From Alma Ata to the Global Fund

Social Medicine (www.socialmedicine.info) - 36 - Volume 3, Number 1, January, 2008

“Global Funds are like stars in the sky, youcan see them, admire them, appreciate their

abundance… but fail to touch them.”Ministry of Health Official, Malawi

AbstractThis paper traces the evolution of international

health policies and international health institu-tions, starting from the birth of the World HealthOrganization, the setting up of the Health for Alltarget at the Alma Ata conference in 1978 and therise of neo-liberal policies promoted by interna-tional financial institutions from 1980 to the pre-sent. The paper looks at different issues surround-ing public-private partnerships and the setting upof the Global Fund to fight AIDS, Tuberculosisand Malaria and the influence of these institutionson the health systems in poor countries.

1. The birth of the World Health OrganizationThe World Health Organization (WHO) was

formally established in June 1948 as a specializedagency of the United Nations. This organizationresulted from the unification of 3 different inter-national agencies concerned with hygiene, publichealth and health emergencies: the Office of In-ternational Public Hygiene (located in Paris), theLeague of Nations Health Organization (locatedin Geneva) and the United Nations Relief andRehabilitation Administration (UNRRA, in NewYork). The Pan American Health Organization(PAHO), set up in 1901, then took on the role ofthe American Regional Office of WHO. Duringthe 1960’s and 70’s the WHO direction was in-fluenced by political events related to the emer-gence from decolonization of African nations, ofnationalist and socialist movements (mainly sup-ported by the non-aligned countries) and the newtheories of long term socioeconomic growth asopposed to short term technical interventions.

Even in the United States of America there werechanges in the political climate after an electoralvictory by supporters of more liberal approachesand the affirmation of civil rights. In this contextthe Primary Health Care strategy was developedto address unsolved problems of basic health caresuch as malaria, to reinforce health infrastructuresespecially in rural areas, as well as support eco-nomic and social development. The WHO Direc-tor General (1973-1988), Halfdan Mahler,strongly supported this approach and convened anInternational Conference .1

2. The Alma Ata ConferenceThe International Conference on Primary

Health Care (PHC) was held in Alma Ata, capitalof the Soviet Republic of Kazakhstan, in Septem-ber 1978. This was an historic event for severalreasons. It was the first time that representativesfrom all countries in the world met to define areference structure for the promotion of healthcare for all; it was also the first time that thehealth care problems of the poorest countries,many of whom had been under oppressive colo-nial rule, were seriously taken into consideration.At this conference both health needs and develop-ment were strongly linked; it was a particularlyopportune moment to reaffirm health as “a stateof physical, mental and social wellbeing, not onlythe absence of disease or infirmity” and a funda-mental human right. In addition, access to thehighest level of health was also seen as an ex-tremely important social objective of global inter-est that presupposed the participation of numer-ous social and economic sectors, not only thehealth sector.

The Conference generated a document rich inrecommendations, and a solemn Declaration thatresumed the principal indications derived by theAssembly.2 The strong and significant politicalmessage was the definition of Primary HealthCare:

“Primary health care is essential health carebased on practical, scientifically sound andsocially acceptable methods and technologymade universally accessible to individuals andfamilies in the community through their full

THEMES AND DEBATES

From Alma Ata to the Global Fund:The History of International Health Policy

Institution: Italian Global Health Watch (OISG)Corresponding author: Dr Gavino Maciocco, President Ital-ian Global Health Watch, Via Borselli 4-6, 40135 Bologna,Italy, Email: [email protected]: http://www.saluteglobale.it/Conflict of Interest: None declared; Peer-reviewed: NoThe Italian Global Health Watch would like to thank Jenni-fer Sardo Infirri for her invaluable contribution to the Eng-lish translation of the Italian version of this paper.

Prepared by the Italian Global Health Watch


participation and at a cost that the communityand country can afford to maintain at everystage of their development in the spirit of self-reliance and self-determination. (...) It formsan integral part both of the country's healthsystem, of which it is the central function andmain focus, and of the overall social and eco-nomic development of the community. (…) Itincludes at least: education concerning pre-vailing health problems and the methods ofpreventing and controlling them; promotion offood supply and proper nutrition; an adequatesupply of safe water and basic sanitation; ma-ternal and child health care, including familyplanning; immunization against the major in-fectious diseases; prevention and control oflocally endemic diseases; appropriate treat-ment of common diseases and injuries; andprovision of essential drugs. (…) It involves, inaddition to the health sector, all related sec-tors and aspects of national and communitydevelopment, in particular agriculture, animalhusbandry, food, industry, education, housing,public works, communications and other sec-tors; and demands the coordinated efforts ofall those sectors.”2

