countries and then try to relate that amount of money to need.

And the metric of need we're using here is the number of disability-adjusted life years that WHO has estimated by country as a metric of the healthy years of life lost in each country in total.  

So when you compare development assistance to this metric of need, you're taking into account both population size as well as countries that have more years of life lost due to mortality or years of life lost due to illness.

So you might imagine a sort of naive hypothesis would say that development assistance for health would flow essentially in proportion to need.  But of course then you'd want to layer on top of that some special priority for low-income countries or other countries that have difficulty raising finance.  And so we might have expected the largest components to be -- let's -- in the low-income countries of sub-Saharan Africa, per unit of need, and other low-income countries in South -- in Asia.  But in fact you see quite a diversity on this map, so countries in red are those with the highest degree of development assistance for health per unit need -- and those include Central America and Guyana and Suriname; strangely, Argentina; a number of countries in Southern Africa, Namibia, Botswana, Zimbabwe; and a handful of countries in other places; many of the Pacific islands have the most dramatic development assistance per-unit need -- but the next tier of countries are the East African bloc, running all the way down to Mozambique, Swaziland and Lesotho, but also a number of countries in Latin America as well.

And so the areas that sort of stick out as being particularly low on spending per-unit need are -- and also low-income -- are Central and many countries in West Africa.

Now another way to look at this, which you won't be able to read on the slide, but you can in the report -- which is Figure 18, I believe, in the report -- is just the sort of -- who are the top recipients of development assistance, on one side, and who are the top sources of the burden of disease on the other side.  And this gives you a flavor of the phenomenon of the countries that seem to get particular focus from the donors.  And so the countries where the arrows go down, connecting the two sides -- on the left, which is development assistance for health, and on the right is burden of disease -- are the ones that in some sense get more development assistance than perhaps they would based on need, places like Tanzania, Ethiopia, Uganda, Kenya, Zambia, Mozambique; and then countries where the arrows go up or are underlined on the right-hand side, places like Sudan or Niger, are places that get substantially less development assistance than you might expect.

We have quite a lot of discussion in this report of development assistance by topic.  This is quite tricky to do, because it requires searching project descriptions for keywords and either pulling the project descriptions and reading them and having a person classify them, or having a computer do this.  And we actually use the computer-based coding strategies.  

And so for all of its warts and limitations, what it suggests and shows is what we all, I guess, know is the huge scale-up for HIV, shown on the graph but also in the report, for TB and malaria; less of a scale-up for maternal, newborn and child health, although there's some; and essentially very little or no scale-up in incredibly small amounts of funds for noncommunicable disease programs in developing countries.

If -- during questions we can certainly go into more detail on this sort of topic-by-topic discussion.

Well, let me just very briefly mention the -- what governments in developing countries are doing with their own resources.  So in the report and in the academic analyses published earlier in the year, we track what governments -- of their own money, not counting the development assistance -- have been spending.  And there's some, you know, messiness and confusion in the numbers.  IMF has one set of numbers.  WHO has another set of numbers.  They don't exactly say the same thing, but they tell a reasonably consistent story.  That is, there's a huge scale-up of resources from governments themselves, on average.  And you can see that in this diagram showing the IMF funds, where, from 1995 to 2006, there's a more than doubling in inflation-corrected figures of domestic financing for health.

However, what happens in the countries that are large recipients of development assistance?  What do governments in those particular places -- particularly Eastern and Southern Africa, where development assistance through PEPFAR, Global Fund, has actually accumulated to quite -- to percentage points of GDP, really large flows -- and we did a -- an econometric analysis of what governments do with their own resources and published that earlier in the year.  

And what that suggests, which is perhaps no surprise to people that work in development but is a bit of a surprise to people that work in health, is that ministries of finance on average, although it's quite variable across countries, move from their own domestic tax-based resources 40 cents to a dollar out of the ministry of health budget for every dollar of development assistance the ministry of health gets.  So this is the phenomenon of "crowding out" or "subadditionality."  Namely, if I give Zambia a dollar, they take away almost a dollar from the ministry of health budget.

As a side note, if I give money to an NGO, this analysis suggests that the ministry of finance doesn't react, at least so far in the data -- so again, feeding into this broad policy discussion about the channels through which development assistance should flow.

Reactions to this finding are very mixed.  Macroeconomists say, in a sense, hallelujah.  Ministries of finance are behaving rationally.  They're getting extra money for health, they have many needs, so they're going to use their scarce resources for education, roads, infrastructure, or other sectors.  People on the health side say, wait a second, part of the deal of giving you this extra money -- for example, written into the rules of the Global Fund -- is that the dollars should be additional.  And so the reaction isn't so much about the empirical finding; it's about whether this is bad or good.

So let me end with a few reflections on where we see the trends going post-2010.  Now, logically, public investment in development assistance for health is really just the product of three factors:  fiscal contraction post-crisis, which we know is coming; hasn't come yet because of stimulus spending.  The fraction of public budgets going for development assistance.  And then, within the development-assistance budget, how much goes for health.

