Public Health

C

The Global Governance Report Card grades international performance in addressing today's most daunting challenges. It seeks to inspire innovative and effective responses from global and U.S. policymakers to address them.

grade

Subject

  • Poor

    Targeting Noncommunicable Diseases

    Over the past four years, the global health governance regime made substantial progress in raising awareness of noncommunicable diseases (NCDs) and their risk factors. The World Health Organization (WHO) issued a call to action in its 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases [PDF], which provided national guidelines and strategies to prevent, monitor, and manage NCDs. In April 2011, health ministers signed the Moscow Declaration [PDF], recommending coordinated global action to target NCDs. In September 2011, after years of lobbying efforts, the United Nations (UN) hosted the first high-level meeting of the General Assembly centered on NCDs, where member states agreed to a political declaration [PDF] to prevent and control NCDs by curbing four main risk factors: unhealthy diet, inactivity, alcohol abuse, and tobacco use. However, momentum toward reducing the use of tobacco in particular stalled, in part due to U.S. refusal to ratify the Framework Convention on Tobacco Control (FCTC), which created guidelines for national tobacco-control programs and monitoring mechanisms.

    Although the UN meeting raised the profile of NCDs, it disappointed many public health experts who hoped for time-specific goals and funding mechanisms. The incidence of NCDs rose precipitously in developing states; in 2008, 80 percent of deaths worldwide from NCDs occurred in low- and middle-income states. However, international efforts to combat NCDs face political, implementation, and funding hurdles. The lack of political incentives and high financial burden meant that NCDs jockeyed for attention on the international development agenda and for highly coveted donor funds, albeit with little success. Complicating matters, the WHO—the organization spearheading efforts to combat NCDs—had its budget cut by 20 percent in 2011.

  • Average

    Continuing the Battle Against HIV/AIDS

    HIV/AIDS continued to receive the bulk of donor attention and resources. The leading institutions and donors are the World Bank, the Gates Foundation, and the United States, which fund innovative mechanisms such as the Global Fund to Fight AIDS, Tuberculosis and Malaria, President's Emergency Plan for AIDS Relief, the Global Alliance for Vaccines and Immunization, and the International Drug Purchasing Facility (also known as UNITAID). The Global Fund, for instance, operates in 150 countries with a total budget of $420 million supporting antiretroviral treatment for more than 3.3 million people. As a result of such efforts, the number of people dying from AIDS-related causes continued to decline due to increased access to antiretroviral therapy and decreased HIV incidence. Between 2009 and 2011, the number of people accessing HIV treatment increased by 63 percent, a finding that underscored international efforts to expand access to lifesaving medicine. In 2011, the Joint United Nations Programme on HIV/AIDS launched a new initiative that set a target of zero new HIV infections and zero AIDS-related deaths by 2015 (although the original target date was 2010).

    Despite the impressive mobilization by donors and multilateral organizations to combat HIV/AIDS, the number of new infections per year—an estimated 2.5 million in 2011—far exceeded the supply of lifesaving medicine. Although global HIV spending increased by 11 percent [PDF] between 2010 and 2011, spending fell short of the stated goal by roughly $4 billion, and many states still relied heavily on international assistance. Private actors such as foundations and nongovernmental organizations helped to bridge some of the financing gaps, but funding sources remained heavily concentrated among few donors, and funding streams from innovative finance mechanisms appeared unsustainable.

  • Average

    Managing Acute Pandemics

    Pandemic preparedness required international, national, and local health authorities to recognize a rapidly spreading disease and quickly implement mitigation efforts. After four years of inconclusive negotiations, the outbreak of H1N1 in 2009 revealed critical gaps in the pandemic management infrastructure. One response was the World Health Organization's (WHO) Pandemic Influenza Preparedness framework (PIP), created in 2011 to facilitate sharing of influenza viruses and vaccines among member states and coordinate responses. Alongside the existing International Health Regulations (IHRs) framework for communication and cooperation (created in 2005) and the Global Outbreak Alert and Response Network, the PIP formed a nascent yet promising framework for pandemic management. States also organized various frameworks in partnership with regional organizations to address pandemic preparedness and response. The Global Health Security Initiative involving the European Commission in partnership with Group of Seven-Plus states, for example, provided a venue to discuss global strategy to address these issues broadly, as well as smallpox and influenza preparedness in particular.

