JUAN GARAY: Salud Global: tendencias y desafíos

Health needs
Physical and psycho-Social
potential developed and fulfiled
If unmet :
physicalhandicaps, chronic
stress, lonelyness, anxiety,depre
ssion
Safety needs : from infections, toxic
agents, unhealthy diets and
sendentarism, accidents and violence
If unmet : infectious
diseases, intoxications, cardiovascular and
metabolic disorders, cancer, trauma.

Basic physical needs : water, air, nutrition.
If un met : malnutrition, dehydration, respiratory conditions.

J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 5

Basic needs : enough water and food

100 50
45
90
40
80 35
30
70
25
60 20
50 15
10
40
5
30 0
1990 2010 1990 2010 1990 2010
20 Developed Developing
Total
countries countries
10
Underweight 1.9 1.4 28.7 15.8 25.4 16.2
0 Stunted
LIC L-MIC H-MIC HIC All 6 6 44 29.2 39.7 26.7

1990 Wasted 0.9 0.7 10 9.6 9 8.6
57 71 89 99 77
Obese 7.9 12.9 3.7 7.2 4.2 9.1
2008 67 86 95 100 87


Safety needs
% DALYs and health potential lost, by unmet safety needs
60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%
air/wat air- water- vector-
air
temper er bioche illicit Unsafe borne borne borne
total trauma total pollutio fat diet tobacco alcohol total
ature particle m drugs sex infectio infectio disease
n
s ns ns s
tortal
safety
Physical chemical biological
unmet
needs
%DALY 17.5% 2.5% 12.0% 3.0% 20.9% 4.0% 1.0% 7.0% 4.1% 4.0% 0.8% 10.0% 5.1% 0.7% 4.0% 0.3% 48.4%
% Potential health lost 3.7% 0.5% 2.5% 0.6% 4.4% 0.8% 0.2% 1.5% 0.9% 0.8% 0.2% 2.1% 1.1% 0.2% 0.8% 0.1% 10.2%


Health fulfillment needs : physical, psychosocial
70.0%
60.0%
50.0%
16.00%
40.0%
30.0% 14.00%
20.0%
10.0% 12.00%
0.0% 10.00%
world HC UMIC LMIC LIC
% DALYs 26.3% 51.4% 44.2% 36.1% 15.6% 8.00%
%deaths 53.3% 66.3% 64.6% 56.6% 41.1%
6.00%

4.00%
7.00
6.00
5.00
4.00 2.00%
3.00
2.00
1.00
0.00 0.00%
WORLD HIC UMIC LMIC LIC world HC UMIC LMIC LIC
Physical inactivity 0.50 0.64 0.91 0.44 0.44 % DALYs 9.00% 14.00% 10.00% 9.00% 7.00%
Overweight and obesity 0.44 0.70 1.12 0.40 0.40 % health potential lost 1.89% 2.94% 2.10% 1.89% 1.47%
High blood pressure 1.17 1.40 2.19 1.18 1.18
High cholesterol 0.41 0.48 0.81 0.32 0.32
High blood glucose 0.53 0.58 0.77 0.44 0.44
Low fruit and vegetable
0.26 0.21 0.46 0.28 0.28
intake
Total sedentary effects 3.30 4.01 6.26 3.06 3.06


Risk combinations of ill health
Unmet basic
needs
10% of ill -health

Unmet fulfillment Unmet safety needs

needs 48% of ill-health
(59,3% if safe delivery added)

35% of ill-health


Present and potential health capacity
85 years LE
2 % health potential?
Healthier lifestyles lost/year
Best country
(Japan)83 years LE
5 % health potential?
lost/year
HIC
(average HICs) 80 LE
12% health potential
World average lost/year

(average HICs) 62 LE
LICs 21 % health potential
lost/year

57 years LE
30,3% health
Lowest health
potential lost/year
state
Zimbabwe 42 years LE
82% health potential
lost/year


J Garay, Challenges for EU and US policies in
Global health : Global Health is Global 11
Justice

Global Health Equity
• Most consistent stratifying variable : income
• Best standards at country level : Upper
quintile
• Best standards at global level : High income
region.
• Narrow disparities, improve global averages
and best standards.