And on the private side, philanthropy, NGO giving, it tracks the value of assets and household disposable income rather closely.  And so that's a little bit easier, in a sense, to understand than perhaps the element of political choice that goes into factors two and three on the public-spending side.

On the good-news front, I think the U.K. austerity budget, which contracted every sector but development assistance, where it actually expanded, was incredibly good news for people interested in development assistance, showing that even in a period of fiscal contraction, it is possible to expand development assistance expenditure.  And early signs suggest that health may still fare rather well in the U.K. budget.

The first formal information about more than the U.K.'s commitment to global health came with the Global Fund replenishment in October.  The Global Fund had a very ambitious set of requests.  The smallest request was 13 billion (dollars), the next request was 17, and then the highest was 20 billion (dollars).  And they came in with $11.7 billion of commitments.  And if you match that up against their stated needs, that's not great, but it does represent continued growth.  So even through 2011, 12, and 13, governments are saying they will expand expenditure on global health.

So in some ways, I think that was a surprise to those who feared that that trend, which was slowing growth, might have meant that governments were going to be cautious about making commitments into the next three-year period.

The question is, is this specific to the Global Fund?  Is this a sort of political statement of confidence in the Global Fund and not so much about global health?  And of course, there's also been in many circles questions about the exact numbers on the replenishment commitment, because there's a little line in there about $1.1 billion of "unstated who" but confidently expected commitments, which is different than the way they reported the numbers in the previous replenishment.

So there's a little bit of a question mark, and if you take away that 1.1 billion (dollars), then we don't actually have growth for the Global Fund.  But I actually think, having talked to some of the people at the Global Fund, that that's not so unreasonable, what they're claiming there.  So I do think that replenishment figures represent at least some expectation of growth in their budget.

On the not-so-good-news side, if you compare the 2006-to-2008 period and then 2008-to-2010 period, we already see quite a large number of donors and organizations flat line or decline.  And in fact, the reason we have continued growth in global health is four entities:  the U.S., the U.K, GAVI and Global Fund; U.S./U.K. bilateral programs, GAVI and Global Fund, also U.S. and U.K., to a large extent, but not exclusively.  If you take them away, Global Fund health funding peaked in 2008.  So what happens to those four entities -- we just spoke about the Global Fund -- is absolutely key for understanding the next few years.  And, you know, with GAVI currently searching for a new leader and the U.S. budget debate, which I'm sure we'll discuss in the question and answer period, you know, lots of reasons to be concerned, particularly about the U.S. component.  

And I think the other factor that you hear -- there's nothing in writing -- is this discussion from representatives of ministries of finance in the European governments particularly about:  Have we overemphasized health compared to other components of development assistance, and why do we have such a focus in times of short money on just three diseases?  And I think that corridor discussion is something that needs to be addressed if we want to continue the focus on global health, for those who are interested in that.

So I end with a personal view, which is, I don't think the macroeconomic drivers, which are absolute on the fiscal space side, are -- dictate the outcome, what happens to development assistance and global health spending.  I think the U.K. is showing that, that there is a lot of influence at the margin that can take place on governments' priorities attached to development assistance and to health, and I think part of that is going to be the need to be rather proactive, both in the short and the medium term, of proving that investments in global health have actually had an impact -- and I certainly think that's true for ARVs and for bed nets and some other cases that we can demonstrate -- but more generally providing the evidence that these investments are actually -- not everywhere -- but in general having a positive effect.  

So, thank you, Laurie.

GARRETT:  Lots of meat to chew on.  And you do have a crib sheet as we go forward.  I'm going to ask Alex to give us some response.

ALEXANDER PREKER:  Well, thanks very much, Laurie, for inviting me here today.  And, Chris, congratulations on this report.  I really say that wholeheartedly.

We tried to do something similar in 2000 under Jeff Sachs' macroeconomic commission where we led subgroup six, where we tried to estimate donor flows.  And it's really a Herculean task what you've done, very impressive.  

We came up at that time with a 6-billion number which probably was -- may have been overestimated a bit, because we didn't have the methodology.  I see now that you're going back; you estimated that the -- 2000 was much lower than that.  So we clearly did a lot of that double counting that you were -- you were indicating.

So I just wanted to make a few comments about both the work and also potential implications.  

First of all, a couple of good messages.  Spending is still going on; it's slowing down, but it's still going on.  And when we (looked to ?) the 10 previous economic crises -- we did some work about a year ago where we looked back to the 1930s and we saw all the economic crises since 1930 and what actually happen with health during those crises, and what -- you know, the best data we have, because, of course, in 1930 you didn't have good data.  

But what happened economically was that you always recovered, so whatever goes down comes back up.  So there's good news, because even with the crisis, the crisis is going to be over and we're going to be back to growth again.  And we know there's a strong correlation between health and total government spending and total economic growth.  So we know eventually health spending is going to go back up again.  So we may be at the point where we're going to have a dip, but that dip is going to disappear and we're going to be back into a spending pattern in the medium term.