3. PHC: Selective versus Comprehensive Care:the “Counter- revolution”

Less than a year had passed after the AlmaAta conference (where the conclusions wereunanimously adopted), when an article was pub-lished in the New England Journal of Medicineentitled: “Selective primary health care: an in-terim strategy for disease control in developingcountries”.3 The principle proposed at the Confer-ence that a “comprehensive” approach to the so-lution of health care problems in the poorestcountries was theoretically the most just waschallenged by the World Bank (WB). The costsof such an approach were estimated as too high(between 5.4 to 9.3 billion dollars by the year2000) and a postponement of these approachessuggested. Instead, it was proposed to pursue thefight against a limited number of diseases by con-centrating on specific interventions that, accord-ing to the authors, would be most cost-efficient:vaccinations, promoting longer breast feeding,anti-malaria activities and oral rehydration. Thearticle by J.A. Walsh and K.S.Warren was notjust an academic exercise of two distinguishedresearchers of the Rockefeller Foundation. It rep-resented the start of a movement (called SelectivePHC) in a direction exactly opposite to the AlmaAta declaration. UNICEF, although a co-

promoter of the Conference, had no difficulty inclimbing on board the Selective PHC movementby launching a campaign in 1982 called “A Chil-dren’s Revolution”4 built on the need to concen-trate on four specific cost-effective objectives:oral rehydration to combat diarrhea, vaccinations,promotion of breast feeding and the systematicuse of the growth chart. Growth charts wouldsubstitute for anti-malarial therapy in the list ofpriorities, as the latter was judged to be too ex-pensive.

From that moment on, international organiza-tions adopted Selective PHC as their strategyeven though confronted with all the evidence thatthe determinants of progress and improved healthin any population go well beyond the fightingagainst only one or two diseases. In April 1985 ameeting with the title “Good Health at Low Cost”was organized by the Rockefeller Foundation inBellagio (Como, Italy). The meeting was attendedby officials, economists and demographers fromChina, Sri Lanka, Costa Rica and Kerala State,India. These four areas, all with low gross na-tional product and limited resources dedicated tohealth care, had nonetheless been able to producegood results in terms of their populations’ health.5

The participants, after having examined the re-sults presented at the conference, unanimouslyadopted the following recommendations: “Thefour states that had obtained ‘good health at lowcost’ have demonstrated a clear political and so-cial commitment towards an equitable distribu-tion of income in their societies. Given this com-mitment, it seemed that three other factors playeda major role in their success, shown by themarked decline in infant mortality and deathrates of children below 5 years of age, and in-creased life expectancy at birth, approaching thelevels of developed countries. These factorsbrought the participants to give the following rec-ommendations for development programs in othercountries: equitable distribution of income, access to

public health care services for all, and pri-mary health care reinforced by secondaryand tertiary services;

an education system accessible for all, par-ticularly at primary level, with possibility tocontinue to secondary and tertiary levels;

food security and adequate nutrition for alllevels of society.”6

The rather academic recommendations fromthe conference report were soon forgotten; a po-litical choice had already been made (in NewYork, London or Geneva) to favor sectorial inter-


ventions and vertical programs, an orientationthat marked international health cooperation fordecades. Prof. Andrew Green of the NuffieldInstitute for Health in Leeds writes: “The verticalprogramme approach is contrary to the idea ofintegrated PHC services. The use of centrallydefined criteria to select the problems to be ad-dressed reduced the possibility of involving popu-lations in the choice of priorities. All this impli-cates a return to the medical health model thatignores the importance of development in thewider sense and at the practical level this strat-egy does not take into account the need to rein-force or construct an adequate infrastructurewithout which no programs succeed.”7 Accordingto the late Professor K.W. Newell, from the Liv-erpool School of Tropical Medicine, “SelectivePHC is a threat and must be considered as acounter-revolution. It is a form of health feudal-ism that is destructive rather than an alternative.Attractive to professionals, financing agenciesand governments that are seeking results in theshort term, but it is a pure illusion.”8

4. The eclipse of WHO and the advent ofWorld Bank domination

4.1. The economic recession of the eighties andthe policy of “Structural Adjustment”

The petrol crisis of the 1970s and 1980s, fol-lowed by the Arab-Israeli war (1973) and the Ira-nian revolution (1979), had profoundly negativeeffects on the global economy, seriously affectingall petrol-importing countries. Further, the meas-ures adopted to cope with the increased cost ofenergy, and the resulting inflation, triggered aperiod of grave recession. For developing coun-tries, that during the sixties had achieved signifi-cant economic growth, the consequences weredoubly devastating because the increase in priceof petrol (and other products imported from in-dustrialized countries) added to the drop in priceof their principal exports (primary commodities),caused by a global slump in demand. In the in-dustrialized countries recovery from the petrolshock was rather rapid. For several countries,mainly Asian (South Korea, Taiwan, Singapore),this was the opportunity to restructure theireconomies and increase internal production (forexport). For most of the poorest countries, mainlyAfrican, with fragile and vulnerable political, so-cial and economic structures, the petrol shockwas the initial sign of a long (and still ongoing)period of crisis, increased poverty and debt. Therecipe devised by the WB, the IMF and the US

Treasury (the so called “Washington Consensus”)during the eighties for “recovery” or “structuraladjustment” of the poorest and most indebtedcountries (and the contractual conditions for ob-taining credit) were simple, pitiless and coherentwith the neo-liberal policies dominant in the USAand Great Britain in that period. These bold rec-ommendations included drastic cuts in consump-tion and public spending (including social ser-vices such as health and education) to reduce in-flation and public debt, privatization in all sec-tors, decentralization, and a lower profile forcentral governments.

