Global Health Initiatives (GHIs) are humanitarian initiatives that raise and disburse additional funds for infectious diseases – such as AIDS, tuberculosis, and malaria – for immunizations and for strengthening health systems in developing countries. GHIs classify a type of global initiative, which is defined as an organized effort integrating the involvement of organizations, individuals, and stakeholders around the world to address a global issue (i.e.: climate change, human rights, etc.).
History The initial Global Health Initiative was launched by Kofi Annan at the annual meeting of the World Economic Forum in 2002. Annan stated that the GHI's mission was to engage businesses in public-private partnerships to tackle HIV/AIDS, tuberculosis, malaria, and health systems.
Examples of GHIs are the President's Emergency Plan for AIDS Relief (PEPFAR), the Global Fund to Fight AIDS, Tuberculosis and Malaria (Global Fund), and the World Bank's
PEPFAR – an initiative established in 2003 by the Bush Administration – and PEPFAR II (PEPFAR's successor in 2009 under the Obama AdministrationIn May 2009, the Obama Administration announced that it would be launching a six-year aid programme called the Global Health Initiative with a commitment of $63bn.) are bilateral agreements between the United States and a recipient of its development aid for HIV/AIDS – typically an international non-government organisation INGO or a recipient country's government. The Global Fund, established in 2002, and the GAVI Alliance, launched in 2000, are public-private partnerships that raise and disburse funds to treat AIDS, Tuberculosis and Malaria, and for immunization and vaccines. The World Bank is an International financial institution. It is the largest source of funding for HIV/AIDS within the United Nations System and has a portfolio of HIV/AIDS programmes dating back to 1989.By way of comparison, UNAIDS' Unified Workplan 2010/11 has a budget of $US484m over the two-year period. Of this, $US136.4m (the interagency fund), is set aside to pay for country level activities and staff In 2000, the Bank launched the first phase of its response to HIV/AIDS in Sub-Saharan Africa – the Multi-Country AIDS Program (MAP). This came to an end in 2006 when a second phase – Agenda for Action 2007-11 – came into effect.Sophie Harman (2007) The World Bank: Failing the Multi-Country AIDS Program, Failing HIV/AIDS. Global Governance: A Review of Multilateralism and International Organizations: October–December 2007, Vol. 13, No. 4, pp. 485-492.
Functions In terms of their institutional structure, GHIs have little in common with each other. In terms of their function – specifically their ability to raise and disburse funds, provide resources and coordinate and/or implement disease control in multiple countries – GHIs share some common ground, even if the mechanisms through which each of these functions is performed are different.Biesma R., Brugha R., Harmer A., Walsh A., Spicer N. and Walt G. The effects of global health initiatives on country health systems: a review of the evidence from HIV/AIDS control. Health Policy and Planning 2009 24(4): 239-252
Funding
Tracking funding from GHIs poses challenges.Bernstein M. and Sessions M. A Trickle or a Flood: Commitments and Disbursement for HIV/AIDS from the Global Fund, PEPFAR, and the World Bank's Multi-Country AIDS Program (MAP), 2007, Centre for Global Development; Oomman N., Bernstein M. and Rosenzweig S. Following the Funding for HIV/AIDS: A Comparative Analysis of the Funding Practices of PEPFAR, the Global Fund and World Bank MAP in Mozambique, Uganda and Zambia, 2007. Centre for Global Development[www.cgdev.org CGDEV] However, it is possible to determine the amounts of funding GHIs commit and disburse from sources such as the OECD CRS online database, as well as data provided by individual GHIs (Figure 1).
Since 1989, the World Bank has committed approximately US$4.2bn in loans and credits for programs, and has disbursed US$3.1bn. Of this total, the Bank's MAP has committed US$1.9bn since 2000. Through bilateral contributions to HIV/AIDS and Tuberculosis programmes and donations to the Global Fund, PEPFAR has donated approximately US$25.6bn since 2003. In July 2008, the U.S. Senate re-authorised a further US$48 bn over five years for PEPFAR II, of which US$6.7bn has been requested for FY 2010. During the period 2001–2010, donors have pledged US$21.1bn to the Global Fund, of which US$15.8bn has been paid by donors to the Fund. Gavi has approved US$3.7bn for the period 2000-2015World Bank data: World Bank, HIV/AIDS data. PEPFAR data: World AIDS day 2009: Pepfar latest results. Global Fund data: Pledges and Contributions . GAVI data: Approved support (Aug 08 data). Sources accessed 08/02/10.