Second of all, in the donor spending, I guess we have to ask the question, what are the implications of all of this?  And certainly the work that has been done recently shows three problematic issues related to donor spending.

One-to-one, you say, fungibility, we actually came out with a much -- more negative story, because the work we had done showed that for every dollar spent in donor aid, only 20 cents actually was additional.

So it's nice to see that -- with the new data that -- you know, we're actually talking about 60.  That's a big -- much more positive message than we got when we looked at 20, because we saw a fungibility factor of 80; 80 was lost.

Volatility is a very major problem because one of the issues that we find with much of the donor money, it's going into all these priority areas.  And donors are very bad at keeping a steady flow of money.  So we will do a $50 million loan in the bank, but that doesn't mean the government gets 50 million (dollars).  That 50 million (dollars) is spread over five years, and depending on whether or not we think the government is doing what we want them to do, we may or not -- we may or may not turn the tap on or off about -- on their spending.  So the fact that they actually have money on paper doesn't mean they can spend the money.  All donors do the same.

So there's a huge volatility in the spending patters, and that volatility is applied to often what is -- are the most fragile and the most critical programs.  So donor spending is very problematic.

And then, of course, there's the sustainability issue.  You know, we have now heard stories about, you know, the biggest contingent liability in the U.S. is actually not Social Security, but may actually be the PEPFAR commitment to international health.  So I'm exaggerating here.  That's not the case, but, you know, donors are making huge commitments.  What does that mean to the taxpayer out in the future, because this is not something that's going to be taken over by the local governments.  I mean, these huge amounts of money in the critical programs are not suddenly going to be taken over by low-income countries in Africa.  So there's a sustainable issue -- a sustainability issue, which is a very serious issue.

Going from donor funding to governments, we were -- I've been working the last few years with a particular focus on Africa.  And in 2001, the African government signed on to what was called the Abuja convention, which was to say that given the challenge of the MUGs, the heads of state signed a declaration that they were -- by the year 2015, they were going to pledge that they'd be spending 15 percent of their national budgets on health -- called the Abuja Declaration for health financing.

The ministers of health -- or ministers of finance got together this spring and March and abrogated that agreement.  So one, political commitments are not necessarily sustainable out in the future.  And second of all, when we analyze what actually happened from 2001 to 2005, a very troubling finding was that 50 percent of the countries, the spending went up in terms of what they were spending as a part of total government spending, but the other 50 percent of the countries, including the one that hosted the meeting, Nigeria, the spending actually went down in the five years.  So despite the declaration, despite a national commitment, spending actually went down.  So, you know, translating political commitment and translating rhetoric into action is not easy.

Third part I just want to mention:  the private spending.  This, of course, is the area that's most difficult to get a (grips ?) on.  You have to look at household data to get that spending.  We do know from past experience that both the ability and willingness of households to spend money on health in low-income countries is often greater than the willingness and ability of governments to collect taxes.  And that's one of the reasons why often you find very large out-of-pocket spending in low-income countries.  It's not so much that people like spending their own money on health; it's the fact that governments are not spending a lot, and people are more willing to spend their own money than governments are able to collect that money in taxes.  So you have a very large share of out-of-pocket spending in lower-income countries.

Just to give an example, I think your number is 241 billion (dollars) for spending in developing countries.  When one uses the WHO data, the total spending in developing countries is about $500 billion.  So public spending is about 50 percent.  The other 50 percent is out of pocket.  So we shouldn't forget that that 50 percent is a very important spending on health.

And that gets affected very dramatically during economic downturn for two reasons.  First of all, people may be willing to spend, but actually they don't have the ability because they lose their jobs.  So out-of-pocket spending very often, in the studies I've seen, goes down during economic crises.  But the second part, which is very important, comes related to a recent study by the Hudson Institute on remittances, which showed that a large share of remittances, as much as maybe 50 percent, actually go back to health, because when a family in a low-income country in sub-Saharan Africa appeals to their family to send them money through -- you know, through one of the mechanisms, it's not to by a TV; it's often because a relative is sick.  And so a lot of those remittances are actually going into health.

Now, because we know what's happening economically in Europe and U.S., those remittances -- the flows are now going down.  We are seeing that.  And so that could have an indirect impact on health that may be much greater than actual official aid.  And then the final message I just wanted to mention is sometimes crisis can be a time when you actually make positive change.  We've seen this often, you know, sometimes you need a shock effect to change.  

We've had a lot of positive things happening in the last decade in international health, no question about it, and I think you're starting to demonstrate that and its been a huge international commitment to health.  But the issue is -- has that development assistance been effective?  When one looks at the writings of Bill Easterly and other people who question what we're actually doing, particularly in low-income countries, particularly in countries that are most exposed to donor aid, countries like Uganda, that, you know, have a 50 percent dependence on overseas assistance, other countries.  What are we actually doing in those countries in terms of the story that you were saying, treasuries, when they get donor money, put the money in something else?  