Health disparities
90
dispersion of life expectancy

11.000

80
10.500

Life expectancy
70
10.000 men
women 60
9.500 all y = 6.3959Ln(x) + 12.433
R2 = 0.7041
50
9.000
40
8.500
1990 2000 2008 30
0 10 000 20 000 30 000 40 000 50 000 60 000 70 000 80 000 90 000
years
GDP pc PPP 2008


Different risks and forms of ill health
30.00%

25.00%

20.00%
Injuries
Neuropsychiatric disorders + self injuries
NCDs -MH/Injuries
15.00%
Infectious diseases
Nutritional deficiencies

10.00% Perinatal conditions
Maternal conditions

5.00%

0.00%
WORLD LICs LMICs UMICs HICs


Excess ill-health vs. best regional standards
1800000
1600000
1400000
1200000
1000000
800000
600000
400000 Injuries
200000 mental health
0
-200000 NCDs -MH/Injuries
-400000
LOW INCOME LOWER MIDDLE INCOME UPPER MIDDLE INCOME Infectious diseases
Injuries 214203 549165 130480 Nutritional deficiencies
mental health -23750 -119174 2064 Perinatal conditions
NCDs -MH/Injuries 63441 385607 167824
Maternal conditions
Infectious diseases 696672 382814 259105
Nutritional deficiencies 54884 61483 15694
Perinatal conditions 260550 231043 29470
Maternal conditions 55229 43802 6810

Injuries Maternal conditions
25% 3%
Perinatal conditions
14%
Nutritional deficiencies
4%
NCDs -MH/Injuries
17% Infectious diseases
37%


Excess burden of disease vs. HICs
100%

90%

80%

70%

60%

50%
rest of burden

40% Excess burden

30%

20%

10%

0%
LOW INCOME LOWER MIDDLE INCOME UPPER MIDDLE INCOME TOTAL EXCESS BURDEN OF DISEASE
rest of burden 1184034 4577872 1158219 6920125
Excess burden 1321229 1534741 611446 3467415


Distribution and trend of life
expectancy


Distribution of child and adult mortality


Excess deaths due to health inequity
25000000 25000000

20000000
20000000

15000000

15000000

10000000

10000000

5000000

5000000
0
1990 2000 2008
Upper middle
1549017 1912015 1792779
0 income
1990 2000 2008 Lower middle
11180365 11759717 10716957
Avoidable 15-60 7209077 9007941 8921937 income
Avoidable <5 10859818 11251207 10408335 Low income 5339512 6587417 6820535


Proportion of deaths due to inequity = injustice?
60000 90.0%

80.0%
50000
70.0%

60.0%
40000

50.0%

30000 40.0%

30.0%
20000
20.0%

10000 10.0%

0.0%
Lower middle Upper middle
0 Low income
year 1990 year 2000 year 2008 income income

% inequity deaths 1990 81.1% 65.5% 49.6%
35.51% 36.34% 34.13%
rest of deaths 2000 84.0% 68.4% 57.3%
32887 33846 36586
2008 83.8% 66.8% 57.1%
inequity detahs 18110 19320 18960


Trend , burden and share of ill health
35.0%

30.0%

25.0%

20.0%

15.0%

10.0%

5.0%

0.0%
world HIC UMIC LMIC LIC
2002 22.8% 12.5% 17.3% 17.5% 32.0%
2008 21.8% 12.3% 19.9% 17.2% 30.3%
0.250
70.0%

0.200 60.0%
50.0%
0.150 40.0%

0.100 30.0%
20.0%
0.050 10.0%
0.0%
0.000 LIC LMIC UMIC world
LIC LMIC UMIC world
2002 60.8% 28.3% 27.5% 45.1%
2002 0.195 0.050 0.047 0.103
2008 59.4% 28.4% 38.2% 43.5%
2008 0.180 0.049 0.076 0.095


And national health inequities?
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
LIC (n=29) LMIC (n=23) UMIC (n=6)
Rest 5.9% 11.1% 30.4%
GHiE 67.5% 66.7% 37.8%
NHiE 26.6% 22.2% 31.7%

Justice

Conclusion GH situation and equity
• Unprecedented average increase in life
expectancy (one day every three days)
• GH Inequity remained stagnant last 20 years
• GH inequity translates in some 20 m
premature deaths per year, one in three and
half of the burden of ill health
• NH inequity contributes to one third of the
global health gap on average (more in LMICs)


Annual death toll by…

• Non equity and progress : 20 m
• Non progress (since 1990) and equity : 12 m

The response of health systems
Dynamics : Situation analysis Definition of Costing and Monitoring
BHCP/organization budgeting scenarios HIS/applied
of services/health research
system pillars

Health priorities Reproductive health Child health care & Endemic Prevalent non-
covered services nutrition communicable communicable
diseases /emerging diseases vs. chronic
threats* vs. Acute conditions.
conditions.