    However, member-state adoption of pandemic preparedness guidelines—the crux of WHO-based regulation—has been mixed. Whether because of lack of capacity or will, many states failed to make significant progress toward a comprehensive institutional framework for managing acute pandemics, and many developing states lacked the requisite infrastructure to fulfill the obligations outlined by the IHRs and PIP. Further complicating matters, Indonesia—with initial support from other states—invoked the notion of "viral sovereignty," the principle that viruses belong to the state in which they are discovered, to prevent and delay sharing data and samples of H1N1 influenza. This incident was particularly troubling, as it threatened the ability to develop vaccines and medicine for dangerous communicable diseases that cross national borders. Finally, early detection remained a challenge, with critical gaps in monitoring animal populations from which most recent pandemics have arisen (as zoonoses).

  • Good

    Addressing Infectious Diseases

    Spurred by the Millenium Development Goals to reduce deaths among children under the age of five, the global health governance regime made significant improvements to combat infectious diseases since 2008, notably by improving vaccine coverage and increasing funding. In 2010, the Gates Foundation pledged $10 billion over ten years for research, development, and delivery of vaccines targeting neglected diseases in developing states, and committed an additional $750 million to the Global Alliance for Vaccines and Immunization (GAVI) in 2012 to fill funding shortfalls brought on by the financial crisis. The following year, the UN Foundation and GAVI pledged $4.3 billion toward vaccinations for an additional 250 million children by 2020, aiming to prevent a variety of life-threatening diseases such as diarrhea, river blindness, and trachoma.

    As a result of these efforts, in 2010, 83 percent of children worldwide received the required doses of the combined diphtheria, tetanus, and pertussis vaccines (known as DTP3). In November 2011, GAVI approved funding for fifty-one immunization programs in thirty-seven states for a total of $1.1 billion, and received a record number of applicants for vaccines. At the same time, deaths from infectious diseases dropped significantly and access to vaccines became more equitable after concerted efforts to roll out efficient and effective immunization campaigns. Despite this progress, twenty-four million children, primarily in developing states, remained without access to vaccines.

    In addition, efforts to address neglected tropical diseases (NTDs), while improved, were inadequate. Diarrheal and enteric diseases were the second-leading cause of death in children, and accounted for 4 percent of all deaths worldwide. Moreover, NTDs disproportionately affected the world's poorest people, many of whom suffered from multiple diseases at the same time. Although medicine for NTDs was relatively inexpensive compared to other diseases, serious supply shortages and distribution challenges persisted. There were signs of progress, however. In 2008, the U.S. government launched a new initiative to target NTDs, and the United Kingdom pledged fifty million pounds to the cause. The Gates Foundation also invested in research for new treatments and tried to promote and implement structural solutions such as improved access to fresh water, sanitation systems, and nutrition. Finally, Guinea worm disease neared complete eradication, thanks to an impressive grassroots campaign spearheaded by the Carter Center.

  • Incomplete

    Managing Biosecurity

    Global efforts to prepare for, secure, and prevent the use of biological weapons by both state and nonstate actors remained rudimentary. The primary mechanism for biosecurity management was the 1972 Biological and Toxin Weapons Convention, which prohibits states from using biological weapons but lacks crucial monitoring and enforcement mechanisms. Subsequently, the United Nations Security Council adopted Resolution 1540 (2004) to monitor developments relating to weapons of mass destruction, including biological and chemical weapons, through the creation of the 1540 Committee. Over the past four years, the committee served as a venue to "provide assistance to states that need it" and track the enforcement capacity of states to secure their stockpiles of weapons of mass destruction.

    Outside of the 1540 Committee, discrete groups of states and regional organizations played integral roles in fashioning a response to biosecurity. Unfortunately, the G8 Global Partnership Against the Spread of Nuclear Weapons, formed in 2002, focused almost exclusively on nuclear rather than biological and chemical weapons of mass destruction. The European Union's Health Security Committee developed concrete strategies and contingency planning for breaches in biosecurity, and it was active in the response to the H1N1 influenza outbreak in 2009. Given the transnational nature of contemporary terrorist networks, policing related to biosecurity leveraged Interpol and Europol expertise and the ability to reach police officers globally through various training exercises and institutes. In 2010, Interpol's Bioterrorism Prevention Unit reshaped its training curriculum in response to an undisclosed event and increased its efforts to embed its personnel and training in local police agencies.

    Efforts to manage biosecurity were further complicated by the growing debate among policymakers and experts from the intelligence community, on the one hand, and bioscience researchers, on the other, regarding the "dual-use dilemma" of biological technology that can be used for both peaceful and malicious purposes. This debate came to a head in 2011 when two research institutions independently created easily transmissible strains of the H5N1 virus that proved to be exceptionally dangerous in 2009. Despite these and other growing risks, existing institutions of global health governance were unable to address the growing threats posed by advancements in biological technology and their potential use by rogue states and terrorist networks.

