Global Health Funding Kaiser Permanente Resident Elective Health Policy Program 10 May 2017 Prof. Corrina Moucheraud UCLA Fielding School of Public Health

Overview of financing types & trends Estimated minimum expenditure, per capita per year, for basic life-saving services: US$ 44 34 countries are below US$50 / year (7 are < $20) WHO Fact Sheet, “Spending on health: A global overview” (2012).

Per capita total health expenditure (US$) WHO Global Health Expenditure Database

Typology of global health institutions PUBLIC PRIVATE Bloom BR. (2011). WHO Needs Change. Nature.

Don’t forget about domestic health financing! Public Unearmarked or earmarked Taxes Private Voluntary pre-payment Out-of-pocket

Govt expenditure on health as % of total health expenditure WHO Global Health Expenditure Database

Out-of-pocket expenditure as % of private expenditure on health WHO Global Health Expenditure Database

External resources as % of total expenditure on health WHO Global Health Expenditure Database

Health development assistance Public funds Bilateral aid govt A  country B (* or organization/company B) Multilateral aid countries A, B, C  agency  countries, regions, etc Private funds Foundations (e.g., Gates Foundation) & charities Corporations Innovative financing mechanisms

Bilateral aid Many high-income countries have official development assistance (ODA) organizations within the govt Usually within foreign affairs or trade ministries In US: US Agency for International Development (USAID), within State Dept

Remember that health is only 1 sector! OCED-DAC, http://www.oecd.org/dac/

USAID mission “We partner to end extreme poverty and promote resilient, democratic societies while advancing our security and prosperity.” World’s largest ODA agency; but one of the lowest allocations as % of GNI Total ODA, as % of gross national income, 2000-15 OECD (2016), Net ODA (indicator). doi: 10.1787/33346549-en

Multilateral agencies UN agencies: World Health Organization UNICEF UNAIDS World Bank Others too (e.g., regional development banks)

Major UN organizations & agencies working on health World Health Organization (WHO) UN Children Fund (UNICEF) UN Development Programme (UNDP) UN High Commissioner for Refugees (UNHCR) UN Population Fund (UNFPA) UNAIDS UN Environment Program (UNEP) Food and Agriculture Organization (FAO) International Labour Organization (ILO) UN Conference on Trade and Development (UNCTAD) … and many more

WHO activities Normative functions: intl conventions, agreements, regulations, standards, recommendations Directing & coordinating functions: including disease-specific programs Research & technical cooperation: emergencies, disease eradication

WHO financials Where does WHO get its money? “Assessed contributions” (dues) Calculated biannually for each member, based on population & economy size “Voluntary contributions” (earmarked $) 2016-17 programme budget – financed by: Assessments: US$ 929 million Voluntary contributions: US$ 3.5 billion

Programme budget changes

UNICEF Unlike WHO, UNICEF has an implementation function and strong in-country presence 1946: created with focus on emergency food & healthcare after WWII Annual budget: ~$4 billion – from countries, private sources (including individuals, corporate sponsors) Current ED: Anthony Lake (2010-)

UNICEF Annual Report 2015

World Bank Group “World Bank” International Finance Corporation International Bank for Reconstruction and Development (IBRD) Loans to middle-income countries International Development Association (IDA) Loans & grants to poor (plus non creditworthy) countries (n=77) International Finance Corporation Private-sector development Multilateral Investment Guarantee Agency International Centre for Settlement of Investment Disputes

Structure of the WBG Member govts contribute to the capital of each institution, and get voting rights Assigned votes at time of membership: 250 votes + 1 per share in Bank capital (based on size of economy) Can add votes later with additions to capital Some votes depend on $ contribution

Voting distribution IBRD DISTRIBUTION: USA: 16.7% Japan: 7.2% China: 4.65% Germany: 4.22% France: 3.95% UK: 3.95% Russia: 2.91% Italy: 2.53% IDA DISTRIBUTION: USA: 10.36% Japan: 8.36% UK: 5.99% Germany: 5.4% France: 3.78% Saudi Arabia: 3.2% India: 2.93% China: 2.1%

2015 funding for IBRD & IDA (Remember, not just health!) Compare to WHO or UNICEF budgets... http://www.worldbank.org/en/about/annual-report

1994-2014 Dieleman et al, 2017, Evolution and patterns of global health financing 1995–2014: development assistance for health, and government, prepaid private, and out-of-pocket health spending in 184 countries. Lancet.

Dieleman et al, 2016, Development assistance for health: past trends, associations, and the future of international financial flows for health. Lancet.

Dieleman et al, 2016, Development assistance for health: past trends, associations, and the future of international financial flows for health. Lancet.