Little consideration was given to the entirelypredictable catastrophic effects of degrading lev-els of education and health care (adding to thetragedy of the HIV/AIDS epidemic entering thescene in that period) on the fundamental basis ofany future possible development in those coun-tries. In 1987 the WB published the first docu-ment entirely dedicated to health9, a technical ap-pendix to the structural adjustment policy. It con-tained a series of prescriptions, obviously manda-tory for the most indebted countries, for restruc-turing health services in developing countries.The document comprised four chapters, each con-taining a specific directive: Enforce fee payment for health services

(justified as follows: “the most usual ap-proach in developing countries was to con-sider that health care is a right for all citizensand so provided free; this approach generallydoes not work.”)

Encourage the privatization of health services Promote (private) insurance programs Decentralize the management of health care.

These four directives are strongly linked. Theintroduction of user fees in government structuresis not only a way of making users pay, it is alsoessential for promoting insurance systems. On theother hand without an insurance system the gov-ernment hospitals cannot apply tariffs sufficientto cover costs. The privatization of services andprogram decentralization are the other two essen-tial components of the proposed strategy, clearlymeant to reduce to a minimum the role of govern-ments in health care, leaving space for systems ofprivate care and health insurance. The effects ofstructural adjustment policies were soon rapidlyand dramatically evident. At the same time, in its1989 annual report10, UNICEF denounced struc-tural adjustment (“inhuman, unnecessary, ineffi-cient”) as the cause of the worsening conditionsof life and health (“at least half a million childrenhave died in the last 12 months as a consequence


of the economic crisis that has enveloped thedeveloping countries”).

4.2 The eclipse of WHO.In 1988 a Japanese researcher, Hiroshi Naka-

jima, was elected Director General of the WHO.His election marked the beginning of a decade ofgrave crisis in the institution. This was due to anumber of factors, only partially linked to thenew Director’s low profile (the exact opposite ofhis predecessor H. Mahler).11-13 The lack of aninfluential guide at the head of WHO aggravateda series of problems:

A frozen budget and the conflict betweenWHO and USA: Beginning in 1980 the WHObudget remained unaltered, progressively losingvalue due to inflation. In spite of this, Nakajimadoubled the number of staff at the director leveland the USA repeatedly withheld funding. TheUSA was irritated by the Mahler administration’sbold promotion of the International Code onBreast Milk Substitutes (a move seen as an attackon the free market) and the launching of the Es-sential Drugs Program (fiercely opposed by thepharmaceutical industry).

Program financing through extra-budgetaryfunding: While, on the one hand, the WHO ordi-nary budget, set by the country representatives atthe World Health Assembly, was increasinglyreduced (thus undermining the institutional coreof the Organization), on the other hand, programswere being financed ad hoc through extra-budgetary funds provided by various donors.These were the rich nations and multi-lateralagencies such as the WB. By the early ninetiesthe extra-budgetary funds represented 54% of theentire budget of WHO. Such financing generated“vertical” programs such as those to combatAIDS or provide universal vaccination coverage.In these programs decisions were made by thedonors and so that they were effectively outsideof the control of the Organization. Donors justi-fied this approach by pointing to WHO’s ineffi-ciency and their lack of confidence in the internalmanagement of WHO. It was better, they argued,to finance and manage important programs di-rectly. However, it was already clear that suchprograms were not functioning, particularly thevaccination programs funded mostly by UNICEFand other partners such as Rotary International.At the end of the eighties huge efforts had beenmade to attain maximum coverage in the poorestcountries thanks to generous incentives providedto local staff to reach targets. The results wereabsolutely brilliant but ephemeral. Ghana attained

100% immunization coverage of children in1990, only to return to the preceding levels of 40-50% when the incentives were reduced. A similarsituation occurred in Nigeria: maximum coverageof 70% was attained in 1990, then fell below 20%by 1994.