Health pillars Human resources for Infrastructures and Access to medicines Health fair financing
health * logistics and fungible health schemes
products*

Health system Inclusive leadership Universal Coverage Patient centered Health in all
principles

(WHA 62.12)


Gaps in health system resources
100.0 5 000

90.0 4 500

80.0 4 000

3 500
70.0
3 000
60.0
2 500
50.0
2 000
40.0
1 500
30.0
1 000
20.0
500

10.0
0

0.0 Low income 27 11
Lower middle
Low income 5.3 41.9 58.1 8.7 83.1 3.7 80 34
income
Lower middle income 4.3 42.4 57.6 7.8 90.5 5.3 Upper middle
488 269
Upper middle income 6.4 55.2 44.8 9.4 69.0 26.4 income
High income 11.2 61.3 38.7 17.2 36.1 51.4 High income 4 405 2 699


Gaps in health system capacities and performance

120
90

80 100

70
80
60
60
50

40 40

30
20
20
0
10 Births Immunizat
attended Births by ion Contracep Antiretrovi
0 by skilled caesarean coverage tive ral therapy
health sectionb among 1- prevalenc coverage
Low income 4 10 15 personnel (%) year-oldsd eg (%) (%)
b (%) (%)
Lower middle
10 14 18 Low income 43 3.3 75 39.6 40
income
Lower middle income 65 13.0 82 65.8 42
Upper middle
24 40 39 Upper middle income 95 28.6 92 67.5 49
income
High income 28 81 58 High income 99 26.8 95 70.1 90


Threshold effect?
Govt fin x H pc vs U5MR

300

250
Angola 105/220
200

150

100

50

0
Vietnam 72, 14

0 20 40 60 80 100 120 140 160


Best efficient use of resources for health
Country Life expectancy U5MR AMR
Maximum CI GHStandards
(HIRegion) 69 20 186
Georgia 72 30 157
Paraguay 74 28 139
Guatemala 69 34 228
Sri Lanka 69 17 209
Syrian Arab Republic 72 16 150
Morocco 72 36 118
Fiji 70 18 204
Vanuatu 69 33 182
Philippines 70 32 174
Tonga 71 19 188
Honduras 70 31 179
Cape Verde 71 29 185
Republic of Moldova 69 17 227
Micronesia (Federated States of) 69 39 172
Viet Nam 73 14 150
Nicaragua 74 27 165
Solomon Islands 70 36 160
total/average 71 27 176

Potential gap per Potential total Potential gap per Potential total
Country capita gap Country capita gap
Somalia 95 847970000 India 47 55105902498
Lao People's
Democratic
Republic 46 286798203
Kenya 44 1698006238
Myanmar 93 4626706050 Mozambique 42 935340804
Democratic
Republic of the Comoros
Congo 93 5975509500 39 25851135
Eritrea 85 417639395 Ethiopia 38 3092508752
Sierra Leone 82 453570055 Kyrgyzstan 37 200772776
Sudan 79 3270406535 Haiti 37 364009205
Yemen 79 1799622530 Malawi 37 545483742
Guinea-Bissau 78 122255000 Nigeria 36 5417034889
Central African
Zambia
Republic 77 332053657 35 439600712
Burundi 75 604989306 Chad 34 369766320
Niger 73 1068860495 Cameroon 32 610679289
Guinea 71 700888267 Burkina Faso 29 443019463
Afghanistan 70 1912466881 Madagascar 26 502115027
Mauritania 69 223183130 Uzbekistan 23 617853199
Togo 69 445505071 Zimbabwe 19 238120773
Uganda 64 2039481887 Congo 18 63589840
Nepal 59 1708625067 Philippines 17 1517190241
Tajikistan 58 396884638 Bangladesh 15 2355532468
Liberia 56 213656772 Benin 11 94888745
Ghana 55 1290703174 Senegal 8 98176440
Pakistan 53 9406922191 Gambia 5 8144072
Iraq 53 1580040000 TOTAL
J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice 114468324431 32