So that's a very big issue.  Second of all, in our priorities, aren't we unwillingly, actually, undermining government's commitment to the highest priorities because when we come in and give money to HIV/AIDS or malaria, aren't we basically taking over the two areas that we think are so important but we're now taking over the responsibility of local governments to actually finance those two critical areas?

So we're substituting for responsibility by doing that.

I don't have a solution on what to do about that, but it's a dilemma that I think we need to sort out in terms of international development.  

So I'll just end on a note saying that, you know, really, congratulations.  You said in the -- or just before the session started that you're planning to do this on a yearly basis.  I think this is fantastic.  I think if over a few years we have several of these reports to track the trends over time, this is really going to be a gift to the understanding of international health.

So thank you, Chris, for this very good work.

GARRETT:  Fantastic.  Well, I'm going to take the chair's prerogative to throw a few questions to both of you before opening it for what's going to be an unusually long amount of time for Q&A.  Everybody who is eager should have a chance, and so you needn't get too anxious in the first stages of Q&A.

Let me -- let me start, Alex, by asking you, the World Bank put out this report, the World Bank group's response to the global economic crisis, and it covered not just the Bank, but the whole group of funding agencies, the Bretton Woods group as we often put it.  

One of the things that's very gripping in this analysis, which I urge everyone to take a good look at, is just how severe the crisis actually has been, how close country after country came to going over the brink and what scale of substantial investment was necessary from the various bank-related agencies.

Do you have any way when you look -- this doesn't actually break out health spending per se.  Do you have any way when you look from the bank's point of view at the scale of the investment the bank is having to make and the IOC has had to make and so on, to bail these countries out, keep them from going over the edge, how that has had perhaps a distorting effect or long-term policy effect within these countries on how they allocated for public goods, and in particular, for health?

PREKER:  Well, I don't have the exact number because I have the same problem as Chris.  Our numbers are, you konw, delayed by a year, and particularly because when we commit money, we don't know what the country is actually spending, you know.  You sign the commitment, but you don't actually know what they're going to spend.  But our volume went up from 20 (billion dollars) to 30 billion (dollars) to about 100 billion (dollars).  So we basically quadrupled our commitment to assistance to countries that were in trouble.  Ironically, the Africa region, which, you know, is one of the most fragile regions was also the region that its banking system actually didn't get hit very hard by the crisis, partially because they were not exposed to real estate holdings.  And so the Africa region has had the effect of the economic downturn, but actually not from the financial crisis.

Now, on the health side, it also went up and I remember in February of 2008, our vice president from the Africa region basically told us to spend another billion dollars on Africa.  It's quite hard, actually, to spend another billion dollars in Africa between February and June.  

So, you know, it's -- so, you know, the whole organization really went into overdrive to -- you know, to find ways to channel that money into priority areas.  So I think, you know, there's been a pretty serious attempt by a lot of organizations to respond to the crisis.  Now, whether that was good or not, of course, is the rhetorical question that we need to be asking.

GARRETT:  Two things that you -- one you raised and one you didn't that should figure into our picture of how the world financial crisis -- the general economic crisis is affecting health in poor countries.  You mentioned the remittances issue.  And as we look forward, beyond this year, at unemployment figures and at the tremendous decrease that appears to have occurred in immigration, so that we have a downward trend in immigration into the United States, many other rich countries have fewer -- lesser absorption, let's say, of immigrants -- so the big picture on combining those two entities seems to mean a huge decrease in remittances is likely to persist, if not grow, going forward for the next 12 to 24 months.

The other is food inflation.  When families have to decide whether to spend out of pocket for getting mom for -- a prenatal workup versus spending out of pocket to put food on the table, and food inflation is going at such an extraordinary pace, particularly basic grains, rice and soy, do we have any way of factoring that in?  Do we have any guesstimates on how that's affecting the situation?

PREKER:  Well, let me -- let me make a comment on food and let me -- on the remittance I'll throw to Chris.  Because -- well, on the food side, this has been a very big issue, and it's been one of the key areas that we're worried about in the Bank, because of the connection between food and poverty.  And, you know, with our focus on poverty, we're very concerned with anything that impacts on potential -- driving people further into poverty.  So that's been a big area of focus in some of our responses.

On the remittances side, this is problematic, because the only way you can get the data is through a household survey, and we have not been able to do that in a systematic way.  So maybe, Chris, do you want to say a few things about that?  Because it would be fantastic if somehow your exercise here could expand to that in the future.

MURRAY:  Yeah, remittances have always been hard to track.  But as you say, one source is through household surveys.  And that's part of the scope of what we're trying to do on our systematic analysis of household-survey data.

You know, we've all benefited in global health from the widely available survey programs from UNICEF, the MIX (ph) program and from the U.S. government, the demographic and health surveys.  But most of the household budget and expenditure data don't come from those sources.  They actually come from national expenditure surveys that are usually conducted to serve the needs of tracking national accounts and other domestic planning purposes.  So they're less standardized, and there is less of a sort of tradition of having those in large data archives.