4.3 The medical trap of the poorThe WB entitled its 1993 annual report Invest-

ing in Health.14 To write the document, a highlypaid team of internationally renowned expertswas recruited. With this report the WB made aspectacular entrance as the major financial insti-tution in the health scene, further tarnishing andobscuring the role of WHO (an institution thathad already been discredited).15 The report ad-dressed two important technical-scientificthemes: the definition (and economic estimate) of the

package of essential clinical services andpublic health interventions that governmentsshould assure to their entire population;

the introduction of a new indicator to meas-ure the state of a country’s health: the DA-LYs (Disability Adjusted Life Years). TheDALYs measure the burden of diseases of acommunity by combining two different indi-cators: the loss of life due to premature deathand the loss of healthy life due to disability.The role of these variables was to measurethe cost of interventions for prevention and/orcure of specified diseases, then using thisevaluation instrument to allocate resourcesand define priorities.16

This type of selective approach to PHC pro-vided further grist to the mill confirming the hos-tility of the WB to the conclusions of the AlmaAta Conference. Notwithstanding the WB ex-perts’ recommendations of “Investing in Health”,the health of the poorest countries, and particu-larly the sub-Saharan African, precipitated into anabyss. The quota of the gross national product(GNP) destined to health care fell17; so did theamount spent on public services which variedfrom $ 2 to $8 per capita yearly, quite below the$14 recommended by the experts to fund the es-sential package of health interventions. A flood ofprivatization occurred within already crumblingpublic structures. Outside of the public institu-tions a private health care market was thriving, amarket based largely on the sale of pharmaceuti-cals, available everywhere, in private clinics, indrug stores, on market stalls and street corners.These pharmaceuticals were often out of date orcounterfeit, and almost always distributed by un-


registered people. The reason for this drug boomwas soon clear: lack of access to the formal buttoo expensive private services (hospitals, healthcenters, public and private non profit and privatefor profit, all by payment) forced the vast major-ity of the population to turn to anyone able to pro-vide care for the few coins they had in their pock-ets. The most simple care: a pill or an injection.

“In the past two decades, powerful interna-tional trends in market-oriented health-sectorreforms have been sweeping around the world,generally spreading from the northern to thesouthern, and from the western to the easternhemispheres. Global blueprints have been ad-vocated by agencies such as the World Bank topromote privatisation of health-service provid-ers, and to increase private financing—viauser fees—of public providers. Furthermore,commercial interests are increasingly pro-moted by the World Trade Organisation,which has striven to open up public services toforeign investors and markets.This policycould pave the way for public funding of pri-vate operators in health and education sec-tors,especially in wealthy, industrial countriesin the northern hemisphere.

Although such attempts to undermine publicservices pose an obvious threat to equity in thewell established social-welfare systems ofEurope and Canada, other developments posemore immediate threats to the fragile systemsin middle-income and low-income countries.Two of these trends—the introduction of userfees for public services, and the growth of out-of-pocket expenses for private services—can,if combined, constitute a major poverty trap.18

This is the introduction to an important articlepublished in the Lancet18 by Margaret Whitehead(Professor of Public Health at the University ofLiverpool, and consultant to the British govern-ment), Goran Dahlgren (Director of the NationalInstitute of Public Health in Stockholm) andTimothy Evans (Director of the Health EquityDivision of the Rockefeller Foundation of NewYork). The authors present an impressive list ofthe consequences produced by WB health poli-cies in the poorest countries, summarized in fourcategories: 1) Untreated diseases, 2) Reducedaccess to care, 3) Irrational use of drugs, and 4)Long term impoverishment. The most serioussocial and development consequences are: 1)when people are forced to purchase health care,

they often jeopardize other aspects of their exis-tence since health care costs are rarely discretion-ary and thus 2) families become indebted, beingforced to sell their assets (a piece of land or ani-mals) or to forsake other vital expenditures suchas their children’s education.

The negative social impact of user fees forhealth care is greater than in other sectors of lifebecause these expenses are not foreseeable andthe total cost is unpredictable and unknown untilthe end of the treatment.

5. Public-Private-Partnership (PPP)In 1998, when the credibility and the prestige

of the WHO were at their lowest, the formerPrime Minister of Norway, Gro HarlemBrundtland, was elected Director General. Herelection stemmed the Organization’s decline andreturned the question of health to the internationalpolitical agenda. Important initiatives achievedunder her direction include the publication ofWorld Health Report 2000 which establishedevaluation criteria for health systems (criteriasubjected to considerable debate); the institutionof the Macroeconomics and Health Commissionpresided by Professor Jeffrey Sachs, and theadoption by the WHO Assembly of the “WHOFramework Convention on Tobacco Control”.However, the policy adopted by the Bruntlandleadership was not significantly different fromthat of the WB and the road map for WHO wasobviously adopted from the 1993 WB Report“Investing in Health.9 In the 5 years of her direc-tion (from 1998 to 2003) there was also a prolif-eration of activities financed by extra-budgetarymechanisms; these soon greatly outnumberedthose funded by the WHO regular budget ($1.40billion as opposed to $800 million in 2002). Thefollowing programs were promoted and financedby public and private donors (PPP): EuropeanPartnership Project on Tobacco Dependence,Global Alliance for TB Drug Development,Global Alliance to Eliminate Lymphatic Filaria-sis, Global Alliance to Eliminate Leprosy, GlobalAlliance for Vaccines and Immunization, GlobalElimination of Blinding Trachoma, Global FireFighting Partnership, Global Partnerships forHealthy Aging, Global Polio Eradication Initia-tive, Global School Health Initiative, MultilateralInitiative on Malaria, Medicines for Malaria Ven-ture, Partnership for Parasite Control, Roll BackMalaria, Stop TB and the UNAIDS/Industry DrugAccess Initiative.