Public financing gap for global health
standards/equity
11.5
7.8
6.5 HDA to PFG

2.7 Add redistr
Add ODA 0,7%
Add HAD 15%
Rest gap

89.5


Ecological dimension : trans-
generational equity
12.8

11.2

9.6

8

6.4

4.8

3.2

1.6

0
SHE
30.0 40.0 50.0 60.0 70.0 80.0 90.0


Countries with SHE
Country Life expectancy Hectare use
Indonesia 69.4 1.2

Sri Lanka 74.9 1.2

Morocco 72.2 1.2

Moldova 69.3 1.4

Viet Nam 75.2 1.4

Dominican Republic 73.4 1.5

Syrian Arab Republic 75.9 1.5

Peru 74 1.5

Nicaragua 74 1.6

Algeria 73.1 1.6

Egypt 73.2 1.7

Armenia 74.2 1.8

Guatemala 71.2 1.8

Georgia 73.7
J Garay, Challenges for EU and US policies in Global health : Global Health is Global Justice
1.8 35

Countries with ëfficient”SHE”
Country Hectare use Country Hectare use
Georgia 1.8 Tonga
Paraguay 3.2 Honduras 1.8
Guatemala 1.8 Cape Verde
Sri Lanka 1.2 Republic of Moldova 1.4
Syrian Arab
Republic 1.5 Micronesia
Morocco 1.2 Viet Nam 1.4
Fiji Nicaragua 1.6
Vanuatu Solomon Islands

Philippines 1.3


Ill health

legal
values governance resources
frameworks
Physical and psycho-
Social potential developed
and fulfiled
If unmet :
physicalhandicaps, chronic
health system stress, lonelyness,
anxiety,depression

national social
governance
national legal Safety needs : from
frameworks
national
infections, toxic
economic
Income levels agents, unhealthy diets and
governance
and distribution sendentarism, accidents and
violence
national
Human
ecological If unmet : infectious
solidarity and diseases, intoxications, cardi
governance
ecological
equilibrium ovascular and metabolic
global social disorders, cancer, trauma.
governance

Global legal global economic
frameworks governance
Basic physical needs : water, air, nutrition.
Natural
global ecological
resources and
If un met :
governance
conditions malnutrition, dehydration, respiratory
conditions.

Justice

The world’s response
• Weak global rights framework
• Weak global economic governance
(regulation, tax redistribution)
• Weak global social governance (global social
security)
• Weak global health governance (WHO
democratic leadership)
• Weak global ecological governance
(commitments, compliance)

Inequity deaths 1990 vs MDG targets

20000000

18000000

16000000

14000000

12000000
Non MDG
Total MDG 6
10000000
MDG5 target
8000000
Target MDG 4
6000000

4000000

2000000

0
Low income Lower middle Upper middle Total
income income


Needs vs health ODA
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
% LIC % DC % ODA
Injuries 11. 18 12.79 1
Mental health 10. 81 14.00 1
Noncommunicable conditions 26. 52 34.96 1
Comm Diseases 34. 53 25.12 54
Nutritional deficiencies 2. 82 2.33 2
Perinatal conditions (e) 11. 18 8.54 2
Maternal conditions 2. 96 2.26 8

Justice

Health system fragmented
• > 100 global initiatives
• Advocacies by problems, isolated funding gap
analysis (consolidated > 30 b!), vertical
approaches, duplication and opportunity cost
• The case of a safe delivery : basic service
– Vs. divided into? :
• MDG 4 : reducing neonatal death
• MDG 5 : SRHRs : reducing maternal deaths
• MDG 6 :
– AIDS : PMTCT
– Malaria : AN PrTx
– Tb : BCG


Justice

Mozambique
Health Financing 2001-2008
350

300

250

Paris? Which
200 Paris?
Budget

150

100

50

0
2001 2002 2003 2004 2005 2006 2007 2008
Year
Government budget Common Funds Vertical Funds


Aid effectiveness example: predictability and longevity of ODA must
be improved

Donor Commitments for Health as % of Total Health Donor Commitment for Health as % of Total Health
Expenditure Expenditure