Political economy
The amount of political priority given to Global Health Initiatives varies between national and international governing powers. Though evidence shows that there exists an inequity between resource allocation for initiatives concerning issues such as child immunization, HIV/AIDS, and family planning in comparison to initiatives for high-burden disorders such as malnutrition and pneumonia, the source of this variance is unknown due to lack of systematic research pertaining to this subject. Global political priority is defined as the extent to which national and international political leaders address an issue of international concern through support in the forms of human capital, technology, and/or finances in order to aid efforts to resolve the problem. Global political priority is demonstrated through national and international leaders expressing sustained concern both privately and publicly, political systems and organizations enacting policies to help alleviate the issue, and national and international agencies providing resource levels that reflect the severity of the given crisis.
The amount of attention a given global initiative receives is considerably dependent on the power and authority of actors connected to the issue, the power and impact of ideas defining and describing the issue, the power of political contexts framing the environments in which the actors operate to address the issue, as well as the weight and power of issue characteristics indicating the severity of the issue (i.e.: statistical indicators, severity metrics, efficacy of proposed interventions, etc.). Factors including objective measurability, scalability of the issue and proposed interventions, ability to track and monitor progress, risk of perceived harm, as well as simplicity and affordability of proposed solutions all contribute to the degree to which a given global initiative is likely to receive political attention.
However, case studies have shown that the likelihood of global initiatives garnering public and political attention is not limited to the aforementioned factors. For example, initiatives concerning polio eradication continue to receive substantial resources in spite of the relatively small global burden of disease as compared to chronic diseases such as cancer, cardiovascular disorders, diabetes, and some communicable diseases such as pneumonia which comparatively attract fewer worldwide resources irrespective of the high morbidity and mortality rates associated with such diseases. These cases highlight the need for extensive research methods and evaluative measures to assess the relative causal weights of factors used to determine how global political priority is attributed to global health initiatives. Existing debates also attribute factors such as the increasing influences of economic globalization, international organizations, and economic actors with little to no previous health remit as each contributing to the evolution of global health governance.
Impact on country health systems There is much discussion about the extent to which the volume of these additional funds creates multiple effects that positively and/or negatively impact both health systems and health outcomes for specific diseases. Assessing the direct impact of GHIs on specific diseases and health systems poses challenges pertaining to the issue of attributing particular effects to individual GHIs.Macro International Inc. 2009, The Impact of Collective Efforts on the Reduction of Disease Burden, Global Fund FiveYear Evaluation: Study Area 3, Submitted to the Global Fund, Macro International Inc., Maryland. As such, a common response in evaluations of GHIs is to acknowledge the inherent limitations of establishing causal chains in what is a highly complex public health environment, and to base conclusions on adequacy statements resulting from trends that demonstrate substantial growth in process and impact indicators.
However, existing literature argues that this approach towards evaluating GHIs can inadvertently result in overlooking the impact of social determinants on a disease, as implementers and evaluators are less likely to tackle the complexity of a disease within the larger social, political, cultural, and environmental system. Even if a GHI is effectively evaluated – perhaps showing a decrease in disease prevalence – the challenge remains of comprehensively analyzing the long-term impacts of the GHI by addressing the root social, political, or environmental causes of the disease. Accordingly, existing debates suggest that GHIs should be less concerned with the eradication of specific diseases, and should instead focus primarily on factors – such as basic living conditions, sanitation, and access to nutritious food – that are essential to delivering a sustainable heath program.
Research on the effects A small number of institutions have shaped, and continue to shape, research on GHIs. In 2003, researchers at Abt Associates devised an influential framework for understanding the system-wide effects of the Global fund which has informed much subsequent research, including their own studies of system-wide effects of the Global Fund in Benin, Ethiopia, Georgia and Malawi – often referred to as the 'SWEF' studies.Bennett S. and Fairbank A, The system-wide effects of the Global Fund to fight AIDS, Tuberculosis and Malaria: A conceptual framework, Oct 2003, Partners for Health Reformplus and Abt Associates Inc. Document summaries and links to each of the SWEF studies are accessible through the Global health Initiatives Network database
Abt continues to support ongoing research on the effects of GHIs in multiple countries. The Washington-based Center for Global Development has also been very active in its analysis of GHIs, particularly PEPFAR financing. With hubs in London and Dublin, the Global Health Initiatives Network (GHIN) has been coordinating and supporting research in 22 countries on the effects of GHIs on existing health systems.
Knowledge of the effects of GHIs on specific diseases and on health systems comes from multiple sources. Longitudinal studies enable researchers to establish baseline data and then track and compare GHI effects on disease control or country health systems over time. In addition to Abt Associates' SWEF studies, additional early examples of this type of analysis were three-year, multi-country studies of the Global Fund in Mozambique, Tanzania, Uganda and Zambia.Brugha et al (2005) Global Fund Tracking Study: A Cross-country Comparative Analysis, LSHTM, London. PDFs of each country study is accessible through the GHIN database In 2009, research findings were published from tracking studies in Kyrgyzstan, Peru and Ukraine that sought to identify the health effects of the Global Fund at national and sub-national levels.