  • Poor

    Developing Health Systems in Poor Countries

    Developing states often suffered from weak health infrastructure, including understaffed, underfunded, or nonexistent services, as well as a chronic lack of access to essential medicines. However, these problems gradually gained attention. For example, a Millennium Development Goal calling for reducing the maternal mortality rate by 75 percent highlighted the correlation between maternal health and robust health systems. Thus far, however, actions fell short of this target. Since the World Health Organization published its report on universal health coverage in 2010, national governments—including, for the first time, African and Asian states such as Rwanda, Indonesia, India, and China—engaged in serious discussions on how to expand coverage and spending.

    These efforts to achieve systemic changes appear to be delivering results. Following a three-year, $124 billion effort, China provided health insurance to 95 percent of its citizens in 2011. At a BRICS meeting of health ministers in 2011, each state committed itself to promoting universal health-care access both among their own constituents and globally. This development coincided with increased government spending on healthcare worldwide. Recent studies indicated that increased health coverage and lower out-of-pocket costs for patients were becoming more prevalent as states realized that "creating universal healthcare systems is a necessity for long-term economic development" given decreased discretionary spending and negative externalities for education associated with health problems.

    In practice, however, mobilizing international aid for developing health systems was complicated by expectations that developing states provide blueprints for their own health systems and funding from national budgets. This donor resistance to funding health systems continued, despite the documented benefits of such initiatives in boosting the economic and social prospects of recipient populations and states. But some states like Norway defied this trend by advocating for a more holistic approach that integrates health services and strategies across various issue areas.

  • Poor

    Ensuring Global Health Financing

    Given the lingering effects of the global recession, tightening domestic budgets, and shifting donor priorities, the funding outlook for global health governance appeared grim. In the wake of the global financial crisis, major international institutions like the World Health Organization (WHO) and the Global Fund to Fight AIDS, Tuberculosis and Malaria, along with wealthy states led by members of the European Union, slashed or fell short of their financial commitments, and even high-profile initiatives with steady funding streams faced challenges. The WHO, charged in principle with coordinating global public health governance, faced a reputational and funding crisis; the Global Fund to Fight AIDS, Tuberculosis and Malaria struggled to recover from allegations of corruption and was unable to disperse new grants; and the U.S. government and the Gates Foundation continued to favor financing that privileged specific types of projects and diseases over others.

    The contemporary disease-specific focus was not only unsustainable but also counterproductive to achieving the goal of a healthier population, primarily because it prioritized selective projects over broader strategic coordination. Rather than address shortcomings in national health systems or the global public health regime as a whole, the majority of global health donors financed disease-specific, or "vertical," programs and initiatives, such as the President's Emergency Plan for AIDS Relief, the President's Malaria Initiative, and several Gates Foundation-funded projects. These programs operated independently and in an ad hoc fashion; as a result, they were often poorly integrated into local health systems. While such initiatives undoubtedly provided lifesaving treatments and services, they also distracted from the broader goal of building effective and sustainable health infrastructure at both the national and international levels. The most conspicuous obstacle was that the majority of funding comes from national governments, whose budgets faced domestic constraints and typically varied from year to year—complicating multilateral agreements and coordinated support for sustained, multiyear programs.

Leader

leaders-icon

United States

Gates Foundation

Global Alliance for Vaccines and Immunization

Gold Star

gold_star-icon

World Bank

United Kingdom

Brazil

Japan

Most Improved

most_improved-icon

China

India

laggard

laggard-icon

World Health Organization

Detention

detention-icon

Global Fund to Fight Aids, Tuberculosis, and Malaria

European Union

Class Evaluation

The Bill & Melinda Gates Foundation has been the "game changer" for global health provision. Its deep pockets—accounting for 68 percent of all private giving—have funded global health research, programs, and treatments for a long list of infectious diseases.

As a result, it increasingly shapes international health priorities. The United States—by far the largest contributor of health aid—and the Global Alliance for Vaccines and Immunization (GAVI) are also at the top of the list for their leadership roles in advancing health efforts worldwide. Thanks to impressive immunization campaigns spearheaded by GAVI, vaccine-preventable diseases are plummeting worldwide. Between 2008 and 2011, GAVI vaccinations led to an additional 150 million children immunized, and country applications for support grew to a record high in 2011.