The most prominent of these ventures was theBill and Melinda Gates Foundation’s donation in


September 2002 of $2.8 billion, $750 million ofwhich was for a Global Alliance for Vaccines andImmunization (GAVI), a PPP in which WHO hada very marginal role. In another PPP, Roll BackMalaria, there were more than 80 partners amongbilateral, multilateral, NGOs and private organi-zations (including the WB, Gates Foundation,Amref, Bayer, Novartis, ENI, the Italian Govern-ment); here WHO had a dominant role. How-ever, the multiplicity of actors caused seriousmanagement and governance problems in boththe center and periphery so that WHO itself de-cided to set up an autonomous institute for ma-laria, the Global Malaria Program.19 As alreadybeen noted, PPP, the latest trend in vertical pro-gramming, causes more problems than they solveas detailed by Gavin Yamey, the author of a se-ries of articles on WHO in the British MedicalJournal in 2002 (see references 19 and 20).

6. The AIDS pandemic and the Global FundIn 2001, 148 Harvard academics denounced

the fact that in sub-Saharan Africa less than40,000 people were receiving antiretroviral treat-ment in an area where 25 million people wereinfected by HIV or ill with AIDS and where theepidemic caused 2.2 million deaths each year.Andrew Natsios, then director of USAID (U.S.Agency for International Development), pro-claimed his opposition to the distribution of anti-retroviral drugs in Africa on the basis that its in-habitants were unable to take them at regular in-tervals because they had no watches and no cor-rect cognition of time.20 This comment indicatedthe level of attention given to the AIDS pandemicand its tragic impact on the African continent atthe beginning of the new millennium, six yearsafter the successful introduction of antiretroviraltreatment in the rich countries. However, on the25-27 June 2001, a special session of the UNGeneral Assembly in New York dedicated toHIV/AIDS, and entitled “Global Crisis - GlobalAction”, changed things:

We, the heads of States and governments, pre-sent at the UN for the 26th General Assembly,agree on the urgent necessity to re-examineand confront the problem of HIV/AIDS in allits aspects, ensuring a global commitment tothe improvement and growth of the co-ordination and intensification of the efforts atnational, regional and international levels tocombat this phenomenon in all its components.These words introduced the final document of

the special session of the Assembly which indi-cated $7-10 billion as the annual amount the in-

ternational community should allocate to ade-quately tackle the “global crisis.” The UN Secre-tary General, Kofi Annan, personally endorsedthe creation, outside the UN, of a Special Fundfor HIV/AIDS open to governments, the privatesector, foundations and individuals in a “newpartnership.”

Several weeks later, the concluding meeting ofthe Genoa G8 summit approved the creation of aspecial fund dedicated to HIV/AIDS, Tuberculo-sis, and Malaria. “The Global Fund to FightAIDS, Tuberculosis and Malaria” (GF) was for-mally instituted on the 29th of January 2002 inGeneva. Its aim was to “attract, manage and allo-cate added resources through a new private pub-lic partnership providing a significant and sus-tainable contribution to the reduction of the infec-tion, illness and mortality caused by HIV/AIDS,Tuberculosis and Malaria, mitigating their im-pact on needy countries and aiding poverty re-duction as part of the “’Millennium DevelopmentObjectives.’”

6.1. The GF: functions and structure.The GF (www.theglobalfund.org) is a financ-

ing agency and not an implementing or projectmanaging entity. It receives funds from publicdonors (93% from governments) as well as pri-vate donors, mainly Bill Gates (7%), and it allo-cates funds to projects developed locally by pub-lic and private organizations. At the nationallevel, project selection takes place through theCountry Coordinating Mechanisms (CCM), a col-legial body made up of representatives from gov-ernments, universities, bilateral and multilateralinstitutions, NGOs, private organizations and pa-tients. At the central level, project evaluation iscarried out by a group of experts, the TechnicalReview Panel (TRP), whose recommendationsare used by the GF Board in their decisions onproject feasibility. The GF Board is made up ofrepresentatives from donor and receiving coun-tries, NGOs, private organizations and affectedcommunities. There are 20 members plus nonvoting representatives from multilateral institu-tions, WHO, UNAIDS and the WB (which acts asthe GF bank). At the present moment the manage-ment of the GF is in the hands of a Secretariatcomposed of 335 people under the leadership ofExecutive Director Michel Kazatchkine (France).Project proposals are called for on annual basis.Round 8 of the GF will open in March of 2008.

