From primary health services to specific health objectives
International health work in the 1990s was mainly concerned with development assistance, headed by the WHO, UNICEF and UNFPA, along with large national development programmes with the USA (United States Agency for International Development), the UK (Department for International Development), Germany (Deutsche Gesellschaft für Internationale Zusammenarbeit), the Netherlands and the Nordic countries at the forefront. Primary health services were in focus. Emphasis was put on child health, vaccination and reproductive health, and increasingly on health reform and coordinated health sector commitments, with the WHO and the World Bank in leading roles.
However, the results were not convincing. Around the turn of the millennium there was widespread impatience to achieve specific goals. The WHO saw the need for new policy measures, and helped to launch several weighty new initiatives, among them Roll Back Malaria (RBM) and the GAVI vaccine alliance. In this way, new stakeholders from both the private and the voluntary sectors became involved. The UN Millennium Declaration with its three health-related Millennium Development Goals (child health, maternal health and a collective goal for AIDS, tuberculosis and malaria) created fertile ground for a particular mobilisation to achieve these goals. A separate political declaration on HIV and AIDS was adopted by the UN in 2001, and the UN Secretary General involved himself in the proposal to establish a separate fund to deal with this challenge. The G8 countries took this further at their meeting in Okinawa. This was the basis for the Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM) which was established in 2002.
GAVI and GFATM both have substantial resources at their disposal and have produced results that have convinced donors. They are now sought after partners for countries in need of development assistance. Today they are independent foundations registered in Switzerland, with their own executive boards on which national representatives sit together with representatives from the private sector and civil society stakeholders, including user representatives. Both have committed to working within the normative frameworks of the UN system. At the same time, many are worried that the one-sided emphasis on vaccination and on certain diseases has led to insufficient priority being given to investments in infrastructure, personnel and other fundamental elements of a health system.
Private actors such as the Bill & Melinda Gates Foundation have gained importance with regard to financing, prioritisation and choices for global health. The need to create synergies and a common understanding among different stakeholders was the basis for the informal cooperative entity known as H8 (6), where the leadership from the WHO, UNICEF, UNFPA and UNAIDS meet together with the World Bank, GAVI, GFATM and the Gates Foundation. The significance of this entity is still unclear, since it is a forum that is not subject to oversight, does not have the improvement of global synergies as its goal, and does not make binding decisions.
In working with the Millennium Development Goals and with annual reports (7) and resolutions (8) pertaining to the link between foreign policy and health, the UN General Assembly and the UN Secretariat have become an increasingly important actor in the sphere of health architecture, as witnessed by the Secretary General’s Global Strategy for Women’s and Children’s Health (9).
For the last ten years, the G8 countries have channelled much of their development assistance through global initiatives such as GAVI and GFATM. This has led to other donor countries also prioritising these channels. At the same time, civil society stakeholders and the private sector have had the opportunity to participate on executive boards and to influence decisions, which they do not have an opportunity to do in the WHO. Private foundations and non-governmental organisations have thus obtained an important role in financing and controlling health programmes.