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

7 Responses to “A global social health protection fund – feasible or fanciful?”

  • [...] This post was mentioned on Twitter by jranck, Devi Sridhar. Devi Sridhar said: New blog on global social protection fund, http://bit.ly/9rN4YS #globalhealth [...]

  • Gorik Ooms says:

    Dear Andrew,

    Thanks for your comments on and questions about our paper. Each of them would justify lengthy explanations, but that is not the purpose of this blog. So let me give some beginnings of answers to your questions.

    Q1. If donors 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?

    A. Less than a decade ago, the idea that richer countries would finance AIDS treatment for people living in countries that are unable to finance that from domestic resources, seemed illusionary as well. It happened nonetheless, because of a global movement.

    The often heard critique that the fight against AIDS is receiving too many resources, combined with skepticism about the feasibility of doing something similar for health in general, can only lead to the conclusion that we should not provide AIDS treatment in the poorest countries. That is not a position I am willing to accept.

    Q2. Can the poor health that many countries are experiencing be down to the fact that they aren’t spending enough money?

    A. No, but money does seem to help.

    Q3. 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?

    A. One does not exclude the other. As you know, the four authors of this paper have been very critical about IMF fiscal conditions, for example, and we have not changed our mind about that. But I do disagree with your comment, Andrew, that “If only these individual issues could be resolved, then there’d be no need for the kind of fund the authors are proposing”. Even the fairest imaginable market economy generates self-amplifying inequality, because the ‘winners’ at any given point in time invest their gains in future comparative advantages. Any market economy requires permanent correction through redistribution, for the sake of equal opportunity, and so does the global market economy.

    Q4. 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?

    A. A council of optimism, or ‘realistic utopia’, is how I prefer to see this paper.

    Q5. Is aid really temporary? 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’?

    A. Perhaps that won’t happen. But the fact that international assistance is labeled as temporary, even if in reality it isn’t, greatly reduces its potential impact. If poorer countries knew under which conditions international assistance would be sustained, it would allow them to use it for recurrent expenditure (salaries of health workers, for example). At present that is often not the case.

    Q6. 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?

    A. Now you’re sounding even more utopian than we are. There are several ‘burden sharing’ mechanisms for the UN and UN agencies, which seem to work relatively well. For what we propose, we might not need much more than something like the burden sharing mechanisms of the International Development Association of the World Bank. Peer pressure among richer countries seems to work, at least to a certain extent. Not perfect, but a lot better than what we have at present.

    Q7. 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)?

    A. The Global Fund as we know it already has an appeal mechanism for some decisions (see http://www.theglobalfund.org/documents/trp/Rules_Internal_Appeal_en.pdf). Obviously, the Global Fund of our dreams would strengthen this. Again, it will never be perfect, but better than what we have at present – ever heard of an appeal against a decision to stop or reduce bilateral aid?

    Q8. 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.

    A. Free riding may occur in many forms – not only in the form of poorer countries reducing their domestic efforts. With regards to richer countries trying to let other richer countries pay for global health, we propose agreed burden sharing. With regards to poorer countries reducing their domestic efforts, we propose that “A country-owned long-term health plan or compact would form the basis of allocations from the global social health protection fund, and for the accountability for the allocations received.” This compact would include both international and domestic contributions; the accountability would have to work (and be accepted) in both directions.

    Q9. 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?

    A. There are proposals for a Global Fund for Education (see http://www.cfr.org/publication/17839/toward_a_global_fund_for_education.html). Although our paper focuses on health, the rationale of our proposal supports much more than that.

    Thanks for launching this debate!

    Gorik

  • Andrew Harmer says:

    Thanks Gorik for taking the time to respond to each of the points I raised. The purpose of the blog was to generate further interest in the ideas you and your co-authors outlined in your paper. For sure, each point could be debated at length. Hopefully, there will be further comments to follow.

  • Luca says:

    Despite the fact that some of the IMF policies that you blame happened to be true in the past, one should not label all IMF policies as neo-liberist/Washington consensus based.

    Evidence from some countries e.g. Tajikistan reminds us that IMF recently found it more appropriate to create policy schemes that “raise social expenditure” above all in the above-mentioned fields of Health and Education, in order to eradicate poverty.

    Therefore an analysis of the IMF role in enhancing or creating obstacles to the fund you talk about should be addressed on a more country-specific level. Country specific even because, but this is another story, one should not blame liberist policies per se, but analyse the interaction that specific policies have with specific institutions, which are country specific.

    This approach should also help us to avoid ideology, which is a bad companion in economics…

    p.s.

    I really much appreciated the paper.

  • Andrew Harmer says:

    Hello Luca. Many thanks for taking the time to comment on my post. I’m not familiar with the IMF in Tajikistan and so would be interested to know more – particularly any online references I could consult that support your argument. I did have a quick look at the May 2010 IMF Country Report and it seems to confirm my opinion of the IMF as an institution that is informed by neoliberal economic ideas. Have a look at p21 and see how many ideas might be described as neoliberal: low economic development targets (7%); macroeconomic stability; comparative advantage; increased role for the private sector; reform of the banking system. And that’s just on one page!

    The problem with the IMF is that it has a blueprint which it applies to countries irrespective of their economic circumstances; a blueprint fundamentally inspired by neoliberal ideas. Avoiding ideology is, in my opinion, impossible – it’s part of what defines us and the institutions we use to get things done. The IMF is no exception.

  • Luca Citino says:

    Thanks for answering! This topic is very important to me, because I’m going to write my Bachelor thesis (economics) about the pros and cons of the policy scheme above!

    If you add me on facebook I’d like to have a deeper discussion with you about the topics at issue (or my email address is removed by administrator)

    On the issue, I don’t think we should label “liberal” a policy such as “monetary stability”, or “dynamic private sector”. They seem to me (just not to say they objectively are) desirable features of an economic system. Of course this has nothing to do with side effects, but should we throw away whole sections of human knowledge, and achievements, just because they have side effects? Man should not give up the challenge, and try instead to repair the deficiencies of his tools. So we should not throw away the “market economy”, but as Ooms suggests (correctly), we should go in the direction of “redistribution”. See the point?

    Or, put it into more simple terms, “monetary stability” is surely better than “monetary instability” in a developing countries.. isn’t it? :)

    As far as IMF policies are concerned I post you the link of IMF program. In the last, say, 10 years, I think that thanks to PRSp we made a big leap forward; no more “totally blueprint”. Things are changing a lot at IMF.

    http://www.imf.org/external/np/country/notes/tajikistan.htm

    So feel free to answer, and to add me on facebook on the link above!
    thanks!

    Luca

  • [...] faire quelque chose. Andrew Harmer explore un autre mécanisme de financement innovateur dans le blog du global health policy : un fond social mondial de protection de la santé. C’est un mécanisme visant à fournir un [...]


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