Gold stars go to the World Bank, Brazil, Japan, and the United Kingdom. The World Bank continued to enhance its standing by playing a crucial role in the newly formed International Health Partnership, which seeks to coordinate strategies and projects between development partners and national governments, increasingly integrating health indicators into its Poverty Reduction Strategy papers, and harmonizing financial management for a variety of its health projects. Brazil merits commendation for hosting an international conference on social determinants of health in 2011 and beginning to export its national health-care model to developing states in sub-Saharan Africa. Despite significant domestic constraints—including a tsunami and nuclear meltdown—Japan delivered on all of its commitments in 2011 and has continued to push for global health reforms. Similarly, the United Kingdom sustained its funding levels and pushed for broader global health reforms as part of its 2008 "health is global" initiative [PDF]. This initiative linked local health outcomes to transnational challenges and attempted to bolster international institutional effectiveness through proactive engagement in the World Health Organization's (WHO), United Nations, and European Union's (EU) global health portfolios—even in the face of a regional fiscal crisis.

China and India earn the award of most improved. Both states recently increased their health-related development assistance, improved their engagement in global health diplomacy, and expanded health-care coverage to their own sizable populations. In particular, in 2011, China hosted the first meeting of health ministers from Brazil, Russia, India, China, and South Africa, and India significantly lowered the prevalence of polio domestically through an impressive vaccination campaign. Despite their growing economic strength, however, both states remained unwilling to play a more active leadership role in terms of agenda setting and funding within traditional global health governance institutions.

The Global Fund to Fight AIDS, Tuberculosis and Malaria and the European Union, with the notable exception of the United Kingdom, sit in detention. After revolutionizing the global health landscape through its provision of lifesaving treatment for HIV/AIDS, tuberculosis, and malaria, the Global Fund was rocked by a corruption scandal in 2011. Despite serious, albeit promising, reform efforts, it still faced a critical funding shortfall and will not accept new grant requests until 2014. In addition, a majority of EU member states slashed their modest global health portfolios and rescinded aid commitments in the wake of the eurozone crisis.

Amid a severe budget crisis, the WHO found itself increasingly marginalized by better funded and more flexible organizations and initiatives. Although it pursued an extensive reform agenda to improve its ability to set priorities and create effective programs, enhance its ability to govern transparently, and reform its management structure to improve accountability for program-matic success and failure, the WHO faced serious implementation hurdles.

Table of Contents

Back to Top

Introduction

Over the past four years, global health governance made significant progress in a few areas. Institutions, national governments, funds, public-private partnerships, and foundations mobilized resources to dramatically expand vaccine coverage for childhood preventable diseases, reduce HIV/AIDS mortality, and lower the prevalence of diseases like malaria and tuberculosis. In addition, states established the Pandemic Influenza Preparedness (PIP) Framework for the Sharing of Influenza Viruses and Access to Vaccines and Other Benefits to more effectively coordinate responses in the event of a transnational pandemic outbreak. Finally, the World Health Organization (WHO) and other major actors raised the profile of noncommunicable diseases (NCDs) on the international development agenda through new initiatives for obesity-related diseases, tobacco control, road traffic injuries, and alcohol abuse. These efforts will likely be supported by the increasing trend toward universal health care that has witnessed uneven but noteworthy progress.

However, sustaining attention, securing reliable financial support, and making steady improvements remained persistent and complex challenges. The growing number of health-related institutions, organizations, and actors, coupled with the diversity of needs and priorities among states, produced a crowded international landscape. As traditional donors in the developed world turn inward, emerging states like India, Russia, and China remained on the sidelines, apparently unwilling to take the lead on global health initiatives, preferring instead to act bilaterally or regionally while focusing on shoring up domestic health infrastructure and insurance coverage.

At the same time, global disease burdens and mortality rates remained high. Preventable diseases continued to kill an estimated thirty-six million people each year despite significant medical advancements and vaccine distribution campaigns. International health assistance plateaued and, in some cases, declined in the wake of the 2008 financial crisis. The global economic slowdown further reduced budgets for bilateral assistance and depleted the endowments of philanthropic associations. Further complicating matters, donor priorities tended to drive the global health agenda, resulting in disproportionate levels of funding for high-profile diseases like HIV/AIDS, often at the expense of other health issues such as combating NCDs, reducing the incidence of neglected tropical diseases, and providing water and sanitation projects. There also remained little new financing from traditional donors to build health systems in developing states or combat emerging threats like biosecurity. The WHO, previously charged with coordinating an international response to global pandemics and global health issues, faced severe cuts to its budget and a lengthy process to implement its reform agenda, while the Global Fund, currently unable to disperse new grants, also underwent major reform in the aftermath of scandal.

There are four major areas for improvement. First, emerging powers should be encouraged to integrate their initiatives and interventions into existing and forthcoming global health governance institutions and frameworks. Second, the international community should support the WHO reform agenda process. Third, the global health agenda and accompanying funding should be reoriented toward actual disease burdens and integrated into the post-2015 successor framework for the Millennium Development Goals (MDGs). Finally, the United States should shift its priorities toward comprehensive global health strategies and programs.