100 60.00

80 50.00
Mauritania Guinea
40.00
60 Benin
Tanzania 30.00
40 Burundi
Mali 20.00
Liberia
20
10.00
Eritrea
0 0.00
1997 1998 1999 2000 2001 1997 1998 1999 2000 2001

44

Ext Health aid vs Pot Fin Gap

600

Niue -1003/551
500

400

Palau
651/323
300

7,8 Bn Marshall, Mi
cronesia, Na
uru 200 11,5 Bn

Israel -
100
1700/50

0
-3500 -3000 -2500 -2000 -1500 -1000 -500 0 500
Justice

Justice

A new global solidarity framework?
• Resources for Minimum country dignity : 3300
• Maximum to keep average : 19000

0-
1

10
15
20
25
30

0
5
30 000
0- 00
1 -4

200 000
400 000
600 000
800 000
1 000 000
1 200 000
1 400 000
1 600 000
1 800 000

0
30 000
00 60 00 0
-4 00
60 00 -
00 0 90 700
00 0
90 -70 -
00 0 0 12 100
00 0
12 -100 0- 0
00 00 15 13 0
0 00 0
15 -13 0- 0
00 00 16
0 0 18
18 -16 00 000
00 00 0-
0 0 21 19 0
21 -19 00 0
00 00 0- 0
0 0 24 22 0
24 -22 00 0
00 00 0- 0
0 0 27 25
27 -25 00 000
00 00
0 0 0-
30 28 0
30 -28
00 00 00 0
0 0 0- 0
33 -31 33 31 0
00 00 00 0
0 0 0- 0
GDP frequency/population
GDP frequency/countries

36 34
36 -34
00 00 00 000
0 0 0-
39 -37 39 37 0
00 00
0
00 0
0 0- 0
42 -40 42 40 0
00 00
0 00 0
0 0- 0
45 -43 45 43 0
00 00 0
0 0 00
0- 0
48 -46 48 46
00 00
0- 0 00 000
49 0-
00 49
0 00
0
Countries and poulations under mDp

GDP gap, public financing gap
• 2,235 Trillion
• 20% public financing gap : 447 Bn
• GPGs (1,5 % GDP at global level?) : 700 Bn
• 1,147 Bn
• 75% direct GDP SS : 1,11% GDP
• 25% indirect GlTr SS : 1,9% GlTr

Global SS vs. ODA

100%

90%

80%

70%

60%
Gap
50%
ODA
40%

30%

20%

10%

0%
Level Predictable Alligned Equitable
Gap 1047 5 85 50
ODA 100 1 15 50

US vs. EU on Global Health
• Social values :
– Internationalism (EU > US)
• should deal with its own problems and let other
countries deal with their problems as best they can…
– Exceptionalism (US > EU)
• their culture is superior to that of other nations
– Role of the state (EU > US)
• it is more important for everyone to be free to pursue
their life’s goals without interference from the state


US vs EU constitution
• concept of rights :

– the U.S. Bill of Rights is a list of individual rights
AGAINST the interference of the state,
– the EU Charter of Fundamental Rights (Part II of
the Treaty) includes a long list of rights to services
provided by the state, including education, paid
maternity leave, social security benefits and social
services, preventive health care and high levels of
environmental and consumer protection.


Health ODA and equity in the last decade (for all?)
Inequity deaths 1990 vs MDG targets

• Focus on MDGs 20000000
18000000
16000000
14000000

• Emphasis on Results 12000000 Non MDG
Total MDG 6
10000000
MDG5 target
8000000
Target MDG 4
6000000

• Boost of health ODA : 4 to 16 Bn $ 4000000
2000000
0
Low income Lower middle Upper middle Total
income income
• Progress : 4 m Tx AIDS
Commitments
14.000,00

• Distortion/restriction : 12.000,00
MDG 6

GH inequity remains 10.000,00
Other H ODA

H systems remain weak +distorted by diseuse-
8.000,00

approaches?
6.000,00

4.000,00

2.000,00

0,00
2002 2003 2004 2005 2006 2007

Justice

Federailsm
7

6

5

4

3

2

1

0
US EU
Federal/EC 3.7 0.16
States and local 3.1 6.3


US vs EU economy and income equality
Indicator US EU
GDP pc (PPP) 46970 30973
Ratio US/EU GDP pc 1,4
GDP/employed 1,3
GDP/hour 1,09
Employment (1970,  66  80 70  67
2005)
Income distribution