So the task here is really -- a lot of it is trying to get ahold of enough of these household surveys to be able to track that.  And like with child mortality or maternal mortality or other outcomes that are survey-based in many poor countries, there's such an intrinsic lag to things that we learn through surveys that it'll be a number of years after the full effect that we actually have real evidence.  And this is always sort of a challenge for these rather timely issues that require survey-based data.

GARRETT:  Well, Chris, let me ask you a couple of questions, and then I -- I'm sure -- I can just feel the eagerness in the room, with the questions to come.

Recently, Sweden pretty much started cutting off certain types of funding to the Global Fund, challenging the inability of the Global Fund to track what looked like corruption in a few key countries -- Cameroon, Mauritania, Mali, Zambia.  Zambia's had one corruption scandal in the health sector after another and seems almost unable to just do a routine survey of how many health department employees have recently built swimming pools or purchased BMWs in order to track the money.

And we see that in this atmosphere there's greater vulnerability to -- on the donor side.  You find some cause to question the reliability of the recipient, the reliability of the process or of the multilateral institution, and now you have an excuse to pop in in a financial crisis and say funding goes down.

So I guess what I'm asking you we're -- are we in a politically sensitive moment that is hypersensitive because of the general background of the financial crisis?

MURRAY:  I think there's no question that when you have intense competition for resources and acrimonous public discourse about budget priorities, every bit of nuanced information can turn that debate.  I think institutions like the Global Fund are pretty aware of this, and are trying very hard to protect themselves against that.

But, you know, I think that these things play out and it's -- that's why it's I think important to do the sort of analyses that we're doing, which is to make sure you don't get carried away by the one single anecdote, and track the larger picture.  And it comes back to Alex's point, which is the ultimate issue here is:  Is there a relationship between the money that flows in from high-income treasures or individuals' pockets to improved outcomes?  And if there is, then we really don't care that much about what happens at the margins.  I mean, of course you want good accounting and good practice, but that's really the central question.

GARRETT:  Well, we're lucky that Jen Kates joined us here from the Kaiser Family Foundation.  Those of you who are accustomed to receiving their reports and looking at their amazing website and how they track the flow particularly of U.S. dollars will appreciate and probably want to talk to Jen afterwards.

One of the things they recently put out was an assessment of what's happened with U.S. philanthropic support for HIV/AIDS.  Now, this is both for domestic and foreign.  But overall, two worrying trends:  There's been a sharp decline in the amount of money coming out from the private-sector donor pool; and now, the Gates Foundation, a single donor, represents about 57 percent of all U.S. philanthropic giving.

And when I combine that finding with some of the key points that you had, Chris, it is politically somewhere between worrying and terrifying for me to see that the U.S. is now responsible, according to your report, not only for igniting this new era of global health giving and concern, but also for sustaining it through a time when countries like Ireland that had been donors are likely to completely disappear from the landscape; Spain, Italy, Greece, et cetera.

So that it looks like an extraordinarily vulnerable moment for both the private and public side right here in the USA, with a new Congress coming in, a new sense of, well, we've got to tighten our belts, you know, we all care a lot about what happens in the world, but we have a deficit, we have a debt.  I -- this vulnerability looks extraordinary.  How do you view this?

MURRAY:  Well, I think you've hit on it; which is that the sort of enterprise of global health is a -- an Atlantic-Anglo enterprise.  It's U.S. and U.K. have been the dominant drivers of the expanded dollar flows -- not the only drivers, but the dominant drivers.  And together, they count for a very large fraction of the money flows and a very large fraction of the increase.

So I think that's why the David Cameron budget results, or the chancellor's budget in the U.K., is so extraordinary; that in these difficult times, they've not only sustained but enhanced their commitment to development assistance.  And I'm hopeful that that'll translate into sustained commitment to health.  But it does mean that what happens in the U.S. will be extraordinarily important.

I think the asset price recovery for some organizations, some philanthropies like the Gates Foundation, means that they will come out of a phase of flatline expenditure, and probably go back to growth, is a good -- is a reasonable guess.

So that's also good news.  And probably it'll be a little bit of rough waters for private giving to NGOs for a while.  And the key issue then is the U.S. government budget debate.

And so I think everything, you know, I'm not -- I'm in the other Washington.  So I don't actually get the day-to-day feed that others who are inside the Beltway do on where that debate is going, but I think it's absolutely essential.

GARRETT:  The always cautious World Bank.  (Scattered laughter.)

So I'm going to open it up, and you have seen that Esther, Manuel, James and Seth have already done what you're supposed to do, and I'm going to try really hard to get the names down in the order in which I see the cards turn.  My goodness, let me catch up with all you guys.  

Okay.  And here's what I'm going to ask that you please do when you ask a question.  One, press your button.  Two, introduce yourself; not everybody in the room knows who you are.  Three, we have enough time that you can make some comments, but let's try to remember that this really is a Q&A time, so a long speech would not be a good idea.  And if you have a specific individual you'd like to address your remarks to or your question to, please indicate whether you'd prefer to have Alex or Chris take it on.