Back to Top

Background

During the past twenty years, the world has witnessed what experts have correctly termed a "public health revolution." Global health governance—comprising states, international and regional organizations, and nongovernmental organizations—expanded vaccine coverage; significantly decreased mortality due to malaria, tuberculosis, and AIDS-related causes; lowered infant mortality; and raised life expectancy worldwide. The MDGs, established in September 2000, cemented the place of global health in the international agenda. Three of the eight MDGs address specific health issues—HIV/AIDS, maternal health, and child health—and four others target the "social determinants of health." From 1990 to 2010, global health funding grew exponentially, from $5.6 billion to $27 billion, thanks to fresh emphasis placed on health as an international priority and the development of innovative financing mechanisms.

As a result of heightened attention and funding, however, the institutional landscape of global health became increasingly fragmented. The WHO, ostensibly the leader in global health governance, was joined by a range of new multilateral initiatives, public-private partnerships, philanthropic foundations, multinational corporations, and nongovernmental organizations to combat global health problems. Overall, there were more than forty bilateral donors, twenty-five UN agencies, twenty global and regional funds, and ninety global initiatives that target health activities and assistance. Often charged with overlapping mandates, these players jockeyed for finite (and in many cases dwindling) resources to shape the global health agenda.

Back to Top

Class Evaluation

The Bill & Melinda Gates Foundation has been the "game changer" for global health provision. Its deep pockets—accounting for 68 percent of all private giving—have funded global health research, programs, and treatments for a long list of infectious diseases. As a result, it increasingly shapes international health priorities. The United States—by far the largest contributor of health aid—and the Global Alliance for Vaccines and Immunization (GAVI) are also at the top of the list for their leadership roles in advancing health efforts worldwide. Thanks to impressive immunization campaigns spearheaded by GAVI, vaccine-preventable diseases are plummeting worldwide. Between 2008 and 2011, GAVI vaccinations led to an additional 150 million children immunized, and country applications for support grew to a record high in 2011.

Gold stars go to the World Bank, Brazil, Japan, and the United Kingdom. The World Bank continued to enhance its standing by playing a crucial role in the newly formed International Health Partnership, which seeks to coordinate strategies and projects between development partners and national governments, increasingly integrating health indicators into its Poverty Reduction Strategy papers, and harmonizing financial management for a variety of its health projects. Brazil merits commendation for hosting an international conference on social determinants of health in 2011 and beginning to export its national health-care model to developing states in sub-Saharan Africa. Despite significant domestic constraints—including a tsunami and nuclear meltdown—Japan delivered on all of its commitments in 2011 and has continued to push for global health reforms. Similarly, the United Kingdom sustained its funding levels and pushed for broader global health reforms as part of its 2008 "health is global" initiative [PDF]. This initiative linked local health outcomes to transnational challenges and attempted to bolster international institutional effectiveness through proactive engagement in WHO, UN, and EU global health portfolios—even in the face of a regional fiscal crisis.

China and India earn the award of most improved. Both states recently increased their health-related development assistance, improved their engagement in global health diplomacy, and expanded health-care coverage to their own sizable populations. In particular, in 2011, China hosted the first meeting of health ministers from Brazil, Russia, India, China, and South Africa (BRICS), and India significantly lowered the prevalence of polio domestically through an impressive vaccination campaign. Despite their growing economic strength, however, both states remained unwilling to play a more active leadership role in terms of agenda setting and funding within traditional global health governance institutions.

The Global Fund and the European Union, with the notable exception of the United Kingdom, sit in detention. After revolutionizing the global health landscape through its provision of lifesaving treatment for HIV/AIDS, tuberculosis, and malaria, the Global Fund was rocked by a corruption scandal in 2011. Despite serious, albeit promising, reform efforts, it still faced a critical funding shortfall and will not accept new grant requests until 2014. In addition, a majority of EU member states slashed their modest global health portfolios and rescinded aid commitments in the wake of the eurozone crisis.

Amid a severe budget crisis, the WHO found itself increasingly marginalized by better funded and more flexible organizations and initiatives. Although it pursued an extensive reform agenda to improve its ability to set priorities and create effective programs, enhance its ability to govern transparently, and reform its management structure to improve accountability for programmatic success and failure, the WHO faced serious implementation hurdles.

Back to Top

U.S. Performance & Leadership

B

Since 2008, the United States has played a leading role in advancing global health. Through major bilateral and multilateral initiatives such as the President's Emergency Plan for AIDS Relief (PEPFAR) and the President's Malaria Initiative (PMI), both launched under the administration of George W. Bush, the United States became the single largest contributor of financial assistance for global health initiatives. In 2011, the U.S. government provided 52 percent of global health funding and 58 percent of global HIV/AIDS assistance. As many other developed states retract their previous commitments, the United States largely filled the gap.

