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

http://journals.sfu.ca/socialmedicine/index.php/socialmedicine/article
/download/\186/380

Italian Global Health Watch (OISG). Gavino Maciocco, President
Italian Global Health, Bologna, Italy. Social Medicine - Volume 3,
Number 1, January, 2008

"….Global Funds are like stars in the sky, you can see them, admire
them, appreciate their abundance… but fail to touch them…." Ministry
of Health Official, Malawi

Abstract: This paper traces the evolution of international health
policies and international health institutions, starting from the
birth of the World Health Organization, the setting up of the Health
for All target at the Alma Ata conference in 1978 and the rise of neo-
liberal policies promoted by international financial institutions
from 1980 to the present. The paper looks at different issues
surrounding public-private partnerships and the setting up of the
Global Fund to fight AIDS, Tuberculosis and Malaria and the influence
of these institutions on the health systems in poor countries.

Conclusions
The overview of the last sixty years of international health policy
presented in this paper results in the uncomfortable impression of a
substantial shift from a publicly funded, comprehensive system
approach to ensuring the right of health for all (enshrined in the
Alma Ata Declaration) to a privately-influenced, segmented, "just-for-
some" provision of health care goods and services typified by the
work of the Global Fund to Fight AIDS, Tuberculosis and Malaria.
Although it has been promoted as a foundation -- not a U.N. agency or
a broader development agency – and as such acting primarily as a
financing mechanism, rather than an implementing agency, the Global
Fund "works in cooperation with other groups -- multilateral
organizations, bilateral agencies, NGOS, civil society and faith
based groups -- that help design programs, provide technical
assistance, and otherwise provide support for country programs."30
As such the Global Fund has been and still is very influential in
shaping major international health policy choices that
warrant serious scrutiny from the global health community.

The Global Fund's failures described in this paper may be summarized
in the limited resources provided as compared to the Fund's declared
ambitions, its disappointing results (e.g. in terms of treatment
coverage) and its wider harmful consequences due, for instance, to
the competitive recruitment of staff in privileged areas of
intervention and consequent neglect of other sectors.

As these "collateral effects" have long been described since the
earliest debate on comprehensive as opposed to selective Primary
Health Care in the `80s, the Global Fund story represents in our
opinion a further example of how difficult it is to learn from
history, that is to aim at an evidence- based international health
policy. No health system in the world is actually built on "vertical"
programs. Nonetheless because of the GF an unduly strict selective
approach to health care delivery has often been introduced into poor
countries in the early stages of their development; this has had
destructive effects on their health systems, as even the IMF itself
has been forced to admit. In this world-view, a false distinction has
been perpetuated whereby the legitimate exercise of setting
priorities among competing needs has been translated into rigid, self-
contained programs that have often jeopardized local health systems.

As it is clear that the different financing mechanisms that support
international health policy choices have inevitably a substantial
bearing on health outcomes, it is imperative that those mechanisms
are adopted that are designed to:

Ensure universal access to basic health care, giving absolute
priority to the poorest and most vulnerable groups in the population
(children and women);

Reinforce whole health systems, instead of basing strategies on
vertical programs;

Strengthen infrastructures, organization and control of programs,
purchase and distribution of essential medicines (including
antiretroviral drugs for the treatment of AIDS);

And, above all, invest in human resources within the public health
sector through training, motivation, appropriate and just remuneration
of health personnel that will help block the drain of staff to the private
sector and abroad.