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The final report of the CMH concluded that a major increase in donor financing would be needed to support critical health interventions throughout the developing world. It identified the need for ‘an additional [US]$22 billion per year by 2007 and [US]$31 billion per year by 2015’ in grant financing for country-specific interventions against infectious diseases and nutritional deficiencies, which are important prerequisites for creation of GPGs. The CMH further emphasized that these amounts should be augmented by increased aid flows in other health-related areas, such as education, sanitation and water supply. Above and beyond these country-specific interventions, it called for additional grant funding of US$5 billion in 2007 and US$7 billion in 2015 for research and development on diseases of the poor and other GPGs, such as epidemiological surveillance, for a total of US$27 billion in 2007, rising to US$38 billion in 2015 – as against current ODA for health of around US$6 billion (CMH, 2001: 11).⁸

The disparity between the commitments that would be needed even for a minimal package of essential health interventions and current levels of development assistance calls into serious question the likelihood of achieving health-related development goals. For example, in 2001 the G8 committed itself to ‘work with developing countries to meet the International Development Goals, by strengthening and enhancing the effectiveness of our development assistance’ (Genoa Communiqué, para. 14); and recommitted itself to the updated MDGs at the 2002 Kananaskis summit (G8, 2002, para. 8).⁹ The IDGs, jointly published in 2000 by the World Bank, the IMF, the OECD and the UN, call for reducing infant and under-five child mortality by two-thirds between 1990 and 2015 (IMF et al., 2000: 12–13). The World Bank recently concluded, based on a scenario of 3.6 per cent annual per capita income growth in the developing countries between 2005 and 2015, that South Asia was the only region likely to achieve the target (World Bank, 2002a: 31).¹⁰

One of the reasons the IDG health targets are unlikely to be met is the increasing collapse of health-care infrastructure in many countries, particularly in sub-Saharan Africa. Although there are a number of contributory factors, key has been reduced public expenditure on health in at least 29 of the poorest African countries (UNDP, 2000), with all but six countries falling below the US$60 per capita figure recently advocated by the WHO Director-General (Brundtland, 2000). Some analysts argue that public health systems have been undermined by a combination of structural adjustment policies and health sector reform; their impact on sub-Saharan Africa is reviewed in Chapter 9. Whatever the reason, public health spending in developing countries, both per capita and as a percentage of GDP, remains considerably lower than in G7 countries (see Figure 3.1, below).¹¹ The persistence in health budgets of disproportionately high spending on tertiary and specialised services coexists with chronic underfunding of basic health services, which in many cases are unable to meet their running costs. Declining child vaccination coverage is just one indication of the deterioration of health systems, albeit one with special significance in view of our earlier discussion of GPGs. Although coverage declined in all developing continents during the 1990s, the decline in Africa is particularly troubling (Sanders et al., 2002). Almost 50 per cent of African children are now not adequately vaccinated (Social Watch, 2002; Simms et al., 2001; UNICEF, 2000: 89; WHO, 2002b). Perhaps the most serious reflection of the collapse of African health systems lies in the situation regarding health personnel, a point we take up later in this chapter.

It is fundamental to understand that the CMH’s estimates of the minimum necessary increase in donor spending on health interventions assume that developing countries have well-functioning, well-staffed health systems accessible to those in greatest need. Although developed countries generally do better than developing countries in ensuring that the poor obtain access to health care, health care in poorer countries still tends to favour the wealthy over the poor, and hospital care over primary care. Gains from ensuring health-care access for the poor in developing countries are much more substantial than they are for the poor in wealthier nations (Wagstaff, 2001).

Figure 3.1: Average Annual Key Health Indicators and Health Expenditures in G7, Low-Income Countries and Sub-Saharan African (SSA) Countries

Source: World Bank (2002d: Tables 2.15 & 2.20)
Note: Where no bars appear on the graph, the numbers are so low they do not register. See data tables in Appendix 2 for actual numbers.

Table 3.6, below, shows that, despite the economic, political and social difficulties Africa has faced this past decade, many countries have attempted to increase the portion of their GDP spent on public health care. This table is a measure of effort, not of capacity, which would entail adjustments for actual GDP trends for 1990–98, taking into account population changes, improvements in health service delivery and management, and the emergence of new health problems such as the AIDS pandemic.

Table 3.6: Changes in Expenditures for Public Health Services Africa, 1990–98

Source: Social Watch (2002: 52–4)

Legend:

The absence of an effective public health-care system in poorer countries undermines the more technical disease interventions supported by the GFATM and the Global Alliance for Vaccines and Immunization (GAVI). Over 90 per cent of the first round of grants from GAVI went to research on new vaccines and injection equipment (Hardon, 2001). Although this is an important investment, an initial assessment of GAVI in four African countries reported that there are major inadequacies in health-system infrastructure, including poor staffing levels, infrequent supervision, insufficient transport and fuel, and poorly functioning refrigeration for vaccines (Brugha et al., 2002). Health officials in these countries expressed concern that they would be unable to sustain the cost of vaccines should GAVI funding stop after five years. There is worry that the GAVI funding proportions (where the bulk goes to pharmaceuticals and laboratory research) will be replicated by the GFATM, compounding a problem already identified in the fund’s initial assessment: ‘The great burden of these three diseases [AIDS, tuberculosis and malaria] falls on Africa, and most especially on children and young adults living in sub-Saharan Africa. There, AIDS, and TB linked to AIDS, and malaria, are straining an already frayed public health infrastructure’ (WHO, 2002d: 6; emphasis added).

Access to sufficient and affordable quantities of anti-retroviral drugs remains an issue, partly due to extended patent protection under the Agreement on Trade-Related Intellectual Property (TRIPS). As an indication of the potential gains, Brazil’s policy of free, publicly funded anti-retroviral therapy – which relies as far as possible on locally manufactured drugs – is credited with substantially reducing deaths from AIDS and the incidence of opportunistic infections, while improving patient quality of life (Galvão, 2002). But without adequate resources to support the delivery of basic health care, overcoming problems of treatment supply alone may do little to control the AIDS pandemic in Africa (Attaran & Gillespie-White, 2001).

Endnotes to Health System Infrastructure

⁸ A higher cost-estimate range of US$40–52 billion per year in new health funding by 2015 is provided in a summary of the report of the Working Group responsible for these estimates (Jha et al., 2002). Both estimates include a US$8 billion annual allocation to the GFATM.

⁹ Box 2.2 in the previous chapter presents these two sets of goals and describes their similarities and differences.

¹⁰ The WHO Coordinates report (2002d), which provides the first assessment of progress toward meeting the goals that motivated the establishment of the Global Fund, avoided any quantitative assessment of this point.

¹¹ Per capita spending is so low in sub-Saharan Africa (averaging US$20/year) that it does not even track on Figure 3.1; see Appendix 2 for detailed data for this figure. Averages also overstate health care available for the poor in sub-Saharan Africa, since they include both public and private spending (World Bank, 2002d: 105).

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