At the same time, however, the United States set global public health priorities that primarily reflect U.S. national interests and preferences—in both health and security—rather than aligning with worldwide disease burdens and global mortality statistics. For instance, the United States refused to sign the WHO Framework Convention on Tobacco Control (FCTC), despite the fact that tobacco use kills more people globally than HIV/AIDS, malaria, and tuberculosis combined. Similarly, the United States failed to lead negotiations to create a new, legally-binding international treaty to combat climate change—an issue with significant impact on health outcomes. Finally, the Global Health Initiative (GHI)—the signature health initiative of the Obama administration that attempted to coordinate global health policymaking—was largely ineffective as initial funding targets were missed and programs developed slowly.

Back to Top

Targeting Noncommunicable Diseases

Poor

Over the past four years, there has been progress in raising awareness of NCDs, but not enough to meet the global challenges posed by them. The WHO issued a call to action in its 2008-2013 Action Plan for the Global Strategy for the Prevention and Control of Noncommunicable Diseases [PDF], which provided national guidelines and strategies to prevent, monitor, and manage NCDs. In April 2011, health ministers signed the Moscow Declaration [PDF], recommending coordinated global action to target NCDs. In September 2011, after years of lobbying efforts, the UN hosted the first high-level meeting of the General Assembly centered on NCDs, where member states agreed to a political declaration [PDF] to prevent and control NCDs by curbing four main risk factors: unhealthy diet, inactivity, alcohol abuse, and tobacco use. However, momentum toward reducing the use of tobacco in particular stalled, in part due to U.S. refusal to ratify the FCTC, which created guidelines for national tobacco-control programs and monitoring mechanisms.

Although the UN meeting raised the profile of NCDs, it disappointed many public health experts who hoped for time-specific goals and funding mechanisms. The incidence of NCDs rose precipitously in developing states; in 2008, 80 percent of deaths worldwide from NCDs occurred in low- and middle-income states. However, international efforts to combat NCDs face political, implementation, and funding hurdles. The lack of political incentives and high financial burden meant that NCDs jockeyed for attention on the international development agenda and for highly coveted donor funds, albeit with little success. Complicating matters, the WHO—the organization spearheading efforts to combat NCDs—had its budget cut by 20 percent in 2011.

Back to Top

Continuing the Battle Against HIV/AIDS

Average

HIV/AIDS continued to receive the bulk of donor attention and resources. The leading institutions and donors are the World Bank, the Gates Foundation, and the United States, which fund innovative mechanisms such as the Global Fund, PEPFAR, GAVI Alliance, and UNITAID. The Global Fund, for instance, operates in 150 countries with a total budget of $420 million supporting antiretroviral treatment for more than 3.3 million people. As a result of such efforts, the number of people dying from AIDS-related causes continued to decline due to increased access to antiretroviral therapy and decreased HIV incidence. Between 2009 and 2011, the number of people accessing HIV treatment increased by 63 percent, a finding that underscored international efforts to expand access to lifesaving medicine. In 2011, UNAIDS launched a new initiative that set a target of zero new HIV infections and zero AIDS-related deaths by 2015 (although the original target date was 2010).

Despite the impressive mobilization by donors and multilateral organizations to combat HIV/AIDS, the number of new infections per year—an estimated 2.5 million in 2011—far exceeded the supply of lifesaving medicine. Although global HIV spending increased by 11 percent [PDF] between 2010 and 2011, spending fell short of the stated goal by roughly $4 billion, and many states still relied heavily on international assistance. Private actors such as foundations and nongovernmental organizations helped to bridge some of the financing gaps, but funding sources remained heavily concentrated among few donors, and funding streams from innovative finance mechanisms appeared unsustainable.

Back to Top

Managing Acute Pandemics

Average

Pandemic preparedness required international, national, and local health authorities to recognize a rapidly spreading disease and quickly implement mitigation efforts. After four years of inconclusive negotiations, the outbreak of H1N1 in 2009 revealed critical gaps in the pandemic management infrastructure. One response was the WHO's Pandemic Influenza Preparedness framework (PIP), created in 2011 to facilitate sharing of influenza viruses and vaccines among member states and coordinate responses. Alongside the existing International Health Regulations (IHRs) framework for communication and cooperation (created in 2005) and the Global Outbreak Alert and Response Network, the PIP formed a nascent yet promising framework for pandemic management. States also organized various frameworks in partnership with regional organizations to address pandemic preparedness and response. The Global Health Security Initiative involving the European Commission in partnership with Group of Seven-Plus states, for example, provided a venue to discuss global strategy to address these issues broadly, as well as smallpox and influenza preparedness in particular.