So out of the corner my eye, the first one I saw flip was Seth Berkley.

QUESTIONER:  I'm Seth Berkley.  Thank you, Chris, so much for an extraordinary contribution, and going all the way back to the world development report you keep cutting new ground and I think it's fabulous.

To Laurie's point, Ireland just came back as a donor to IAVI,  Now, that may not last, but it's interesting.  It does talk about this ability during financial shifts to be able to hold on if there is political will.

I wanted to comment, Chris, on the -- on this issue of additionality.  I think that's extremely important, I must say, the religious fever at which people have talked about swap financing as the way to move forward.  And I think one of the things that would be really interesting over time is if you can look at additionally by cost-effectiveness because what Alex said, I think, is right, is probably some cost-effective things are getting funded externally and fees, you know, local accounts are being pulled away from those and that's a bad trend.

The two questions I really wanted to ask you was, one, you mentioned in the beginning that you are thinking about this, I know you are, about the cost-effectiveness issue.  You haven't done it systematically.  But how do you think the world is doing, the donors are doing in being most cost-effective with their financial flows in this area?  And then, second, at a time of financial crisis, health research, which is a longer term issue, but obviously is incredibly important in terms of creating more effective interventions, you know, may or may not affected by this.  Have you done any work on looking at the health research trends, both at a national level and globally for, you know, diseases of poverty?

MURRAY:  So on the cost-effectiveness front, I think if you look at the last 20 years in global health, there's these two broad themes that touch on that.  One theme is the technology-focused assessment of cost and consequence of adopting or switching to new drugs, vaccines, procedures.  And the other side is the health system performance agenda, which looks at the structures that deliver those technologies, the human resources, the managerial capacity, the IT systems, the physical infrastructure.  And these worlds have largely remained unrelated.  And I think the agenda in my mind and its work that we're trying to work on with funding from the Gates Foundation is to try to bring those two together and ask the question, is there a way to assess the cost and consequence of, you know, investing in human resources or IT systems that expand your capacity to reach underserved groups?  And also do -- compare that to the more technology-specific investments.

Now, the group that's out in front on this is UNICEF on terms of trying to take that integrative framework and say, let's compare investing, in their case, for improving equity for children, investing in specific technologies versus investing in the systems.  But that I think is the issue.

To the question about whether donors are doing an effective job, I think in some ways the driver of the scale-up of the last decade ultimately goes back to the HIV epidemic, the sense of moral urgency around ARVs.  And that -- essentially, cost effectiveness had nothing to do with that discourse.  And so in many ways, I think there has been less of that issue on the policy discussion.  It's now coming back in a very big way, because even if you have an optimistic view of the expansion of global health, the needs around HIV alone -- let alone TB, malaria, NCDs -- are going to so outstrip the financing that there is now that sense of we may be not only -- maybe we don't want to call it cost effectiveness, but we need to be efficient.

And so I hear a lot more interest, concern.  For example, there's probably 10- to 20-fold variation in the cost per completed year of ARVs within low-income countries alone.  So, boy, if we could learn from the people that are one-tenth, we could do a lot more in the future.  So I think that's coming.

To your second question on health research, we've tried a little bit to look at health research funding.  It's very tricky.  And so we have yet to feel like we can be in a strong enough position to say anything about it.  We started with that idea, and it's just so ad hoc, the way to try to track, and so inconsistent across classification schemes, that we have not done much.

There's a group in Australia that's doing quite a bit more on neglected tropical diseases, so that area I think has got some good tracking.  But generally, no.  I think what happens to the NIH budget in the budget debates is hugely important and will influence, mid- to long-term, the global health as much as this discussion will.

GARRETT:  James.

QUESTIONER:  Hi.  I'm James Tunkey, and director of I-OnAsia.

Thank you again for your comments.  And my question is going to take a slightly different tack, and looking at the corporate adjustments that you made to corporate pricing.  And just in terms of the value of the donations and the pricing of these drugs, I'm just wondering if you could give me an -- your own interpretation, Chris, of what you think the impact is going to be on the debate for the pricing of these drugs and negotiations with governments, as well as on the difference between -- I think, for the new malaria vaccines that are going to be coming out, and how you think these might -- this might influence the debate for what the -- what the good pricing might be for those vaccines.

MURRAY:  I'm not sure this finding will have much influence.  I think this is a little bit a quirk of U.S. tax law governing NGOs.  Very strict for the corporations making the donations, so what's on their books is the production costs.  But the NGOs are allowed to book it at wholesale prices, which are really, really high compared to the international prices.  And you -- the part that we couldn't understand about this is what would be the motivation.  And it turns out the motivation's really obvious, and they told us, a number of the NGOs; namely, NGOs compete by size and efficiency.  And the efficiency measure is their overhead costs, divided by total turnover.  If you can make your total turnover look bigger, your overhead costs go smaller; you look like a more efficient NGO.  So there's this incentive on NGOs to use this opportunity on the tax law.