(top 20%/ low 20%, R : 45/4.8, R : 9.8 38,5/8,3, R : 4.7
ratio)
GINI index 52.5 40


US vs. EU fiscal policies
US EU

Tax revenue from GDP 24,8 39,6

Tax on income and 9,8 11,4
profits
Tax on property 2,3 1,5

Tax on goods and 4,5 11,8
services
Contributions to social 6.6 11.8
security


US vs. EU healthy lifestyles?
40

35

30

25

20

United States of America
15 European Union

10

5

0
Adults aged ≥15 years who are obese Alcohol consumption among adults Prevalence of smoking any tobacco
(%) aged ≥15 years product among adults aged ≥15 years
(litres of pure alcohol per person per (%)
year)


US vs. EU child mortality
Neonatal and under five mortality rate EU-US
14.0

12.0

10.0

8.0

6.0

4.0

2.0

0.0
1990 2000 2008 1990 2000 2008 1990 2000 2008 1990 2000 2008 1990 2000 2008 1990 2000 2008
Male Female Both sexes Male Female Both sexes
Neonatal mortality rate (per 1000 live births) Under-five mortality rate
United States of America 11.0 8.0 7.0 8.0 7.0 6.0 10.0 7.0 7.0 13.0 9.0 9.0 10.0 8.0 7.0 11.0 9 8
European Union 10.5 6.6 4.7 8.2 5.3 3.7 9.3 5.9 4.4 12.6 7.8 5.7 10.0 6.4 4.5 11.4 6.9 5.1


US vs. EU adult mortality rates
Adult health EU-US
500

450

400

350

300

250

200

150

100

50

0
1990 2000 2008 1990 2000 2008 1990 2000 2008 2004 2004
Male Female Both sexes CD NCD Injuries CD NCD Injuries
Adult mortality rate
(probability of dying between 15 and 60 years A-S mortality Life years lost
per 1000 population)
United States of America 172 144 135 91 83 79 132 114 107 36.0 450.0 50.0 9.0 73.0 18.0
European Union 167.1 141.3 122.5 77.5 66.9 58.3 122.9 104.6 90.7 27.0 456.2 37.7 5.7 82.6 11.7


US vs. EU health systems
Health financing EU-US
80

70

60

50

40

30

20

10

0
2000 2007 2000 2007 2000 2007 2000 2007 2000 2007 2000 2007 2000 2007
Social security
General General
Total Private expenditure on Out-of-pocket Private prepaid
government government
expenditure on expenditure on health as % of expenditure as % plans as % of
expenditure on expenditure on
health as % of health as % of general of private private
health as % of health as % of
gross domestic total expenditure government expenditure on expenditure on
total expenditure total government
product on healthb expenditure on health health
on healthb expenditure
health
United States of America 13.4 15.7 43.2 45.5 56.8 54.5 17.1 19.5 33.5 27.9 25.5 22.6 60.3 63.5
European Union 8.1 8.8 74.9 76.2 25.1 23.8 13.8 15.1 50.6 51.2 70.7 68.1 21.3 21.4


US vs. EU health spending
Health spending per capita, EU-US
8000

7000

6000

5000

4000

3000

2000

1000

0
2000 2007 2000 2007 2000 2007 2000 2007
Per capita total expenditure Per capita total expenditure Per capita government Per capita government
on health at average on health expenditure on health at expenditure on health
exchange rate (US$) (PPP int. $) average exchange rate (US$) (PPP int. $)
United States of America 4703 7285 4703 7285 2032 3317 2032 3317
European Union 1518 3182 1864 2754 1164 2463 1419 2119


Signed and ratified international treaties
International treaties US EU (all EU member states
directly, by EU or
“acquis”)
CESCR NO YES
CCPR YES YES
CCPR-OP1 NO YES
CCPR-OP2-DP NO YES
CERD YES YES
CEDAW NO YES
CEDAW-OP YES YES
CAT YES YES
CRC NO YES
CRC-OP-AC YES YES
CRC-OP-SC YES YES
MWC NO YES
RPD NO EU and all 27 MSs

US vs. EU development policies
Common features US specificities EU specificities
Structure Coordination across relevant Development Policy under Development Policy under
sectors National Security: development foreign policy/partly
as a central pillar of US national independent.
Policy coherence security policy, equal to
diplomacy and defense.