However, member-state adoption of pandemic preparedness guidelines—the crux of WHO-based regulation—has been mixed. Whether because of lack of capacity or will, many states failed to make significant progress toward a comprehensive institutional framework for managing acute pandemics, and many developing states lacked the requisite infrastructure to fulfill the obligations outlined by the IHRs and PIP. Further complicating matters, Indonesia—with initial support from other states—invoked the notion of "viral sovereignty," the principle that viruses belong to the state in which they are discovered, to prevent and delay sharing data and samples of H1N1 influenza. This incident was particularly troubling, as it threatened the ability to develop vaccines and medicine for dangerous communicable diseases that cross national borders. Finally, early detection remained a challenge, with critical gaps in monitoring animal populations from which most recent pandemics have arisen (as zoonoses).

Back to Top

Addressing Infectious Diseases

Good

Spurred by the MDGs to reduce deaths among children under the age of five, the global health governance regime made significant improvements to combat infectious diseases since 2008, notably by improving vaccine coverage and increasing funding. In 2010, the Gates Foundation pledged $10 billion over ten years for research, development, and delivery of vaccines targeting neglected diseases in developing states, and committed an additional $750 million to GAVI in 2012 to fill funding shortfalls brought on by the financial crisis. The following year, the UN Foundation and GAVI pledged $4.3 billion toward vaccinations for an additional 250 million children by 2020, aiming to prevent a variety of life-threatening diseases such as diarrhea, river blindness, and trachoma.

As a result of these efforts, in 2010, 83 percent of children worldwide received the required doses of the combined diphtheria, tetanus, and pertussis vaccines (known as DTP3). In November 2011, GAVI approved funding for fifty-one immunization programs in thirty-seven states for a total of $1.1 billion, and received a record number of applicants for vaccines. At the same time, deaths from infectious diseases dropped significantly and access to vaccines became more equitable after concerted efforts to roll out efficient and effective immunization campaigns. Despite this progress, twenty-four million children, primarily in developing states, remained without access to vaccines.

In addition, efforts to address neglected tropical diseases (NTDs), while improved, were inadequate. Diarrheal and enteric diseases were the second-leading cause of death in children, and accounted for 4 percent of all deaths worldwide. Moreover, NTDs disproportionately affected the world's poorest people, many of whom suffered from multiple diseases at the same time. Although medicine for NTDs was relatively inexpensive compared to other diseases, serious supply shortages and distribution challenges persisted. There were signs of progress, however. In 2008, the U.S. government launched a new initiative to target NTDs, and the United Kingdom pledged fifty million pounds to the cause. The Gates Foundation also invested in research for new treatments and tried to promote and implement structural solutions such as improved access to fresh water, sanitation systems, and nutrition. Finally, Guinea worm disease neared complete eradication, thanks to an impressive grassroots campaign spearheaded by the Carter Center.

Back to Top

Managing Biosecurity

Incomplete

Global efforts to prepare for, secure, and prevent the use of biological weapons by both state and nonstate actors remained rudimentary. The primary mechanism for biosecurity management was the 1972 Biological and Toxin Weapons Convention, which prohibits states from using biological weapons but lacks crucial monitoring and enforcement mechanisms. Subsequently, the UN Security Council adopted Resolution 1540 (2004) to monitor developments relating to weapons of mass destruction, including biological and chemical weapons, through the creation of the 1540 Committee. Over the past four years, the committee served as a venue to "provide assistance to states that need it" and track the enforcement capacity of states to secure their WMD stockpiles.

Outside of the 1540 Committee, discrete groups of states and regional organizations played integral roles in fashioning a response to biosecurity. Unfortunately, the G8 Global Partnership Against the Spread of Nuclear Weapons, formed in 2002, focused almost exclusively on nuclear rather than biological and chemical weapons of mass destruction. The EU's Health Security Committee developed concrete strategies and contingency planning for breaches in biosecurity, and it was active in the response to the H1N1 influenza outbreak in 2009. Given the transnational nature of contemporary terrorist networks, policing related to biosecurity leveraged Interpol and Europol expertise and the ability to reach police officers globally through various training exercises and institutes. In 2010, Interpol's Bioterrorism Prevention Unit reshaped its training curriculum in response to an undisclosed event and increased its efforts to embed its personnel and training in local police agencies.

