Arlen Fuller is the executive director of the FXB center for health and human rights at the Harvard school of public health. He has led several research investigations focused on human rights and complex emergency response, as well as conducted field projects in both health and education service delivery. Mr. Fuller has also experience in international policy, federal government operations, and legislative strategy. He has worked as a senior member on the legislative staff of the U.S. Congress' International Rescue Committee, working on a policy campaign to increase U.S. funding for global health efforts. He's also worked for Senator Edward Kennedy, serving on the senator's health, education, labor, and pensions committee staff, and focused on issues related to the National Institutes of Health. He received his B.A. in economics from the College of the Holy Cross, holds a master's degree in peace and conflict studies from the University of Ulster, in Northern Ireland, and a J.D. from Boston College Law School. We're going to call this the show me the money lecture. One of the big reasons for the ascendancy of global health in the past few decades has been the, the infusion of money from both government and non-government organizations. Dr. Fuller is not only going to explain where this money comes from, but how it is spent. He'll also explain that although financial underwriting is almost always a precondition of success in global health. Money alone does not solve problems. >> Since the early 1990s, we've probably seen a monumental increase in the funding for, for global health we're talking about a quadrupling of funding. From about, about $6 billion in, in 2010, to about $26 billion in, in 2011. And we're talking about an enormous shift that's due in large part to the development of the global fund and PEPFAR. When we're talking about, sort of the, the key actors involved in global health financing. We're looking at the sources of funds, the funders, we're looking at the, managers of money, and then the recipients of funds and the implementors. On the funding level, we're looking at we're, talking about governments, such as the U.S. and PEPFAR, we're talking about the Global Fund. But we're also talking about major foundations like the Gates Foundation, that drive so much in terms of the funding for, for health related services. On the management side we have a number of multi lateral organizations such as the, the GAVI alliance, or the Global Fund as well. That is key in delivering the, the funds and driving the strategies involved with the delivery of, of global health services. When we're talking about the Gate's Foundation, I think it's, it's impossible not to talk about the overall scope and the effect that the Gates Foundation has. With other foundations and their involvement in global health, these are issues of magnitudes of tens of millions of dollars. But when, when we consider the Gates Foundation, this is billions of dollars. I mean, this is a, an increase in the order of magnitude of about a hundred times. And it's something that shouldn't be discounted when we're talking about how effective the Gates Foundation is. Not only in terms of doing good, but also in driving the overall global strategy for how we address the right to health. So why in the last 20 years have we seen a quadrupling of global health aid? I think that's in large part due to the HIV/AIDS crisis. And I think that's probably understandably so to, to most people who would think about it. The HIV AIDS crisis has been so large in terms of, the epidemics effect on the way in which we see human rights, generally speaking. That the, the global response to HIV AIDS has been met by, a historically unparalleled response. And that's been goods and it's also had it's complications. When we look at PEPFAR and we look at HIV AIDS funding. Now the positive is this has been the great driving for quadrupling funds. But it also has dictated a very vertical approach towards how we deliver global health funds and how we deliver services. And that's actually a bit of a difficulty because we're now looking at very specific, disease specific responses at times. When many times when we're looking at an overall public health or a health response for a community. Sometimes there's a greater need towards health systems strengthening, towards the opening and development of, of clinics, towards the education and hiring of doctors and nurses. And sometimes that's difficult when you're stuck within a vertical approach towards financing. Sometimes you need a horizontal approach towards this idea of, on health system strengthening that can really allow a country, or even a local community, to respond to their specific needs. In the specific context to what they identify for the, for the, for their health response. So let's take the question of maternal mortality and morbidity. One of the biggest indicators for the, the issue of poverty and for the issue of, of poor resources within a country is the rate in which women die in child birth. And that's really a reflection on, on the overall strength of the health system in that country. Women should not die in child birth. 99% of the women who die, and we're talking about one woman every two minutes, 99% are avoidable. So when you are talking about the difference between vertical interventions and a horizontal approach. When you are reflecting on certain health needs sometimes the approach towards building a stronger health system is what you actually need. At the same time, when we're talking about people who are in resource poor areas and have very little information and understanding on what their health problems might be. No one walks in to, in to a community or community clinic and says, excuse me, I need to be admitted, I have tuberculosis. Nobody, nobody knows what exactly they have. They come to a health clinic because they're not feeling well. And when you don't have a strong health system. You've run the risk of having less and less engagement with the community. Because, they either know that the clinic doesn't have enough Doctor's. That the wait times are too long, or that there are stock outs and shortages on the medicines that they may need. So, as a result, if you want to have stronger interventions that are disease specific. Sometimes it makes sense to have a stronger community and system approach, because then you'll be more engaged with the community. And you'll be better to engaged to, to know what their needs are. And that you'll be able to do the case funding that's necessary to then move to the next level on disease-specific response. The schematic for global health financing can really be broken down into 3 different categories. That of the funding sources, those who provide funds, the channels of assistance, those who really manage funds, and the implementing institutions, those who spend the funds and deliver the services. Now, in the funding sources, there really are the national treasury's of, of the countries involved. There's the debt repayment to international financial institutions. There's the private philanthropist and the foundations that provide a large amount of money as well in comparison to the government. And then there's corporate donations that really also drive the smaller part, but certainly something shouldn't be discounted. The channels of the systems we're looking at, the bilateral development agencies. Organizations like the, the UN's, the UNFPA, the WHO and UNICEF, the World Bank, and the Global Fund, and the GAVI Alliance. They're all channels of assistance where they can direct the funds in a strategic way so that the recipients are best able to, to actually put these, these funds into practice. And then, finally, the international NGOs and the foundations, are also the foundations that are responsible not just for funding, are also the ones who would direct the funds to the implementing institutions. On the implementing side you have government programs, the national industries of health, the national disease control programs that are quite responsible for the public sector spending. And then you have the non governmental programs. Those organizations like the National MGOs, and civil society, private sector contractors, university and research institutions. So whether it's a government, or whether it's an NGO ,or whether it's a multilateral institution. The, the amount of communication between these actors, and the understanding that's necessary for everyone to be on the same page and reach the same long term goals is quite critical. I think the difficulty is well with the varying actors is not only do they have different strategies, but they also have different timelines. Even within the US government, we have multiple federal departments that are involved in global health financing. Everything from the Department of Treasury, to the Department of State, to the Department of Defense. And if you think about whether the one department or another has a goal of responding to global health because it has a diplomatic objective, or a defense objective, or a development objective. All of these things have different timelines and different strategies for how these sorts of things get accomplished. And I think that's something critical to, to also understand, that it's, it's multiple different players with multiple different strategies that, that need to, to speak openly in the way in which we address global health.