6.2. The GF: the results.The most recent GF document from February


2007, Partners in Impact. Results Report, pro-vides the following data. As of 31 December2006, the GF had signed agreements and fundingcommitments for a total of $5.3 billion, for 410projects in 132 countries. Overall, in more than 3years, the GF allocated $3.5 billion (precisely$3,527,176,186 by Feb. 2007). Figure 1. On the1st of December 2006, 770,000 people were un-dergoing antiretroviral treatment, 2 million werein DOTS treatment against tuberculosis, 18 mil-lion mosquito nets treated with insecticides hadbeen distributed to protect families from malaria.Figures 2 and 3. As a consequence of these re-sults, the GF report claims that by the 31st ofJanuary 2007, 1,460,000 lives had been saved(3,000 a day). The breakdown of funds for thethree illnesses was as follows: 56% for AIDS,28% for malaria and 16% for tuberculosis. GF

funds went to governments (59%), NGOs (30%),multilateral agencies (9%), and private organiza-tions (2%), and covered the following sectors:prevention (33%), treatment (44%), assistanceand support (7%), administration (7%), strength-ening of health system (6%), monitoring andevaluation (1%), other (2%). Figure 4.

Does the GF work or not? How can these re-sults be evaluated in terms of resources spent(input), services delivered (output) and the healthresults achieved (outcome)? In attempting to an-swer these questions we will look particularly atHIV/AIDS the condition which has absorbedmost of the GF funds.

6.2.1: InputsThe financial objective recommended in the

final document of the special UN Assembly inJune 2001 for the campaign against AIDS was$7-10 billion per year. However, the funds effec-tively spent by the GF were on average slightlymore than $1billion per year for the 3 illnesses.Of these, only about $600 million were spent onAIDS. As is shown in Figure 5 the GF contrib-uted only 21% of the $3 billion spent globally onAIDS; this is less than half the objective set bythe UN. Moreover Figure 6 shows that in recentyears there has not been a significant increase infunds per capita in the campaign against AIDSthroughout the world, with only Sub-Saharan Af-rican countries registering a slight but constantincrease. (+$ 0.50 per capita in four years).

6.2.2: OutputsIn September 2003 the WHO Director Gen-

eral, Lee Jong-Wook, the UNAIDS Director Gen-eral, Peter Piot, and the Executive Director of GF,Richard Feacham, declared that the current lowlevel of access to antiretroviral drugs was unac-ceptable in countries with low and medium levelsof development and that it was necessary tolaunch a powerful campaign to rapidly expandtreatment access. This was called “3 by 5”, aim-ing to treat 3 million people by 2005, or in otherwords reach 50% of the population eligible fortreatment. (Figure 7) The results of the “3 by 5”were disappointing. At the end of 2005 accordingto UNAIDS data, only 1,300,000 people were intreatment (43% of the target, 20% of the eligiblepopulation). The coverage achieved was the resultof multiple initiatives leading to a situation wherethe sum of the levels of coverage claimed by thevarious actors was greater than that certified byUNAIDS. To the 770,000 people in treatment atthe end of 2006 cited by GF we must add PEP-

$ 3.527.176.186

Figure 1: Source: The Global Fund


Figure 4: Use of GF Funds (Source: The Global Fund)

Figure 3 (Source: The Global Fund)


FAR (www.pepfar.gov, the President’s (Bush)Emergency Plan for Aids Relief) with 822,000;CHAI (www.clintonfoundation.org, the ClintonFoundation HIV/AIDS Initiative) with 415,000;the many foundations of Bill Gates (65,000 inBotswana alone). Deciphering the data on thelevels of antiretroviral treatment is extremely dif-ficult as an analysis of the UNAIDS documentshows strongly contrasting data from differentsources.

6.2.3. OutcomesThe GF claims one and a half million lives

saved, a rate of 3,000 per day. Although thesefigures are acceptable, outcome evaluation ismuch more complex. The opportunity cost of theGF must be taken into consideration, i.e. whatother alternatives have been forfeited in adoptingthe GF strategy. Thus, although the GF achievedseveral health objectives in the area of HIV/AIDS, Tuberculosis and Malaria, during the sameperiod there was a decline in African health stan-dards in the maternal and child sector (Figure 8);maternal and child health are considered the mostaccurate index of the general functioning of ahealth system in terms of access and quality ofservices and personnel. This decline could also bea direct result of the GF policy and mechanismssuch as the competitive recruitment of its ownstaff and consequent neglect of other activitiessuch as pre-natal programs and infant assistance(not included in special funds or vertical pro-grams).

