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A global social health protection fund – feasible or fanciful?

A paper just published in the journal Globalization and Health outlines thinking around a global social health protection fund. The seeds of this idea appeared in Plos Medicine in 2006, emerged as a PhD thesis in 2008, and now regularly appear in various quality publications (see the Lancet for example). Hyperbole surround many announcements of a paradigm shift in this or that aspect of global health financing, but maybe not in this case: a mechanism to provide recurrent financing, to address persistent threats to health, grounded in rights and duties, and based on need? That’s some shift. The article raises many questions: here are some that struck me on last night’s commute home:

  1. The third replenishment of the global fund has shown donors’ true colours when it comes to funding global health initiatives in hard times. If they won’t commit sufficient funds to cover even the cheapest of conservative financing scenarios for a fund that focuses primarily on just three diseases, how can we expect them to commit to a holistic fund requiring much, much more?
  2. Economic determinism? Can the poor health that many countries are experiencing be down to the fact that they aren’t spending enough money? What about non-economic factors like politics or society? Put crudely, some countries spend loads on maternal and child health and see diminishing returns while others spend relatively little and get impressive health outcomes.
  3. If IMF fiscal conditions, or debt repayments, or misalignment of funding with county needs, or capital flight are the problem, then why not invest time, effort and thought on resolving them rather than run the risk of misdirecting energy to grander schemes? If only these individual issues could be resolved, then there’d be no need for the kind of fund the authors are proposing.
  4. Related to the point above, are we listening to the council of despair? Is it too late to expect reform of the various obstacles listed above
  5. Is aid really temporary? In theory, I can understand the argument, but in practice? Is it at all likely that at some point in the future, governments will turn round to poor countries and say, ‘Sorry, you’re not getting any more development aid. We never said it would be forever’. That would be political suicide, surely? So the argument about sustainability is kind of a  straw man, isn’t it? Sure, there may not be enough funding, but there’ll never be no funding.
  6. Recurrent financing based on rights and needs makes me think about the distinction between political and civil rights, and social, economic and cultural rights. First, if rights motivate IDA at all then it is likely to be a conception informed by the former set of rights than the latter. I imagine there would be less political buy-in to a mechanism based on economic redistribution. Second, if the mechanism is rights-based, and presumably we mean human rights-based, will it be possible for developing countries to sue the Fund if its donors fail to provide – maybe at the ECHR or the ICC?
  7. Which prompts a thought on the political process. Citizens can, in principle, hold governments to account for what they do, or don’t do, through elections. The process is often highly compromised, but it is still a process, and it can be improved. How will citizens hold the fund to account if it reneges on its commitments (this question holds true for the Global Fund as we know it now, but when the fund is responsible for ‘one health’ it takes on a more significant dimension)
  8. Free rider logic may apply here, to the detriment of a country’s health. Rather than invest in health and graduate out of the proposed fund, a developing country government may prefer the easier option of relying on these sustainable funds to implementing its own health reforms.
  9. Finally, the authors mention the problem of boundaries – where does the proposed fund’s responsibilities end? Would it include responsibility for a country’s education (the link between education and good health is well established) or its infrastructure, or any other non-health (but inextricably health-related) component of  a country’s development?

Perhaps understandably, the authors avoid discussion of the minutiae of the mechanism, preferring to focus on the vision. It’s an exciting vision, undeniably, but is it feasible?

Andrew

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