Director of Development
agency (USaid and Europaid) in Interagency Development Joint EU coordination and joint
charge lf development policies Policy Committee aimed at programming.
and reports to US Secretary of coherence across all
State/EU Foreign Office chief. Government departments

US Global Development
Council for consultation with
stakeholders
Principles Economic growth as main pull US leadership and effective Development aid is a priority
effect for development partnership and a modern for EU external action in
architecture that elevates support of EU's interests for a
Country ownership development and harnesses stable and prosperous world.
development capabilities (in
support of “common Inclusive and sustainable
objectives”). economic growth is crucial to
long-term poverty reduction and
USAID as the world’s leading growth patterns are as important
development agency. as growth rates.

US vs. EU development priorities
Priorities Good governance "Game-changing" initiatives Energy : Address price
such as vaccines for neglected volatility and energy security.
Public administration and diseases, weather-resistant seed Link to climate change,
service delivery varieties, and clean energy including access to low carbon
technologies, technologies. Access to secure,
affordable, clean and
Sector reforms Global Health Initiative : High sustainable energy services.
priority given to targeted health
FTT/sustainable agriculture challenges Social cohesion : share target
(but see different approaches)
for social inclusion and human
development of at least 20% of
Attention to climate change EU aid : Support sector reforms
that increase access to quality
health and education services,
mainly through „sector reform
contracts‟ with intensified
policy dialogue.
Different approaches on some Agriculture and food security: Comprehensive approach to food Agriculture and food security:
priority areas security by accelerating economic Safeguarding of ecosystem
growth and raising incomes services, priority to locally-
through greater agricultural developed practices and focusing
productivity, increasing incomes on smallholder agriculture and
and market access for the rural rural livelihoods. Strengthen
poor and enhancing nutrition. nutrition standards, food security
Establishment of the Global governance and reducing food
Agriculture and Food Security price volatility at international
Program (GAFSP) based at the level.
World Bank designed to help
poor farmers grow, market and 64
earn more.

Agriculture, food security and aid
modalities
Aid modalities Selective sectors and countries Renew the US leadership in the In line with the Operational
multilateral development banks Framework on Aid Effectiveness.
Ownership of country priorities and the G20 (seen as the premier
forum for US international A new element is the increased
economic cooperation) differentiation between
Donor coordination Millennium Challenge developing countries as several
Corporation –MCC- (aligned partner countries (notably the
Leverage private funds support-sector budget support- BRICS) have become donors
like), more connected to while others are facing increasing
Aligned support to country infrastructures and water- fragility.
systems : EU GBS, US MCC sanitation, based on governance
and corruption assessments.
General Budget Support (GBS):
Leverage to private investments. aligned, untargeted and
predictable support to Ministries
Attention to fragile contexts of Finance. Now called
through LRRD-like approaches. development contracts

Strengthen key multilateral Blending instruments.
capabilities.
Sector reform contracts.


US vs. EU development aid levels
EU and US development aid levels
90000

80000

70000
Million dollars

60000

50000

40000

30000

20000

10000

0
2003 2004 2005 2006 2007 2008 2009 2010
EU DAC members 41427.53 47290.44 60063.5 64741.92 67560.25 76433.07 71098.44 73733.23
US 18257.49 20604.13 28750.32 24531.56 22690.52 27414.13 29659.18 31159.3


EU and US ODA as % of GDP
0.0600

0.0500

0.0400
ODA % of GDP

0.0300

0.0200

0.0100

0.0000
2003 2004 2005 2006 2007 2008 2009 2010
US ODA/GDP 0.0165 0.0175 0.0229 0.0184 0.0163 0.0193 0.0214 0.0216
EU(DAC) ODA/GDP 0.0356 0.0386 0.0468 0.0465 0.0457 0.0497 0.0472 0.0479


US vs. EU ODA distribution
Ratio LDCs/all
EU and US distribution by income regions 0.6

100%

90%
0.5

80%

70% 0.4

60%

50% UMICs 0.3

LMICs
40% other LICs
LDCs 0.2
30%

20%

0.1
10%

0%

US EU US EU US EU US EU US EU US EU US EU US EU 0
US EU US EU US EU US EU US EU US EU US EU US EU

2003 2004 2005 2006 2007 2008 2009 2010
2003 2004 2005 2006 2007 2008 2009 2010
Ratio LDCs/all 0.38 0.45 0.31 0.41 0.22 0.42 0.33 0.39 0.35 0.42 0.41 0.43 0.43 0.38 0.48 0.44