6.3. Implementation crisis.The apotheosis of the PPP: how else can we

define such a relentless growth of these phenom-ena in the arena of global health? The PPP“Global Fund to Fight AIDS, Tuberculosis and

Figure 5: HIV/AIDS Funding Sources:Source: The Global Fund

Per capita HIV and AIDS expenditures by country income level*Per capita HIV and AIDS expenditures by country income level*

0.0

0.5

1.0

1.5

2.0

2.5

2000 2001 2002 2003 2004 2005

US$percapita

Low income

Lower middle

Higher middle

Low income SSA

• Trends based on a sample of 25 countries from sub-Saharan Africaand 57 countries from other regions

3.9

Figure 6

Source: UNAIDS


Malaria” came into existence when there werealready specific PPPs for each of the areas con-cerned (AIDS, Tuberculosis and Malaria) such asUNAIDS (www.unaids.org), Roll Back Malaria(www.rbm.who.int), Stop TB (www.stoptb.org).Although many PPP actors are omnipresent, thisis often not sufficient in itself and they set up ac-tions and autonomous finances within the samesectors (eg. G.W.Bush’s PEPFAR) leading to aexcess of actors and protagonists at all levels:finance, programming, management, field work,and evaluation. This situation was the subject of areport by UNAIDS in 2005,21 which noted withconcern that a significant increase in availablefinances was accompanied by a serious lack ofco-ordination in fund management and organiza-tion producing duplication and competition be-tween various sponsors and provoking what theUNAIDS defined as “the implementation cri-sis”, caused by unsustainable organizations andextremely high administrative costs. The chaoticsituation is shown well in Figure 9, which de-scribes the various functions of the AIDS pro-gram and the mass of sponsors involved in vari-ous ways. A recent Lancet editorial22 focuses ona paradoxical aspect of this disorganization,caused by the verticalization of services. The co-existence of HIV/AIDS and Tuberculosis com-pounds the problem, affecting about 11 millionpatients who are also those with the greatest con-centration of resistance to antiTb drugs (XDR-TB). Although it is crucial that patients sufferingfrom the two diseases be treated by the same ser-vice and health workers, the reality is that twoprograms (AIDS and TB) operate separatelycausing enormous problems for patients.

6.4. Strengthening health systems.“Perversely, the large inflows of donor assis-tance targeted to these diseases (through so-called vertical disease programs) have weak-ened the infrastructure and drained the hu-man resources required for preventing andtreating common diseases (such as diarrhea,and upper respiratory infections) that maykill many more people. Furthermore, multi-ple donors, each with their own priorities,bureaucratic requirements, and supervisorystructures, have created waste and confusionwith recipient nations. Lastly, an importantconcern is the sustainability of these verticalprograms, since donors’ funds may not provestable or longlasting. For recipient countries,these inflows have created difficult chal-lenges in the management of the health sec-tor.”23

It is surprising that such statements appear in arecent IMF document (particularly a WorkingPaper), given that this institution (the twin of theWB) bears all the responsibility for the promotionof vertical programming and PPP. It is probablysign that the time for these strategies is over andthey are no longer defendable. Some rethinkingon the issue has also gone on within the technicalstructure of the GF, the Technical Review Panel,triggered by the Malawi incident.

In Malawi funds were made available only forFigure 7

Figure 8


drugs and laboratory tests, totally excluding in-vestment in human resources. An already over-worked staff was suddenly overwhelmed by anenormous quantity of new work in precariousconditions. The GF action also was in direct con-tradiction to Malawi government policy whichhad recently adopted the Sector Wide Approach,another WB recipe (from the late ‘90s and nowout of date) which established that local govern-ments have the prerogative to decide on the desti-nation of donations.24 Following protests fromthe government, the GF, in Round 5, conceded anadditional fund of $40 million to Malawi. Thiswas used to hire 5,228 community health workersfor Malawi’s Essential Health Package programwhich included actions for HIV/AIDS, malaria,tuberculosis, and other illnesses.

Round 5 (2005) permitted for the first time thesubmission of projects oriented towards thestrengthening of health systems. Rwanda was oneof the few countries that took advantage of thisability and obtained funds for the promotion ofsocial security. Round 7 also provided this possi-bility of HSS (Health System Strengthening). Inthis context the useful and worthy work of Physi-cians for Human Rights (PHR http://physiciansforhumanrights.org/) should be men-tioned including their publication in March 2007(Figure 10) of a guide to promote the use of GF

for strengthening health systems.The GF and its first Executive Director, Rich-

ard G. Feacham, also addressed this issue in aLancet article of August 200625offering a gener-ally positive and highly optimistic picture of GFactivities. In the last two paragraphs, however, heis more critical. First, on the question of the“vertical programming versus strengthening thehealth systems” Feacham ends with a proposaltaken from the Shakow Report concerning a divi-sion of roles between the GF which is assignedtasks of rapid intervention for specific illnesses,and the WB which is responsible for developing astrategy of long term change in health systems.26

Second, on the issue of restriction of funds at thedisposal of the GF, Feacham states that “Theoriginal vision was to allocate $7b to the GF justfor HIV/AIDS” but “the results obtained showthat it was worthy of more funds”.