And so you get Albendazole, which is a case brought to our attention, where the international price is one-thousandth of the wholesale price.  And so on Albendazole alone, there's probably a billion-dollar business out there of inflating the value in some sense.  And that's an extreme case on Albendazole, but there are -- you know, we wanted to look at this rather systematically.

I think as we're involved in multiple countries doing costing work, the thing that comes through dramatically is the extraordinary variation even within a developing country of price -- price from the provider side, let alone the consumer side -- where order-of-magnitude variation for a malaria drug or a diagnostic is normal.  And it's not easily explainable by cost of supply chain, for example.  There's a lot more to it, and it has to do with negotiation power and sophistication.

And I think one way to say -- to think about this, which sort of we're puzzled by, is:  Okay, if there's so much variation -- and medical devices even more than drugs, it turns out -- incredible variation in price; probably a hundredfold is the norm across the world, or more.  Well, if everybody paid the lowest price, would -- is -- would the sector continue to exist?

And I don't think it probably would if everybody paid the price at 100.  So then there's a little bit of question about, you know, what is the achievable level with better information flow on pricing.  And I don't know whose fault it is, but the -- in terms of the high-income countries, PHARMAC in New Zealand has uniformly the lowest prices.  They're the best negotiators as a single buyer for a whole country.  And -- but you know, could everybody have PHARMAC?  There would be -- hard to know how that would  be sustainable in the sense of where would the funding for innovation come from.  So I think there's -- it's a pretty complicated story to figure out.

I do think right now who pays the extra -- you know, where you capture consumer surplus is not on some, you know, rational basis.  It's pretty much based on lack of sophistication, so that some of the poorest clients pay the highest prices, paradoxically.  

GARRETT:  If you look at page 25, you'll see the list of the ranking of NGOs, and if you want to get an idea of how stark the impact of this was, this discovery about the tax law skewing and so on, go online to the IHME website, look at the 2009 report and compare the chart in there on NGOs to this one.  You'll see a totally different list and a totally different ranking.  It was a -- (chuckles) -- it popped right out to me, and whoa, wait a minute; what happened?  Did all the world's money to NGOs suddenly change?  It was quite a dramatic difference.

So I think next is Esther.

QUESTIONER:  Thank you.  I'm Esther Dyson.  I invest in health-related start-ups and a lot of other things.  So I was thrilled to hear the discussion of cost-effectiveness and then the next discussion of how impossible it is to really figure this out with prices, et cetera.  

So my question was more on the receiving end.  Where-- where's the thinking currently about transparency, so that people in a receiving country know the funds that are being allocated; know, you know, a hospital's supposed to be built or these drugs are supposed to show up, so that even if you don't have necessarily a measurement of ROI, at least you can have some transparency that the money is actually spent properly, some accountability?  And you know, even if you can't get market feedback because people aren't paying and so you don't have pricing signals, how can we improve the signals the recipients send back?

PREKER:  Well, I mean, obviously -- I mean, we are very concerned about how people spend our money.  So you know, this is a pretty fundamental thing, and we've also just gone through, in the World Bank Group, a revision of internal corruption and external corruption.  So it's a key focus.

But I think Chris is right, in fact, and I'd be curious to hear your follow-up, Chris.  There really is a trade-off between obsessiveness with the corruption issue and then making the development agenda work, because somewhere along the way, if you really want to control everything very, very tightly, nothing happens.  And I think there are some times where we find ourselves in a situation where we may have a large operation, and we are concerned, and so at the end of the day, we don't spend the money, and of course we shouldn't be spending the money, because we don't want people to steal it and put it in Switzerland.  So there's reason there.  But then at the end of the end of the day, we actually don't do anything.  

So it's a really difficult thing.  And obviously public corruption is part of it, but it's not just public corruption.  You know, a lot of things happen also in the NGO sector and the private sector.  

So it's a very, very difficult thing, and I think if one looked carefully at this issue, one would find that it does hurt development tremendously, because it plays into fair competition, it plays into who can be part of the playing field and a lot of things.  So it's a very big issue, and I don't think we have a solution yet, other than just tighten the screws a bit.  And of course when you tighten the screws, the money doesn't flow.  

GARRETT:  But I would point out -- Chris, can you -- you didn't get into but it's in the report that there actually has been tremendous improvement in transparency.

QUESTIONER:  Yeah, just one sentence.  I'm not suggesting the World Bank shouldn't spend the money but that maybe having some local transparency will improve how it's spent.

MURRAY:  So I think transparency from the donor side has actually improved quite a bit.  There's a lot more sense of providing the public with detail about projects, and that's making our sort of task and many others who are interested in tracking this easier.

I think the area -- the fact that we even have a debate about the empirical finding about what governments do in their own resources in 2010 is pretty extraordinary.  You know, we've had 60 years of post-World War II development efforts, and we don't -- cannot answer the question, has country X spent more on education this year than last year?  Complete lack of clarity about public accounts, and only recently more clarity on what the donors spend the money on.