Efforts to manage biosecurity were further complicated by the growing debate among policymakers and experts from the intelligence community, on the one hand, and bioscience researchers, on the other, regarding the "dual-use dilemma" of biological technology that can be used for both peaceful and malicious purposes. This debate came to a head in 2011 when two research institutions independently created easily transmissible strains of the H5N1 virus that proved to be exceptionally dangerous in 2009. Despite these and other growing risks, existing institutions of global health governance were unable to address the growing threats posed by advancements in biological technology and their potential use by rogue states and terrorist networks.

Back to Top

Developing Health Systems in Poor Countries

Poor

Developing states often suffered from weak health infrastructure, including understaffed, underfunded, or nonexistent services, as well as a chronic lack of access to essential medicines. However, these problems gradually gained attention. For example, a Millennium Development Goal (MDG) calling for reducing the maternal mortality rate by 75 percent highlighted the correlation between maternal health and robust health systems. Thus far, however, actions fell short of this target. Since the WHO published its report on universal health coverage in 2010, national governments—including, for the first time, African and Asian states such as Rwanda, Indonesia, India, and China—engaged in serious discussions on how to expand coverage and spending.

These efforts to achieve systemic changes appear to be delivering results. Following a three-year, $124 billion effort, China provided health insurance to 95 percent of its citizens in 2011. At a BRICS meeting of health ministers in 2011, each state committed itself to promoting universal health-care access both among their own constituents and globally. This development coincided with increased government spending on healthcare worldwide. Recent studies indicated that increased health coverage and lower out-of-pocket costs for patients were becoming more prevalent as states realized that "creating universal healthcare systems is a necessity for long-term economic development" given decreased discretionary spending and negative externalities for education associated with health problems.

In practice, however, mobilizing international aid for developing health systems was complicated by expectations that developing states provide blueprints for their own health systems and funding from national budgets. This donor resistance to funding health systems continued, despite the documented benefits of such initiatives in boosting the economic and social prospects of recipient populations and states. But some states like Norway defied this trend by advocating for a more holistic approach that integrates health services and strategies across various issue areas.

Back to Top

Ensuring Global Health Financing

Poor

Given the lingering effects of the global recession, tightening domestic budgets, and shifting donor priorities, the funding outlook for global health governance appeared grim. In the wake of the global financial crisis, major international institutions like the WHO and the Global Fund, along with wealthy states led by members of the EU, slashed or fell short of their financial commitments, and even high-profile initiatives with steady funding streams faced challenges. The WHO, charged in principle with coordinating global public health governance, faced a reputational and funding crisis; the Global Fund struggled to recover from allegations of corruption and was unable to disperse new grants; and the U.S. government and the Gates Foundation continued to favor financing that privileged specific types of projects and diseases over others.

The contemporary disease-specific focus was not only unsustainable but also counterproductive to achieving the goal of a healthier population, primarily because it prioritized selective projects over broader strategic coordination. Rather than address shortcomings in national health systems or the global public health regime as a whole, the majority of global health donors financed disease-specific, or "vertical," programs and initiatives, such as PEPFAR, PMI, and several Gates Foundation-funded projects. These programs operated independently and in an ad hoc fashion; as a result, they were often poorly integrated into local health systems. While such initiatives undoubtedly provided lifesaving treatments and services, they also distracted from the broader goal of building effective and sustainable health infrastructure at both the national and international levels. The most conspicuous obstacle was that the majority of funding comes from national governments, whose budgets faced domestic constraints and typically varied from year to year—complicating multilateral agreements and coordinated support for sustained, multiyear programs.

Back to Top

Areas for Improvement

The existing regime governing global public health requires improvement in four major areas:

  • Existing international institutions and forums should engage emerging powers as constructive and responsible global health players, soliciting their leadership and financial contributions to global health governance.

  • The WHO, with strong support from other organizations, must implement a meaningful reform agenda to effectively address and coordinate emerging global health challenges.

  • Existing donor funds, priorities, and initiatives—both multilateral and bilateral—should be better aligned with disease burdens and should be harmonized to avoid duplication and incoherence. Disease-specific programs should be integrated with the MDGs, as well as the post-2015 successor framework.

  • The United States should shift its funding priorities toward initiatives focusing on improvements to health-care infrastructure, provide increased funding to combat noncommunicable diseases, and enhance cooperation within regional organizations and multilateral forums.

Credits

Produced by the Council on Foreign Relations and Threespot

  • Executive Producer: Stewart Patrick
  • Web Producer: Andrei Henry
  • Producer / Writer: Farah Faisal Thaler
  • Assistant Producer: Isabella Bennett
  • Research Associates: Ryan Kaminski, Alexandra Kerr, Andrew Reddie, Emma Welch
  • Design and Development: Threespot