Share bilateral/multilateral of EU and US ODA
100%
90%
80%
70%
60%
50%
40%
30%
20%
10%
0%
US EU US EU US EU US EU US EU US EU US EU US EU
2003 2004 2005 2006 2007 2008 2009 2010
Multilat 1671 1343 3466 1697 2363 1750 2380 1927 2895 2333 2992 2610 3667 2617 3775 2655
Bilat 1658 2799 1713 3031 2638 4256 2215 4546 1979 4423 2442 5032 2599 4492 2738 4717

70

Compliance with aid effectiveness
2005 2007 2010 Average Target

US EU US EU US EU
Ind 3 : disbursed/estimated
aid 66 58 73 62 64 61 41 85
Ind 4 : TA coordinated with
country programming 47 36 54 50 37 50 57 50
Ind 5a : Use of country
systems :PFM 10 41 3 40 4 56 48 55
Ind 5 b : use of country
systems : Procurement 12 42 5 36 4 55 44 55
Ind 6 : Reduction of
programme Implementation
units (2005 baseline) 0 0 0 48 04 61 30 60
Ind 7 : Aid Disbursements
predictable and captured by
national budgets 29 51 37 63 30 60 43 71

Ind 8 : Untied aid 70 80 79 86 80 92 86 89
Ind 9 : Programme-based
support 51 27 47 36 59 48 45 66
Ind 10 : Donor missions
coordinated 28 34 9 37 6 25 19 40
Ind 11 : Country analysis
coordinated 40 45 37 90 39 59 43 66

US vs. EU policies on global health
Features EU-US GH policy US GH specificities EU GH specificities
commonalities
Principles Country ownership Gender focus. Equity

Support to health systems Research and innovation Governance

Monitoring frameworks Coherence

Priority areas Special attention to MDG5 AIDS (80% of the Universal health coverage
programmed support) through aligned support (50%
Health system strengthenning use of country systems and
Malaria 66% through programme
based apporaches).
Neglected tropical diseases
Governance through increased
core support to WHO (>50%).
Mother and child care

Coherence in trade, migration,
Nutrition
security, food security and
climate change.

Targets Inputs : Financial allocations. Process : aid affectiveness and
governance.
Impacts : Patients prevented or
treated.


US vs. EU levels of HDA
8000

7000

6000

5000

4000

3000

2000

1000

0
EU US
other 1207
Nutrition 112 75
SRHR 280 455
Basic health care 602
Mother and child care 495
Malaria 60 382
Tuberculosis 35 162
HIV/AIDS 564 5509


US HAD equity
Equity distribution of US GH pc
50

45

40

35

30

25

20

y = -0.003x + 4.887
R² = 0.025 15

10

5

0
-2500 -2000 -1500 -1000 -500 0 500


EU HDA equity
20
18
16

14
EU pc health aid

12
10
8
6
y = -0,0031x + 0,9267
2 4
R = 0,0078
2
0
-250,00 -200,00 -150,00 -100,00 -50,00 0,00 50,00
potential pc public health financing gap


Challenges for EU and US on GHE
• PERTINENCE

• Health development aid (hereafter HDA) does not address the main root causes of the main
challenge in global health: stagnant global health equity. These causes are related to high income
disparities within and between countries.

• HDA follows the MDG framework, which only targets 60% of the overall gap of global health
equity, when under the main stratifying variable, that of income, the upper regional quintile (high
income region) is considered the best standard.

• Countries with lower public spending per capita should maximize their potential of fiscal revenue
(to at least 20% of GDP) and the public budget allocation to health (to some 15% , as the OECD
average and the Abuja commitments for Africa). The gap remaining after those increased domestic
revenues are estimated, affects the 44 countries listed in annex 4, for a total of over 100 Bn a
year, that is, some 6 times higher than the present levels of HDA.

• Besides lower than required levels of HAD, the distribution is not equitable in relation to the
mentioned public financing needs. Only 30,9% of ODA goes to countries that are under this
financial gap. Both, the EU and the US show low HAD equity levels.


JUAN GARAY: Salud Global: tendencias y desafíos

JUAN GARAY: Salud Global: tendencias y desafíos

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