Alexander Shakow, a retired WB official, pro-posed solutions to the health problems in poorcountries in line with established policies of WBand IMF:

“The area of expertise of the WB lies in itscapacity to reconstruct in a systematic mannerthe health care sector. This characteristic isfundamental to progress not only for the AIDSaction, but also the other diseases and moregenerally to ensure the sustainability of all the

Figure 9. The Implementation Crisis (Source: UNAIDS)


means to improve human health in the poorestcountries. This is an intervention area that iscomplex and difficult and for which no otheragency has the power, experience and compe-tence of the WB, including the ability to linkthe health sector into the macroeconomic andfinancial context of each country. Similarly theWB would be able to help governments to bemore strategic and selective in establishing thepriorities in the field of AIDS and other healthcare activities; thus, encouraging countries touse their own limited capacities to implementthose activities that would have the maximumimpact on the epidemic”A proposal of this nature (with due justifica-

tion in appendices) might seem to be a provoca-tion or even a spoof, but the nature of the sourceis such that we can be sure that there are seriousintentions at foot to institutionalize the role thatthe WB has de facto carried out in the last twodecades, i.e. a “global super health ministry.”

With regard to the application of macro-economics to health issues, all the documentsproclaim that GF funds should be additional tolocal government budgets and not substitutes forthem. However this is often not the case. In real-ity (e.g. Mozambique and Uganda27) a macro-economic school of thought (WB and IMF) fo-cuses on the risks to local economies posed bytoo generous aid funds (increase in inflation,strengthening of local currency, reduced competi-tiveness for exports, etc.), a syndrome called theDutch Disease.28,29

Lastly, as in general with other types of for-eign aid, the issue of sustainability of the GlobalFund initiative over time has not yet been explic-itly addressed. Rather, some of the examplesquoted above (e.g. Malawi) point to the poten-tially perverse effects of interventions that tend toconcentrate on the immediate delivery of goodsand services at the expense of human and institu-tional capacity building efforts aimed at makinglocal health systems and communities at leastpartly self-sustainable in the long run.

ConclusionsThe overview of the last sixty years of interna-

tional health policy presented in this paper resultsin the uncomfortable impression of a substantialshift from a publicly funded, comprehensive sys-tem approach to ensuring the right of health forall (enshrined in the Alma Ata Declaration) to aprivately-influenced, segmented, “just-for-some”provision of health care goods and services typi-fied by the work of the Global Fund to Fight

AIDS, Tuberculosis and Malaria. Although it hasbeen promoted as a foundation -- not a U.N.agency or a broader development agency -- andas such acting primarily as a financing mecha-nism, rather than an implementing agency, theGlobal Fund “works in cooperation with othergroups -- multilateral organizations, bilateralagencies, NGOS, civil society and faith basedgroups -- that help design programs, provide tech-nical assistance, and otherwise provide supportfor country programs.”30 As such the Global Fundhas been and still is very influential in shapingmajor international health policy choices thatwarrant serious scrutiny from the global healthcommunity.

The Global Fund’s failures described in thispaper may be summarized in the limited re-sources provided as compared to the Fund’s de-clared ambitions, its disappointing results (e.g. interms of treatment coverage) and its wider harm-ful consequences due, for instance, to the com-petitive recruitment of staff in privileged areas ofintervention and consequent neglect of other sec-tors. As these “collateral effects” have long beendescribed since the earliest debate on comprehen-sive as opposed to selective Primary Health Carein the ‘80s, the Global Fund story represents inour opinion a further example of how difficult itis to learn from history, that is to aim at an evi-dence-based international health policy. Nohealth system in the world is actually built on“vertical” programs. Nonetheless because of theGF an unduly strict selective approach to healthcare delivery has often been introduced into poorcountries in the early stages of their development;this has had destructive effects on their healthsystems, as even the IMF itself has been forced toadmit. In this world-view, a false distinction hasbeen perpetuated whereby the legitimate exerciseof setting priorities among competing needs hasbeen translated into rigid, self-contained pro-grams that have often jeopardized local healthsystems.

As it is clear that the different financingmechanisms that support international health pol-icy choices have inevitably a substantial bearingon health outcomes, it is imperative that thosemechanisms are adopted that are designed to: Ensure universal access to basic health care,

giving absolute priority to the poorest andmost vulnerable groups in the population(children and women);

Reinforce whole health systems, instead ofbasing strategies on vertical programs;

Strengthen infrastructures, organization and


control of programs, purchase and distribu-tion of essential medicines (including antiret-roviral drugs for the treatment of AIDS);

And, above all, invest in human resourceswithin the public health sector through train-ing, motivation, appropriate and just remu-neration of health personnel that will helpblock the drain of staff to the private sectorand abroad.

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From Alma Ata to the Global Fund

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