And so I think there's a huge value in just getting more transparency about where money flows, particularly, also government money on the recipient side so that this question about -- and it may be that we all agree that, you know, 50 cents on the dollar additionality is great.  That's a different issue, but you can't even have that -- a reasoned discussion about that until we get more clarity on what governments do with their own resources and what donors do with their own resources.

So I think transparency is enormously helpful in that regard, but no agency currently wants to champion that.  The brief should fall to the IMF, and if you ask the IMF, they say, look, this is just not a priority, getting governments to be transparent.  They have a thing called the government financial statistics they're supposed to report to them.  And the IMF themselves says, you know, we're not going -- we don't have the resources or the time or the attention to invest in that like the global community did for national accounts or for macroeconomic indicators in general, where the system's good even for low-income countries because everybody said these are essential to know.

And so we haven't had that sense of it's really important to understand where the dollars go.

GARRETT:  Emmanuel.

QUESTIONER:  Emmanuel d'Harcourt.  I'm the senior health director at the International Rescue Committee.  So thanks a lot.  As Seth said, we've been reading and learning from your articles for many years now, and they've influenced how we view things and how we act.

So my question is in a way an outgrowth of what Esther was saying, but from a different angle and maybe a more cynical angle, which is, why is there this investment in public health and global health, because I don't see that question discussed a lot.  As Alex implied, you know, it's not an entirely rational investment, because first of all, we know that there are lots of other things like education that, you know, at least deserve some of the attention -- or economic growth.  We know child survival improves dramatically with improved household outcome.  Why aren't we -- or income.  Why aren't we doing more on that front?

And also -- I mean, from -- you could view it -- if we were investors, you know, in health, what we're doing by -- one you could argue is to invest in a factory, taking over a factory, which has been poorly managed.  And so as a result, the machinery is completely ruined, and we're looking at replacing not even all the machinery, parts of the machinery, without changing the management.  And, you know, as investors, that wouldn't make much sense, and we probably wouldn't do this.  And yet, you know, arguably, that's what we're doing.

So it might be helpful, both in doing better monitoring and evaluation and just also influencing this investment both in its nature and its quantity, to understand why is it that David Cameron or the U.S. government or others are making these investments.  Now, it'd be nice to think that it's because people really care about health, but, you know, then why would donors be so different in their effectiveness or approach?

GARRETT:  Okay.  I think we got the question.  I'm going to let Alex take it.

PREKER:  Well, I don't think this is -- I mean, there's no a clear answer.  There's -- a lot of focus on this issue right now is how do you become more effective?  And I think it has a lot to do with the question I said is, as a donor, the people we're responsible to -- in the bank, it's the board, it's (continuations ?) across the world.  They want us to spend our money on priority areas.  So -- they don't want us to spend our money on areas that are not considered priorities.  So we get -- it's like a magnet.  You go into the priority areas.  Well, those are the areas that the governments should be spending their own money on, and it's the area that the government should have at the top of their list.

So I think this is where the new mechanisms where the donor money doesn't go through politics, but it goes through the Treasury or it goes through the Ministry of Health, it tries to re-empower the governments to take over the areas that are considered the priority areas, where the donors don't come in in a turnkey way and do the thing for the governments.  Instead of that, you say, well, if you need a hundred million dollars, I'm going to give that money to your ministry of finance.  And then the ministry of finance will channel the money back to the ministry of health.  And they'll -- it'll go through the normal apparatus, and it'll be part of the normal national priority-setting process.

So if you take -- a good country of an example for that is Ghana.  Most of the money in Ghana goes through what is called a swap mechanism, and so the -- it goes through the country's priority and the country implement.  But it's very difficult, because when you do that, say, for instance, in Sierra Leone, the execution rate is 20 percent.  You know, so that's not a good thing, for me to come back to my shareholders and say, well, look, you know, I'm spending the money, but the execution rate is 20 percent.  How do I explain that?  

And U.S. Congress, of course, has the same thing.  Your Foreign Assistance Act or whatever it is of 1964, there's a very strong accountability for every dollar spent, and you have to show where that dollar's spent.  You know, public money is not supposed to be thrown down the tube.  And so you have to -- the tie-up is very close.  And as soon as you do the tie-up, which is close, you end up doing things which take away the local ownership.  I mean, it's really a dilemma.

GARRETT:  Karen.

QUESTIONER:  Hi.  My name is Karen Grepin.  I'm a professor at NYU.  My question is for Chris.  So the sort of big take-home or the really sort of hopeful story from the report is that funding is going up.  It has gone up through 2009, 2010.  But of course those are based on your quote-unquote estimates or your projections.  You know, I'm trying to think if -- you know, if I had tried to estimate housing prices four years ago or something, I probably wouldn't want to put a lot of weight on those today.  So my question is, how much confidence do you have in those figures?  And, you know, sort of, is it really the story that we're telling here in this room?

MURRAY:  So I think the historic relationship over at least a 15-year period between approved government budgets in the high-income countries and expenditure is incredibly tight -- not a hundred percent, but for a given government it's --

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